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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 patients 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 patients 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 patients 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 patients 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 patients community
can prove invaluable. Ideally, this would be an individual who knows
the patient and the patients 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.
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