A Cochrane review [Abstract] 1 included 9 trials (7 RCTs, 2 quasi-RCTs) involving a total of 5 257 subjects. Studies that used bundled interventions were excluded from the review. Late patient tracers (home visit and letter; 3 studies) were shown to be beneficial in increasing adherence to tuberculosis treatment compared with no late patient tracer. The results from almost all the 6 reminder trials, except one, showed benefits of different types of reminders compared to no reminder on adherence to tuberculosis clinic appointments.
Another Cochrane review [Abstract] 2 on material incentives and enablers in the management of tuberculosis included 11 trials involving predominantly male drug users, homeless, and prisoner subpopulations in the USA. Material incentives may increase the return rate for reading of tuberculin skin test results compared to normal care (RR 2.16, 95% CI 1.41 to 3.29; 2 trials, n=1 371). Similarly, incentives probably improve clinic re-attendance for initiation or continuation of antituberculosis prophylaxis (RR 1.58, 95% CI 1.27 to 1.96; 3 trials, n=595), and may improve subsequent completion of prophylaxis in some settings (RR 1.79, 95% CI 0.70 to 4.58; 3 trials, n=869). Material incentives may also be more effective than motivational education at improving return for tuberculin skin test results, but may be no more effective than peer counselling, or structured education at improving continuation or completion of prophylaxis. Cash incentives may be more effective than non-cash incentives (return for test results [1 trial, n=651]: RR 1.13, 95%CI 1.07 to 1.19; adherence to tuberculosis prophylaxis [1 trial, n=141]: RR 1.26, 95%CI 1.02 to 1.56) and higher amounts of cash may be more effective than lower amounts (return for test results [1 trial, n=404]: RR 1.08, 95%CI 1.01 to 1.16).
A systematic review 3 included five randomized or pseudorandomized controlled trials of interventions to promote adherence with curative or preventive treatment for TB. All of the interventions tested improved adherence. The relative risk for tested reminder cards sent to patients who defaulted on treatment was 1.2 (95% CI 1.1-1.4), for help given to patients by lay health workers 1.4 (CI 1.1-1.8), for monetary incentives offered to patients 1.6 (CI 1.3-2.0), for health education 1.2 (CI 1.1-1.4), for a combination of a patient incentive and health education 2.4 (CI 1.5-3.7) or 1.1 (CI 1.0-1.2), and for intensive supervision of staff in tuberculosis clinics 1.2 (CI 1.1-1.3). It remains unclear whether health education alone leads to better adherence to treatment.
Comment: The quality of evidence is downgraded by limitations in study quality.
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