Evaluation of a medication monitor-based treatment strategy for drug-sensitive tuberculosis patients in China: study protocol for a cluster randomised controlled trial

Telenursing Intervention for Pulmonary Tuberculosis Patients - A Scoping Review

Management of care for people with Pulmonary TB at home using Information and Communication Technology (ICT) tools and innovative approaches, such as tools for telecommunications online education. In the nursing sector, the use of telecommunications is called telenursing. The purpose of this study is to determine the types of telecommunications-based interventions, especially telenursing, in monitoring the level of treatment adherence in patients with pulmonary TB. This study used a scoping review method approach to determine the type of telecommunications-based interventions, especially telenursing, in monitoring the level of treatment adherence in patients with pulmonary TB. Literature distribution using several sources, namely EBSCOhost, Scopus (Elsevier), and PubMed. To facilitate obtaining appropriate literature, PICO techniques are used in conducting literature searches, P (population/problem/patient), I (intervention, prognostic factor, exposure), C (comparison, control), and O (outcome). Keywords used in English "Tuberculosis OR Pulmonary Tuberculosis AND Telehealth OR Telehealth Nursing AND Medication Adherence OR Medication Compliance OR Behavior". In total from the 13 articles obtained, the articles used several telehealth to pulmonary TB patients with various implementations, such as the Directly Observed Therapy, Short Course (DOTS) (n = 7). These four implementations have the same goal and support adherence to taking medication and daily recovery in pulmonary TB patients. Overall characteristics of pulmonary TB patients in the reviewed articles are pediatric TB patients (0-14 years), adult TB (18-30 years). A total of 9 studies used a sample population of adult TB patients (18-30 years), TB undergoing Directly Observed Treatment Short-course (DOTS), TB receiving medical care and TB patients actively receiving treatment. The most influential effectiveness of telehealth in helping the treatment process of Pulmonary TB patients is Directly Observed Treatment Short-course (DOTS) because the main focus of the DOTS strategy is patient discovery and cure, priority is given to infectious TB patients without ruling out other types of TB.

Digital Health Interventions to Enhance Tuberculosis Treatment Adherence: Scoping Review

Background

Digital health technologies are widely used for disease management, with their computing platforms, software, and sensors being used for health care. These technologies are developed to manage chronic diseases and infectious bacterial diseases, including tuberculosis (TB).

Objective

This study aims to comprehensively review the literature on the use of digital health interventions (DHIs) for enhancing TB treatment adherence and identify major strategies for their adoption.

Methods

We conducted a literature search in the PubMed, Cochrane Library, Ovid Embase, and Scopus databases for relevant studies published between January 2012 and March 2022. Studies that focused on web-based or mobile phone-based interventions, medication adherence, digital health, randomized controlled trials, digital interventions, or mobile health and ubiquitous health technology for TB treatment and related health outcomes were included.

Results

We identified 27 relevant studies and classified them according to the intervention method, a significant difference in treatment success, and health outcomes. The following interventions were emphasized: SMS text messaging interventions (8/27, 30%), medicine reminders (6/27, 22%), and web-based direct observation therapy (9/27, 33%). Digital health technology significantly promoted disease management among individuals and health care professionals. However, only a few studies addressed 2-way communication therapies, such as interactive SMS text messaging and feedback systems.

Conclusions

This scoping review classified studies on DHIs for patients with TB and demonstrated their potential for the self-management of TB. DHIs are still being developed, and evidence on the impact of digital technologies on enhancing TB treatment adherence remains limited. However, it is necessary to encourage patients' participation in TB treatment and self-management through bidirectional communication. We emphasize the importance of developing a communication system.

Digital adherence technologies to improve tuberculosis treatment outcomes in China: a cluster-randomised superiority trial

BACKGROUND

Drug-sensitive tuberculosis treatment requires 6 months of therapy, so adherence problems are common. Digital adherence technologies might improve tuberculosis treatment outcomes. We aimed to evaluate the effect of a daily reminder medication monitor, monthly review of adherence data by the health-care provider, and differentiated care for patients with adherence issues, on tuberculosis treatment adherence and outcomes.

