title: Implementation of universal directly observed therapy at a New York City hospital and evaluation of an out-patient directly observed therapy program.
abstract: METHODS
  Directly observed therapy (DOT) program for tuberculosis (TB) at a New York City hospital.
  
  
  OBJECTIVE
  To describe a specific TB DOT program model utilizing active prospective identification of inpatients, and identify factors associated with patient acceptance of voluntary DOT and with their retention in therapy.
  
  
  METHODS
  Recruitment for DOT by daily surveillance of in-patients. DOT was offered as the patient's choice together with concrete services and incentives. On-site DOT was offered in an out-patient clinic. Outreach efforts were initiated when a patient missed one or more DOT visit.
  
  
  RESULTS
  During the study period, 95% of 176 in-patients with TB were evaluated for DOT. Of the 137 who were eligible for DOT, 85% (95% confidence interval [CI], 77.5% to 90%) elected to receive DOT. Illicit drug use was independently associated with a higher likelihood of acceptance of DOT (odds ratio[OR], 4.88; 95% CI, 1.5-15.7). Among the 101 patients who received onsite DOT, illicit drug use (OR, 0.21; 95% CI, 0.08-0.6) and previous TB therapy (OR, 0.27; 95% CI, 0.27-0.7) were both independently associated with lower retention in therapy. However, with intensive case management, only 1% of this cohort was lost to follow-up and the overall treatment completion index was 98%.
  
  
  CONCLUSIONS
  In-patient surveillance is a highly effective DOT recruitment strategy. A DOT model which elicits patient participation in discharge plans and offers incentives can yield a high rate of voluntary acceptance. Outpatient case management is a highly effective means of ensuring treatment completion, especially in those at risk for poor retention.
authors.affiliation: Department of Medicine, Beth Israel Medical Center, New York, NY 10003, USA.
authors.forename: N
authors.initials: N
authors.lastname: Salomon
authors.forename: D C
authors.initials: DC
authors.lastname: Perlman
authors.forename: A
authors.initials: A
authors.lastname: Rubenstein
authors.forename: D
authors.initials: D
authors.lastname: Mandelman
authors.forename: F W
authors.initials: FW
authors.lastname: McKinley
authors.forename: S R
authors.initials: SR
authors.lastname: Yancovitz
mesh_terms: D000328:Adult; D000553:Ambulatory Care / Q000379:methods / Q000458:organization & administration / Q000706:statistics & numerical data*; D000995:Antitubercular Agents / Q000627:therapeutic use*; D016001:Confidence Intervals; D005260:Female; D006760:Hospitalization; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009519:New York City / Q000453:epidemiology; D016017:Odds Ratio; D010349:Patient Compliance; D015397:Program Evaluation; D011446:Prospective Studies; D012959:Socioeconomic Factors; D019966:Substance-Related Disorders / Q000150:complications / Q000453:epidemiology; D014376:Tuberculosis / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology
chemical_list: D000995:Antitubercular Agents