Directly Observed Therapy And Maximizing Adherence

DOT Presentation / 12/2009

1. Alisha Blair, Nurse Consultant
Heartland National TB Center
December 10
th
, 2009
Directly Observed Therapy
and Maximizing Adherence

2. Objectives
•Define DOT and Explain Why We Use This Method
–DOT Do’s and Don’t
–Advantages and Disadvantages of DOT
•Discuss the Role of the DOT Provider
– Responsibilities
–Expanded Role
•Identify Barriers that make Adherence to DOT Difficult
–Cultural and Social
–Patient
•Adherence
–Discuss Court Ordered Treatment
–Indications
•Review Cases

3. Objectives
•Discuss the Goals of DOT
– incentives and Enablers
–Importance of Treatment Adherence
•Importance and Implications for TB Treatment
Adherence
–Drug Resistance
–Treatment Failure/Relapse
– Reduced Public Health Threat
–Economic Burden
– Impact of Co-Morbid Conditions

4. What is DOT ????
•DOT is an acronym for Directly
Observed Therapy
•It is a strategy devised to
assure TB patients adhere to
and complete treatment
•Observation of Medication
Administration- They swallow,
you watch!

5. Why DOT???
•It’s the most Effective Strategy for ensuring TB Treatment completion
•Reduces risk of developing drug resistance, relapse or reactivation
•Patient becomes non-infectious sooner
•Associated with Better Treatment completion Rates and Outcomes
•It helps solve problems that might interrupt treatment
•Allows the health care worker monitor the patient regularly for side effects
and response to therapy
•2003 CDC/ATS/ISDA Guidelines Standard of Care

6. DOT Is Not!!!
•DOD
–Dropped Off at the Door
•SOT
–Self Observed Therapy
•FOT
–Family Observed Therapy

7. DOT Don’ts
–leaving TB medications with the patient to
self-administer except as prescribed by the
physician for weekends or holidays
–… leaving TB medications at the patient’s
home when the patient is not present
–… dispensing TB medications and “verifying”
ingestion/adherence by performing pill counts
–… permitting medical professionals to self-
administer their TB medications

8. Advantages and Disadvantages of DOT
Advantages
•It ensures that the patient
completes an adequate regimen
•It lets the health care worker
monitor the patient regularly for
side effects and response to
therapy
•It helps the health care worker
solve problems that might
interrupt treatment
•By ensuring the patient takes
every dose of medicine, it helps
the patient become noninfectious
sooner
Disadvantages
•It is time consuming
•It is labor intensive
•It can be insulting to some
patients
•It can imply that the patient is
incapable or irresponsible
•It can be perceived as
demeaning or punitive

9. Who May Provide Dot
•Trained TB Clinic or Health Department staff
–Nurses, outreach workers, other health care providers
•Trained staff of other health care facilities
•Just because they are medical professional does not mean they
are familiar with the principles and requirements for DOT
•Other
•Trained School Nurses, Occupational Health Nurses

10. DOT Worker Responsibilities
•Verify prescribed TB Medication
–Against TB 400 A/B
–Original Orders
•Deliver Medication
•Assess for Drug Toxicity
–Question, Listen, Observe
•Observe Patient Swallowing Medications
•Document Visit
•Report Possible Drug Toxicity or Other Concerns

11. The Expanded Role of The DOT Worker
•Foreign Language Skills
–Many DOT Workers Serve as Interpreters
•Patient Advocate
•Link Between Patient and Other Case Management
Team Members

12. Promoting DOT Adherence
•Treatment of Tuberculosis, American Thoracic Society,
CDC and Infectious Disease Society of America, 2003
–“… any public health program or private provider ( or both)
undertaking to treat a patient with tuberculosis is assuming a
public health function that includes not only prescribing an
appropriate regimen but also ensuring adherence to the regimen
until treatment is completed”

13. Social Barriers that Affect DOT Adherence
•Drug Addictions
–Competing priority of obtaining drugs vs. being available to
receive DOT
•Employment
–Patient may work in another city and can’t make it to the clinic
for DOT
•Mental Illness
–Patient can’t comprehend the disease and the need for
medications
–Denial

