New nurse-driven Irish TB smartphone study published on World TB Day
Posted on: 24 March 2023
The study from the HIHI Trinity Hub at St James’s Hospital shows remarkable health system savings, increases treatment access and supports self-management in the community.
Tuberculosis (TB) is the leading cause of death worldwide from an infectious agent, resulting in more deaths than HIV and malaria. Deaths from TB rose for the first time in more than a decade due to Covid 19 (WHO, 2022).
Although TB is treatable, non-adherence to medication leads to ongoing transmission, disease progression and development of drug-resistant strains. Treatment is lengthy, ranging from six months to two years depending on the type and location of TB.
The Health Innovation Hub Ireland (HIHI) Trinity Hub and National TB centre (both based at St James’s Hospital, Dublin) studied 34 patients over 18 months, to investigate the use of technology in contrast to in-person care in Tuberculosis (TB) medication adherence.
16 study participants were on the current Irish standard of care - Direct Observed Therapy (DOT) – where a public health nurse must physically witness patients taking medication. 18 participants were randomised to the World Health Organisation (WHO)-recommended UK and US standard of care: Video Observed Therapy (VOT). VOT allows patients to take TB medications remotely, recording through their smartphone and sending securely to the clinical team. A total of 3,634 videos were viewed during the study period.
Revenue – Health Service Executive (HSE) financial and budget implications: Using the current method of Direct Observed Therapy (DOT), the HSE cost is €3,362 per patient over six months, compared to €300 with Video Observed Therapy (VOT) for same period.
Workflow - HSE resources saved: The time for each public health nurse to carry out DOT in person, using hard copy records for one patient was up to 60 minutes. Using VOT, each patient video took - on average - one minute of the public health nurse’s time at the computer.
Clinical pathway - Patient self-management: Seven participants were transferred from DOT to VOT due to an inability to comply with DOT, citing work hours, or reported undue stress due to DOT. Patient sentiment however, with VOT was extremely positive. VOT empowered continuation of normal work/life routines and allowed patients to take medications at a time convenient to them. Contrastingly, those on DOT had to be available at set times suitable to the public health nurses, which was disempowering and restrictive.
The study also showed that VOT had higher levels of treatment observation in the first two months of treatment and remained consistently high throughout treatment compared to DOT. VOT can facilitate twice daily dosing at no additional cost. For patients on twice daily dosing on DOT, typically the second afternoon dose in the PM could not be facilitated due to time constraints of the public health nurse. As a result, not all doses were observed, which presents a significant health risk.
Health Innovation Hub Ireland Manger, Dublin, Eimear Galvin (Clinical Medicine, School of Medicine, Trinity College) said:
“Health Innovation Hub Ireland’s focus is introducing innovative solutions to our health system that meet priority needs of Irish patients. HIHI was thrilled to work with the TB team to deliver this important study, which shows remarkable health system savings, increases treatment access and supports self-management in the community. The need for this kind of remote care and patient self-management is even more obvious now since Covid-19.”
Co- Principal Investigators, TB Clinical Nurse Specialist Lorraine Dolan and Professor Ann Marie McLaughlin (both, national TB Centre) said:
“TB remains a public health imperative. We are using World TB day to urge the Irish health system to review TB care in Ireland based on the overwhelming results of this new study. VOT is hugely cost saving; time saving across staff teams, supports patient self-management and increased TB patient medication observation per day. Due to resource constraints in Ireland, the Health Protection Surveillance Centre advises selective DOT. However, universal observation is most beneficial to stop the transmission chain and resource is not an issue using VOT.”
Convinced of the efficacy of VOT in TB care, TB Clinical Nurse Specialist, Lorraine Dolan, approached HSE and Enterprise Ireland partnership, Health Innovation Hub Ireland, in 2019 to collaborate on the first of its kind research study in Irish TB care. The study site was the National TB Centre, St James’s Hospital, in the outpatient department, incorporating the Respiratory Assessment Unit.
Video Observed Therapy (VOT) uses a mobile smartphone application that allows patients to remotely record and send videos asynchronously of every medication dose ingested. A nurse views the date and time stamped videos on a secure web-based client management system that is password protected. Once a patient’s videos upload to the web portal, they are automatically deleted from the smartphone. Currently in Ireland, a public health nurse physically visits a patient, observes each medication dose and records it manually on a hard copy – Direct Observed Therapy (DOT). Either the nurse visits a patients’ home or the patient attends a local health centre once or twice a day, seven days per week.