TUBERCULOSIS (TB) is a timeless disease found virtually everywhere around the world. It's caused by Mycobacterium tuberculosis, a highly infectious bacterium that infects millions of people. Worldwide, it's the second leading cause of death by an infectious agent, right behind HIV.1,2 In the United States, 9,287 new cases of TB were reported in 2016.1
If diagnosed early, TB can be successfully cured. A strategy to ensure adherence to treatment is directly observed therapy (DOT), in which a trained healthcare professional, in most instances a nurse, watches the patient ingest prescribed medications to ensure adherence to the regimen. This article discusses how video directly observed therapy (VDOT) can improve patient satisfaction, save nursing time, and reduce costs associated with traditional DOT.
Complex treatment regimen
Standard treatment for TB involves the use of four first-line drugs, which must be taken for many weeks on a precise timetable. (Details about recommended treatment regimens are beyond the scope of this article.) Because of the length and complexity of treatment, many patients fail to complete the regimen as prescribed, leading to treatment failure and encouraging the creation of drug-resistant organisms.
DOT is a strategy designed to ensure that patients maintain the treatment regimen and achieve a good outcome. However, because DOT is time-consuming and requires adequate staffing, it can be burdensome to the local health department, patients, and nurses, especially in rural communities where nurses need to make home visits to accomplish DOT. Patients who must commute to the health department can lose valuable time at work and depend heavily on reliable transportation. This is particularly an issue in the intense first 2 months of daily medication observation because of the daily commute of the patient or the nurse. In addition, adverse reactions are more likely to occur during this time, especially the first 2 weeks.3,4
As technology is penetrating every aspect of healthcare and public health, it's also affected how nurses implement DOT for TB treatment. Designed to improve convenience and efficiency, VDOT is part of an initiative for electronic directly observed therapy (eDOT), which has been approved and supported for further study as a valid alternative to DOT by the CDC and the World Health Organization.5 VDOT consists of using video apps such as Skype, FaceTime, Facebook Messenger, or specialized communication apps with video capability so the clinician can remotely observe the patient taking medications in real time at home, at work, or in the field.
Multiple recent small-scale studies have shown greater patient satisfaction and similar adherence and completion rates compared with traditional DOT, giving VDOT a promising start.3,6,7 Several states, including North Carolina, Washington, and Kentucky, are embracing this new option to bolster stretched-thin resources at the local health department level.2,4
In the small-scale studies, DOT was conducted face-to-face, via VDOT, or with an app specifically created for TB medication administration. In all cases, patients had similar outcomes in terms of completion, adherence, adverse reactions, and loss to follow-up.3,6,7
The benefits of eDOT, especially VDOT, are numerous. Patient autonomy and independence are center stage when using apps. Patients don't need to rearrange their lives to meet nurses at the office, in their home, or elsewhere in the community. Parents of children with active TB don't need to stay out of work or even quit their job for the daily visits.7 In addition, patients report fewer confidentiality concerns about the nurse entering the patient's private spaces such as the home or work. With VDOT, the patient sets the time he or she will call in so a nurse can watch him or her take the medication.
Better resource management is another advantage of VDOT. Nurses are in demand everywhere, and public health departments are no exception. Rarely do health departments have a spare nurse. Monitoring medication therapy of several patients can take a nurse out of the clinical setting for hours on end, not to mention the time spent on documentation. In counties with only one nurse for all services, this can be an extreme drain on resources. Having patients call in can save time for the nurse and money for the health department.
According to the studies, VDOT can save more than $1,000 per patient.3,7 Additionally, adherence and completion rates are similar to rates achieved with traditional face-to-face DOT.3,7,8
Finally, use of apps, either via a specialized app or Skype/FaceTime, can increase the patient's access to a nurse as well as enhance monitoring. Customized apps feature information for the patient, such as common adverse reactions from the medication, or questions for the provider to answer before each medication administration. The nurse is alerted to any issues requiring medical follow-up that can be addressed in a timely fashion through making an appointment in the clinic and/or lab for blood work. With Skype, for instance, the patient has the option of texting, which can enhance communication with a nurse. Responding to texts is generally less time-consuming than listening and responding to lengthy voice mails.
Concerns have been raised that patient rapport and trust toward the healthcare provider suffer from the lack of face-to-face interaction.3,6,7 On the contrary, research shows that patients enjoy the added freedom of calling in on their lunch breaks or from across the country while on vacation.3,6,7
Risks and disadvantages
VDOT does raise some issues to be considered before implementation. As Chuck and colleagues pointed out, inability to connect to patients because of transmission problems can be a key issue.3 A missed dose, either through a missed appointment or bad connection, can't be counted toward the patient's completion. If too many missed doses accumulate, the completion time may need to be extended or, in the worst-case scenario, antibiotic resistance may result.3,4 An alternative, such as taking videos via Skype or an app as mentioned above, should be considered to avoid missed doses if reception is poor.
A second issue to consider is how severe adverse reactions will be addressed. If a patient has a life-threatening adverse reaction to medication, such as anaphylaxis, the nurse isn't physically there to intervene. Education about when to call 911 or go to the ED must be part of patient teaching from the beginning of treatment. For safety, patients should be observed with traditional DOT for at least 2 weeks before starting VDOT so clinicians can observe for any immediate adverse reactions.3,4
The risk of violating patient privacy, confidentiality, and the Health Insurance Portability and Accountability Act (HIPAA) is another important concern. For example, it could be a HIPAA violation if someone other than the nurse, provider, or patient sees a recording of the patient taking medication. A phone or other app platform can be stolen, hacked into, or lost. Messages may be sent to the wrong patient.2,4,5,7 To prevent these and other possible breaches of confidentiality, clinicians need to know and follow their employer's policies and procedures for VDOT; these should be as stringent as those for face-to-face interaction. No personal or medical questions should be discussed over the video app, and the patient and nurse should both be in a quiet and private place during VDOT.
Finally, patients need to provide informed consent to participate in VDOT. The patient must understand the advantages and disadvantages of VDOT and inclusion and exclusion criteria for this therapy. The patient also needs to be aware of the consequences of missed calls. Missed calls, hence missed doses, can result in extending treatment, creating antibiotic-resistant strains, the withdrawal of permission from using VDOT instead of traditional DOT, or, in extreme cases, involuntary hospitalization.4 The consent process should also include clear language about the responsibilities of the health department and the patient when interacting over the phone or other media. Policies and procedures should address these points:
- whether the patient will use a personal phone or a device loaned to the patient
- which apps can be chosen from and what security measures need to be implemented (PIN protected, encrypted, and so on)
- what will be done with any recorded media
- what happens if the patient reports adverse reactions
- how follow-up on missed VDOT appointments will be handled
- the option for the patient to withdraw from VDOT and criteria for the patient to be withdrawn from the service.
Over the past several years, VDOT as an alternative to face-to-face DOT for active TB treatment has gained popularity, and the first small studies have demonstrated successful treatment outcomes. While not perfect, it's a viable and cost-effective alternative to traditional DOT.
TB is a serious disease that requires many resources at the local health department level. VDOT may help ease the burden on health departments, clinical staff, and the patients themselves.