Quality standard

Quality statement 5: Directly observed therapy

Quality statement 5: Directly observed therapy

Quality statement

People with active tuberculosis (TB) from under-served groups are offered directly observed therapy.

Rationale

The complex social and clinical interactions surrounding a person with TB can be a challenge to treatment participation and adherence. Suboptimal uptake of, and adherence to, TB treatment for people with active TB can lead to increased morbidity and mortality, increased infectiousness, and the emergence of drug resistance. Enhanced case management including directly observed therapy is key to improving treatment adherence and completion, in particular in relation to vulnerable groups or those at risk of non-adherence.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.

Structure

Evidence of local arrangements to ensure that people with active TB from under-served groups are offered directly observed therapy.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from service protocols.

Process

a) Proportion of people with active TB who are experiencing homelessness who have directly observed therapy.

Numerator – the number in the denominator who have directly observed therapy.

Denominator – the number of people with active TB who are experiencing homelessness.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from patient records.

b) Proportion of people with active TB who misuse substances who have directly observed therapy.

Numerator – the number in the denominator who have directly observed therapy.

Denominator – the number of people with active TB who misuse substances.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from patient records.

c) Proportion of people with active TB who have been in prison who have directly observed therapy.

Numerator – the number in the denominator who have directly observed therapy.

Denominator – the number of people with active TB who have been in prison.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from patient records.

d) Proportion of people with active TB who are vulnerable migrants who have directly observed therapy.

Numerator – the number in the denominator who have directly observed therapy.

Denominator – the number of people with active TB who are vulnerable migrants.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from patient records.

Outcome

a) Proportion of people from under-served groups with active TB lost to follow-up.

Numerator – the number in the denominator lost to follow-up.

Denominator – the number of people from under-served groups with active TB.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from patient records. National and regional data on the proportion of people with drug-sensitive TB who were lost to follow-up at last reported outcome is collected in the Office for Health Improvement and Disparities' TB strategy monitoring indicators.

b) TB treatment completion rates for people from under-served groups.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from patient records. National and regional data on the proportion of people with drug-sensitive TB with at least 1 social risk factor who completed treatment within 12 months is collected in the Office for Health Improvement and Disparities' TB strategy monitoring indicators.

c) TB treatment completion rates for people from under-served groups with multidrug-resistant TB.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from patient records.

What the quality statement means for different audiences

Service providers (secondary care services) ensure that people with active TB from under-served groups are offered directly observed therapy as part of enhanced case management.

Health and social care practitioners (such as a nurse or lay person supported by a healthcare professional) offer directly observed therapy as part of enhanced case management to people with active TB from under-served groups.

Commissioners (integrated care systems and clinical commissioning groups) ensure that they commission services that have the capacity to provide directly observed therapy as part of enhanced case management for people with active TB from under-served groups.

People with active TB who are likely to find it difficult to take their medicine regularly are offered the choice of meeting a specific healthcare worker each time they take a dose of anti-TB medicine.

Source guidance

Tuberculosis. NICE guideline NG33 (2016), recommendation 1.7.1.3

Definitions of terms used in this quality statement

Under-served groups

This term includes people of any age, and from any ethnic background regardless of migration status. Groups classified as under-served include:

  • people who are experiencing homelessness

  • people who misuse substances

  • people who have been in prison

  • vulnerable migrants.

[Adapted from NICE's guideline on tuberculosis, terms used in this guideline]

Directly observed therapy

This involves a trained health professional, or responsible lay person supported by a trained health professional, providing the prescribed TB medicine and watching the person swallow each dose. Directly observed therapy should be considered as an integral part of enhanced case management in complex cases such as those from under-served groups.

[Adapted from NICE's full guideline on tuberculosis, section 9.2.6 and glossary]

Equality and diversity considerations

Healthcare professionals, and lay people supported by healthcare professionals, who are involved in providing directly observed therapy for people with TB from under-served groups should be aware that people from these groups face barriers to treatment completion. They may find it difficult to express what these barriers are and may feel stigmatised because of their diagnosis of TB. All communication with people with TB from under-served groups should be sensitive to their needs.