title: Noncompliance with directly observed therapy for tuberculosis. Epidemiology and effect on the outcome of treatment.
abstract: OBJECTIVE
  To describe the epidemiology and clinical consequences of noncompliance with directly observed therapy (DOT) for treatment of tuberculosis.
  
  
  METHODS
  Retrospective review.
  
  
  METHODS
  An urban tuberculosis control program that emphasizes DOT.
  
  
  METHODS
  All patients treated with outpatient DOT from 1984 to 1994.
  
  
  RESULTS
  We defined noncompliance as follows: (1) missing > or = 2 consecutive weeks of DOT; (2) prolongation of treatment > 30 days due to sporadic missed doses; or (3) incarceration for presenting a threat to public health. Poor outcomes of therapy were defined as a microbiologic or clinical failure of initial therapy, relapse, or death due to tuberculosis. Fifty-two of 294 patients (18%) who received outpatient DOT fulfilled one or more criteria for noncompliance. Using multivariate logistic regression, risk factors for noncompliance were alcohol abuse (odds ratio, 3.0; 95% confidence interval, 1.2 to 7.5; p = 0.02) and homelessness (odds ratio, 3.2; 95% confidence interval, 1.5 to 7.2; p = 0.004). Noncompliant patients had poor outcomes from the initial course of therapy more often than compliant patients: 17 of 52 (32.7%) vs 8 of 242 (3.3%); relative risk was 9.9; 95% confidence interval was 4.5 to 21.7 (p < 0.001).
  
  
  CONCLUSIONS
  In an urban tuberculosis control program, noncompliance with DOT was common and was closely associated with alcoholism and homelessness. Noncompliance was associated with a 10-fold increase in the occurrence of poor outcomes from treatment and accounted for most treatment failures. Innovative programs are needed to deal with alcoholism and homelessness in patients with tuberculosis.
authors.affiliation: Department of Public Health, Danver Health and Hospitals, CO 80204, USA.
authors.forename: W J
authors.initials: WJ
authors.lastname: Burman
authors.forename: D L
authors.initials: DL
authors.lastname: Cohn
authors.forename: C A
authors.initials: CA
authors.lastname: Rietmeijer
authors.forename: F N
authors.initials: FN
authors.lastname: Judson
authors.forename: J A
authors.initials: JA
authors.lastname: Sbarbaro
authors.forename: R R
authors.initials: RR
authors.lastname: Reves
mesh_terms: D000328:Adult; D000437:Alcoholism / Q000453:epidemiology; D000553:Ambulatory Care; D000995:Antitubercular Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D002423:Cause of Death; D003120:Colorado / Q000453:epidemiology; D005260:Female; D006703:Ill-Housed Persons / Q000706:statistics & numerical data; D006801:Humans; D016015:Logistic Models; D008297:Male; D015999:Multivariate Analysis; D010349:Patient Compliance; D012008:Recurrence; D012189:Retrospective Studies; D012307:Risk Factors; D017211:Treatment Failure; D016896:Treatment Outcome; D016312:Treatment Refusal / Q000706:statistics & numerical data*; D014397:Tuberculosis, Pulmonary / Q000188:drug therapy* / Q000453:epidemiology / Q000517:prevention & control; D014504:Urban Health / Q000706:statistics & numerical data
chemical_list: D000995:Antitubercular Agents