Elsevier

Clinics in Chest Medicine

Volume 18, Issue 1, 1 March 1997, Pages 135-148
Clinics in Chest Medicine

DIRECTLY OBSERVED THERAPY IN NEW YORK CITY: History, Implementation, Results, and Challenges

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BACKGROUND

In the 1890s, the New York City Department of Health, under the leadership of Hermann Biggs, established what was probably the first modern tuberculosis control program. This program eventually consisted of mandatory reporting, free laboratory services, education, forced isolation for some patients, and, significantly, intensive nursing follow-up of individual patients.2, 13 This nursing follow-up, conducted by the health department as well as the Visiting Nurse Service of New York, emphasized

EARLY REPORTS TO PROVIDE OBSERVED THERAPY

In 1979, the Bureau of Tuberculosis Control received approximately $75,000 from the Centers for Disease Control to initiate a program for a form of directly observed therapy (known as supervised therapy or STP) for patients identified as nonadherent.

The targeted population was homeless individuals, and the early patients lived primarily in the Bowery, one of the city's “skid rows.” These patients were generally older men who were willing to accept an outreach worker coming to their home or a

DIRECTLY OBSERVED THERAPY AS STANDARD OF CARE

To advocate successfully for increased local and national resources, the Department of Health emphasized that, unlike many other health and social problems, tuberculosis could be cured and the epidemic reversed. The Department emphasized completion of treatment in order to reverse the epidemic and established directly observed therapy (DOT) as the standard of care and primary means of increasing the completion rate.

The difficulty that individuals have adhering to many types of medical treatment

INITIATING A LARGE SCALE DOT PROGRAM

Federal, state, and local governments responded to the deteriorating situation by directing monies to improve the local infrastructure for tuberculosis control. The partnership between different levels of government was crucial to helping the New York City Department of Health develop its large-scale DOT program. However, the initiation and implementation of the DOT program entailed a “sea of change,” in attitudes of staff in the Bureau, the medical establishment, public health administrators,

ORGANIZATION OF DIRECTLY OBSERVED THERAPY IN NEW YORK CITY

The organization of DOT services in New York City's Bureau of Tuberculosis Control is somewhat complex. DOT is provided by both Department of Health and non–Department of Health community providers, and patients may receive their medical care from a private doctor, but have their DOT with a Department of Health staff member. The non– Department of Health programs were funded by the New York State Department of Health through an initial start-up grant and are sustained by reimbursement for

COMMISSIONER'S ORDERS FOR DIRECTLY OBSERVED THERAPY AND DETENTION

In April 1993, the New York City Health Code was amended to allow the Commissioner of Health to order patients with proven or suspected tuberculosis to (1) be examined; (2) complete a course of antituberculosis treatment; (3) adhere to a DOT program (Commissioner's Order for DOT; CoDOTs); (4) be detained, if infectious; and (5) be detained, even if no longer infectious, until cure, if necessary, and if all other reasonable alternatives have failed.15

The statute included protection of the

THE SUCCESSFUL DIRECTLY OBSERVED THERAPY WORKER

As already noted, prior to the current expansion, DOT was not a respected assignment. One of our goals has been to elevate the status of DOT workers by recognizing them as the true heroes of modern public health. The culture of our organization now emphasizes respect for these workers' role. The successful DOT worker is one who is able to build a trusting, reliable relationship with his or her patients. Patients often come to depend upon DOT workers as friendly visitors who are available for

DIRECTLY OBSERVED THERAPY PROGRAM DATA

From July 1992 through December 1995, 5693 patients in New York City started DOT (New York City Department of Health, unpublished data, April 1996) (Fig. 2). In the same period, there was an upward trend in the percentage of reported patients with tuberculosis who have ever been on DOT. In 1995, DOT services were provided at 15 sites within the Department of Health (including outreach, clinics, tuberculosis shelter for men, and SROs), and 20 public and private hospitals and clinics (New York

DIRECTLY OBSERVED THERAPY PROGRAM COSTS

Estimating both the costs and the savings from DOT is complicated. If the direct costs of the DOT workers' salaries, patient incentives, and operational support (cars, parking, health and retirement benefits, training time, and so on) are calculated, they total approximately $40,000 per worker and $600 per patient (for incentives). Because a worker can treat about 10 patients at a time, or 25 patients a year (fewer patients with multidrug-resistant tuberculosis), that cost amounts to about $400

DIFFICULT ISSUES OF THE DIRECTLY OBSERVED THERAPY PROGRAM

Despite the success of DOT in New York City, difficult issues must be addressed, and still more difficult issues remain. A critical challenge of the DOT program in the New York City Department of Health has been to standardize patient care at all levels while maintaining flexibility. The most important message has been to instill in Bureau staff that all patients should be treated with respect. Patients with active tuberculosis are regarded as the program's “V.I.Ps.” Second, as previously

CONCLUSION

Virtually all ambulatory trials of antituberculosis medication regimens have used DOT for the entire course of treatment.6, 12, 21 In fact, self-administered ambulatory treatment of tuberculosis can be accurately characterized as experimental, unproven, and potentially dangerous. Nevertheless, it must be recognized that most tuberculosis patients in the world today do not receive DOT. There is a clear rationale for prioritizing provision of DOT— at a minimum, to AFB-smear positive patients

ACKNOWLEDGMENT

The authors would like to thank Sharlette Cook, Frances DeLott, Rose Gasner, Laurie Gulaid, Sheldon Levin, Khin Lay Maw, and Joanne Yarde for providing data. We also would like to extend our appreciation and gratitude to the staff of the Bureau of Tuberculosis Control, especially the DOT workers, for the commitment and dedication that have helped make the program such a success.

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  • Cited by (0)

    Address reprint requests to Paula I. Fujiwara, MD, MPH, Bureau of Tuberculosis Control, 125 Worth Street, Box 74, Room 214, New York, NY 10013

    *

    From the Bureau of Tuberculosis Control, New York City Department of Health, New York, New York (all authors); and the Division of Tuberculosis Elimination, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention (PIF, TRF), Atlanta, Georgia

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