Comparing Electronic and in-Person Tuberculosis Directly Observed Therapy

BACKGROUND:   To ensure tuberculosis treatment adherence, directly observed therapy (DOT) is the standard of care. However, DOT represents a large commitment of time and resources for patients, public health authorities, and healthcare systems as every dose must be observed. Electronic monitoring of patients taking their medication (e-DOT) has the potential to make treatment more acceptable and less costly. In 2009, Clark County Public Health (CCPH) began a pilot program allowing tuberculosis patients to use their choice of in-person DOT or e-DOT for any continuation phase dose. Electronic doses could be performed in real time (real-time e-DOT) or could be recorded using video software (recorded e-DOT). Patients could use their home computer or smartphone for either form of e-DOT. This study evaluates the clinical and cost implications of e-DOT compared to in-person DOT.

METHODS:   We reviewed medical charts for all CCPH active tuberculosis cases reported since 2009. Information abstracted from these charts included demographics, clinical information, tuberculosis treatment data, including length of treatment, whether and when the case used e-DOT, and treatment adherence data. We measured costs by applying tuberculosis staff salary and benefits packages to the average time spent on DOT.

RESULTS:   CCPH administered DOT to 52 patients with active tuberculosis. Of these, 12 patients received at least one dose by e-DOT, accounting for 1016 doses. All of the cases on e-DOT completed treatment or treatment was in progress at the time of data abstraction. In mixed generalized linear models, those doses administered by e-DOT were not more likely to be missed than those administered in-person (OR:1.74, 95% CI:0.76-4.01). Stratified by type of e-DOT, video-recorded doses were not statistically more likely to be missed than in-person doses (OR:0.79, 95% CI:0.47-1.35). CCPH saved an estimated $12,790 in staff time and $15,771 in mileage. In total CCPH saved $28,561 by using e-DOT, a savings of $28.11 per e-DOT dose.

CONCLUSIONS:   e-DOT can lower costs while achieving similar treatment outcomes as doses were equally likely to be missed as in-person DOT doses, however cost far less in travel and staff time. Further, staff could easily manage case’s out-of-jurisdiction travel or treatment during inclement weather. Given the overall cost savings, CCPH was able to offer a tablet computer loaner program that allows tuberculosis patients without a home computer or a smartphone the option of using e-DOT. e-DOT is an innovative method that minimizes the burden DOT places on patients while also reducing program costs.