Innovation is no longer a want, it is a need: People centric approach for MDR-TB management

Alice Sagwidza-Tembe, CNS Correspondent, Swaziland
It is essential that any healthcare program in its advancement does not forget the population for whom it is  developed. At the recent 47th Union World Conference on Lung Health with the theme of ‘Confronting resistance: Fundamentals to innovations’, countries shared interesting food for thought and unique advanced approaches to people focused quality care for innovative management of MDR-TB.

For an extended period of time we have had the directly observed treatment short-course (DOTS) for TB patients, in which healthcare workers observe patients as they take their medicines. It introduced task shifting, a concept that was first met with hesitancy by mostly healthcare workers and the general population at large. But it remains an internationally recommended highly efficient and cost-effective strategy for TB control. However, noting the increase in the number of patients that need to be directly observed and the limited space to house them in hospitals, the administration of TB medication is slowly shifting to community care givers or lay healthcare workers trained for a specific task. Perhaps it is time to innovate and replace traditional DOTS with e-DOTS.  

Dr Liu Yuhong, Managing Director at the National Clinical Centre on Tuberculosis, China, felt that traditional face-to-face DOTS is not a people centred approach for disease management as it is not feasible for long-term treatment; does not protect patient privacy; and also puts the DOTS provider to unnecessary exposure to TB infection. He shared that China (which has the 2nd largest number of TB cases in the world, with 900 000 new infections occurring annually) has developed a mobile application for better disease management of patients with TB. This is a new innovation in the form of a TB Aid and TB Doctor App, that has been developed for e-DOTS system. TB Aid App is for patients’ use. It reminds drug taking and follow up visits, monitors adherence, provides patient education, and allows between patient-patient and patient-doctor communication. There is an auto app reminder for drug taking and for follow up visit, followed by auto sms reminder in case of no response.

If the patient still does not respond then health worker from CDC or community visits his/her home. TB Doctor is for doctors’ use. It links to TB Aid to monitor the linked patients and answer their questions. It also allows for technical discussion amongst doctors, and for doctors’ education through online training. This e-DOTS strategy has already been piloted in 1 hospital and in 1 county CDC in Beijing. Dr Yuhong said that the next steps for this project are to simplify the App, making it more patient friendly and simpler to use, establish patients and doctors rewarding system for best use, expand the project with a controlled cohort to compare cost and quality effectiveness as well as translate it into other languages (right now it is available in Chinese only).

The e-DOTS approach is certainly challenging the techno-advanced era into healthcare quality improvement. From the top of my head, this app brings many benefits. It can (i) encompass comprehensive and holistic healthcare; (ii) reduce the patients’ influx to hospitals/clinics that are high risk zones for cross infection; (iii) minimise manpower for patient management and monitoring, especially in resource limited settings; (iv) provide infection control for community healthcare workers; (v) increase direct patient interaction with doctors; (vi) reach public health education to all; (vii) improve quality of care through multi-disciplinary approach; and above all (viii) maintain the patients’ privacy while letting them take control of their treatment.

Dr Marian Loveday, Scientist at Health Systems Research Unit in Cape town, South Africa shared her experience of decentralization policy of MDR-TB treatment and care in South Africa. Pilot studies have been done in the country to evaluate cost effectiveness of 5 different models of care for MDR-TB patients:
  • Centralized—Initial hospitalization; monthly visit to a centralised hospital after discharge
  • Decentralized 1—Initial hospitalization; monthly visit to a de-centrelized hospital after discharge
  • Decentralized 2—Hospitalization for full duration of intensive phase; monthly visit to a de-centralized hospital after discharge
  • Community-based Clinic—No hospitalization; monthly visit to a de-centralized hospital
  • Community-based mobile van—No hospitalization; monthly visit to a de- centralized hospital
While there was no significant difference in treatment success rate across these 5 models of care, community-based models were found to be most cost-effective. Hospitalization was the main cost driver and, in fact, the cost per patient was 2 to 6 times higher in models which included hospitalization. Our target should be to make high quality TB services accessible to all with no barriers to treatment and care. And as Dr Paul farmer said: “There are no patients who refuse their treatment; there are patients who refuse the system. The innovation of our work should be to change the system that does not care about them the medical personnel who do not smile and do not see them as individuals.”

Alice Sagwidza Tembe, Citizen News Service - CNS
November 9, 2016
(Alice Tembe is providing thematic coverage from the 47th Union World Conference on Lung Health in Liverpool, UK, with kind support from Lilly MDR TB Partnership. Follow her on Twitter: @Tembe3)