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Noncompliance With Directly Observed Therapy for Tuberculosis : Epidemiology and Effect on the Outcome of Treatment FREE TO VIEW

William J. Burman; David L. Cohn; Cornelis A. Rietmeijer; Franklyn N. Judson; John A. Sbarbaro; Randall R. Reves
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Affiliations: From the Department of Public Health, Denver Health and Hospitals; and the Department of Medicine, Division of Infectious Diseases, University of Colorado Health Sciences Center, Denver,  From the Department of Public Health, Denver Health and Hospitals; and the Departments of Preventive Medicine and Biometrics, University of Colorado Health Sciences Center, Denver,  From the Department of Public Health, Denver Health and Hospitals; and the Department of Medicine, Division of Infectious Diseases; and the Departments of Preventive Medicine and Biometrics, University of Colorado Health Sciences Center, Denver,  From the Departments of General Internal Medicine, and Preventive Medicine and Biometrics, University of Colorado Health Sciences Center, Denver

Affiliations: From the Department of Public Health, Denver Health and Hospitals; and the Department of Medicine, Division of Infectious Diseases, University of Colorado Health Sciences Center, Denver,  From the Department of Public Health, Denver Health and Hospitals; and the Departments of Preventive Medicine and Biometrics, University of Colorado Health Sciences Center, Denver,  From the Department of Public Health, Denver Health and Hospitals; and the Department of Medicine, Division of Infectious Diseases; and the Departments of Preventive Medicine and Biometrics, University of Colorado Health Sciences Center, Denver,  From the Departments of General Internal Medicine, and Preventive Medicine and Biometrics, University of Colorado Health Sciences Center, Denver

Affiliations: From the Department of Public Health, Denver Health and Hospitals; and the Department of Medicine, Division of Infectious Diseases, University of Colorado Health Sciences Center, Denver,  From the Department of Public Health, Denver Health and Hospitals; and the Departments of Preventive Medicine and Biometrics, University of Colorado Health Sciences Center, Denver,  From the Department of Public Health, Denver Health and Hospitals; and the Department of Medicine, Division of Infectious Diseases; and the Departments of Preventive Medicine and Biometrics, University of Colorado Health Sciences Center, Denver,  From the Departments of General Internal Medicine, and Preventive Medicine and Biometrics, University of Colorado Health Sciences Center, Denver

Affiliations: From the Department of Public Health, Denver Health and Hospitals; and the Department of Medicine, Division of Infectious Diseases, University of Colorado Health Sciences Center, Denver,  From the Department of Public Health, Denver Health and Hospitals; and the Departments of Preventive Medicine and Biometrics, University of Colorado Health Sciences Center, Denver,  From the Department of Public Health, Denver Health and Hospitals; and the Department of Medicine, Division of Infectious Diseases; and the Departments of Preventive Medicine and Biometrics, University of Colorado Health Sciences Center, Denver,  From the Departments of General Internal Medicine, and Preventive Medicine and Biometrics, University of Colorado Health Sciences Center, Denver


1997 by the American College of Chest Physicians


Chest. 1997;111(5):1168-1173. doi:10.1378/chest.111.5.1168
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Abstract

Study objectives: To describe the epidemiology and clinical consequences of noncompliance with directly observed therapy (DOT) for treatment of tuberculosis.

Design: Retrospective review.

Setting: An urban tuberculosis control program that emphasizes DOT.

Patients: All patients treated with outpatient DOT from 1984 to 1994.

Measurements and results: We defined noncompliance as follows: (1) missing ≥2 consecutive weeks of DOT; (2) prolongation of treatment >30 days due to sporadic missed doses; or (3) incarceration for presenting a threat to public health. Poor outcomes of therapy were defined as a microbiologic or clinical failure of initial therapy, relapse, or death due to tuberculosis. Fifty-two of 294 patients (18%) who received outpatient DOT fulfilled one or more criteria for noncompliance. Using multivariate logistic regression, risk factors for noncompliance were alcohol abuse (odds ratio, 3.0; 95% confidence interval, 1.2 to 7.5; p=0.02) and homelessness (odds ratio, 3.2; 95% confidence interval, 1.5 to 7.2; p=0.004). Noncompliant patients had poor outcomes from the initial course of therapy more often than compliant patients: 17 of 52 (32.7%) vs 8 of 242 (3.3%); relative risk was 9.9; 95% confidence interval was 4.5 to 21.7 (p<0.001).

Conclusions: In an urban tuberculosis control program, noncompliance with DOT was common and was closely associated with alcoholism and homelessness. Noncompliance was associated with a 10-fold increase in the occurrence of poor outcomes from treatment and accounted for most treatment failures. Innovative programs are needed to deal with alcoholism and homelessness in patients with tuberculosis.


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