Rebecca C.J. Lin, M.D. Taoyuan General Hospital, Ministry of Health and Welfare PROMISING SPECIALIZED AND FRIENDLY PATIENT-CENTERED CARE 1

Area: 36,193 Km2 Population: 23 million TB prevalence: 72.5 (2005) to 45.6 (2015) National health insurance National surveillance network of communicable diseases BACKGROUND INFORMATION Easy access to medical care Universal coverage of health insurance Real-time electronic monitoring system Easy access to medical care Universal coverage of health insurance Real-time electronic monitoring system 2

Treatment DOT Contact screening National Health Insurance National Surveillance Network of Communicable Disease Centers for Disease Control 3

299 pts from males, 84 females, mean age: 47.3 y/o Eur Respir J 2006; 28:

Treatment factors: Diagnostic delay Ineffective regimen Co-morbidity System factors: Lack of programmatic approach Coordination with public health Doctor/hospital shopping LOW CURE RATE 5

Medication related: Adverse effect Long duration Pain associated with injection High pill burden Service provider related: Conflicting timing of jobs Behavior of service provider Poor counseling HIGH DEFAULT RATE 6 PLOS ONE | DOI: / August 24, 2015

Socio-economic factors: Stigma and discrimination Lack of family and social support Unemployment and financial constrains Patient related: Lack of awareness Myths and misbeliefs regarding disease Substance abuse Confidentiality issues HIGH DEFAULT RATE 7 PLOS ONE | DOI: / August 24, 2015

8 HOW WE TACKLE THE PROBLEMS? POLITICAL COMMITMENT

SPECIALIZED MDRTB PROGRAM National surveillance network: Previous TB treatment record System alarm upon MDRTB detection Central research lab: Rapid diagnosis: GenoType® MTBDR, GenoType® MTBDRsl Standardized lab result: phenotypic 2 nd line DST Cluster investigation Taiwan MDRTB Consortium MDRTB treatment team 9

TAIWAN MDRTB CONSORTIUM (TMTC) Designated treatment network 5 medical teams to cover 5 different regions Hospital-led care and DOT No out-of-pocket expenses from patients Full reimbursement of medical expenses from government funding Quarterly meeting 10

National Surveillance Network of Communicable Disease 11 Centers for Disease Control confirmation TMTC 2 nd line DST DOTTreatment DOT MDRTB treatment DOT MDRTB treatment Central Research Lab MDR alarm

TMTC Expert committee Outcome analysis and feedback Forming consensus Experience sharing and case discussion Surgical evaluation 12

TYGH EXPERIENCE Totally 100 patients from May, 2007 till now 13 Co-morbid condition: DM (29%) Alcohol abuse (26%) Psychiatric disorder (14%)

PATIENT-CENTERED CARE MODEL MDRTB center (physician, case manager) MDRTB center (physician, case manager) Hospital-based: Establish rapport Drug ramping Adverse effects management Co-morbidity treatment Counseling & education Psychiatric evaluation Hospital-based: Establish rapport Drug ramping Adverse effects management Co-morbidity treatment Counseling & education Psychiatric evaluation Community-based: Flexible DOT Health status monitoring Psychosocial support Nutritional support Incentive Stigma elimination Community-based: Flexible DOT Health status monitoring Psychosocial support Nutritional support Incentive Stigma elimination 14

SIDE EFFECTS MANAGEMENT 15 ＤＯＴ

CO-MORBIDITY MANAGEMENT 16 Co-morbidityHospital-based careCommunity-based care Diabetes mellitus Alcoholism Psychiatric disease Optimize sugar control Diet consultation and education DM-related complication evaluation Monitor finger blood sugar Diet control Lifestyle modification Insulin injection Withdrawal management Psychiatric evaluation Complication evaluation Liver function monitoring Lifestyle monitoring Psychosocial support Psychiatric evaluation: Diagnosis Treatment Behavioral consultation Rehabilitation Psychosocial support

SPECIALIZED, FRIENDLY, AND PATIENT-CENTERED 17 Hospital-based care Community-based care