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Directly Observed Therapy (DOT)
& Video Directly Observed Therapy (VDOT)

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The Ultimate Guide to Directly Observed Therapy and Video Directly Observed Therapy

It’s been called an “out-of-control epidemic costing more than any single disease” and a “widely-recognized common and costly problem.” The problem is medication nonadherence, or patients not taking medications as prescribed.

Directly observed therapy (DOT) and video directly observed therapy (video DOT) are established solutions to this problem. DOT is the gold standard for ensuring patients take the right medications, the right way, at the right time.

For the patient, taking medications correctly can mean the difference between successfully managing a serious medical condition and illness or death. For healthcare delivery organizations, DOT and video DOT have the potential to improve quality and outcomes while reducing medical spending.

Below, we provide an all-encompassing rundown of DOT and video DOT, including the history of these practices, explanations of how they work, benefits, and the future of video DOT.

What is Directly Observed Therapy and How Does it Work?

DOT is a type of patient-centered care management in which a trained healthcare worker (nurse, coach, or pharmacist) provides a patient with medications and watches the patient take every dose.

Endorsed by the U.S. Centers for Disease Control and Prevention and the World Health Organization as the gold standard for tuberculosis (TB) treatment, DOT is considered the most effective strategy to ensure treatment adherence. During DOT, health workers meet with patients to observe every dose, assist with proper administration, and support patients as they tackle a range of adherence challenges related to medication, motivation, and social determinants of health.

According to the Minnesota Department of Health, DOT can include:

  • Delivering medications to the patient
  • Explaining what the medications do and what side effects to expect
  • Listening to the patient and identifying problems that could lead to non-adherence
  • Checking for side effects
  • Watching the patient swallow or inject the medication
  • Documenting the visit
  • Answering questions
  • Supporting the patient in overcoming any barriers to adherence
  • Notifying the supervising physician if the patient has any side effects, is missing doses, or is otherwise struggling to be adherent

Key to DOT is the daily relationship between the trained healthcare worker and the patient. These short, daily, high-touch interactions foster accountability, empathy, and trust.

History of Directly Observed Therapy

The history and acceptance of DOT are deeply entwined with the management and control of TB. TB requires at least six months of treatment. If treatment is not completed, patients may not be cured and drug resistance may develop.

In the late 1950s, TB infection rates were high across the developing and developed world. At the same time, health care organizations were moving TB patients out of the hospital to treat them in community clinics. Soon, those concerned with TB control in places as diverse as London, Hong Kong, and Madras had concluded that effective TB treatment required direct supervision of therapy.

In the U.S., however, the practice of self-administration continued until the 1980s, when, after decades of decline, TB re-emerged as a serious public health problem. The core issue: the increasing frequency of drug-resistant bacteria. Drug-resistant infections developed and patients relapsed because patients were not strictly compliant with their medication regimens. In 1994, the World Health Organization (WHO) declared TB a global emergency.

As a result, the international community rallied behind WHO to develop a TB strategy that included government commitment to national TB programs, ongoing case investigation, regular supply of anti-TB medications, and mandatory DOT for confirmed cases.

The use of DOT achieved excellent results in New York and other U.S. cities, increasing not only cure rates among patients with TB, but decreasing drug resistance, treatment failure, relapse, and death. By the early 1990s, DOT had become the CDC-endorsed standard of care for patients diagnosed with TB.

But DOT is not only for TB; DOT is the standard of care delivered in hospitals to prevent medication errors. During hospital-based DOT, a healthcare provider or nurse watches a patient take each dose of medication in person. Although not necessarily named as such, observed dosing is also used for methadone as part of medication-assisted treatment for substance use disorder and .

Benefits and Drawbacks of Directly Observed Therapy

According to the CDC, DOT increases cure rates for patients with TB and is also effective in decreasing drug resistance, treatment failure, relapse and mortality.

Because patients see their healthcare worker often, they have many opportunities to ask questions about medications and treatments and report early signs of adverse drug reactions (if any).

However, conventional in-person DOT has some drawbacks. The expectation that patients see their healthcare worker in person daily inconveniences and burdens patients who have obligations to work and family. The practice also requires significant daily travel on behalf of the DOT healthcare worker who commutes from the health department to patient homes dispersed across the city or county. Some health departments have found the economic and environmental impact of this labor-intensive practice to be significant.

History of Video Directly Observed Therapy

With the growth of digital technology, a new, more convenient form of DOT has emerged: video DOT, also known as mobile DOT (mDOT), electronic DOT (eDOT), and video-enhanced therapy. Video DOT is the use of a smartphone or other computer equipment with video capabilities to observe patients taking their medications at a different location from a healthcare worker.

