A randomised study of two policies for managing default in out-patients collecting supplies of drugs for pulmonary tuberculosis in a large city in South India. Strategies to increase adherence with tuberculosis test reading in a high-risk population. Automated telephone reminders in tuberculosis care. Use of automated reminders for tuberculin skin test return. Does routine home visiting improve the return rate and outcome of DOTS patients who delay treatment? Evaluation of the efficacy of health education on the compliance with antituberculosis chemoprophylaxis in school children. A randomized clinical trial.
A randomized controlled study was undertaken to compare 2 policies of default management in out-patients with smear-negative pulmonary tuberculosis attending a large chest clinic in Madras city. All the patients were due to collect monthly supplies of drugs for a year, for daily self-administration at home. In the routine (R) policy, if a patient failed to collect the drug supply on a due date, a reminder letter was posted on the fourth day and, if necessary, a health visitor visited the home a week later. In the intensive (I) policy, a health visitor visited the home on the 4th day and, if necessary, a week later and at 1 and at 2 months. The main analyses concern 150 patients (75 R, 75 I), of whom 16 R and 15 I patients had a positive culture. A total of 29 patients (11 R, 18 I) did not default at any time. For the remaining 64 R and 57 I patients, the mean numbers of defaults were 3.0 and 2.3, and the mean numbers of defaulter retrieval actions were 4.3 and 3.8, respectively. The home visit as the first action (I series) was successful in retrieving defaulters on 65% of 132 occasions, while the reminder letter (R series) was successful in 56% of 193 occasions (P = 0.1). Following the second action, which was a home visit in both the series, these proportions became 80% and 84%, respectively. in the I series, 22 third and 18 fourth actions were taken, but the patient was retrieved in only 4 and 0 instances respectively. The mean number of drug collections during the year was significantly higher in the I series (9.8) than in the R series (8.6). Finally, the proportions of patients who made 12 collections in a 15-month period, a satisfactory target under Indian Programme conditions, were 69% and 52%, respectively (P = 0.07). To determine the most effective strategy to encourage adherence with tuberculosis test reading in a high-risk population. Design. Prospective randomized controlled trial.
                Consecutive sample of 627 children ages 1 to 12 years due for a tuberculosis (TB) test in an urban children's hospital outpatient department. One child per family was enrolled.
                All families received education regarding the importance of skin testing for TB and the need for follow-up, and written and verbal instructions regarding test reading. Families were randomly assigned to one of five strategies for follow-up TB test reading at 48 to 72 hours: 1) routine verbal and written instructions, 2) reminder phone call, 3) transportation tokens and toy on return, 4) withholding of school forms until time of reading and need to repeat TB test if not timely read, 5) parents taught to read induration with nurse home visit. Those who did not have tests read at 48 to 72 hours by a trained professional were phoned 1 week later.
                The five groups did not differ with regard to TB risk factor score, maternal education, transportation source, or perceived importance of TB testing. Before the study the follow-up rate of TB test reading by a trained professional was 45%. Reading rates in this study were 58%, 70%, 67%, 70%, and 72% for groups 1 to 5, respectively. In group 4, only 39% had school forms to be completed and their adherence rate was 84% (53/63). Compared to group 1, the only statistically significant improvement was in group 4, especially for those who needed school forms completed, and in group 5. Those not adhering in groups 1 to 4 did not differ from returnees with regard to TB risk factors, maternal education, transportation, or perceived importance of testing. The most common reasons for failing to return included forgetfulness, transportation, and time constraints. Group 5 was stopped early because of difficulty with nurse visits (N = 98). When told of the nurse visit, 9% (9/98) families could not find a time for the visit. Seventeen percent (17/98) were visited but the child was not home, and 7% (7/98) were not visited because of a nurse scheduling problem.
                In a high-risk population, adherence with TB test reading is poor. However, education and return of school forms at reading time can significantly improve adherence. Although requiring larger investment in resources, visiting nurses may also aid in test reading. This study assessed the impact of automated telephone reminders in a population of 2,008 patients scheduled for appointments in a public health tuberculosis clinic. Overall, remainders increased appointment attendance from 52% to 62%. Reminders were more effective for some applications than others, but the effectiveness of reminders did not differ significantly across patient age, sex, or ethnicity. Counter to theoretical predictions, neither attribution of the reminder message to an authority nor a statement stressing the importance of the appointment significantly increased the effectiveness of the reminder above the level obtained without these enhancements. This study assessed the impact of automated telephone reminders on tuberculin skin test returns.
                A total of 701 English-speaking and Spanish-speaking patients of a public health immunization program were randomly assigned to an intervention or a control group. Those in the intervention group received an automated telephone reminder to return for the reading of their skin test.
                Automated telephone reminders significantly reduced return failures 53% (from 14% to 7%) when the scheduled interval between test administration and reading was three days, but had no impact for a two-day interval. Effectiveness of reminders did not differ significantly by patient age, gender, or language (English versus Spanish).
                Results suggest the value of automated reminder calls for intra-appointment intervals as short as three days. Over a period of 6 months the effect of home visits on compliance with directly observed therapy, short course (DOTS), was studied on 480 new smear-positive tuberculosis patients who had delayed collecting their drugs on one occasion. Patients registered at 15 tuberculosis treatment centres in Baghdad, Iraq, were randomized to an intervention group (receiving home visits from trained personnel) or a control group. Home visits were highly effective in improving the return to treatment of patients who were late for treatment (231/240, 96.3%). The intervention group showed a higher treatment success rate (94.2% versus 76.7%), lower default rate (0.8% versus 10.0%) and higher smear conversion rate after the end of treatment (92.9% versus 75.0%) than controls. Home visiting by trained personnel significantly improves patient compliance with DOTS. Chemoprophylaxis against tuberculosis with isoniazid for 1 year is very useful, but patient compliance is very low. A controlled clinical trial was performed to evaluate the efficacy of three alternative health education strategies and to observe which of them improves compliance with antituberculosis chemoprophylaxis in healthy tuberculin-reactor children. Although all three strategies achieved positive, statistically significant results as compared with the control group, that performed by nursing personnel at the patient's home is the most effective, followed by that performed by the same health professionals by telephone. The least effective strategy by far was that performed by the physician in his surgery.
The included trials show significantly better outcomes among those tuberculosis patients for which late patient tracers and reminders are used. Studies of good quality (large and with rigorous study design) are needed to decide the most effective late patient tracer actions and reminders in different settings. Future studies of reminders in chemoprophylaxis and treatment settings would be useful.