Making DOT state law helps Colorado hold line

When caseloads heat up, statute serves as firewall

Directly observed therapy (DOT) has been the law of the land in Colorado since 1998. In the two years since the statute was quietly placed on the books — with scarcely any fanfare, according to TB experts in the state — it’s had surprisingly little impact on private-sector practices. That’s because even though about half of the TB cases in the state are managed by private providers, community physicians were already in the habit of referring patients to public-health clinics for the DOT part of their treatment by the time the law was passed, says Ellen Mangione, MD, MPH, director of the state’s division of infectious diseases.

What the statute has done is help hold the line in the public health sector, Mangione says. "Sometimes our public health nurses get to feeling a bit overwhelmed, and that’s when this statute helps to hold them to the [DOT] standard. You could say it’s been helping us to maintain."

At the same time, state TB experts agree the statute has probably helped strengthen existing links between the private and public sectors.

"With this statute, we’re not trying to tell private providers they can’t treat their own patients," says Richard Hoffman, MD, medical adviser to the state TB control program. "We just wanted to send the message that if you couldn’t provide DOT yourself, you could turn to the public sector to provide it, or else you’d have to get an exemption." Hoffman has granted just one exemption, for extra-pulmonary TB, since the regulation went into effect.

Law meant to strengthen private/public links

Mangione agrees that the relationship between the private and public sectors here is a congenial one. "We see TB care as very much a partnership," she says. "We try very hard to hook folks up to a private physician in their community and keep them hooked up. The private physicians are the ones who provide follow-up, and they’re also able to give a level of care you just can’t expect from the public sector."

Once a private physician takes on management of a TB case, the public sector, along with providing DOT, functions mostly as a support system, she adds. "We fill the prescriptions for the medications. We make sure the patient comes in for repeat chest X-rays. And we assist with referrals if the patient gets into trouble. It’s really a division of labor."

In Alabama, where DOT is the standard of care (as it is in Mississippi and South Carolina), TB experts say they’d love to have a law like the one in Colorado. "Even though we start 98% of our cases on DOT, there are still some private physicians around who don’t think it’s really necessary," says Nancy Brook, MPH, the state’s TB program manager. "It would be really interesting to see what impact such a law would have on the medical community here."

According to Mangione’s records, rates of DOT in Colorado continued a steady climb once the 1998 statute was passed, evidently without much help from the new law. In 1993, DOT rates stood at 53% of all patients with pulmonary TB; by 1996, that rate was up to 74%; and by 1998, 93%.

Here’s where the statute has really helped. Even though case totals have held fairly steady, the complexity of some cases has increased as more cases involving drug-resistant strains have begun to appear, says Mangione. That means overworked public-health nurses may be occasionally tempted to slack off on DOT.

"In 1998, 18% of our cases involved resistance," mostly among foreign-born residents from Eastern Europe, she says. "Those cases are often more complicated and more time-consuming."

In addition, an increasing number of foreign-born cases arrive with no private insurance, which means the public health sector can’t subcontract out DOT duties (to a visiting nurses’ association or the like) when things get especially busy.

Under ordinary circumstances, public health nurses might be forgiven for letting some patients just come in once a month and pick up their pills. With the statute to back them up, says Mangione, "We tell them,’Sorry, you can’t do that — it’s the law.’"