VDOT: Video Cell Phone - Directly Observed Therapy for Tuberculosis (2010-2012)
Funded by NIH/NIAID Grant R21-AI088326; PI: Richard S. Garfein, PhD, MPH
(Application submitted in June 2009 and funded in April 2010)
The purpose of this study was to develop and pilot test a novel, cost-effective method of assuring high rates of patient adherence to treatment regimens for tuberculosis (TB). An estimated 2.2 billion persons globally are infected with M. tuberculosis, resulting in 9.2 million cases of disease and nearly 2 million deaths annually. TB is now the leading cause of death from an infectious disease. Reports of drug resistant TB cases – the result of poor adherence to antibiotic treatment – has led to an increasing demand for directly observed therapy (DOT) as a means of assuring high treatment adherence. While daily visits with a healthcare worker to receive DOT places significant cost and time burdens on patients and providers, the consequences of poor adherence would be far costlier. The goal of this intervention was to achieve treatment adherence at least as high as traditional DOT at a lower cost and reduced burden to patients and care providers.
An asynchronous (record-and-forward) Video Directly Observed Therapy (VDOT) application was developed through a collaborative effort between the UCSD Division of Global Public Health, the TB Control Programs of San Diego County, CA, USA and the Municipality of Tijuana, BC, Mexico, and the UCSD CALIT-2 (renamed Qualcomm Institute). Prior to this study, some health departments had used videophones, computers, and smartphones to conduct synchronous (live) VDOT to monitor some of their patients’ TB treatment. This was the first study to assess the use of asynchronous VDOT among patients with TB.
The pilot study evaluated the feasibility and acceptability of a novel approach to delivering DOT using cell-phones, through which patients send daily videos of themselves taking their TB medications. Videos were then viewed remotely by a DOT worker located at the TB Control Program office via a web-based video and data management system hosted by CALIT-2 at UCSD (Figure). By allowing patients to send videos at any time from any location via a smartphone, we anticipated that patients would miss fewer observed doses because they may take them on a schedule that better suits their lifestyle and travel time is no longer a hindrance to face-to-face DOT. Through VDOT, the distance between the patient and their health center was no longer a limitation of DOT, which made DOT feasible in some rural areas where it is previously impractical or impossible. The study came at a critical time when drug resistant TB was increasing worldwide and cell phones have for the first time outnumbered landline phones, making interventions such as VDOT both increasingly necessary and feasible. At the time that this asynchronous VDOT application was being developed,
The primary aims of this pilot study were to:
• Aim 1: To identify modifiable barriers and facilitators among patients and providers to delivering VDOT.
• Aim 2: To determine the acceptability and feasibility of VDOT and estimate the level of treatment adherence achieved through this intervention.
• Aim 3: To characterize the experiences of patients after receiving VDOT and identify components of the program that could be improved to enhance adherence and patient satisfaction.
The study aims were achieved through:
1. Conducting focus groups with TB control personnel and patients in San Diego and Tijuana.
2. Using VDOT for a group of TB patients in San Diego (n=43) and Tijuana (n=9) to determine the feasibility and measure adherence to treatment.
3. Interviewing VDOT participants at the beginning and end of treatment to collect information about potential modifiers and mediators of adherence and patient satisfaction to identify correctable problems with the intervention.
RESULTS: 50% were male, and 88% were non-Caucasian. The mean duration of VDOT use was 5.5 months (range 1–11). Adherence was similar in San Diego (93%) and Tijuana (96%). Compared to time on in-person DOT, 92% preferred VDOT, 81% thought VDOT was more confidential, 89% never/rarely had problems recording videos, and 100% would recommend VDOT to others. Seven (13%) participants were returned to in-person DOT and six (12%) additional participants had their phones lost, broken or stolen.
CONCLUSIONS: We found VDOT feasible to implement and highly acceptable to patients and providers in both high- and low-resource settings. VDOT effectively captured medication-taking behavior, allowing DOT workers to observe the ingestion of nearly all expected doses. VDOT provides a promising, low-burden alternative to in-person DOT for monitoring adherence to anti-tuberculosis treatment. The reduced burden on patients and providers using VDOT could also make DOT feasible in resource-limited settings where in-person DOT is impractical, as well as allowing TB program staff more time to provide support for less adherent patients. Larger, controlled trials are needed to evaluate the efficacy and cost-effectiveness of VDOT for improving and maintaining adherence throughout treatment.
