Increased treatment completion for latent TB infection with the Telephone Nurse Monitoring Program (TNMP)

1
Increased treatment completion for latent TB
infection with the Telephone Nurse Monitoring
Program (TNMP)

• Michelle Macaraig, DrPH, MPH
• Assistant Director for Strategic Planning and
  Program Evaluation
• Bureau of Tuberculosis Control
• New York City Department of Health and Mental
  Hygiene

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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

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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

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LTBI treatment initiation and percent completion,
NYC 2004-2007Target 79
Percent completed treatment
Number started 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

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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 patients home one
  month at a time after each successful TNMP call

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Monitoring with TNMP
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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

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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 patients 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

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Mail order medications
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TNMP Historical Dates
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Evaluation of TNMP
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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

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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
• Pearsons chi-square was used to compare
  proportions
• Poisson regression with robust variance estimator
  was used for multivariate analysis

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Results
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Flow diagram of study population
Contacts started treatment for LTBI in 2008,
n912

• Excluded
• n509 (56)
• Less than 1 month on treatment
• Aged lt18 years or no age
• TB disease
• Homeless
• Died during treatment
• Treatment other than INH

Eligible contacts n 403 (44)
Excluded Managed by private provider n158 (39)
Treated at DOHMH chest center n245 (61)
TNMP n59 (24)
No TNMP n186 (76)
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Characteristics of contacts and their index case
enrolled and not enrolled in TNMP, 2008
   Total  Total TNMP TNMP Not in TNMP Not in TNMP  
  n 245 () n59 () n186 () p-value
Age lt35 105 (43) 28 (47) 77 (41) 0.41
Race
Non-Hispanic White 12 (5) 3 (5) 9 (5) 0.18
Asian 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) 0.38
US born
Yes 25 (10) 6 (10) 19 (10) 0.38
No 214 (87) 53 (90) 161 (87)
Unknown 6 (2) 0 (0) 6 (3)
HIV
Positive 0 (0) 0 (0) 0 (0) 0.71
Negative 54 (22) 14 (24) 40 (22)
Unknown 191 (78) 45 (76) 146 (78)
Initial TB test type
TST 213 (87) 50 (85) 163 (88) 0.56
QFT-G 32 (13) 9 (15) 23 (12)
Positive TB test result 223 (91) 54 (92) 169 (91) 0.88
Chest x-ray result of the index case
Cavitary 65 (27) 16 (27) 49 (26) 0.99
Non-cavitary 171 (70) 42 (71) 129 (69)
Unknown 9 (4) 1 (2) 8 (4)
Culture result of the index case
Positive 229 (93) 56 (95) 173 (93) 0.61
Respiratory smear result of the index case
Positive 178 (73) 43 (73) 135 (73) 0.96
HIV status of the index case
Positive 11 (4) 1 (2) 10 (5) lt0.001
Negative 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
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Contacts who started treatment for LTBI enrolled
and not enrolled in TNMP by chest center, N245
    TNMP TNMP No TNMP No TNMP
Chest centers N245 N59 N186
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)
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Number and percent of contacts enrolled and not
enrolled in TNMP by treatment outcome, N245
TNMP TNMP Not in TNMP Not in TNMP
N59 N186 P-value
Completed 48 (81) 124 (67) 0.05
Not completed 11 (19) 58 (31) Referent
Stop treatment 0 (0) 4 (2) Not applicable
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Effect of TNMP on treatment completion for LTBI,
N241
  Completed treatment Completed treatment Did not complete treatment Did not complete treatment Crude relative risk Adjusted relative risk
  N172 () N69 () 95 CI 95 CI
Enrolled 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 ref
Age
lt35 70 (41) 35 (51) ref ref
gt35 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) ref
Respiratory smear result of the index case
Positive 124 (72) 51 (74) 0.97 (0.82, 1.15)
Negative 48 (28) 18 (26) ref
HIV 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 Contacts who stopped treatment due to adverse reactions were excluded Contacts who stopped treatment due to adverse reactions were excluded Contacts who stopped treatment due to adverse reactions were excluded Contacts who stopped treatment due to adverse reactions were excluded Contacts who stopped treatment due to adverse reactions were excluded Contacts who stopped treatment due to adverse reactions were excluded
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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

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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

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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

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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

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Acknowledgments

• Jennifer Pierre, DrPH
• Shama Ahuja, PhD, MPH
• Holly Anger, MPH
• Errol Robinson
• Cheryl Herbert
• BTBC clinic staff

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Changes to the protocol since 2008

• TNMP started after 3 months of successful visits
• TNMP calls were now counted as a patient
  encounter
• Baseline LFT for patients between 35-55 years and
  as ordered by physician

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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

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(No Transcript)
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Duration on treatment (INH) for dropouts
TNMP n11 Clinic n58
Median (range) 4 (2-7) 3 (2-8)
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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
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LTBI Completion RatesProgress towards National
Goals
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TNMP Enrolment by Chest CentersNovember 2006
December 2009
Chest Center 2006 2007 2008
Bedford 0 5 57
Bushwick 0 3 22
Chelsea 17 59 78
Corona 0 22 92
Fort Greene 0 12 127
Jamaica 0 2 20
Morrisania 0 1 73
Richmond 0 9 19
W Heights 0 9 34
Total TNMP 17 122 522
Total LTBI 3,163
on TNMP 16
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TNMP LTBI Treatment Completion Rates BTBC Chest
Centers 2007
Clinic 2007 2007 2007
started completed Completion Rate
Bedford 5 5 100
Bushwick 3 3 100
Chelsea 59 47 79.6
Corona 22 21 95.4
Fort Greene 12 10 83.3
Jamaica 2 2 100
Morissania 1 1 100
Richmond 9 8 88.8
Washington Heights 9 8 88.8
TOTAL 122 105 86
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Why TNMP?

• Completion rates for treatment of LTBI is far
  below the national (CDC) level objectives
• Many efforts (LTBI facilitator DOPT nurse home
  visit incentives) were made to improve
  completion rates with limited success

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Why TNMP? cont.

• Increased use of telemedicine in times of
  decreasing resources, such as
• Videophone for DOT
• ECG signal transmissions via telephone
• Automated telephone reminders for medication and
  appointment adherence
• Increased use of mail order medications
• Increased use of personal cellular phones

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Data sources

• TB Chest Center TNMP logs
• NYC DOHMH TB registry
• TB Chest Center electronic medical record system