Home videophones improve direct observation in tuberculosis treatment: a mixed methods evaluation

Victoria A Wade, Jonathan Karnon, Jaklin A Eliott, Janet E Hiller, Victoria A Wade, Jonathan Karnon, Jaklin A Eliott, Janet E Hiller

Abstract

Background: THE USE OF DIRECT OBSERVATION TO MONITOR TUBERCULOSIS TREATMENT IS CONTROVERSIAL: cost, practical difficulties, and lack of patient acceptability limit effectiveness. Telehealth is a promising alternative delivery method for improving implementation. This study aimed to evaluate the clinical and cost-effectiveness of a telehealth service delivering direct observation, compared to an in-person drive-around service.

Methodology/principal findings: The study was conducted within a community nursing service in South Australia. Telehealth patients received daily video calls at home on a desktop videophone provided by the nursing call center. A retrospective cohort study assessed the effectiveness of the telehealth and traditional forms of observation, defined by the proportion of missed observations recorded in case notes. This data was inputted to a model, estimating the incremental cost-effectiveness ratio (ICER) of telehealth. Semi-structured interviews were conducted with current patients, community nursing and Chest Clinic staff, concerning service acceptability, usability and sustainability. The percentage of missed observations for the telehealth service was 12.1 (n = 58), compared to 31.1 for the in-person service (n = 70). Most of the difference of 18.9% (95% CI: 12.2 - 25.4) was due to fewer pre-arranged absences. The economic analysis calculated the ICER to be AUD$1.32 (95% CI: $0.51 - $2.26) per extra day of successful observation. The video service used less staff time, and became dominant if implemented on a larger scale and/or with decreased technology costs. Qualitative analysis found enabling factors of flexible timing, high patient acceptance, staff efficiency, and Chest Clinic support. Substantial technical problems were manageable, and improved liaison between the nursing service and Chest Clinic was an unexpected side-benefit.

Conclusions/significance: Home video observation is a patient-centered, resource efficient way of delivering direct observation for TB, and is cost-effective when compared with a drive-around service. Future research is recommended to determine applicability and effectiveness in other settings.

Conflict of interest statement

Competing Interests: Victoria Wade declares that she is the unpaid medical director of Design Networks Pty Ltd, a small Adelaide based company that supplied the videophones and network used by RDNS SA to deliver the home videophone service. VW has received reimbursement for conference attendance from Design Networks and Telstra, an Australian telecommunications company. The other authors declare that they have no conflicting interests in the work. This does not alter the authors' adherence to all the PLOS ONE policies on sharing data and materials.

Figures

Figure 1. The workflow of delivering direct…
Figure 1. The workflow of delivering direct observation.
Figure 2. Service comparison cost-effectiveness curve.
Figure 2. Service comparison cost-effectiveness curve.
Figure 3. Videophone service uptake model.
Figure 3. Videophone service uptake model.