14. Knocking Down Social Barriers
•Be Familiar with Alcohol and
drug treatment Centers in your
area
•Call other HD to ask for
assistance with DOT if your
patient is in their area
•Assess for mental health issues
early and give appropriate
referrals

15. Cultural Barriers that Affect DOT Adherence
•Limited or No English
–Trained interpreters should be available
•Ensures patient is receiving the correct information
•Allows patient to communicate accurately with provider
•Immigration Status
–Non-Residents
–Migrant Farm Workers
•Reluctant to undertake activities that might draw attention to
themselves

16. Addressing Cultural Issues
•Be Familiar with Agencies within the
Community that offer Interpreter Services
•Utilize the Language Line
•Assure Patients that No reports from the
clinic will be made to INS
•Be Honest
–Builds Rapport

17. Predicting Adherence
•A Patient’s Adherence with an anti-TB drug Treatment
Regimen is Impossible to Predict
•Adherence is NOT Associated with
–Age
–Sex
–Race
–Education
–Occupation
–Socioeconomic status

18. The Non-Adherent Patient
•Non –Adherence can be caused by
many reasons
•A Patient that is Non-Adherent to
DOT may be….
–Sick for longer Period of Time
–Spread the Disease to Others
–Develop and spread drug-resistant TB

–Die as the result of interrupted treatment

19. Common Causes For Non-Adherence
•Social and Cultural Beliefs
•Competing Priorities
–Education
–Employment
•Patient No Longer Feels Sick
•Mental Capacity
•Lack of Motivation
•Poor Relationships with Healthcare Workers
•Control Issues

20. Tried Everything
•Centers for Disease Control and Prevention
“individuals have the right to ignore a doctor's advice or refuse
treatment if they wish. However, persons with infectious TB may
lose that right if health officials believe these persons risk infecting
others by not taking their prescribed medicine. Patients who are
unwilling or unable to adhere to treatment may be required to do
so by law or may be quarantined or isolated until noninfectious.”
•Health care workers should
• notify the appropriate supervisory clinical and management staff when
patients are non-adherent
•Determine why the patient is non-adherent and begin
strategies that will help the patient finish treatment
before legal measures are taken

21. Quarantine
•When All Else Fails
–TB control programs should not begin procedures for confining
patients to a treatment facility until after the patient has shown that he
or she is unable or unwilling to follow a treatment
•Involuntary confinement or isolation for inpatient treatment
should be viewed as the last resort.
•Criteria for Determining the Need for Involuntary Confinement
–Laboratory results (acid-fast bacilli smears and cultures)
–Clinical signs and symptoms of infectious TB
–An abnormal chest radiograph, especially if cavities are present
–A history of non-adherence (not caused by factors outside patient's
control)
–The opportunity to infect others

22. Case Study 1
You are assigned to deliver DOT to Mrs. Wilson, a 76-
year-old woman who lives alone in the house she and
her husband bought many years ago. Mrs. Wilson was
recently released from the hospital. Upon discharge from
the hospital, she received education about TB and about
the need to take medications until she completes
treatment. She was told that she would be started on
DOT and a health care worker would visit her at her
home to help her take her medication. Mrs. Wilson is
elated to have some company. She happily offers you
cookies and wants to "talk awhile" before she takes her
medication.
•What are the tasks you complete when you deliver DOT
to Mrs. Wilson?

23. Observation
•Check for side effects.
–Before the Medications are Given
– Ask Mrs. Wilson if she is having any problems with the
medications.
–Educate About Symptoms that may Indicated an Adverse
Reaction
–If Adverse Reaction Symptoms are Present, do not give
medications
–Contact the Supervisor
–Arrange and Appointment for the Patient
•Verify the medication.
– Each time DOT is delivered,
– Verify that the Correct Drugs and Dosages are delivered to Mrs.
Wilson
–If this cannot be confirmed, the drugs should not be given.
–Contac the supervisor

