Noncompliance with directly observed therapy for tuberculosis. Epidemiology and effect on the outcome of treatment.
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.
Burman
W J
WJ
Department of Public Health, Danver Health and Hospitals, CO 80204, USA.
Cohn
D L
DL
Rietmeijer
C A
CA
Judson
F N
FN
Sbarbaro
J A
JA
Reves
R R
RR
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
D000995:Antitubercular Agents