METHODS

We did a cluster-randomised superiority trial across four prefectures in China. 24 counties or districts (clusters) were randomly assigned (1:1) to intervention or control groups. We enrolled patients aged 18 years or older with GeneXpert-positive, rifampicin-sensitive pulmonary tuberculosis, who were receiving daily fixed-dose combination treatment. Patients in the intervention group received a medication monitor for daily drug-dosing reminders, monthly review of adherence data by health-care provider, and management of poor adherence; and patients in the control group received routine care (silent-mode monitor-measured adherence). Only the independent endpoints review committee who assessed endpoint data for some participants were masked to study group assignment. Patients were followed up (with sputum solid culture) at 12 and 18 months. The primary outcome was a composite of death, loss to follow-up, treatment failure, switch to multidrug-resistant tuberculosis treatment, or tuberculosis recurrence by 18 months from treatment start, analysed in the intention-to-treat population. Analysis accounted for study design with multiple imputation for the primary outcome. This trial is now complete and is registered with ISRCTN, 35812455.

FINDINGS

Between Jan 26, 2017, and April 3, 2019, 15 257 patients were assessed for eligibility and 3074 were enrolled, 2686 (87%) of whom were included in the intention-to-treat population. 1909 (71%) of 2686 patients were male, 777 (29%) were female, and the median age was 44 years (IQR 29-58). By 18 months from treatment start, using multiple imputation for missing outcomes, 239 (16% [geometric mean of cluster-level proportion]) of 1388 patients in the control group and 224 (16%) of 1298 in the intervention group had a primary composite outcome event (289 [62%] of 463 events were loss to follow-up during treatment and 42 [9%] were tuberculosis recurrence). The intervention had no effect on risk of the primary composite outcome (adjusted risk ratio 1·01, 95% CI 0·73-1·40).

INTERPRETATION

Our digital medication monitor intervention had no effect on unfavourable outcomes, which included loss to follow-up during treatment, tuberculosis recurrence, death, and treatment failure. There was a failure to change patient management following identification of treatment non-adherence at monthly reviews. A better understanding of adherence patterns and how they relate to poor outcomes, coupled with a more timely review of adherence data and improved implementation of differentiated care, may be required.

FUNDING

Bill & Melinda Gates Foundation.

Effect of mobile health reminders on tuberculosis treatment outcomes in Shanghai, China: A prospective cohort study

Background

Poor adherence increases the risk of unfavorable outcomes for tuberculosis (TB) patients. Mobile health (mHealth) reminders become promising approaches to support TB patients' treatment. But their effects on TB treatment outcomes remain controversial. In this prospective cohort study, we evaluated the effect of the reminder application (app) and the smart pillbox on TB treatment outcomes compared with the standard care in Shanghai, China.

Methods

We recruited new pulmonary TB (PTB) patients diagnosed between April and November 2019 who were aged 18 or above, treated with the first-line regimen (2HREZ/4HR), and registered at Songjiang CDC (Shanghai). All eligible patients were invited to choose the standard care, the reminder app, or the smart pillbox to support their treatment. Cox proportional hazard model was fitted to assess the effect of mHealth reminders on treatment success.

Results

260 of 324 eligible patients enrolled with 88 using standard care, 82 the reminder app, and 90 the smart pillbox, followed for a total of 77,430 days. 175 (67.3%) participants were male. The median age was 32 (interquartile range [IQR] 25 to 50) years. A total of 44,785 doses were scheduled for 172 patients in the mHealth reminder groups during the study period. 44,604 (99.6%) doses were taken with 39,280 (87.7%) monitored by the mHealth reminders. A significant time-dependent downward linear trend was observed in the monthly proportion of dose intake (p < 0.001). 247 (95%) patients were successfully treated. The median treatment duration of successfully treated patients in the standard care group was 360 (IQR 283-369) days, significantly longer than those in the reminder app group (296, IQR 204-365, days) and the smart pillbox group (280, IQR 198-365, days) (both p < 0.01). Using the reminder app and the smart pillbox was associated with 1.58 times and 1.63 times increase in the possibility of treatment success compared with the standard care, respectively (both p < 0.01).