References

    1. Snell NJC (1999) Current management of tuberculosis. Exp Opin Pharmacother 1: 31–41.
    1. McDonald PR, Van Helden PD (2009) The global burden of tuberculosis - combating drug resistance in difficult times. New England Journal of Medicine 360: 2393–2395.
    1. Lawn SD, Zumla AI (2011) Tuberculosis. The Lancet 378: 57–72.
    1. World Health Organisation (2009) Global tuberculosis control - epidemiology, strategy, financing. Geneva: World Health Organisation.
    1. Walley JD, Khan MA, Newell JN, Khan HM (2001) Effectiveness of the direct observation component of DOTS for tuberculosis: a randomised controlled trial in Pakistan. The Lancet 357: 664–669.
    1. Lienhardt C, Odgen JA (2004) Tuberculosis control in resource-poor countries: have we reached the limits of the universal paradigm? Trop Med Int Health 9: 833–841.
    1. Volmink J, Garner P (2007) Directly observed therapy for treating tuberculosis. Cochrane Database of Systematic Reviews.
    1. Xu W, Lu W, Zhou Y, Zhu L, Shen H, et al... (2009) Adherence to anti-tuberculosis treatment amoung pulmonary tuberculosis patients: a qualitative and quantitative study. BMC Health Services Research 9.
    1. Zwarenstein M, Shcoerman J, Vundule C, Lombard CJ, Tatley M (1998) Randomised controlled trial of self-supervised and directly observed treatment of tuberculosis. The Lancet 352: 1340–1343.
    1. Malotte CK, Hollingshead JR, Larro M (2001) Incentives vs outreach workers for latent tuberculosis treatment in drug users. Am J Prev Med 20: 103–107.
    1. MacIntyre CR, Goebel K, Brown GV, Skull S, Starr M, et al. (2003) A randomised controlled clinical trial of the efficacy of family-based direct observation of anti-tuberculosis treatment in an urban, developed-country setting. Int J Tuberc Lung Dis 9: 848–854.
    1. Noyes J, Popay J (2007) Directly observed therapy and tuberculosis: how can a systematic review of qualitative research contribute to improving services? A qualitative meta-synthesis. Journal of Advanced Nursing 57: 227–243.
    1. Munro SA, Lewin SA, Smith HJ, Engel ME, Fretheim A, et al. (2007) Patient adherence to tuberculosis treatment: a systematic review of qualitative research. PLoS Med 4: e238.
    1. Moonan PK, Quitugua TN, Pogoda JM, Woo G, Drewyer G, et al. (2011) Does directly observed therapy (DOT) reduce drug resistant tuberculosis? BMC Public Health 11: 19.
    1. Hirsch-Moverman Y, Daftary A, Franks J, Colson PW (2008) Adherence to treatment for latent tuberculosis infection: systematic review of studies in the US and Canada. Int J Tuberc Lung Dis 12: 1235–1254.
    1. Zwarenstein M, Schoeman JH, Vundule C, Lombard CJ, Tatley M (2000) A randomised controlled trial of lay health workers as direct observers for treatment of tuberculosis. Int J Tuberc Lung Dis 4: 550–554.
    1. Khan MA, Walley JD, Witter SN, Imran A, Safdar N (2002) Costs and cost-effectiveness of different DOT strategies for the treatment of tuberculosis in Pakistan. Health Policy Plan 17: 178–186.
    1. Weis SE, Foresman B, Matty KJ, Brown A, Blais FX, et al. (1999) Treatment costs of directly observed therapy and traditional therapy for Mycobacterium tuberculosis: a comparative analysis. Int J Tuberc Lung Dis 3: 976–984.
    1. Mohan CI, Bishai D, Cavalcante S, Chaisson RE (2007) The cost-effectiveness of DOTS in urban Brazil. Int J Tuberc Lung Dis 11: 27–32.
    1. Krueger K, Ruby D, Cooley P, Montoya B, Exarchos A, et al. (2010) Videophone utilization as an alternative to directly observed therapy for tuberculosis. Int J Tuberc Lung Dis 14: 779–781.
    1. Wade V, Izzo J, Hamlyn J (2009) Videophone delivery of medication management in community nursing. e-Journal of Health Informatics 4: e1.
    1. DeMaio J, Schwartz L, Cooley P, Tice A (2001) The application of telemedicine technology to a directly observed therapy program for tuberculosis: a pilot project. Clin Infect Dis 33: 2082–2084.
    1. Hoffman JA, Cunningham JR, Suleh AJ, Sundsmo A, Dekker D, et al. (2010) Mobile direct observation treatment for tuberculosis patients: a technical feasibility pilot using mobile phones in Nairobi, Kenya. Am J Prev Med 39: 78–80.
    1. Tracy J, Rheuban K, Waters RJ, DeVany M, Whitten P (2008) Critical steps to scaling telehealth for national reform. Telemed J E Health 14: 990–994.
    1. Obstfelder A, Engeseth K, Wynn R (2007) Characteristics of successfully implemented telemedical applications. Implementation Science 2.
    1. Grigsby B, Brega AG, Bennett RE, Devore PA, Paulich MJ, et al. (2007) The slow pace of interactive video telemedicine adoption: the perspective of telemedicine program administrators on physician participation. Telemed J E Health 13: 645–656.
    1. Wade V, Littleford A, Kralik D (2011) Home medication management by videophone: translation from pilot project to integrated service. In: Bos L, Goldschmidt L, Verhannenman G, Yogesan K, editors. Handbook of digital homecare: successes and failures. Berlin: Springer-Verlag.
    1. Creswell JR, Plano VL (2007) Designing and conducting mixed methods research. California: Sage.
    1. National Health and Medical Research Council (2007) National statement on ethical conduct in human research. Canberra, ACT.
    1. Diamond A, Sekhon J (2006) Genetic matching for estimating causal effects: a general multivariate matching method for achieving balance in observational studies. UC Berkeley: Institute of Government Studies.
    1. StataCorp (2009) Stata 11 Base Reference Manual vol 1. College Station TX: StataCorp LP.
    1. Microsoft Corporation (2004) Excel 2004 for Mac.
    1. Karnon J, Vanni T (2011) Calibrating models in economic evaluation: a comparison of alternative measures of goodness of fit, parameter search strategies and convergence criteria. Pharmacoeconomics 29: 51–62.
    1. QSR (2009) NVivo 8ed: QSR International.
    1. Braun V, Clarke V (2006) Using thematic analysis in psychology. Qualitative Research in Psychology 3: 77–101.
    1. Harper I (2010) Extreme condition, extreme measures? Compliance, drug resistance, and the control of tuberculosis. Anthropol Med 17: 201–214.
    1. Garner P, Alejandria M, Lansang MA (2006) Is DOTS-plus a feasible and cost-effective strategy? PLoS Med 3: e350.
    1. Frieden TR, Sbarbaro JA (2007) Promoting adherence to tuberculosis: the importance of direct observation. Bulletin of the World Health Organization 85: 407–409.
    1. Rusen ID, Ait-Khaled N, Alarcon E, Billo N, Bissell K, et al. (2007) Cochrane systematic review of directly observed therapy for treating tuberculosis: good analysis of the wrong outcome. Int J Tuberc Lung Dis 11: 120–121.
    1. Marq J, Torfoss T, Getahun H (2007) Patient empowerment in tuberculosis control: reflecting on past documented experiences. Trop Med Int Health 12: 873–885.
    1. Schermer M (2009) Telecare and self-management: opportunity to change the paradigm? J Med Ethics 35: 688–691.
    1. International Telecommunications Union (2011) Measuring the information society: 2011. Geneva: ITU.
    1. Tranter P, Ker I (2007) A wish called $squander: (In)effective speed and effective wellbeing in Australian cities. The State of Australian Cities 2007 National Conference 28–30 November 2007. Adelaide, South Australia.
    1. Fair Work Australia (2011) Nurses (South Australia) Award. Australian Government.
    1. Art and Logic Employee cost calculator. Pasadena, California. Available: . Accessed 6 December 2011.
    1. Australian Taxation Office (2011) Claiming a deduction for car expenses using the cents per kilometre method. Canberra, Australia: Australian Government.
    1. Organisation for Economic Co-operation and Development (2012). Monthly comparative price levels.

Source: PubMed

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