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

2. 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

3. 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

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

5. 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%

6. 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

7. Monitoring with TNMP JanFebMar AprMayJunJulAugSep OctNov 1 st follow-up visit 2 nd follow-up visit 3 rd follow-up visit Initial visit 3 rd TNMP call 15 days 4 th TNMP call 30 days 4 th follow-up visit 1 st TNMP call 15 days 2 nd TNMP call 30 days 5 th follow-up visit

8. 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

9. 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

10. Mail order medications

11. TNMP Historical Dates

12. Evaluation of TNMP

13. 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

14. 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

15. Results

16. Flow diagram of study population Contacts started treatment for LTBI in 2008, n=912 Eligible contacts n= 403 (44%) Excluded n=509 (56%) Less than 1 month on treatment Aged <18 years or no age TB disease Homeless Died during treatment Treatment other than INH TNMP n=59 (24%) No TNMP n=186 (76%) Excluded Managed by private provider n=158 (39%) Treated at DOHMH chest center n=245 (61%)

17. Characteristics of contacts and their index case enrolled and not enrolled in TNMP, 2008 TotalTNMPNot in TNMP n= 245(%)n=59(%)n=186(%)p-value Age <35105(43)28(47)77(41)0.41 Race Non-Hispanic White12(5)3 9 0.18 Asian76(31)19(32)57(31) Non-Hispanic Black52(21)13(22)39(21) Hispanic101(41)21(36)80(43) Unknown4(2)3(5)1(1) Male157(64)35(59)122(66)0.38 US born Yes25(10)6 19(10)0.38 No214(87)53(90)161(87) Unknown6(2)0(0)6(3) HIV Positive0(0)0 0 0.71 Negative54(22)14(24)40(22) Unknown191(78)45(76)146(78) Initial TB test type TST213(87)50(85)163(88)0.56 QFT-G32(13)9(15)23(12) Positive TB test result223(91)54(92)169(91)0.88 Chest x-ray result of the index case Cavitary65(27)16(27)49(26)0.99 Non-cavitary171(70)42(71)129(69) Unknown9(4)1(2)8(4) Culture result of the index case Positive229(93)56(95)173(93)0.61 Respiratory smear result of the index case Positive178(73)43(73)135(73)0.96 HIV status of the index case Positive11(4)1(2)10(5)<0.001 Negative196(80)40(68)156(84) Unknown38(16)18(31)20(11) Close relation to the index case184(75)40(68)144(77)0.14 Contacts Index case

18. Contacts who started treatment for LTBI enrolled and not enrolled in TNMP by chest center, N=245 TNMPNo TNMP Chest centersN=245N=59%N=186% Chest center 140(0)4(100) Chest center 240(0)4(100) Chest center 372(29)5(71) Chest center 4215(24)16(76) Chest center 5282(7)26(93) Chest center 63412(35)22(65) Chest center 73811(29)27(71) Chest center 84912(24)37(76) Chest center 96015(25)45(75)

19. Number and percent of contacts enrolled and not enrolled in TNMP by treatment outcome, N=245 TNMPNot in TNMP N=59%N=186%P-value Completed48(81)124(67)0.05 Not completed11(19)58(31)Referent Stop treatment0(0)4 (2)Not applicable

20. Effect of TNMP on treatment completion for LTBI, N=241 Completed treatmentDid not complete treatmentCrude relative riskAdjusted relative risk N=172(%)N=69(%)95% CI Enrolled in TNMP Yes48(28)11(16)1.19 (1.02, 1.40)1.22 (1.04, 1.43) No124(72)58(84)ref Age <3570(41)35(51)ref >35102(59)34(49)1.12 (0.95, 1.32)1.07 (0.90, 1.26) US born Yes21(12)4(6)0.89 (0.49, 1.61) No148(86)64(93)ref Unknown3(2)1(1)1.07 (0.61, 1.90) Race Non-Hispanic White8(5)4(6)ref Asian57(33)19(28)1.64 (1.40, 1.93)1.51 (1.28, 1.89) Non-Hispanic Black44(26)8(12)1.18 (1.05, 1.32)1.09 (0.93, 1.28) Hispanic59(34)38(55)1.33 (1.17, 1.52)1.23 (1.04, 1.44) Unknown4(2)0(0)1.50 (1.01, 2.24)1.40 (0.95, 2.08) Sex Male106(62)48(70)0.91 (0.78, 1.06) Female66(38)21(30)ref Respiratory smear result of the index case Positive124(72)51(74)0.97 (0.82, 1.15) Negative48(28)18(26)ref HIV status of the index case Positive4(2)7(10)1.93 (0.86, 4.34)0.99 (0.96, 1.01) Negative142(83)51(74)ref Unknown26(15)11(16)0.96 (0.76, 1.20)0.99 (0.96, 1.03) Relation to the index case Close131(76)50(72)1.06 (0.87, 1.28) Casual41(24)19(28) ref *Contacts who stopped treatment due to adverse reactions were excluded

21. 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

22. 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

23. 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

24. 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

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

26. 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

27. 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

29. Duration on treatment (INH) for dropouts TNMP n=11 Clinic n=58 Median (range)4 (2-7)3 (2-8)

30. Overall LTBI Completions in the Chest Centers 2004200520062007 # Overall LTBI starts 5,9055,0754,9373,096 % Overall LTBI completions 47.1%46.3%42.0%52.0%

31. LTBI Completion Rates: Progress towards National Goals

32. TNMP Enrolment by Chest Centers November 2006 – December 2009 Chest Center200620072008 Bedford0 557 Bushwick0 322 Chelsea17 5978 Corona0 2292 Fort Greene0 12127 Jamaica0 220 Morrisania0 173 Richmond0 919 W’ Heights0 934 Total TNMP17 122522 Total LTBI3,163 % on TNMP16%

33. TNMP LTBI Treatment Completion Rates BTBC Chest Centers 2007 Clinic2007 # started# completedCompletion Rate Bedford55100% Bushwick33100% Chelsea594779.6% Corona222195.4% Fort Greene121083.3% Jamaica22100% Morissania11100% Richmond9888.8% Washington Heights9888.8% TOTAL12210586%

34. 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

35. 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

36. Data sources TB Chest Center TNMP logs NYC DOHMH TB registry TB Chest Center electronic medical record system