Improving compliance by Gabit Ismailov

Previous presentations highlighted the scope of problem caused by the drug-resistant tuberculosis. Cases of multidrug-resistant tuberculosis were reported in over 100 countries. In most circumstances, they are results of incomplete and inadequate chemotherapy. Non-compliance remains one of the most serious problems of tuberculosis. It is the major cause of the emerged drug-resistant stains of mycobacterium.

Today I would like to talk more about the problem of non-compliance or poor compliance caused by the patients themselves. I would like to illuminate the number of approaches that were introduced all over the world and their outcomes. Non-compliance caused by insufficient provision or irrational administration of medications is out of scope of today’s discussion mainly because reasons for that are no longer technical, but political and economic.

First of all, what is meant by compliance? In simple terms, compliance to treatment in medicine can be described as an adherence of patient to the prescribed treatment. Compliance can also be defined as the extent to which a patient's behaviour coincides with medical advice. For a number of reasons not all patients behaviour coincides with medical advice. Sometimes they forget to take their medications or chose not to take it, or they can merely not afford them. Patient with tuberculosis might miss one dose of medications and it is unlikely to have any negative consequence. This is not true with a number of other medications, e.g. oral contraceptives. The question is how much non-compliance is acceptable in case of tuberculosis. The WHO defines an interrupted treatment (defaulted) patient as the one who did not collect drugs for 2 months or more at any time after registration.

Secondly, what determines compliance and what makes patient take the drug for a long period? One study of 500 Hondurans tried to disclose the factors that affect patient’s compliance and they’ve discovered that "three socio-economic variables, i.e. the monthly income per capita in a family, the type of house in which the family lived, and the monthly family income" were the major determinants of adherence to the treatment.

Thirdly, how bad is the situation with non-compliance? It varies from country to country. For example, treatment completion rates among cases with active tuberculosis at Harlem hospital used to be as low as 11% before introduction of DOTS. The latest WHO report indicates that in 1997 the average default rate among smear positive cases in 22 high-burden countries under DOTS strategy was 6.4% and 5.3% among non-DOTS cases. Both rates seem to be very low but they might be misleading because of the definition of default. Treatment success rate can be a better indirect indicator of compliance. The global DOTS treatment success rate was 78.3% and only 52.8% for non-DOTS. 8 Other estimates indicate that up to 50% of TB patients do not complete their treatment within 24 months.

What can be done in order to improve patient’s compliance? Over the past decades of the antibiotic era, international medical community accumulated an enormous experience in this field. Problem of poor compliance exists not only in the field of tuberculosis management but also in many other areas of clinical medicine, such as endocrinology (e.g. diabetes), nephrology (e.g. patients on dialysis), etc. We can and we should learn from the experience of related fields in order to achieve our common goal of a better health care. However, there is one significant difference in treatment attitudes of TB patients unlike other patients. That is patients with tuberculosis have to continue their treatment even when they start feeling much better after initiation of chemotherapy whereas patients with many other conditions do not usually have such problem.

  1. Treatment under direct supervision (DOTS) eliminates an element of "forgetfulness" and minimises the risk of developing drug-resistance. Number of studies has shown the beneficial effect of DOTS, its cost-effectiveness and simplicity,. Under certain circumstances DOTS may not be the best solution, e.g. patients living in a very remote and secluded areas. The latest WHO report for the year 1998 tells us that only 43% of the global population had access to DOTS, which is double the rate in 1995.
  2. Provision of basic living essentials. It seems absolutely clear that no long-term treatment success is feasible without provision of patient’s basic living requirements. Mere medications cannot and will not resolve the problem. Living essentials such as decent nutrition and accommodation are the major determinants of good compliance and treatment success. This is especially important in case of nomads. For example, in Somalia there is an experience of community involvement in tuberculosis care, when patient’s family builds a hut in a special treatment settlement. During the course of treatment patient also attends literacy and other classes. The important part is that there is a guarantor responsible for patient’s adherence to treatment.
  3. Patient and public education. For example, lack of injectable medications in a standard regimen may be perceived by some patients as a wrong treatment hence leading to their treatment default. Very often, I was confronted by patients demanding changes in their treatment regimens merely because in their opinion oral medications were not "strong" enough to cure them. On the other hand, there is evidence that patient’s perception of illness is not a necessary determinant of compliance outcome. In Haiti, a Proje Veye Sante study found no significant correlation between patient’s understanding of aetiology of tuberculosis and adherence to their treatment.

    4. One study in Spain found that patient alternative health education had positive effect on the overall compliance. The interesting part about that study is that it discovered that nurse’s home visits were more effective than telephone calls and appointments with physician.

  4. Incentives
    1. Financial
      1. Patient
bulletA $5 biweekly cash incentive improved adherence to tuberculosis preventive therapy among homeless in San Francisco compared with a peer intervention or usual care..
bulletIn Haiti, the Proje Veye Sante project showed that financial aid was the most significant determinant of patient’s adherence to the treatment.3
bulletOne analytical study in the UK has summarised that incentives can be cost effective, particularly for treatment of infectious disease
      1. Healthcare provider. Provision of financial incentives for health workers may give a better outcome than any other method of compliance improvement. This is especially true under the circumstances of low existing financial benefits for health workers. For example, in Kazakstan health workers were not paid for months and had to care for patients. In this situation, financial incentives for patients alone would be insane. From my point of view, priority should be given to healthcare providers.
    1. Non-financial
      1. Social power. Motivation, support and encouragement given by health workers, relatives and public can have a significant impact on the treatment outcome.
      2. Use of "psychological profile". In one study, patients were interviewed for 15 minutes in order to determine details of their daily lives, identify their "daily rituals". Then intake of their medications was associated with a particular routine even. During the follow-up visits health worker had a 5-minute discussion about the pattern of drug intake. Mean overall compliance was significantly higher for the intervention group.
      3. Simple reminders, e.g. reminder cards were found to have a valuable influence on treatment outcomes.
      4. Health care providers. In one study in Korea, health worker motivation was intensified through special regular sessions and closer supervision. Treatment performance was remarkably improved in comparison to control group.
  1. "Punishment"
    1. Psychological punishment. One study in a paediatric outpatient clinic for behaviourally disturbed children had a significant success with intervention that parent were told that if they miss three appointments their child would be assigned to the bottom of the waiting list.
    2. Obligatory treatment in specialised medical institutions is legal in a number of countries (e.g. Kazakstan). Do you think that it is ethically acceptable?

 

*One should assume that constant drug supply is assured.

Conclusions:

bulletNon-compliance in treatment of tuberculosis is a serious problem worldwide;
bulletNon-compliance is a major contributor to the world spread of MDR-TB;
bulletIf not dealt with now it will increased treatment costs in future;
bulletFinancial incentives can improve compliance;
bulletThere is plenty of room for alternative non-financial incentives as long as they are successful;
bulletPublic health education is important;
bulletMedical ethical issues in treatment of tuberculosis remain open for discussion;

 

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