Conclusion

The reminder app and the smart pillbox interventions were acceptable and improved the treatment outcomes compared with the standard care under the programmatic setting in Shanghai, China. More high-level evidence is expected to confirm the effect of mHealth reminders on TB treatment outcomes.

Evaluation of Mobile Application for the Management of Tuberculosis Patients in Tianjin During 2019-2020

PURPOSE

Poor tuberculosis (TB) medication adherence increases the risk of treatment failure and development of drug-resistant TB, while universal implementation of directly observed therapy (DOT) is not feasible in China. EHealth technologies were reported to be promising patient-centered tools for improving adherence. However, only pilot studies have assessed patients' experiences, and the results were discrepant.

PATIENTS AND METHODS

This prospective-cohort study was conducted among TB patients at the outpatient department from 3 March 2019 to 30 May 2020 in Tianjin, China. Data were downloaded from the Tuberculosis Doctor App and TB Information Management System (TBIMS) and merged them by the TBIMS notification number. Logistic regression analysis was used to analyze the factors associated with regular drug-intake. Odds ratios and 95% confidence intervals were estimated with and without adjustment for age, gender, ethnicity and occupation.

RESULTS

Revisit examination was more regularly and frequently in APP group than non-APP group. In APP group, 33.28% patients were regular drug-intake. The whole drug-intake rate was 84.84%. Tuberculosis pleurisy (aOR: 0.42, 95CI%=0.26-0.69) and retreated patients (aOR: 0.40, 95CI% =0.27-0.59) were more likely to have poor medication compliance. Local residents tend to have better medication compliance (aOR: 1.80, 95CI% =1.16-2.79).

CONCLUSION

APP could improve TB patients' revisit examination adherence. Medication adherence was poor in tuberculosis pleuritis and retreated patients, while local residents tend to have better medication adherence. To make full use of the mobile application in TB patient management, more incentive measures should be adopted for patients and doctors, respectively.

Treatment Adherence among Tuberculosis patients: A Concept Analysis

BACKGROUND OF THE STUDY: The principal difficulty of long-term tuberculosis (TB) treatment is patient nonadherence. During pandemic, nonadherence of TB treatment affects mortality since TB patients are more vulnerable with Covid-19. AIM OF THE STUDY: The purpose of this concept analysis was to clarify and analyze the concept of treatment adherence. METHODOLOGY: Analysis concept was conducted using the Walker and Avant’s method from relevant studies published by EBSCO, PubMed, ProQuest, Wiley Online Library, and Springer between  2003 - 2021. RESULTS:  Five attributes characterizing the concept of treatment adherence from thirteen articles were identified: individual behavior, relationship, mutual participation, shared decision making, and agreement. CONCLUSION: This concept analysis revealed that TB treatment adherence involves many aspects, including the patient, family, society, health care professionals, and policy. These findings help to understand the contribution of major attributes, thereby promoting the body of knowledge on TB and contributing to its elimination during COVID-19 pandemic.

Evaluation of implementation and effectiveness of digital adherence technology with differentiated care to support tuberculosis treatment adherence and improve treatment outcomes in Ethiopia: a study protocol for a cluster randomised trial

Background

Digital adherence technologies (DATs) are recommended to support patient-centred, differentiated care to improve tuberculosis (TB) treatment outcomes, but evidence that such technologies improve adherence is limited. We aim to implement and evaluate the effectiveness of smart pillboxes and medication labels linked to an adherence data platform, to create a differentiated care response to patient adherence and improve TB care among adult pulmonary TB participants. Our study is part of the Adherence Support Coalition to End TB (ASCENT) project in Ethiopia.