24. Administration and Documentation
•Watch Mrs. Wilson take the pills
– Medication should not be left for Mrs. Wilson to take on her own.
–The health care worker or Mrs. Wilson should get a glass of water or
other beverage before she is given the pills.
– The health care worker should watch Mrs. Wilson continuously from the
time each pill is given to the time she swallows it.
•Document the visit
–The health care worker should document each visit with Mrs. Wilson
– Indicate whether or not the medication was given
– Document Follow up plans in meds not given

25. Case Study 2
•Nick is a 27-year-old single unemployed male. He has
been in and out of rehabilitation clinics for crack use. He
picks up odd jobs in the warehouses and diners on the
waterfront. He lives in a single room occupancy hotel.
Four weeks ago he was brought by the police to the
emergency room of General Hospital for treatment of
stab wounds to the right arm resulting from a drug deal
gone bad.

26. Continued….
•Upon admission he was intoxicated, appeared poorly
nourished and underweight, and had a productive cough.
•His smears were positive for AFB and he was started on
appropriate therapy. He remained in the hospital for 5
days.
•Against medical advice, Nick then insisted on leaving the
hospital. On the day of discharge, the infection control
nurse telephoned a report to the health department, and
instructed Nick to go to the health department the next
morning for evaluation and a supply of medicine.

27. Non-Adherent Nick
•He failed to keep his appointment. The next week a
health care worker was assigned to locate Nick and
persuade him to come to the clinic. The health care
worker found him lying on a park bench near the hotel
where he lives. The health care worker convinced Nick to
go to the clinic for follow-up tests. At the clinic, Nick
reluctantly agrees to take his medication, although he
does not want DOT. He says he is not a "baby" and can
take the medication on his own.
•How would the health care worker help Nick adhere to
his treatment regimen?
•What can the health care worker say about DOT to
convince Nick of its importance

28. Assessment and Education
• It is important that we ask Nick what he believes about
TB disease and treatment
– Nick doesn't seem to understand the importance of finishing
treatment. Therefore, adherence may be very difficult.
• Educate Nick about TB and its treatment
– As part of patient education, Nick should be told that some
people have trouble staying on the medication schedule
–Help Nick find ways to identify and deal with potential adherence
problems.
•Nick is more likely to be adherent if he helps make the
decisions and chooses the solutions
•Nick may be more likely to follow the treatment plan if he
understands his illness and the benefits of treatment.
•Offer Incentives and/or Enablers to help Nick Adhere to
Treatment.

29. Patient Education and Rapport Building
•Explain the benefits of DOT to Nick and to stress
the fact that DOT is not punitive.
•Explain that DOT is more than watching Nick
swallow each pill.
•DOT Will
–Help him keep appointments
–Provide education when needed
•Point out that DOT will help the health care
worker monitor Nick for any side effects and help
him complete an adequate regimen

30. The Goal of DOT
•To Ensure that Clients with Active
Tuberculosis receive and
Adequately Complete their
Treatment
•Minimize the Risk of Spreading the
Disease to Others
•Reduce the Risk of Developing
Drug-resistant TB

31. Ensure Clients Receive and Complete
Adequate Treatment
•Ensure Clients are Receiving the Correct Doses of
Medication
–Monitor weight as doses are calculated according to body weight
–Incorrect Doses May not be Effective
•Ensure the Client Swallows the Medication
•Follow up on Missed DOT Appointments
–Early detection of adherence problems
•Monitor Adverse Reactions
•Perform Dose Counts Monthly
–Helps Determine Therapy Completion date and gives
information about adherence

32. DOT and Infection Control
•DOT ensures clients are
receiving medications
and these patients
become non-infectious
sooner
–Reduces the Risk of Infecting
Others
•DOT Allows the DOT
worker to observe client
and ensure adherence to
infection control
measures

33. Reduce the Risk for
Acquiring Drug Resistance
•Provide medications as ordered
•Do not allow family members to provide medications
•Encourage Clients to Report Side Effects or Adverse
Reactions Immediately
–Side effects can discourage a client from being compliant with
treatment
•Always Observe the Client Swallowing the Medication
–Do not leave medication at the client’s door step
–DOT is not a drop off service

34. Accomplishing the Goal
with Non-Adherent Patients
•Incentives
– Rewards for desired behavior
•Enablers
–Remove barriers from willing but unable patients
•Both must be tailored to the individual!
BRIBARY DOES WORK!!

