The COVID-19 pandemic left healthcare systems scrambling to find mechanisms for delivering care under new social distancing requirements. Patients with chronic and infectious diseases who need support to adhere to their medications were especially impacted. Public health emergency responses spurred the broad and rapid adoption of telehealth and digital services to support medication adherence and address this urgent need.
In tuberculosis (TB) control programs, verifying medication adherence is as critical to treating patients as it is to controlling the spread of infection and minimizing the development of drug resistance. U.S. public health departments employ Directly Observed Therapy (DOT) — a process that ensures patients are taking their medication correctly through a short, in-person appointment — as the standard of care for verifying medication adherence. But, video Directly Observed Therapy (video DOT) — a technology-assisted version of DOT that reduces the need for in-person DOT — has grown in prominence due to its convenience for patients and care teams and cost-savings for health departments. Many health jurisdictions have adopted video DOT (also called “eDOT” by the CDC) as a monitoring strategy alongside in person DOT, and even deploy it as an exclusive monitoring strategy for some patients.
To understand the impact of COVID-19 on TB treatment adherence, and utilization and effectiveness of vDOT, Dr. Maunank Shah and the study team at Johns Hopkins University School of Medicine partnered with Scene Health (formerly known as emocha Health) to conduct a retrospective cohort study at the Baltimore City Health Department TB Program between April 2019 and April 2021.
In the study, the team found that video DOT utilization using Scene Health’s mobile app increased to 75% during COVID from 43% of patients pre-COVID. Across both time periods, verified adherence was significantly higher overall when using vDOT compared to in-person DOT (median 86% vs. 59%). Adherence was significantly higher when using video DOT compared to traditional in-person DOT in the pre-COVID periods (median 98% vs. 58%). And although verified adherence when using video DOT decreased during the COVID period from its prior levels, it was still higher than in-person DOT (median 80% vs. 62%).
These results are even more significant when considering that video DOT as a treatment monitoring strategy was offered to a broader group during the pandemic than was under non-pandemic conditions. Patients who may not have qualified for remote monitoring based on prior adherence or treatment completion, sputum smear status, or drug resistance prior to COVID-19 were allowed to use video DOT without restriction during the COVID period.
The study shows that video DOT continues to serve as an effective and resilient monitoring strategy for ensuring medication adherence in tuberculosis patients during public health emergencies like COVID, weather emergencies like hurricanes, and for patients with special needs in hard to reach locations as well. With additional programmatic support for digital health programs like those that Scene Health’s technology enables, we can expand video DOT as a monitoring strategy for even broader populations and settings.
Dr. Maunank Shah is the Medical Director for the Baltimore City Tuberculosis Program and an Associate Professor of Infectious Diseases and Epidemiology at the Johns Hopkins School of Medicine.