Direct Observation of TB Treatment at Health Centers May Be Counterproductive

Researchers in the United Kingdom and Pakistan argue that the World Health Organization's (WHO) recommended guidelines for directly observed therapy for tuberculosis may not represent the best treatment option.

Dr. Muhammad Amir Khan and colleagues at the Association for Social Development and the United States Agency for International Development (USAID) office in Islamabad and the Universities of Leeds and York in the United Kingdom conducted a study to "establish the costs and effectiveness of different strategies for implementing directly observed treatment (DOT) for tuberculosis." Directly observed therapy at health centers was the least cost-effective of the DOTS strategies studied, with no significant gain in treatment efficacy, Khan and coauthors found.

The researchers compared the cost-effectiveness of DOT by health care providers with that of DOT by family members and with non-observed therapy. DOT by health care providers included treatment directly observed at health centers and by ambulatory community health workers, they noted.

Despite its recommendation by both WHO and the International Union Against Tuberculosis and Lung Disease, DOT at health centers failed to provide significantly higher cure rates than other forms of directly observed therapy while carrying the highest cost -- $310 for each patient cured. DOT overseen by community workers had the highest cure rate at 67 percent, at a cost of only $172 per cure, study data showed.

One factor contributing to surprisingly low cure rates in DOT patients at health centers -- 58 percent during the first two months of therapy -- was the need to take time off of work for treatment, which reduced patient participation ("Costs and Cost-Effectiveness of Different DOT Strategies for the Treatment of Tuberculosis in Pakistan," Health Policy and Planning, June 2002; 17(2):178-186).

"The community health worker subgroup achieved the highest cure rates (67 percent), with a cost per case only slightly higher than the self-administered group," Khan and colleagues concluded. "This approach should be investigated further, along with other approaches to improving patient compliance."

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