Approaches to Improving Adherence to Antituberculosis Therapy -- South Carolina and New York, 1986-1991

Patients with tuberculosis (TB) who fail to complete a standard course of antituberculosis (anti-TB) therapy are at increased risk for treatment failure and may play a role in both the emergence of drug-resistant strains of Mycobacterium tuberculosis and further spread of TB. During 1986-1991, the South Carolina Department of Health and Environmental Control and the New York City Department of Health (NYCDH) attempted to improve patient adherence to anti-TB therapy by employing a combination of strategies that included incentives, directly observed therapy (DOT) (i.e., health-care worker observation of the patient ingesting each dose of medication), court-ordered DOT, and commitment for inpatient management. This report describes the experiences of selected strategies in South Carolina and New York City and provides recommendations for improving patient adherence to anti-TB therapy. South Carolina

From 1980 through 1985, South Carolina reported approximately 500 new patients with TB annually; 93.9% of these patients completed therapy. Since 1985, most county health departments have routinely used incentives (e.g., food, clothing, or books) and enablers (e.g., free transportation to clinics) to ensure completion of anti-TB therapy. Since 1985, DOT has been administered to 1521 patients with TB in South Carolina who did not adhere to anti-TB therapy; these patients represented 43% of the 3465 patients with TB during that period. Patients who fail to keep appointments for DOT are notified by the local health department that if they do not comply with this recommended therapy they will be required to take the prescribed medications under the supervision of a public health nurse at an appointed time and place under court order. Twenty-three (85%) of 27 such patients completed court-ordered DOT. Four patients who did not complete court-ordered DOT were committed to a secured, long-term- care facility. The average length of stay in the facility was 68 days.

Since 1989, additional efforts between the South Carolina Tuberculosis Control Program and several local county alcohol- and drug-abuse commissions have produced joint treatment programs to treat patients with TB who have alcohol- and/or substance-abuse problems. From 1986 through 1991, by using a combination of these strategies, South Carolina increased the overall completion of anti-TB therapy from 93.9% to 96.5% and decreased the number of new TB cases from 593 in 1986 to 410 in 1991.

The cost to the South Carolina Department of Health and Environmental Control for each strategy has been $0.95-$20 per treatment for patient incentives and enablers; $653 per patient for DOT and court-ordered DOT; $450 (including shelter, food, and dual treatment for TB and for alcohol/substance abuse) per patient in halfway houses; and approximately $10,700 per patient for those requiring commitment to a long-term-care facility. New York City

In New York City, approximately 3700 TB cases are reported annually; 30% of persons with TB are injecting-drug users, and approximately 25% are homeless. Patients who do not adhere to anti-TB therapy are offered residential treatment; however, some patients with histories of repeated nonadherence may be committed for inpatient management. To assess the effectiveness of inpatient commitment, NYCDH evaluated all patients who were committed from January 1, 1988, through April 30, 1991. During this period, TB was diagnosed in 9200 persons citywide; of these, 33 (less than 1%) patients had histories of repeated failure to complete therapy and were committed to 19 voluntary and municipal hospitals. Commitment was continued until three consecutive sputum specimens smear-negative for acid-fast bacilli were obtained from each patient. Of these 33 patients, 17 (52%) had histories of substance abuse (e.g., alcohol, injecting-drug use, and/or crack cocaine use); and 24 (73%) had M. tuberculosis isolates resistant to one or more anti-TB medications. Mean duration of commitment was 62 days (range: 2-308 days).

Nine months after initial commitment, 10 (30%) patients had successful outcomes (i.e., they were either cured {one patient} or were taking medication and were being followed on a monthly basis as outpatients {nine patients}); 11 (33%) patients were lost to follow-up; eight (24%) did not complete TB therapy and were rehospitalized for TB; and four (12%) died.