Principal Investigator: Richard S. Garfein, PhD, MPH
Collaborators: Kevin Patrick, Kathleen Moser, Paris Cerecer Callu, Maria Gudelia Rangel, Maria L. Zuniga, Jose-Luis Burgos, Timothy Rodwell, Frederic Raab, Ganpathy Chockalingam, Mark Sullivan, Allison Flick
Project Coordinator: Jazmine Cuevas-Mota
Research Team: Kelly Collins, Fatima Munoz, Cristhian Colin
1. Garfein R, Collins, K, Munoz F, Moser K, Cerecer-Callu P, Sullivan M, Chockalingam G, Rios P, Zuniga ML, Burgos JL, Rodwell T, Rangel MG, Patrick K. High Tuberculosis Treatment Adherence Obtained Using Mobile Phones for Video Directly Observed Therapy: Results of a Binational Pilot Study. Journal of Mobile Technology in Medicine. 2012 Dec; 1(4S):30. PMID:26260824 DOI:10.5588/ijtld.14.0923
2. Zúñiga, M. L., Collins, K., Muñoz, F.A., Moser, K., Rangel, G., Cuevas-Mota, J., Clark, M., Burgos, J.L., Garfein, R.S. A qualitative study exploring stakeholder perceptions of video directly observed therapy for monitoring tuberculosis treatment in the US-Mexico Border Region. Journal of Mobile Technology in Medicine. 2016 5:2:12-23. DOI:10.7309/jmtm.5.2.3
3. Garfein RS, Collins K, Muñoz F, Moser K, Cerecer-Callu P, Raab F, Rios P, Flick A, Zúñiga ML, Cuevas-Mota J, Liang K, Rangel G, Burgos JL, Rodwell TR, Patrick K. Feasibility of Tuberculosis Treatment Monitoring by Video Directly Observed Therapy: A Binational Pilot Study. International Journal of Tuberculosis and Lung Disease. 2015;19(9):1057-64. PMID: 26260824 DOI: 10.5588/ijtld.14.0923
4. Bojorquez I, Salazar I, Garfein RS, Cerecer P, Rodwell TC. Surveillance or support: The experience of direct observation during tuberculosis treatment. Glob Public Health. 2016 Oct 16:1-15. PMID: 27748157 PMCID: PMC5392434 [Available on 2018-04-16] DOI: 10.1080/17441692.2016.1240823 [Epub ahead of print]
1. Garfein RS, Moser K, Rangel G, Zúñiga ML, Burgos JL, Collins K, Cuevas-Mota J, Clark M, Rodwell TC, Patrick K. Preliminary results of a pilot study to deliver tuberculosis directly observed therapy using cellular phone videos in San Diego, CA and Tijuana, Mexico. Presented at the mHealth Summit, Washington, DC, December 5-7, 2011.
2. *Garfein RS, Collins K, Moser K, Cerecer-Callu P, Zúñiga ML, Muñoz F, Cuevas-Mota J, Sullivan M, Chockalingam G, Rios P, Burgos JL, Rodwell TC, Patrick K. Remote directly observed therapy for tuberculosis using mobile phones – Results of a binational pilot study. Oral-Poster presented at the American Thoracic Society - CDC Poster Session, 2012 ATS International Conference, San Francisco, CA, May 20, 2012.
3. Garfein RS, Collins K, Moser K, Cerecer-Callu P, Zúñiga ML, Muñoz F, Cuevas-Mota J, Burgos JL, Rodwell TC, Patrick K. Binational pilot study of directly observed therapy for tuberculosis treatment: a potential model for monitoring HIV treatment adherence. Poster presented at the 7th International Conference on HIV Treatment and Prevention Adherence, Miami, FL, June 3-5, 2012.
4. * Muñoz F, Garfein RS. Video-Directly Observed Therapy: A promising solution for monitoring TB and HIV treatment adherence for binational patients in the U.S.-Mexico border region. Presented at the 6th Annual CFAR (Center for AIDS Research) International HIV/AIDS Research Day. University of California San Diego, CA, September 18, 2012.
5. Garfein RS, Collins K, Munoz F, Moser K, Cerecer-Callu P, Sullivan M, Chokalingam G, Rios P, Zuniga ML, Burgos JL, Rodwell T, Rangel MG, Patrick K. High tuberculosis treatment adherence obtained using mobile phones for video directly observed therapy: Results of a Binational Pilot Study. Abstract published in Journal of Mobile Technology in Medicine, 2012;1:4S:30.
6. *Bojorquez I, Salazar I, Rodwell T, Garfein RS, Cerecer P. Directly observed treatment and stigma experience in patients with tuberculosis in Tijuana, Mexico. Presented at the15th Annual Conference of Public Health Researchers, Mexico City, Mexico, March 5-10, 2013
7. Garfein RS, Collins K, Muñoz F, Moser K, Cerecer-Callu P, Sullivan M, Flick A, Rios P, Zúñiga ML, Burgos JL, Rodwell T, Rangel MG, Patrick K. Use of mobile phones for video directly observed therapy among tuberculosis patients in high and low income countries. Poster presentation at the Wireless Health 2013, Baltimore, MD, November 1-3, 2013.