How Video DOT Works

Video DOT features two-way asynchronous or live video check-ins between patients and healthcare workers. Patients or caretakers record the administration of treatments and transmit them through a secure mobile application. Videos are reviewed by a nurse, coach, healthcare worker, and/or pharmacist. In each video check-in, patients can take their medication and report any symptoms and side effects. In programs like emocha, patients can track their progress and communicate with team members via in-app chat.

Nurses, coaches, or healthcare workers are trained to assess videos for proper administration and adherence challenges and communicate with the patient’s provider when needed. They also may message patients to build rapport, offer encouragement, and discover how they are doing emotionally.

Video DOT allows healthcare workers to interact with patients for weeks or longer each day through short video check-ins that are extremely accessible, convenient, and personalized.

Benefits of Video DOT

Video DOT has been shown to promote equal or better adherence to therapy than in-person DOT. Benefits include:

  • Greater convenience: For patients and staff
  • Reduced cost: staff travel time, vehicle and fuel and
  • Reduced environmental impact: carbon dioxide emissions through fewer miles driven
  • Improved safety: For patients staff in the community

Examples of Video DOT at Work

Tuberculosis

From 2014 to 2016, researchers performed a multi-center, analyst-blinded, randomized controlled superiority trial comparing video DOT to traditional DOT. The researchers randomly assigned TB patients to either DOT or video DOT, and then measured how many patients completed two full months of observed daily doses of medication. Twice as many video DOT patients as DOT patients completed the full course of observed therapy, leading researchers to conclude that video dot provides “a more acceptable, effective, and cheaper option for supervision of daily and multiple daily doses than DOT.”

In 2018, researchers from Johns Hopkins reported on a pilot implementation of video DOT at three TB clinics in Maryland. They found 94% medication adherence through the video-based methodology – comparable to that of in-person DOT, but with a higher percentage of total treatment doses observed. Video DOT was well-received by staff and patients alike, who cited increased treatment flexibility, convenience, and patient privacy. Video DOT achieved savings of $1,391 per patient during a standard 6-month treatment course.

Asthma

Both adherence and inhaler technique are crucial to controlling and managing asthma; daily use of inhaled corticosteroids can control asthma symptoms and prevent acute episodes. Yet the prevalence of uncontrolled asthma in adults in the U.S. remains above 50%.

In 2021, results from a pilot study of video DOT among pediatric patients at a severe asthma clinic in Baltimore were published in the Journal of Asthma.Using video DOT, patients resolved most inhaler technique errors in just 14 days. At the end of the second week, fewer than 10% of patient videos revealed technique issues.

Pediatric Transplant

Transplant recipients must take their medications consistently, sometimes twice per day at the same time, to avoid graft failure. Yet often, adolescents don’t follow their medication regimens carefully. Pediatric transplant recipients have non-adherence rates as high as 40% to 60%, leading to a greater number of organ rejections.

A pilot study of video DOT in adolescent heart transplant recipients who were struggling with adherence showed that the use of video DOT increased adherence to 90.1%. By contrast, 83.3% of the patients who did not begin video DOT or dropped out were hospitalized or experienced episodes of acute organ rejection.

The Future of Video DOT

The technology and approach of video DOT are maturing, paving the way for its use across a wide swath of conditions. Research is underway to assess its effectiveness in supporting patients with stroke, sickle cell disease, HIV, PrEP, and opioid dependence.

New reimbursement mechanisms may also speed up the adoption of video DOT. Even though medication non-adherence is recognized as a $500B problem, few healthcare stakeholders outside of public health departments have had the processes, personnel, and budget to practice video DOT. However, there are some accelerators to video DOT: 1), the growth of value-based payment systems that reimburse health systems for outcomes, not activities; and 2), the emergence of financial incentives tied to medication adherence-related quality measures.

As clinicians see outcomes from the expansion of video DOT programs, it will be more widely adopted. In turn, payment can catch up to the cost of providing a service that will save healthcare dollars, improve the effectiveness of treatments, and help create healthier populations.

Because asynchronous video is extremely accessible, convenient, and personalized, we at emocha believe it represents the next frontier of digital health. Peer-reviewed studies have already shown it can help patients achieve high levels of adherence, but delivering it to more patients and more conditions requires additional interventions that scale. emocha’s holistic model of care adds interventions such as Comprehensive Medication Reviews, escalation algorithms, high-touch engagement tools, and robust analytics.

Learn more about video DOT with emocha.

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