Methods/Design

We will conduct a pragmatic three-arm cluster-randomised trial with 78 health facilities in two regions in Ethiopia. Facilities are randomised (1:1:1) to either of the two intervention arms or standard of care. Adults aged ≥ 18 years with drug-sensitive (DS) pulmonary TB are enrolled over 12 months and followed-up for 12 months after treatment initiation. Participants in facilities randomised to either of the two intervention arms are offered a DAT linked to the web-based ASCENT adherence platform for daily adherence monitoring and differentiated response to patient adherence for those who have missed doses. Participants at standard of care facilities receive routine care. For those that had bacteriologically confirmed TB at treatment initiation and can produce sputum without induction, sputum culture will be performed approximately 6 months after the end of treatment to measure disease recurrence. The primary endpoint is a composite unfavourable outcome measured over 12 months from TB treatment initiation defined as either poor end of treatment outcome (lost to follow-up, death, or treatment failure) or treatment recurrence measured 6 months after the scheduled end of treatment. This study will also evaluate the effectiveness, feasibility, and cost-effectiveness of DAT systems for DS-TB patients.

Discussion

This trial will evaluate the impact and contextual factors of medication label and smart pillbox with a differentiated response to patient care, among adult pulmonary DS-TB participants in Ethiopia. If successful, this evaluation will generate valuable evidence via a shared evaluation framework for optimal use and scale-up.

Trial registration: Pan African Clinical Trials Registry PACTR202008776694999, https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=12241, registered on August 11, 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06833-x.

Evaluation of adherence monitoring system using evriMED with a differentiated response compared to standard of care among drug-sensitive TB patients in three provinces in South Africa: a protocol for a cluster randomised control trial

BACKGROUND

South Africa has achieved drug-susceptible TB (DS-TB) treatment success of only 77% among people with new and previously treated TB. Alternative approaches are required to improve medication adherence and treatment completion to limit transmission, TB relapse and the development of resistance. This study aims to implement and evaluate the use of adherence medication monitors (Wisepill evriMED 1000) with a differentiated response to patient care, among DS-TB patients in three provinces of South Africa.

METHODS

In total, 18 public health clinics across three provinces were selected. Clinics were randomised to intervention or standard of care clinics. In each clinic, approximately 145 DS-TB patients are being enrolled to reach a total of 2610. All patients have their daily adherence monitored using medication monitors. In the intervention arm, patients are receiving medication monitor reminders and differentiated care in response to adherence data. This weekly review of daily real-time monitoring will be undertaken from a central database. The differentiated care model includes automated SMS reminders with a missed dose, research staff-initiated phone call to the patient with a second or third missed dose, a home visit if four or more doses are missed, and motivational counselling if four or more doses are missed repeatedly. Fidelity of the intervention will be measured through process evaluation. Patients in control clinics will receive medication monitors for adherence tracking, standard of care TB education, and normal clinic follow-up procedures. The primary outcome is the proportion of patients by arm with >80% adherence, as measured by the medication monitor. The feasibility and acceptability of the intervention will be assessed by in-depth interviews with patients, stakeholders, and study staff. A cost effectiveness analysis of the intervention and standard of care clinics will be conducted.

SIGNIFICANCE

This trial will provide evidence for the use of an intervention, including medication monitors and differentiated care package, to improve adherence to TB treatment. Improved adherence should also improve TB treatment completion rates, thus reducing loss to follow-up rates, and TB relapse among people with TB. The intervention is intended to ultimately improve overall TB control and reduce TB transmission in South Africa.

TRIAL REGISTRATION

Pan African Trial Registry PACTR201902681157721 . Registered on 11 February 2019.

Effect of using electronic medication monitors on tuberculosis treatment outcomes in China: a longitudinal ecological study

Background

In China, an indigenously developed electronic medication monitor (EMM) was designed and used in 138 counties from three provinces. Previous studies showed positive results on accuracy, effectiveness, acceptability, and feasibility, but also found some ineffective implementations. In this paper, we assessed the effect of implementation of EMMs on treatment outcomes.

Methods

The longitudinal ecological method was used at the county level with aggregate secondary programmatic data. All the notified TB cases in 138 counties were involved in this study from April 2017 to June 2019, and rifampicin-resistant cases were excluded. We fitted a multilevel model to assess the relative change in the quarterly treatment success rate with increasing quarterly EMM coverage rate, in which a mixed effects maximum likelihood regression using random intercept model was applied, by adjusting for seasonal trends, population size, sociodemographic and clinical characteristics, and clustering within counties.

