Upload
krisna-yoga
View
7
Download
0
Embed Size (px)
DESCRIPTION
Citation preview
3 6 nursing standard august 2/vol14/no46/2000
art&s c i e n c ere s e a rc hnurs ing standard: clinical · research · education
High incidences of tuberculosis (TB) acro s s
London are posing an increasing public health
hazard, particularly to the vulnerable, socially
excluded and deprived sectors of the popula-
tion. TB rates have doubled in many London
boroughs over the past ten years (Hayward
1998). Non-adherence with therapy is the most
serious remaining problem in the control of TB
and the chief cause of relapse, drug resistance
and further transmission.
The authors were interested in investigating
issues in adherence with TB therapy and the use
of directly observed therapy, which can be a sig-
nificant burden for both the nurse and patient in
terms of time and travel (Ustianowski and Zumla
1998). This article reports on a small investiga-
tion into the current use of directly observed
therapy for patients with TB in London, under-
taken as part of a research secondment. The
investigation revealed that directly o b s e rved therapy
was a strategy that was infrequently used.
TB therapy is a regimen of daily oral medication
taken for at least six months. Adherence with
any treatment regimen is influenced by multiple
factors, including quality of communication
between professionals and patients, patient
knowledge, beliefs, culture and social contexts.
In the US, it has been well documented that at
least 35 per cent of patients – re g a rdless of socio-
economic background, culture, or educational
achievement – ignore their physician’s recom-
mendations on TB therapy (Sbarbaro 1980). A
UK study (Ormerod and Bentley 1997) showed
that 20 per cent of patients did not complete a
recommended regimen and nearly 10 per cent
w e re re c o rded as doubtful adherers. Many studies
have found that alcoholism, drug addition,
homelessness and mental illness correlate signif-
icantly with poor adherence (Evans 1995,
Sumartojo 1993, Weis et al 1994).
Directly observed therapy requires that over a
six-month period, every dose of the drugs be
administered by a supervisor. In the UK, this
needs to be established and monitored by the
TB nurses.
In New York City, directly observed therapy
was implemented in 1992 as part of a control
programme in the face of rising cases and out-
breaks of multiple drug-resistant TB with fatality
rates above 80 per cent. Multiple drug-resistant
TB is defined as resistance to both the mainline
drugs, rifampicin and isoniazid, with or without
resistance to any other anti-TB drug.
Just two years later, the city announced a sub-
stantial decrease in new cases. Epidemiological
p a t t e rns strongly suggest that the decre a s e
resulted primarily because of better rates of
completion of treatment and expanded use of
directly observed therapy. The number of staff in
the TB control programmes increased from 144
to more than 600 and the budget increased fro m
$4 million to more than $40 million between
Promoting adherence
Understanding the issues in non-adherence
I n t r o d u c t i o n
Ann Goodburn RGN, RHV, is TB
Nurse Specialist, Camden and
Islington Community NHS Trust.
Vari Drennan MSc, RGN, RHV,
BSc, is Senior Lecturer in Primary
Care Nursing, Department of
Primary Care and Population
Sciences, Royal Free and UCL
Medical School, London.
The use of dire c t l yo b s e rved therapy in TB: a brief pan-London surv e yGoodburn A, Drennan V (2000) The use of directly observed therapy in TB: a brief p a n - London surv e y. Nursing Standard. 14, 46, 36-38. Date of acceptance: June 27 2000.
Aim The objective of this study was to
investigate issues regarding adherence with
tuberculosis therapy and the use of directly
observed therapy.
Method A small-scale survey of TB nurse
specialists at chest clinics in London was
carried out to determine the current use of
directly observed therapy for patients with
tuberculosis in London.
Results Responses to this survey indicate
that directly observed therapy is currently
used in less than half the available services
in London. Many of the specialist TB nurses
indicated that lack of resources and time
were drawbacks to implementing directly
observed therapy.
Conclusion Directly observed therapy was
found to be a strategy that was infre q u e n t l y
used as a last measure for those people
who were previous non-adherers.
A b s t r a c t
■ Infection contro l
■ Tu b e rc u l o s i s
These key words are based
on the subject headings from
the British Nursing Index. This
article has been subject to
double-blind review.
key words
1988 and 1994. Outreach workers travelled to
patients’ homes and workplaces, as well as to
street corners, parks, and even ‘crack dens’ in
abandoned buildings, to ensure that patients
were appropriately treated.
By the end of 1994, more than 1,200 patients
were receiving directly observed therapy, as
compared with fewer than 50 in 1983, giving an
indication of the scale of investment in the pro-
gramme (Frieden et al 1995). Failure to take
notice of increasing rates of TB and ensure
adequate TB control now could result in major
p roblems and expenditure in the future
( H a y w a rd 1998).