8. Collins K, Muñoz F, Moser K, Cerecer-Callu P, Sullivan M, Raab F, Flick A, Rios P, Zúñiga ML, Cuevas-Mota J, Burgos JL, Rodwell T, Rangel MG, Patrick K, Garfein RS. Experience with mobile technology among patients with tuberculosis in San Diego, CA and Tijuana, Mexico. Poster presentation at the annual mHealth Summit, Washington, DC, December 8-11, 2013.
9. *Collins K, Munoz F, Moser M, Cerecer-Callu P, Raab F Flick A, Rios P, Zúñiga ML, Cuevas-Mota J, Burgos JL, Rodwell T, Rangel MG, Patrick K, Garfein RS. High tuberculosis treatment adherence obtained using mobile phones for video directly observed therapy: Results of a binational pilot study. Abstract published in Journal of Mobile Technology and Medicine, 2013,2:4S:13.
10. *Garfein RS, Rodwell TC, Collins K, Muñoz F, Moser K, Cerecer-Callu P, Raab F, Flick A, Rios P, Burgos JL, Zúñiga ML, Rangel MG, Patrick K. Overcoming barriers to TB treatment adherence monitoring via mobile phone video directly observed therapy in high and low resource countries US-Japan Cooperative Medical Science Program's 16th International Conference on Emerging Infectious Diseases in the Pacific Rim: Antimicrobial Drug Resistance in Bacterial and Parasitic Diseases; Dhaka, Bangladesh, February 9-13, 2014.
11. *Garfein RS. Video-Directly Observed Therapy (VDOT): a solution for monitoring TB treatment Adherence. Presented at the 45th Union World Conference on Lung Disease, Barcelona, Spain, October 28 – November 1, 2014.
12. Garfein RS, Muñoz F, Liu L, Collins K, Cuevas-Mota J, Catanzaro D, Moser K, Higashi J, Chuck C, Andrade L, Bulterys M. Six Years of Monitoring TB Treatment with Video Directly Observed Therapy (VDOT) in the U.S. and Mexico: How did it Work? Oral poster presentation at the 21st Annual Conference of The Union-North America Region, Vancouver, Canada. February 22-25, 2017.
1. “Video Directly Observed Therapy (VDOT): Smartphones for Monitoring Adherence to Treatment for Tuberculosis”, presented at UCSD, AIDS Clinical Rounds, San Diego, California, April 6, 2012.
2. “Video Directly Observed Therapy: A novel method for supporting adherence in marginalized populations”, presented at the International Conference on Homelessness, Health and Inclusion, London, UK, February 28, 2013.
3. “Overview of Video-Based Directly Observed Therapy”, Strategies & Approaches for Video-Based Directly Observed Therapy, Rutgers Global Tuberculosis Institute, New Jersey Medical School, May 1, 2014.
4. “Technology for TB Interventions”, Plenary Session presentation at the 2014 National Tuberculosis Controllers Association Conference, Atlanta, GA, June 11-13, 2014.
5. “Binational Study of Video-DOT to Monitor Adherence for Tuberculosis Treatment”, United States – Mexico Border Health Commission: Border Health Symposium – The Power of Collaboration, San Diego, CA, August 7-8, 2014.
6. “Using Telehealth Technology to Monitor Tuberculosis Treatment Adherence”. Invited lecturer for the National Consortium of Telehealth Resource Centers, National Telehealth Webinar Series, July 16, 2015.
7. “Video Directly Observed Therapy (VDOT) for Monitoring Tuberculosis Treatment Adherence”. Invited lecturer for the American Lung Association of the Southeast, TB/RD Institute, Raleigh, NC, August 11-12, 2015.
8. “Thought Leadership” panelist, Verizon Wireless HealthCare and Life Sciences Summit, Coronado, CA, October 8-9, 2015.
9. “Digital Health and Mobile Medicine - The Real Impact on Care Anywhere” panelist, Verizon Wireless HealthCare and Life Sciences Summit, Coronado, CA, October 8-9, 2015.
10. “Verizon Partner Success Stories Demonstrations”, Verizon Wireless HealthCare and Life Sciences Summit, Coronado, CA, October 8-9, 2015.
11. “Video Directly Observed Therapy (VDOT) to Monitor Tuberculosis Treatment Adherence”, 2nd International Symposium on Tuberculosis: Clinical, Molecular and Immunological Aspects, Ensenada, BC, Mexico, December 7-9, 2015.