Directly observed therapy for tuberculosis in New York City: factors associated with refusal

To describe patients who utilize hospital-based directly observed therapy (DOT) programs and to describe factors that influence refusal of DOT.

Retrospective analysis of patients diagnosed with tuberculosis through hospital admission in 1997 at 12 hospital sites with out-patient DOT programs. Data were obtained from hospital patient records and from the New York City Tuberculosis Case Registry.

Of 443 patients diagnosed with tuberculosis in 1997 at the 12 hospital sites and available and/or eligible for DOT, 52 (12%) refused DOT. The two main reasons for DOT refusal were that the patients felt they could self-medicate (21%) and that their work schedule interfered with a DOT program (19%). White non-Hispanic race/ethnicity was associated with refusal of DOT (P = 0.001). Conversely, interview for DOT while in the hospital (P < 0.001) and enrollment in drug treatment were associated with acceptance of DOT (P = 0.05). The five hospitals with tuberculosis clinics on site had the lowest percentages (0-9%) of patients refusing DOT.

To increase patient acceptance of DOT, programs need flexible hours that accommodate patients in the workforce. Patient education should focus on the difficulty of completing tuberculosis treatment on a self-administered regimen and the importance of the support offered through DOT.