In the UK, where TB is treated by experienced
physicians working closely with TB health visitors
or nurses, directly observed therapy is recom-
mended for patients who are unlikely to adhere
to treatment. These include patients who are
homeless, patients who abuse alcohol or drugs,
drifters, those who are seriously mentally ill,
patients with multiple drug resistance, and those
with a history of non-adherence with anti-TB
medication, either in the past or documented
during treatment monitoring (JTCBTS 1998). It is
also recommended that directly observed therapy
should be considered for new immigrants and
refugees (JTCBTS 1998).
In the UK, Volmink and Garner (1997)
reviewed five trials of strategies to improve
adherence. Interventions examined were:
■ Reminder letters.
■ M o n e t a ry incentives and help from peer
group through community health workers.
■ Health education.
■ Monetary incentives and health education.
■ Intensive supervision by staff.
All of the interventions tested improved adher-
ence. Monetary incentives were the most eff e c t i v e
in promoting adherence (£3 and bus tokens for
a clinic appointment).
Analyses in the US suggest that both selective
and universal directly observed therapy policies
are cost effective when compared with conven-
tional therapy (JTCBTS 1998). There is a need for
research that attempts to define the different
methods used to deliver directly observed therapy
and to determine which are cost effective as
well as acceptable to patients (Sumart o j o
1993). In the UK there have been no published
studies re g a rding the extent to which dire c t l y
o b s e rved therapy is used, the associated costs
or its eff e c t i v e n e s s .
This small survey was undertaken to gain greater
understanding of the use of d i rectly observ e d
t h e r a p y in TB services across London and of how
the TB specialist nurses working in the s e rv i c e s
viewed d i rectly observed therapy. The pan-London
perspective was considered important, because
mobility rates for many vulnerable groups are
high across borough and health authority
boundaries. Questionnaires were distributed to
TB nurse specialists at the 25 listed chest clinics
across London.
The TB specialist nurses reported that d i re c t l y
o b s e rved therapy was being offered by 12 of the
20 services that responded. At these 12 clinics,
the number of patients on directly observed
therapy at the time ranged from three to 14,
with between three and eight the most frequent
number.
The nurses reported on the characteristics of
the patients to whom d i rectly observed therapy
was off e red (Table 1). A history of non-adhere n c e
was the most frequently reported characteristic
in this survey for placing a patient on d i re c t l y
o b s e rved therapy.
Nine of the 12 services had a written protocol.
Five of these were identical – four were from dif-
ferent trusts in the same health authority area.
All indicated that the TB nurse specialists super-
vised directly observed therapy in clinics, but
referred to the possibility of other community
nurses and key workers supervising therapy in
community settings.
The nurses were asked to offer their views on
the benefits and problems of using directly
observed therapy . Most of the respondents (16)
said the benefit of directly observed therapy was
the ability to ensure that a patient has taken his
or her medication.
Five nurses specifically mentioned its role in the
prevention of drug-resistant tuberculosis. Five
also re f e rred to the opportunities dire c t l y
observed therapy gave to support the patient
regarding other issues, such as housing and
Views on using directly observed therapy
Protocols for directly observed therapy
Re s u l t s
The surv e y
august 2/vol14/no46/2000 nursing standard 37
art&s c i e n c ere s e a rc hnursing standard: clinica l · research · education
History of non-adherence on previous treatment 11
Substance abuse 5
Psychiatric disorder 5
Chaotic lifestyle 4
Unable to supervise own therapy 4
or confused by drug regimen
Homeless 3
Drug resistance 3
Table 1. Characteristics of patients given directly observed therapy
social problems, and for health promotion.
Half the nurses said the drawback of directly
observed therapy is that is too time-consuming
for staff and/or patients. Three respondents said
the lack of resources in the service to undertake
directly observed therapy was a clear drawback.
Six respondents commented on negative effects
for the patient, such as creating mistru s t
between the nurse and patient.
Six nurses said that directly observed therapy
created problems for patients because they had
to visit the clinic frequently. Two respondents
were concerned by the likelihood of increased
side effects for the patient on directly observed
therapy when the usual daily medication was
given in larger doses three times a week.
This survey might indicate that directly observed
therapy is currently used in less than half the
services in London. This would support Evans’
(1995) view that there is a lack of coherence or
agreement in the strategy for managing TB in
the UK. Total notifications of people with TB in
London in 1997 were 2,429 (Hayward 1998).