Results

Among all 69 678 notified TB cases, the treatment success rate was slightly increased from 93.5% [95% confidence interval (CI): 93.0–94.0] in second quarter of 2018 to 94.9% (95% CI: 94.4–95.4) in second quarter of 2019 after implementing EMMs. There was a statistically significant effect between quarterly EMM coverage and treatment success rate after adjusting for potential confounders (P = 0.0036), increasing 10% of EMM coverage rate will lead to 0.2% treatment success rate augment. Besides, an increase of 10% of elderly or bacteriologically confirmed TB will lead to a decrease of 0.4% and 0.9% of the treatment success rate.

Conclusions

Under programmatic settings, we found a statistically significant effect between increasing coverage of EMM and treatment success rate at the county level. More prospective studies are needed to confirm the effect of using EMM on TB treatment outcomes. We suggest performing operational research on EMMs that provides real-time data under programmatic conditions in the future.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40249-021-00818-3.

Adherence to Multidrug Resistant Tuberculosis Treatment and Case Management in Chongqing, China - A Mixed Method Research Study

Aim

This paper evaluated the treatment adherence for multidrug-resistant tuberculosis (MDR-TB) and MDR-TB case management (MTCM) in Chongqing, China in order to identify factors associated with poor treatment adherence and case management.

Methods

Surveys with 132 MDR-TB patients and six in-depth interviews with health care workers (HCWs) from primary health centers (PHC), doctors from MDR-TB designated hospitals and MDR-TB patients were conducted. Surveys collected demographic and socio-economic characteristics, as well as factors associated with treatment and case management. In-depth interviews gathered information on treatment and case management experience and adherence behaviors.

Results

Patient surveys found the two main reasons for poor adherence were negative side-effects from the treatment and busy work schedules. In-depth interviews with key stakeholders found that self-perceived symptom improvement, negative side-effects from treatment and financial difficulties were the main reasons for poor adherence. MDR-TB patients from urban areas, who were unmarried, were female, had migrant status, and whose treatments were supervised by health care workers from primary health clinics, had poorer treatment adherence (P<0.05). Among the MDR-TB patients surveyed, 86.7% received any type of MTCM in general (received any kind of MTCM from HCWs in PHC, MDR-TB designated hospital and centers of disease control/TB dispensaries and 62.50% received MTCM from HCWs in PHC sectors). Patients from suburban areas were more likely to receive both MTCM in general (OR=6.70) and MTCM from HCWs in MDR-TB designated hospitals (OR=2.77), but female patients (OR=0.26) were less likely to receive MTCM from HCWs in PHC sectors, and patients who were not educated about MTCM by TB doctors in designated hospitals were less likely to receive MTCM in general (OR=0.14). Patients who had not been hospitalized were less likely to receive MTCM from HCWs in MDR-TB designated hospitals (OR=0.21).

Conclusion

Stronger MTCM by HCWs in PHC sectors would improve treatment adherence among MDR-TB patients. Community-based patient-centered models of MTCM in PHC sectors and the use of digital health technology could help to improve case management and thereby improve adherence.

All nonadherence is equal but is some more equal than others? Tuberculosis in the digital era

Adherence to treatment for tuberculosis (TB) has been a concern for many decades, resulting in the World Health Organization's recommendation of the direct observation of treatment in the 1990s. Recent advances in digital adherence technologies (DATs) have renewed discussion on how to best address nonadherence, as well as offering important information on dose-by-dose adherence patterns and their variability between countries and settings. Previous studies have largely focussed on percentage thresholds to delineate sufficient adherence, but this is misleading and limited, given the complex and dynamic nature of adherence over the treatment course. Instead, we apply a standardised taxonomy - as adopted by the international adherence community - to dose-by-dose medication-taking data, which divides missed doses into 1) late/noninitiation (starting treatment later than expected/not starting), 2) discontinuation (ending treatment early), and 3) suboptimal implementation (intermittent missed doses). Using this taxonomy, we can consider the implications of different forms of nonadherence for intervention and regimen design. For example, can treatment regimens be adapted to increase the "forgiveness" of common patterns of suboptimal implementation to protect against treatment failure and the development of drug resistance? Is it reasonable to treat all missed doses of treatment as equally problematic and equally common when deploying DATs? Can DAT data be used to indicate the patients that need enhanced levels of support during their treatment course? Critically, we pinpoint key areas where knowledge regarding treatment adherence is sparse and impeding scientific progress.

