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Evidence summaries

Strategies to Promote Adherence to Tuberculosis Treatment

Late patient tracing, reminder cards sent to patients, help given by lay health workers, material incentives, health education, and intensive supervision by the staff of tuberculosis clinics all appear to improve patient adherence to tuberculosis treatment. Level of evidence: "B"

A Cochrane review [Abstract] 1 included 9 trials (7 RCTs, 2 quasi-RCTs) involving a total of 4654 subjects. For people being treated for active TB, clinic attendance and TB treatment completion were higher in people receiving pre-appointment reminder phone-calls (clinic attendance: 66% versus 50%; RR 1.32, 95% CI 1.10 to 1.59, one trial (USA), 615 participants, low quality evidence; TB treatment completion: 100% versus 88%; RR 1.14, 95% CI 1.02 to 1.27, one trial (Thailand), 92 participants, low quality evidence). Clinic attendance and TB treatment completion were also higher with default reminders (letters or home visits) (clinic attendance: 52% versus 10%; RR 5.04, 95% CI 1.61 to 15.78, one trial (India), 52 participants, low quality evidence; treatment completion: RR 1.17, 95% CI 1.11 to 1.24, two trials (Iraq and India), 680 participants, moderate quality evidence).For people on TB prophylaxis, clinic attendance was higher with a policy of pre-appointment phone-calls (63% versus 48%; RR 1.30, 95% CI 1.07 to 1.59, one trial (USA), 536 participants); and attendance at the final clinic was higher with regular three-monthly phone-calls or nurse visits (93% versus 65%, one trial (Spain), 318 participants).For people undergoing screening for TB, three trials of pre-appointment phone-calls found little or no effect on the proportion of people returning to clinic for the result of their skin test (three trials, 1189 participants, low quality evidence).

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.

    References

    • Liu Q, Abba K, Alejandria MM et al. Reminder systems to improve patient adherence to tuberculosis clinic appointments for diagnosis and treatment. Cochrane Database Syst Rev 2014;(11):CD006594. [PubMed]
    • Lutge EE, Wiysonge CS, Knight SE et al. Material incentives and enablers in the management of tuberculosis. Cochrane Database Syst Rev 2012;(1):CD007952. [PubMed]
    • Volmink J, Garner P. Systematic review of randomised controlled trials of strategies to promote adherence to tuberculosis treatment. BMJ 1997 Nov 29;315(7120):1403-6. [PubMed]

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