This survey indicates that a small percentage of
these (67 people) are having their therapy
directly observed to ensure it is completed,
while between 20 per cent and 35 per cent
might be having difficulties completing therapy.
Another reason why patients do not adhere to
therapy is that they simply forget.
The patients placed on directly observed therapy
a re those at the extreme end of non-adherence. It
is being used as a last measure for people who
w e re previous non-adherers. However, a number
of the nurses recognise the potentially negative
impact of such a policy for both the patients
and their clinical relationship.
M o re than half of the specialist TB nurses (11)
cited lack of re s o u rces and time as a drawback
to implementing directly observed therapy. It is
well documented that an efficient dire c t l y
o b s e rved therapy programme usually re q u i re s
a substantial financial and technical invest-
ment in TB programmes (Garner and Vo l m i n k
1997). When patients do not comply with
treatment, the responsibility must be in part due
to inadequate programmes (Sumartojo 1993).
Two of the services that responded to the survey
cover the cost of fares for patients who have
their therapy observed. Research has shown
m o n e t a ry incentives, including transport costs, to
be highly effective in pro m o t ing compliance
(Sumartojo 1993, Volmink and Garner 1997).
The protocols demonstrated many similarities,
but also a number of differences. The services
might be assisted by a pan-London template
protocol, amended in the light of local issues.
This might also provide a more unified approach
in supporting those people who move fre q u e n t l y
w i t hin London.
The consequences of patients developing dru g -
resistant bacilli are treatment failure, the added
expense and side effects of treating multiple
drug-resistant TB, and the real possibility of
transmitting multiple dru g - resistant TB to others.
Therapy is re q u i red for a minimum of six months
and parallels can be drawn with the need for
total adherence to antire t roviral therapy for HIV
patients.
TB is a growing problem in London, just as it
was in New York City ten years ago, when the
neglect of TB control led to rapidly escalating
rates of disease, extremely high levels of multiple
drug-resistant TB and the need for massive rein-
vestment to restore control.
In London, available resources for TB preven-
tion and control are focused around the initial
acute care and management of the disease.
There is a legal requirement for notification of
initiation of treatment, but rates of completion
and outcomes of treatment are not routinely
recorded and are unknown. Directly observed
therapy is not widely used in London, is mainly
clinic based and the British Thoracic Society
guidelines (JTCBTS 1998) are far from being
addressed.
Community nurses, care workers, adhere n c e
buddies and family members could have an
i m p o rtant role to play in encouraging adhere n c e
with treatment. There is a range of questions to
be explored re g a rding the variety of possible
methods for helping patients with TB therapy in
the UK
C o n c l u s i o n
D i s c u s s i o n
3 8 nursing standard august 2/vol14/no46/2000
art&s c i e n c ere s e a rc hnursing standard: clinical · research · education
■ To ensure greater control over increasingTB rates, directly observed therapy couldbe introduced more widely
■ Nurses involved in treating patients withTB might have an important role inencouraging adherence with treatment
Implications for practice
REFERENCES Evans MR (1995) Is tuberculosis taken
seriously in the United Kingdom?British Medical Journal. 311, 1483-1485.
Frieden TR et al (1995) Tuberculosis inNew York City: turning the tide. NewEngland Journal of Medicine. 333, 4,229-233.
Garner P, Volmink J (1997) Directlyobserved therapy. Lancet. 350, 666-667.
Hayward A (1998) Tuberculosis Control inLondon: The Need For Change .Report for the Thames RegionalDirectors of Public Health, NHSExecutive.
Joint Tuberculosis Committee of theBritish Thoracic Society (1998) BritishThoracic Society Guidelines. Thorax.53, 7, 536-548.
Ormerod LP, Bentley C (1997) Themanagement of pulmonarytuberculosis notified in England andWales in 1993. Journal of the RoyalCollege of Physicians. 31, 6, 662-665.
Sbarbaro JA (1980) Public health aspectsof tuberculosis: supervision of therapy.Clinics in Chest Medicine. 1, 2,253-263.
S u m a rtojo E (1993) When tuberc u l o s i st reatment fails: a social behaviouralaccount of patient adhere n c e .American Review Respiratory Disease.147, 5, 1311-1320.
Ustianowski A, Zumla A (1998)Tuberculosis: an increasing healthproblem. British Journal ofCommunity Nursing. 3, 6, 303-304.
Volmink J, Garner P (1997) Systematicreview of randomised controlled trialsof strategies to promote adherence totuberculosis treatment. British MedicalJournal. 315, 1403-1406.
Weis SE et al (1994) The effect of directlyobserved therapy on the rates of drugresistance and relapse in tuberculosis.New England Journal of Medicine .330, 17, 1179-1184.