35. Offer Incentives
•Interventions to motivate
the patient, tailored to the
patient wishes and needs
–Incentives work for both
young and old
– Food, Snacks, Gift Cards,
Bus Passes, Clothing

36. Identify Enablers
•Interventions that Assist the patient complete Therapy
–Child Care
–Adjustment of Clinic Hours
–Appointment Reminders
–Appropriate Referrals
–Clinic Personnel who speak the languages of the populations
served
•Remember Both Incentives and Enablers must be
Tailored to the Patient in Order to be Effective

37. Importance and Implications
of Treatment Adherence
•Reduces the Risk of Developing Drug Resistance
–Sporadic Treatment coupled with non-compliance fosters Drug
Resistant TB
•Reduces the risk of Treatment Failure and Relapse
–DOT and proper treatment adherence is associated with fewer
rates of relapse and/or reactivation
–DOT allows the identification of problems early
•Reduces the threat to Public Health
–Person adherent to DOT are usually infectious for shorter
periods of time

38. Improved Health and Outcomes and
Reduced Economic Impact
•No Quarantine
–Adherence daunts the need for Court-Ordered Treatment
Management
•Improves Individual Health Outcomes
–Patient Health Improves and the patient Feels better earlier
•Reduces the Economic Impact
–DOT and the adherence to DOT reduces the cost of treating TB
–Drug Sensitive TB can be treated intermittently by DOT which is
cost effective

39. Impact of Co-Morbidities
•Reduces the impact of co-morbidities i.e. surgical
Interventions and Hospitalization
–DOT benefits the patient not only from a TB Treatment
Standpoint but it also allows the Case Management team to
ensure co-morbid conditions are not exacerbated by
Tuberculosis
– DOT ensures patients are receiving medications and these
patients tend to feel better sooner, negating the need for ED
visits for exacerbation of the disease and possible surgical
intervention

40. Pulling It All Together
•DOT
–strategy devised to assure TB patients adhere to and complete
treatment
–Observation of Medication Administration- They swallow, you watch!
–DOT is not a Milk Man service so medication should not be dropped of
at the door step
•Why DOT
–It’s the most Effective Strategy for ensuring TB Treatment completion
–Reduces risk of developing drug resistance, relapse or reactivation

41. Pulling It All Together
•The Role of the DOT Provider
–The DOT provider should assess the patient, administer and
supervise medication swallowing and document
–Deliver medications as scheduled and report adverse reactions
immediately
•Dot Providers
–Trained TB Clinic or Health Department staff
•Promoting Adherence
–There are many barriers that patients face that foster Non-
adherence to DOT and anti-TB treatment
•Social
•Cultural
–Identify these factors and offer incentives and/or enablers to maximize
treatment adherence

42. Pulling It All Together
•No way to predict adherence
–However assess patient’s current situation to determine possible
problems that may hinder adherence
–Assessment should be ongoing throughout treatment
•Court Ordered Treatment
–After all else fails consideration for court ordered management should
be the last resort
•Criteria for Determining the Need for Court Ordered
Confinement
–Laboratory results (acid-fast bacilli smears and cultures)
–Clinical signs and symptoms of infectious TB
–An abnormal chest radiograph, especially if cavities are present
–A history of non-adherence (not caused by factors outside
patient's control)
–The opportunity to infect others

43. Pulling It Together
•Incentives and Enablers
–Movie Tickets, Food Coupons, Gift cards, Bus Passes
–Motivation to complete treatment
–Tailor to Patient’s Needs
•Importance of DOT and Adherence to Treatment
–Reduces the Risk of Treatment Failure
–Reduces the rate of Relapse/Reactivation
–Lowers Economic Burden
–Reduces Complications from Co-Morbid Conditions

44. “DOT succeeds for one reason … DOT
makes the health care system, not the
patient, responsible for achieving a cure”

45. Special Thanks
Dawn Farrell, RN, San Antonio
Jane Moore, RN, Wisconsin