Increased treatment completion for latent TB infection with the Telephone Nurse

Monitoring Program (TNMP)

Michelle Macaraig, DrPH, MPHAssistant Director for Strategic Planning and Program Evaluation

Bureau of Tuberculosis Control

New York City Department of Health and Mental Hygiene

Evaluation of contacts to TB cases in NYC

• Contacts to TB patients are screened and evaluated at – Field (TB test)– TB chest centers– Hospitals– Other providers

• DOHMH case managers ensure proper evaluation and follow-up of all contacts

• Evaluate approximately 4,000 contacts annually– Over 500 start treatment for latent TB infection of which 50%

are treated at a TB chest center

Treatment of contacts with latent TB infection in TB chest centers

• Treatment for LTBI is nine months on self-administered isoniazid (INH)

• Treatment completion among contacts with LTBI in NYC is consistently below 70%

• Limited success to increasing treatment completion with– Directly observed therapy for LTBI

– Nurse home visits

– Incentives

• Barriers to completing treatment include– Length of treatment (9 months)– Required monthly clinic visits– Lengthy waiting times at TB chest centers

LTBI treatment initiation and percent completion, NYC 2004-2007

Target: 79%

56% 59%

68%65%

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2005 2006 2007 2008

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Number of contacts started treatment Percent of contacts completed treatment

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Why Telephone Nurse Monitoring Program (TNMP)?

• Improve completion rate for treatment of latent TB infection (LTBI)

• Leverage existing technology to facilitate treatment adherence despite decreases in resources

• Address barriers to treatment completion• In 2006, piloted TNMP in one chest center and

found that treatment completion increased to 77%

What is TNMP?

• Program to engage and monitor eligible patients while they are on treatment for LTBI

• Treatment monitoring– First three months monitored by doctor and nurse, then

nurse at subsequent months

– Follow-up monitoring by telephone call interspersed with in-person clinic visits

– Total of five clinic visits and four TNMP calls

• Medications are mailed to patient’s home one month at a time after each successful TNMP call

Monitoring with TNMP

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov

1st follow-up

visit

2nd follow-up

visit

3rd follow-up

visit

Initialvisit

3rd TNMP

call

15 days

4th TNMP

call

30 days

4th follow-up

visit

1st TNMP

call

15 days

2nd TNMP

call

30 days

5th follow-up

visit

Eligibility Criteria for TNMP

• Low risk for hepatic complications– Baseline for liver function test

• Completed the three months of treatment• Greater than or equal to 18 years old• Able to communicate with nurse directly or with

translation through Language Line• Read instructions on medication label• Verified stable address

– Not homeless at the time of diagnosis

• Verified phone number

Preparing patients for TNMP call

• Schedule with the patient the dates and times of the call following clinic visits– Enter scheduled calls in the Electronic Medical Record

– Document calls in patient’s treatment card

• Discuss the process with the patients– Expect calls within 15 minutes of agreed time

– Two call attempts will be made

– Establish security question or code to verify the nurse reached the patient

• Educate on what to do in case of adverse reaction

Mail order medications

TNMP Historical Dates

Evaluation of TNMP

Study design

• Study population: eligible contacts who started treatment for LTBI in 2008 in one of the NYC DOHMH TB chest centers

• Excluded– Died during treatment– Developed active TB– Treatment for LTBI was other than INH alone

Analysis

• Examined demographic and clinical characteristics of contacts and their associated index case

• Compared the proportion of contacts enrolled in TNMP versus contacts not enrolled in TNMP who completed treatment

• Examined the effect of being enrolled in TNMP on treatment completion while adjusting for other variables

• Pearson’s chi-square was used to compare proportions• Poisson regression with robust variance estimator was

used for multivariate analysis

Results

Flow diagram of study population

Contacts startedtreatment for LTBI

in 2008, n=912

Eligible contactsn= 403 (44%)

Excludedn=509 (56%)• Less than 1 month on treatment• Aged <18 years or no age• TB disease• Homeless • Died during treatment• Treatment other than INH

TNMPn=59 (24%)

No TNMPn=186 (76%)

ExcludedManaged by private providern=158 (39%)

Treated atDOHMH chest center

n=245 (61%)

Characteristics of contacts and their index case enrolled and not enrolled in TNMP, 2008

   Total TNMP Not in TNMP    n= 245 (%) n=59 (%) n=186 (%) p-valueAge <35 105 (43) 28 (47) 77 (41) 0.41RaceNon-Hispanic White 12 (5) 3 (5) 9 (5) 0.18Asian 76 (31) 19 (32) 57 (31)Non-Hispanic Black 52 (21) 13 (22) 39 (21)Hispanic 101 (41) 21 (36) 80 (43)Unknown 4 (2) 3 (5) 1 (1)

Male 157 (64) 35 (59) 122 (66) 0.38US bornYes 25 (10) 6 (10) 19 (10) 0.38No 214 (87) 53 (90) 161 (87)Unknown 6 (2) 0 (0) 6 (3)

HIVPositive 0 (0) 0 (0) 0 (0) 0.71Negative 54 (22) 14 (24) 40 (22)Unknown 191 (78) 45 (76) 146 (78)

Initial TB test typeTST 213 (87) 50 (85) 163 (88) 0.56QFT-G 32 (13) 9 (15) 23 (12)

Positive TB test result 223 (91) 54 (92) 169 (91) 0.88Chest x-ray result of the index caseCavitary 65 (27) 16 (27) 49 (26) 0.99Non-cavitary 171 (70) 42 (71) 129 (69)Unknown 9 (4) 1 (2) 8 (4)

