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BMJ No 7120 Volume 315 Papers - Abstracts Saturday 29 November 1997
Systematic review of randomised controlled trials of strategies
to promote adherence to tuberculosis treatment Systematic review of randomised controlled trials of strategies to promote adherence to tuberculosis treatmentJimmy Volmink, Paul Garner See Paper (abstract only) p 1407, and Editorial by Squire and Wilkinson p 1395 AbstractObjective: To determine the effectiveness of strategies to promote adherence to treatment for tuberculosis.Identification: Searches in Medline (1966 to August 1996), the Cochrane trials register (up to October 1996), and LILACS (Literatura Latinoamericana y del Caribe en Ciencias de la Salud) (1982 to September 1996); screening of references in articles on compliance and adherence; contact with experts in research on tuberculosis and adherence. Inclusion criteria: Randomised or pseudorandomised controlled trials of interventions to promote adherence with curative or preventive treatment for tuberculosis, with at least one measure of adherence. Main outcome measure: Relative risks and 95% confidence intervals for estimates of effect for categorical outcomes. Results: Five trials met the inclusion criteria. The relative risk for tested reminder cards sent to patients who defaulted on treatment was 1.2 (95% confidence interval 1.1 to 1.4), for help given to patients by lay health workers 1.4 (1.1 to 1.8), for monetary incentives offered to patients 1.6 (1.3 to 2.0), for health education 1.2 (1.1 to 1.4), for a combination of a patient incentive and health education 2.4 (1.5 to 3.7) or 1.1 (1.0 to 1.2), and for intensive supervision of staff in tuberculosis clinics 1.2 (1.1 to 1.3). There were no completed trials of directly observed treatment. All of the interventions tested improved adherence. On current evidence it is unclear whether health education by itself leads to better adherence to treatment. Conclusions: Reliable evidence is available to show some specific strategies improve adherence to tuberculosis treatment, and these should be adopted in health systems, depending on their appropriateness to practice circumstances. Further innovations require testing to help find specific approaches that will be useful in low income countries. Randomised controlled trials evaluating the independent effects of directly observed treatment are awaited.
South African
Cochrane Centre, International Health Division, Correspondence to: Dr Volmink email: cochrane@eagle.mrc.ac.za
Comparison of cost effectiveness of directly observed treatment (DOT) and conventionally delivered treatment for tuberculosis: experience from rural South AfricaKatherine Floyd, David Wilkinson, Charles Gilks See Paper (abstract only), p 1403 and Editorial by Squire and Wilkinson, p 1395 AbstractObjective: To conduct an economic evaluation of directly observed treatment (DOT) and conventionally delivered treatment for the management of new cases of tuberculosis in adults.Design: Community based directly observed treatment, which has been implemented in the Hlabisa district of South Africa since 1991, was compared with a conventional approach to tuberculosis treatment widely used in Africa. Each was assessed in terms of cost, cost effectiveness, and feasibility of implementation within existing resource constraints. Setting: Hlabisa Health District, South Africa. Subjects: Adult patients with new cases of tuberculosis on smear testing; the number of cases increased from 20 per month to over 100 from 1991 to 1996. Main outcome measures: Cost of case management in 1996, cost effectiveness in terms of the cost per case cured, and bed requirements in comparison with bed availability for the 1990, 1993, and 1996 caseload. Costs are expressed in US dollars at values for 1996. Results: Directly observed treatment was 2.8 times cheaper overall than conventional treatment ($740.90 compared with $2047.70) to deliver. Directly observed treatment worked out 2.4-4.2 times more cost effective, costing $890.50 per patient cured compared with either $2095.60 (best case) or $3700.40 (worst case) for conventional treatment. The 1996 caseload of tuberculosis required 47 beds to be dedicated to tuberculosis to implement directly observed treatment, whereas conventionally delivered treatment would have required 160 beds; the current number of beds for tuberculosis treatment in Hlabisa is fixed at 56. Conclusions: Because of the reduced stay in hospital, directly observed treatment is cheaper, more cost effective, and more feasible than conventional treatment in managing tuberculosis in Hlabisa, given the existing hospital bed capacity and the escalating caseload due to the HIV/AIDS epidemic. Such results may hold elsewhere, and wherever conventional tuberculosis management is practised a switch to directly observed treatment will increase hospital capacity to cope with a growing caseload. Division of Tropical Medicine, Centre
for Epidemiological Research, Correspondence to: Dr Gilks email: gilks@liverpool.ac.uk Mefloquine to prevent malaria: a systematic review of trialsAshley Croft, Paul GarnerAbstractObjective: To evaluate the research evidence on the efficacy and tolerability of mefloquine chemoprophylaxis.Search strategy: Any potentially relevant trial from the Cochrane Infectious Disease Group's register of controlled trials; systematic searches of Medline, Embase, Lilacs and Science Citation Index; scanning citations; and consulting drug companies and key investigators. We considered studies in all languages. Inclusion criteria: Trials carried out in non-immune adult travellers, and in non-travelling volunteers, where an attempt had been made to conduct a randomised comparison of mefloquine against placebo or against alternative standard prophylaxis. Results: 37 potentially eligible trials of mefloquine prophylaxis were identified, and 10 met the inclusion criteria. These 10 trials comprised a total of 2750 non-immune adult participants randomised to mefloquine or to a control. One placebo controlled trial examined malaria incidence directly and showed mefloquine to be highly effective in preventing malaria in an area of drug resistance. However, four placebo controlled trials showed that mefloquine was not well tolerated, and withdrawals were consistently higher in mefloquine treatment arms than in placebo arms (odds ratio 3.49 (95% confidence interval 1.42 to 8.56)). Five field trials compared mefloquine with other chemoprophylaxis. Mefloquine was no worse tolerated than other chemoprophylaxis, although there was possibly a trend towards higher withdrawals in mefloquine arms (odds ratio 1.33 (0.75 to 2.36)). Conclusion: One trial showed mefloquine to be effective in preventing malaria, but withdrawal rates, presumably from side effects, were high across most studies. This is likely to impair mefloquine's effectiveness in general travellers, and it may therefore not be useful for routine prophylaxis. Mefloquine may be useful in specific situations such as for groups travelling to regions with a high risk of chloroquine resistant malaria and only limited access to effective medical care. Headquarters
Defence Secondary Care Agency, International Health Division, Correspondence to: Major A M J Croft The validity of general practitioners' self assessment of knowledge: cross sectional studyJocelyn M Tracey, Bruce Arroll, David E Richmond, Philip M BarhamAbstractObjective: To determine whether general practitioners can make accurate self assessments of their knowledge in specific areas.Design: 67 general practitioners completed a self assessment of their level of knowledge over a variety of topics using a nine point semantic differential scale. An objective assessment of their knowledge was then made by administering true-false tests on two of the topics: thyroid disorders and non-insulin dependent diabetes. The study was repeated with another group of 60 general practitioners, using sexually transmitted diseases as the topic. Setting: General practices in New Zealand. Subjects: Random sample of 67 general practitioners in Auckland. Main outcome measure: Test scores for self assessment and for actual knowledge. Results: Correlations between self assessments and test scores were poor for all three topics studied (r=0.19 for thyroid disorders, 0.21 for non-insulin dpendent diabetes, 0.19 for sexually transmitted diseases). Conclusions: As general practitioners cannot accurately assess their own level of knowledge on a given topic, professional development programmes that rely on the doctors' self perceptions to assess their needs are likely to be seriously flawed.
Goodfellow Unit, Department of General Practice,
Faculty of Medicine and Health Science,
Correspondence to: Dr Tracey email: j.tracey@auckland.ac.nz
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