A Promising HIP Intervention — Electronic Directly Observed Therapy for Active TB Disease

Tuberculosis overview

Tuberculosis (TB) is the leading cause of infectious disease death worldwide. The TB bacterium is spread when a person with TB disease of the lungs or throat coughs. In 2022, a total of 8,331 persons received a diagnosis for TB disease in the United States1.

Most TB disease can be treated by taking certain medications for 6 or more months. To be effective, patients must maintain and complete medication and treatment regimens.

Directly Observed Therapy (DOT) and Electronic Directly Observed Therapy (eDOT)

Directly observed therapy (DOT) is a key element of TB case management. DOT entails a trained observer watching the patient swallow anti-TB medications.

A majority of the population owns a mobile phone, computer, or tablet, allowing DOT to be done electronically.23 One form of electronic DOT (eDOT) allows a member of the health care team to watch the patient swallow the anti-TB medications. They can do this via live or real-time video, or a recorded video submitted for later review.

Multiple studies have shown that eDOT is effective and acceptable to patients. These studies also identified potential cost savings from reduced staff time and travel expenditures for patients and medical staff.456789101112131415 They also found that regularly attending scheduled sessions and treatment completion with eDOT has been comparable with in-person DOT.

A study from New York City watched 61 patients on eDot and 329 on in-person DOT. It found:

• Patients maintained 95% of eDOT and 91% of in-person DOT scheduled sessions
• Treatment completion was similar (96% eDOT and 97% DOT)
• Money saved (2016 USD) from eDOT treatment ranged from $1,8111016 to $14,355 per patient.1416

Selected pilots and small case studies with cost data regarding eDOT

Suburban Illinois Pilot14

Summary: The DuPage County Health Department, Illinois, piloted an eDOT program from January 2013 to December 2014. The program enrolled 11 patients with active TB (non-multidrug resistant TB) and likely to have high adherence (i.e., stable housing).

• 9 patients used smartphones
• 2 patients used personal computers

Results: Patients received 1,083 eDOT doses with a 97% adherence rate. The eDOT program saved:

• An average of 9,499 travel miles
• 579 hours in staff time
• $144,750 and $13,159 in travel miles/expenses16

Urban Washington State/Seattle-Tacoma Metropolitan Area Pilot15

Summary: From 2002 to 2006, two local health jurisdictions in Pierce and Snohomish Counties, Washington, conducted a retrospective chart review of 57 patients with TB disease who used videophones for medication monitoring.

Results: Medication adherence was documented 95.6% of the time. The average patient in eDOT saved $2,449 in travel expenses compared to in-person DOT patients.5

Medical staff saved:

• $139,576 in staff salaries, benefits, and travel costs (2016 USD)16
• 2,994 hours of travel time
• 103,632 miles in travel

Recent studies of eDOT

An economic evaluation assessed health department and patient costs for eDOT and in-person DOT in low-, medium- and high-TB incidence settings in the United States. Among the different DOT types, both types of video DOT (live, recorded) were associated with lower patient and health department costs when compared with traditional forms of DOT. By setting, the cost of recorded eDOT was significantly lower than cost of community-based DOT in medium- and high-incidence settings. However, the cost of recorded eDOT was not too different from the community DOT in low-incidence settings. This finding demonstrates an economy of scale - when there are fewer patients to spread fixed costs, the cost per dose is higher. 17

The study found:

• 89.8% of doses were completed with eDOT compared to 87.2% of doses with in-person DOT.
• Issues affecting medication observation (scheduling issues, operating software, etc) was highest for community-based in-person DOT observations (19%), followed by live-video eDOT (10%), recorded-video eDOT (8%), and clinic-based in-person DOT (6%).
• 84% of patients preferred continuing treatment with eDOT. 18

Both types of eDOT were significantly lower than in-person DOT for medium- and high-incidence settings.

However, the cost of video DOT with recorded videos was not too different from community DOT in low-incident settings. This finding shows an economy of scale where if there are fewer patients to spread fixed costs, the cost per dose is higher.

An eDOT resource

As of 2015, 42% of TB programs surveyed used eDOT in some form with 36% planning to begin it in the next year.9

To support TB programs, CDC published a resource for programs considering an eDOT program. The toolkit, called "Implementing an Electronic Directly Observed Therapy (eDOT) Program: A Toolkit for Tuberculosis (TB) Programs," looks at the benefits and drawbacks of eDOT. It will help programs gain insights related to management and regulation concerns and how to use available resources.