Hospital’s DOT program contributes to TB reduction
Patients are encouraged to come to clinic
When the TB treatment program began at Harlem Hospital in New York City in the early 1990s, the area’s TB cases were the nation’s worst: There were 240 TB cases for every 100,000 people, a rate that equaled the rates of TB in many developing nations. New York City’s rate was about 60 per 100,000 at that time.
Now there are fewer than 40 cases per 100,000 people in Harlem, and New York City’s TB rate is 20 per 100,000.
"I think you could say that New York City was the worst in the country for this explosion of TB cases in the late 1980s and early 1990s," says Paul Colson, PhD, program director of the Charles P. Felton National Tuberculosis Center at Harlem Hospital of Columbia University.
In response to Harlem’s alarming TB epidemic, TB experts and clinicians at Harlem Hospital quickly developed an innovative TB program, using some of the same direct observational therapy (DOT) methods that had been proven successful for TB treatment, but adding elements that would better suit the Harlem community. Since HIV infection, homelessness, substance abuse, and other problems often go hand-in-hand with TB infection, the program was designed to touch on these issues as well, Colson says.
Wafaa El-Sadr, MD, MPH, director of the division of infectious diseases at Harlem Hospital, and medical director of Charles P. Felton National Tuberculosis Center, was the key architect of what has proven to be a highly successful TB program, Colson says. The hospital’s TB program now has a greater than 95% success rate among all patients with active TB, and these include those who are HIV-infected and actively abusing drugs and alcohol, Colson says.
"One of the innovations of El-Sadr’s DOT program is that she thought more broadly about the idea of incentives," Colson says. "A lot of people coming into the DOT program were homeless, substance abusers, loners, and they didn’t seek medical care readily, so she created a group atmosphere in which they could hang out and chat and eat and be reinforced by group activities."
How it works
Here is a brief overview of how the TB program works:
• It’s an on-site clinic. While one of the hallmarks of TB DOT programs has been the outreach work that has made it possible to for homeless people, drug addicts, and others marginalized in society to follow a complicated medication regimen, the Harlem Clinic mostly treats patients who voluntarily appear at the clinic when needed, Colson says. "When we decided in the early 1990s to use DOT for TB, we thought we’d make it as convenient as possible for patients," Colson says.
What investigators discovered was that in Harlem, which is a geographically small community, it wouldn’t be necessary to send outreach workers to park benches and people’s homes, because most of the clients did not work and have plenty of time to make their way to a clinic, he explains. "Scheduling is not a problem in their lives, but they have all these other problems that need to be addressed," Colson says. "So for efficiency’s sake, we decided to have an on-site clinic that they could easily come to, and we’d make it attractive for them to visit." There are always a few clients that outreach workers must visit, but for the most part, the on-site clinic model has worked, he adds.
• Give patients incentives to visit the clinic. Patients were originally given subway/bus tokens and now are given New York City metro cards to pay for their round trip fare to the clinic, and they are given coupons for lunch. But the incentives don’t stop there. The clinic does not have a clinical atmosphere, and when patients arrive they can quickly take their medications and leave, or they may stay around to eat, chat, read wall posters, or talk with a caseworker about any problems they may have. Also, on holidays such as Thanksgiving, the clinic sponsors a dinner so patients can enjoy a big meal with people they’ve gotten to know through the clinic.
Once a year, El-Sadr clinic rents a bus and takes interested patients to the Great Adventure Amusement Park as a reward for adhering to their TB therapy. And when they complete their treatment, they are thrown a party, Colson says. The atmosphere itself is an incentive, as it has comfortable chairs, food, and beverages readily available.
• Paraprofessionals hand out medications. Community health workers give patients the medications, and a nurse is available if they need to see a clinician. Otherwise, patients may attend the clinic each day for a week and never see a physician or nurse. "There’s a de-emphasis on professionals," Colson says. "Patients see a paraprofessional who knows them by the name and who either sees patients every day or twice a week."
The paraprofessionals typically are people who have experienced TB disease or TB infection and who understand the TB patient population, Colson explains. "One peer worker is a guy who had been in treatment for active TB disease," Colson reports. "He had been on the streets for a long time, injecting drugs, and he was brought into the DOT program."
The man initially was uncooperative and wouldn’t show up to take his medications, but the clinic’s staff would go out and find him. "After a while, it dawned on him that these people really cared about him, and they proved it by bringing him in and giving him medicine and food, and he started figuring out that if they cared about him that much then maybe he should care about himself," Colson says.
The man began to adhere to his medication regimen and eventually became a peer worker himself. "The paraprofessionals realize that they’re not officially social workers, but they have the mentality to think about patients’ needs and lives, and they respond to those issues," Colson explains.
When a patient has substance abuse problems or is living in an abusive situation or is homeless, the paraprofessional may request that the patient visit with the clinic’s case worker, who might be able to offer some assistance. "That’s what adherence is all about," he adds. "Our philosophy is that taking pills is only a small piece of adherence because you have to look at what’s going on in a person’s life."
• El-Sadr W, Medard F, Berthaud V, et al. Directly observed therapy for tuberculosis: The Harlem Hospital experience, 1993. Am J Public Health 1996; 86:1,146-1,149.
• El-Sadr W, Medard F, Dickerson M. The Harlem family model: A unique approach to the treatment of tuberculosis. J Public Health Manag Pract 1995; 1:48-51.
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