Patients were more likely to have a successful outcome if the length of commitment for inpatient management was more than 62 days (eight {62%} of 13 patients versus two {10%} of 20 with less than 62 days {relative risk (RR)=6.2; 95% confidence interval (CI)=1.5-24.5}) and if patients were domiciled (eight {50%} of 16 versus two {12%} of 17 homeless {RR=4.3; 95% CI=1.1-17.1}). Neither abusing substances nor having an isolate resistant to anti-TB medications was associated with a lower likelihood of a successful outcome.

The NYCDH reviewed the status of the 10 patients with successful outcomes 1-25 months after initial commitment; two patients were cured, four were still under care, and the remaining four had unsuccessful outcomes (i.e., one died, one was rehospitalized for TB, and two were lost to follow-up). Estimated expenditures for treatment of patients requiring commitment for inpatient management were approximately $66,000 per patient.

Reported by: C Pozsik, MPH, J Kinney, MSW, D Breeden, MD, South Carolina Dept of Health and Environmental Control. B Nivin, MPH, T Davis, PhD, Div of Disease Intervention, New York City Dept of Health. Div of Tuberculosis Elimination, National Center for Prevention Svcs; Div of Field Epidemiology, Epidemiology Program Office, CDC.

Editorial Note

Editorial Note: The paramount goal of TB-control programs is to ensure that TB patients complete their prescribed course of therapy. Among patients who have not completed unsupervised therapy, DOT has been the most cost-effective method of increasing adherence (1-3). In South Carolina, the completion rate for TB treatment (96.6% in 1991) exceeded the national completion rate (79% in 1990) (CDC, unpublished data). In addition, the experience in South Carolina indicates that most patients who are chronically nonadherent can be cost-effectively treated using a variety of approaches other than commitment for inpatient management (4).

Homelessness and illicit drug use are barriers to completion of therapy. The findings from New York City indicate that even an approach as intense as commitment does not ensure that patients will be cured. Those findings also suggest that commitment for periods less than the full course of therapy may be ineffective.

To increase completion of anti-TB therapy, local and state health departments are encouraged to 1) employ the full range of TB-therapy strategies according to individual patient needs; 2) provide accessible clinical TB services and anti-TB medications at no cost to patients; 3) monitor adherence among patients; and 4) develop working relations with other agencies that provide social services, treatment for drug and alcohol abuse, and residential facilities for patients who need them (5,6).

CDC and the American Thoracic Society recommend that consideration be given to treating all TB patients with DOT (5). Commitment for inpatient management is indicated for patients who, after receiving a range of less restrictive treatment options, remain nonadherent and who pose a substantial risk to the health of their community. In some cases, nonadherent patients may need to be committed until the full course of therapy is completed. Commitment should be instituted with careful consideration of appropriate local, state, and federal laws and regulations regarding the patient's civil liberties (7).

References

1. Sbarbaro JA, Johnson S. Tuberculosis chemotherapy for recalcitrant outpatients administered twice weekly. Am Rev Respir Dis 1968;96:895-

3. Addington WW. Patient compliance: the most serious remaining problem in the control of tuberculosis in the United States. Chest 1979;76:S741-3.

4. McDonald RJ, Memon AM, Reichman LB. Successful supervised ambulatory management of tuberculosis treatment failures. Ann Intern Med 1982;96:297-303.

5. Pozsik CJ. Using incentives and enablers in the tuberculosis control program. In: American Lung Association of South Carolina/South Carolina Department of Health and Environmental Control, eds. Tuberculosis control: enablers and incentives. Columbia: American Lung Association of South Carolina, 1989.

6. American Thoracic Society/CDC. Control of tuberculosis in the United States. Am Rev Respir Dis 1992;146:1623-33.

7. CDC. Initial therapy for tuberculosis in the era of multidrug resistance: recommendations of the Advisory Council for Elimination of Tuberculosis (ACET). MMWR 1993(RR in press).

8. Gostin LO. Controlling the resurgent tuberculosis epidemic. JAMA 1993;269:255-61.

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