Culture result of the index casePositive 229 (93) 56 (95) 173 (93) 0.61

Respiratory smear result of the index casePositive 178 (73) 43 (73) 135 (73) 0.96

HIV status of the index casePositive 11 (4) 1 (2) 10 (5) <0.001Negative 196 (80) 40 (68) 156 (84)Unknown 38 (16) 18 (31) 20 (11)

Close relation to the index case 184 (75) 40 (68) 144 (77) 0.14

Con

tact

sIn

dex

case

Contacts who started treatment for LTBI enrolled and not enrolled in TNMP by chest center, N=245

    TNMP No TNMP

Chest centers N=245 N=59 % N=186 %

Chest center 1 4 0 (0) 4 (100)

Chest center 2 4 0 (0) 4 (100)

Chest center 3 7 2 (29) 5 (71)

Chest center 4 21 5 (24) 16 (76)

Chest center 5 28 2 (7) 26 (93)

Chest center 6 34 12 (35) 22 (65)

Chest center 7 38 11 (29) 27 (71)

Chest center 8 49 12 (24) 37 (76)

Chest center 9 60 15 (25) 45 (75)

Number and percent of contacts enrolled and not enrolled in TNMP by treatment outcome, N=245

TNMP Not in TNMP

N=59 % N=186 % P-value

Completed 48 (81) 124 (67) 0.05

Not completed 11 (19) 58 (31) Referent

Stop treatment 0 (0) 4 (2) Not applicable

Effect of TNMP on treatment completion for LTBI, N=241  Completed treatment Did not complete treatment Crude relative risk Adjusted relative risk

N=172 (%) N=69 (%) 95% CI 95% CIEnrolled in TNMP Yes 48 (28) 11 (16) 1.19 (1.02, 1.40) 1.22 (1.04, 1.43) No 124 (72) 58 (84) ref refAge <35 70 (41) 35 (51) ref ref >35 102 (59) 34 (49) 1.12 (0.95, 1.32) 1.07 (0.90, 1.26)US born Yes 21 (12) 4 (6) 0.89 (0.49, 1.61) No 148 (86) 64 (93) ref Unknown 3 (2) 1 (1) 1.07 (0.61, 1.90)Race Non-Hispanic White 8 (5) 4 (6) ref ref Asian 57 (33) 19 (28) 1.64 (1.40, 1.93) 1.51 (1.28, 1.89) Non-Hispanic Black 44 (26) 8 (12) 1.18 (1.05, 1.32) 1.09 (0.93, 1.28) Hispanic 59 (34) 38 (55) 1.33 (1.17, 1.52) 1.23 (1.04, 1.44) Unknown 4 (2) 0 (0) 1.50 (1.01, 2.24) 1.40 (0.95, 2.08)Sex Male 106 (62) 48 (70) 0.91 (0.78, 1.06) Female 66 (38) 21 (30) refRespiratory smear result of the index case Positive 124 (72) 51 (74) 0.97 (0.82, 1.15) Negative 48 (28) 18 (26) refHIV status of the index case Positive 4 (2) 7 (10) 1.93 (0.86, 4.34) 0.99 (0.96, 1.01) Negative 142 (83) 51 (74) ref ref Unknown 26 (15) 11 (16) 0.96 (0.76, 1.20) 0.99 (0.96, 1.03)Relation to the index case Close 131 (76) 50 (72) 1.06 (0.87, 1.28) Casual 41 (24) 19 (28) ref  

*Contacts who stopped treatment due to adverse reactions were excluded

Limitations and Strengths

• Limitations– Contacts were not randomized to TNMP– Although, characteristics of contacts enrolled and not enrolled in

the program were similar, there may be other factors not examined that could have biased the results in either direction

– Thirty-nine percent of eligible contacts were excluded because they were treated by an outside provider and could not be offered TNMP

• Strengths– Data on enrollment and follow-up of patients were available for

contacts in all chest centers

Conclusion

• Contacts enrolled in TNMP were more likely to complete treatment compared to contacts not enrolled in TNMP

• Proportion of contacts enrolled in TNMP remained low (less than 30%) despite efforts to expand to other chest centers

• Increased enrollment in the program could improve overall treatment completion among DOHMH chest center patients

Challenge

• Patients change phone numbers or address

• Language barriers– Patients did not fully understand the process

when first accepted TNMP– Calls took longer with interpreter

• More time for staff when multiple attempts needed to reach patient

Benefits of TNMP

• Facilitates completion of treatment• On average 45% fewer clinic visits = less

inconvenience for patient• Can receive call at home, workplace or any

other place of patient choice• Patient/nurse can initiate call on given

appointment date and time• Can save provider time for higher priority

patients

Acknowledgments

• Jennifer Pierre, DrPH

• Shama Ahuja, PhD, MPH

• Holly Anger, MPH

• Errol Robinson

• Cheryl Herbert

• BTBC clinic staff

TNMP Evaluation of Chelsea Patients

• Preference for Monthly follow-up– 12 (86%) prefer the nurse to call– 1 (7%) prefer to come to the clinic– 1 (7%) says it depends on the situation

Overall LTBI Completions in the Chest Centers

2004 2005 2006 2007

# Overall LTBI starts

5,905 5,075 4,937 3,096

% Overall LTBI

completions

47.1% 46.3% 42.0% 52.0%

LTBI Completion Rates:Progress towards National Goals

0%

10%

20%

30%

40%

50%

60%

70%

80%

Overall 75% 47% 46% 42% 52%

CDC Goals 2004 2005 2006 2007