Weighing the pieces of a good program
October 1, 2002 4 minutes read
Study: Accountability equals DOT in importance
Of all the parts and pieces that go into making a good TB control program, it’s often asserted that directly observed therapy (DOT) is the most important. But according to a recently published study from the Newark-based New Jersey Medical School’s National Tuberculosis Center, accountability is no less important, and can substantially increases a program’s success when added to DOT.1
"There are many important components of TB treatment, not just DOT alone," says Bonita Mangura, MD, lead author of the study and director of clinical studies at the Tuberculosis Center. "But until we did our analysis, there had been no studies that tried to measure the impact of each component. Without accountability for completion of treatment, patients invariably fall through the cracks."
If that seems obvious, well, that’s just the point, says Mangura, which all good programs must somehow manage to incorporate accountability, whether or not they explicitly acknowledge doing so. Likewise, a lack of accountability might explain why some programs that incorporate DOT are still getting poor results, she adds.
Measuring the separate impacts of DOT and accountability, though, hadn’t been done before, bit was possible because of the way the National Tuberculosis Program’s Lattimore Clinic added the two elements over a period of time.
A series of reforms
Back in early 1994, in what served as the baseline cohort in the study’s retrospective analysis, the majority of patients at the TB Center’s Lattimore Clinic were still self-administering their medications, with DOT reserved for a selected few. In mid-1994, the clinic implemented universal DOT.
The following year, the decision was made to assign responsibility for each patient outcome to a single registered nurse. That left one more problem — patient care delivery at the clinic was fragmented, with outreach workers reporting to one set of bosses, and clinic nurses to another. The two programs were then integrated, making it possible to convene multidisciplinary teams that could hash out problems that arose during the course of a patient’s treatment. That package of reforms became known as nurse case management.
The study set out to measure the impact of the sequence of the series of changes, by looking back at treatment outcomes of 343 patients at the clinic, divided into six cohorts, who were treated between the start of 1994 and the end of 1996.
What researchers found was that adding universal DOT raised the proportion of patients completing treatment adequately from 57% to 69%. ("Adequate treatment" was defined as getting a certain number of doses into a patient within a certain length of time, which varied according to the type of TB disease. For pan-sensitive disease, for example, completing 180 doses within a year was deemed adequate.)
When nurse case management and systems integration were added on top of DOT, the percent of patients completing adequate treatment rose to 81%. Adequate treatment levels stayed high (at 86%, 81%, and 81%, respectively) in successive cohorts using the same mix of DOT and nurse-case management.
A system everyone liked better
The 1995 reforms — systems integration and assignment of accountability — both made a huge impact on morale and patient care, recalls Karen Galanowsky, RN, BSN, MPH, nurse consultant in the TB program at the New Jersey Department of Health and Senior Services. Before, "we had a clinic on one side run by the nurses, and on the other side, we had TB program outreach workers," she says. The outreach workers "would bring a patient into the clinic, but there wouldn’t be a doctor, and the patient would have a fit."
Of course, the clinic nurses could have done other things — take a history, collect sputum, do education or blood work — but they wouldn’t, because it wasn’t their job, she recalls. The other problem was that everyone involved, from physicians to nurses to outreach staff, had their own incomplete picture of the patient, she adds.
With the advent of nurse case management, all that changed, Galanowsky says. "Patients loved it — they knew they were part of a team, and they knew who their case manager was," she says. Nurses liked it, too, because at last they knew exactly what they were supposed to be doing." In team meetings, she adds, "everything comes into focus. Problems get solved, and plans gel."
Instituting accountability ends troubles such as those Galanowsky encountered recently in an outlying county, where two public health nurses had decided to split one patient’s DOT, and ended up getting only half the necessary doses into the man. But in the New Jersey model, accountability means more than saying where the buck stops: "It’s about defining the nurse’s role and laying out exactly what the nurse is supposed to be doing," she says.
Because it puts so much responsibility on the registered nurse, the system is not for anyone who is less than passionate about their calling, she adds. After she recently finished writing a self-study module detailing the myriad duties of the nurse case manager, Galanowsky says she looked back over the material and thought: "Wow, maybe the next chapter should be called, How the nurse walks on water.’"
Reference
1. Mangura B, et al. Directly observed therapy (DOT) is not the entire answer: An operational cohort analysis. Int J Tuberc Lung Dis 2002; 6:1-8.
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