© 2005 American Thoracic Society
And The Beat Goes OnTo the Editor:DOT Works and is Essential DOT Works but is Obtrusive DOT Doesn't Work Ever since the directly observed therapy (DOT) strategy was endorsed by the World Health Organization (1), it has been a beacon of controversy. Even though it is virtually intuitive that administering (the original term, although not immortalized by an acronym, was directly administered therapy) or observing drug taking ensures adherence, it has engendered controversy. The reasons behind the controversy, however, are not considered in Jasmer's analysis (2) or Burman and Reeves' editorial (3) essentially. DOT does not equal DOT, depending on the specific program. Zwarenstein (4), in an article considered the main detractor of DOT, reported 50% compliance with DOT, yet it is widely acknowledged that this was a poor program. Recently, at the New Jersey Medical School National TB Center, we teased out exactly what component of the commonly used activities in TB control was most effective in curing patients (5). Employing a fortuitous stepwise change in program components over time, we showed in successive cohorts of patients using self-administration, self-administration with selective DOT, universal DOT alone, and DOT plus case management that only the addition of case management to DOT raised level of treatment completion and care from 50% to almost 90% (case management is an overarching system merging quality service with accountability for program performance) (6). The key concept is that observing medication taking along with accountability of staff for program components is the successful ingredient. The San Francisco program as described (2) does not just observe patients, but does so in a meaningful, responsible manner (e.g., case management). It is time to ascribe its success to this modality combined with DOT. Simply put, case management is connecting the "dots" of a patient's journey through TB care from many different aspects: child care to social service to transportation and other medical services needed. Enablers and incentives in a program cannot happen by themselves: a responsible, accountable person needs to manage and coordinate these services for the patient.
New Jersey Medical School National Tuberculosis Center, Newark, New Jersey FOOTNOTES Conflict of Interest Statement: L.B.R. does not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript; B.T.M. does not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript. REFERENCES
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