IMPACT study on intervening with a manualised package to achieve treatment adherence in people with tuberculosis: protocol paper for a mixed-methods study, including a pilot randomised controlled trial

INTRODUCTION

Compared with the rest of the UK and Western Europe, England has high rates of the infectious disease tuberculosis (TB). TB is curable, although treatment is for at least 6 months and longer when disease is drug resistant. If patients miss too many doses (non-adherence), they may transmit infection for longer and the infecting bacteria may develop resistance to the standard drugs used for treatment. Non-adherence may therefore risk both their health and that of others. Within England, certain population groups are thought to be at higher risk of non-adherence, but the factors contributing to this have been insufficiently determined, as have the best interventions to promote adherence. The objective of this study was to develop a manualised package of interventions for use as part of routine care within National Health Services to address the social and cultural factors that lead to poor adherence to treatment for TB disease.

METHODS AND ANALYSIS

This study uses a mixed-methods approach, with six study components. These are (1) scoping reviews of the literature; (2) qualitative research with patients, carers and healthcare professionals; (3) development of the intervention; (4) a pilot randomised controlled trial of the manualised intervention; (5) a process evaluation to examine clinical utility; and (6) a cost analysis.

ETHICS AND DISSEMINATION

This study received ethics approval on 24 December 2018 from Camberwell St. Giles Ethics Committee, UK (REC reference 18/LO/1818). Findings will be published and disseminated through peer-reviewed publications and conference presentations, published in an end of study report to our funder (the National Institute for Health Research, UK) and presented to key stakeholders.

TRIAL REGISTRATION NUMBER

ISRCTN95243114 SECONDARY IDENTIFYING NUMBERS: University College London/University College London Hospitals Joint Research Office 17/0726.National Institute for Health Research, UK 16/88/06.

Using electronic medication monitoring to guide differential management of tuberculosis patients at the community level in China

Background

In settings such as China, where universal implementation of directly observed therapy (DOT) is not feasible, innovative approaches are needed to support patient adherence to TB treatment. The electronic medication monitor (EMM) is one of the digital technologies recommended by the World Health Organization (WHO), but evidence from implementation studies remains sparse. In this study, we evaluated acceptance of the EMM among health care workers and patients while implementing the device for differential TB patient management at the community level.

Methods

Zhenjiang City in Jiangsu Province was purposively selected for the study. All participating patients were allowed to select their preferred management approach. If patients declined to use the EMM, DOT was offered. The EMM was designed to hold 1 month of anti-TB drugs for once-daily dosing of fixed-dose combination (FDC) tablets. Patient EMM records were monitored monthly by a physician; if 20 to 50% of doses were missed twice, or more than 50% of doses were missed once, the patient was switched to DOT. The four physicians and five nurses involved in the study at four designated hospitals were surveyed using a structured questionnaire to assess their acceptance of the EMM.

Results

From October 2017 through January 2018, 316 pulmonary TB patients were notified in the TB information management system, and 231 (73.1%) met the study enrollment criteria. Although 186 patients (80.5%) initially consented to use the EMM, 17 later refused to use it. Among the 169 patients who used the EMM, 15 (8.9%) were switched to DOT due to poor adherence, and the other 154 completed the treatment course. The median adherence rate was 99.3%. Surveyed health care workers from designated hospitals found the EMM acceptable, although eight of nine felt use of the device moderately increased their workload. However, the EMM program significantly reduced the workload of community physicians by reducing patient visits by 87.9%.

Conclusions

This study demonstrated the acceptability of using an indigenously developed EMM for differential management of TB patients at the community level. However, more operational research should be conducted before introducing and scaling the technology throughout China.