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.
Highlights
The treatment of tuberculosis (TB) requires patients to take multiple antibiotics for a minimum of six months; if medication is taken correctly and completely, success rates for both active and latent TB approach 100% [1]
A Cochrane review containing 11 randomized controlled trials (RCTs) concluded that there was no significant difference in TB cure rates between direct observation and self administration of medication, and recommended that funding spent on direct observation would be better directed to other aspects of TB control [7]
The uptake of direct observation in South Australia is shown in Table 2, which combines the Royal District Nursing Service of South Australia (RDNS SA) data with the Chest Clinic data from 2006
Summary
The treatment of tuberculosis (TB) requires patients to take multiple antibiotics for a minimum of six months; if medication is taken correctly and completely, success rates for both active and latent TB approach 100% [1]. The direct observation of patients with TB taking their medication is intended to improve adherence, and is recommended by the World Health Organization (WHO) as part of standardized short-course chemotherapy [4]. Only one of these RCTs achieved the WHO treatment target of 85% success rate, indicating poor adherence was an issue in all countries. The use of direct observation to monitor tuberculosis treatment is controversial: cost, practical difficulties, and lack of patient acceptability limit effectiveness. 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
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