a) Treatment Failure & The Problem of Non Adherence
AU : Rom WN & Garay SM
TI : Tuberculosis : Adherence to regimens and Directly Observed Therapy
SO : Tuberculosis, Little, Brown & Company, Boston, 1996, p. 927-934
DT : M
AB :

Since chemotherapy first proved efficacious for TB, a significant number of patients have failed to complete an adequate course of therapy. An enormous research performed over the last 40 years has contributed greatly to our understanding of the complex nature of why patients fail to take their medication as prescribed. Despite our increased knowledge of such patient behaviours, modern medical practitioners, to date, have neither the means to identify in advance all patients who will fail to take their medication, nor the means to detect all those who are not taking their medication during the course of their therapy. In the case of a communicable disease such as TB, the well-being of the patient and the interest of the public health overlap. Physicians, in general, and public health officers, in particular, are charged not only with ensuring that individuals are adequately treated so that they may be cured of their disease, but health care professionals are legally obligated to ensure that adequate treatment occurs to protect the public from the threat of TB.

The authors have deduced six steps to optimize patient adherence which is termed as “Denver Model” The principles of using these steps would maximize the efficiency of DOT by eliminating as many barriers as possible and by creating a structure that readily locate the “lost” patient. They are: (i) Know the patient: Initial encounters with the patient should be used to aggressively gather information. The goal of these sessions should be to identify as many points as possible at which the patient connects with the community. (ii) Assign a case manager: Each patient should have one health care professional who is identified as a specific contact. If at all possible, this contact should have fluency in the patient’s first language; if that is not possible, the contact should arrange for an adequate translator to be present for sessions with the patient. Ideally, the case worker and patient will establish a sound and stable therapeutic relationship. (iii) Establish inducements and enablers: Many patients with TB are afflicted with numerous social ills in addition to their disease. Homelessness, hunger, and substance abuse can make TB seem the least of their worries; thus, adherence to medication assumes a low priority. If the TB clinic can meet some of the patient’s other needs, contact with the clinic assumes a higher priority, and the likelihood of adherence to therapy is much greater. The use of “enablers” has also been advocated. Enablers are services that remove barriers to the patient’s participation. For a patient without transportation an enabler might be a bus token or a taxi voucher; for a mother it might be child care so that she can come to the clinic. All of this sounds expensive, but the ultimate total cost of inducements and enablers is far less than the cost of inpatient care in the case of the patient who fails these outpatient efforts, not to mention the cost of caring for the additional cases that will result from failure to treat. (iv) Be flexible: Every attempt should be made to accommodate the patient’s needs and schedule. Whenever possible, reliable contacts in the community should be identified so the patient can get medication 24 hours a day. (v) Involve community workers: Part-time employment of reliable members of the patient’s community can prove invaluable. Ideally, this would be an individual who knows the patient and the patient’s neighbourhood, someone who could quickly locate the patient if he/she failed to show for an appointment and who could determine the reason for the missed appointment as well as administer the missed dose. (vi) Issue an order of quarantine: Patients should clearly understand that their adherence to medical therapy is legally mandated and is offered in lieu of physical quarantine. The patient should receive an order of quarantine that clearly explains this and makes clear that failure to present for medication doses may result in incarceration for the duration of therapy.

Nearly thirty years of experience with the direct observation of antituberculous chemotherapy in Denver have proven these to be effective measures. Each case of TB in Denver County is treated with impartiality. Every patient with TB received DOT and no exceptions are made.