RetourIt is important to remember that: 1) decisions on the model of care for a particular situation should not be made in the belief that only one model serves the needs of all patients in a particular setting; and 2) in some settings, allowing community health-care workers to do more and different types of jobs to relieve staff shortages and to encourage more meaningful community participation may be important to allow services to be available to all patients. Therefore, in real-life circumstances, multiple models of care may be used depending on the needs of the patient and the resources of the health-care system.
Some patients may need hospital-based care (inpatient model) either while receiving complicated treatment or when on end-of-life care. This is because hospitals play a very important role in the clinical management of severe TB disease and DR-TB. This includes: treatment of TB comorbidities (such as HIV or noncommunicable diseases (e.g. diabetes, severe mental health disorders); surgical treatment of selected TB patients; management of severe adverse drug reactions (particularly to second-line anti-TB drugs); treatment of pulmonary complications in patients with severe TB disease; medical support during palliative and end-of-life care; and the initial care of patients who are homeless, have difficult family situations, or who live in remote areas where TB care is difficult or DR-TB care is not yet available.
However, in some settings, depending only on an inpatient model of care may result in problems, namely: it may slow down or even make it impossible to get all patients into treatment due to the high costs of hospital care; create long patient waiting lists due to the lack of hospital beds; cause longer than necessary suffering of patients with TB; and create catastrophic costs for patients. An outpatient system must be in place to support patients upon discharge even in settings that rely mainly on a hospital-based model. Thus, the ability to provide ambulatory TB care has to be built into whatever model is used.
When comparing different treatment models, a number of issues have to be considered (see Box 5) and ethical concerns need to be respected. While outpatient care is often socially more acceptable to patients and reduces heath system costs, the creation of outpatient person-centred treatment support is challenging. It requires access to a primary health care network, strong social support and community-based care. However, in some settings, the community-based decentralized model of care is the only way to achieve universal access to treatment.
Whichever model is chosen to provide treatment for TB, a multidisciplinary team of providers – including physicians, nurses, psychologists, social workers and community health workers or volunteers – should be involved in care. The roles and responsibilities of each of these groups of providers will vary depending on the needs and resources available in specific settings.
Adherence to TB treatment – particularly DR-TB treatment – is challenging and therefore social support and social protection measures to improve adherence should be used, whichever model is chosen (see Section 3.1).
The risk of TB (with particular concern for DR-TB) transmission when proper infection control measures are not being used occurs in all models of care whenever the patient remains sputum smear-/culturepositive. However, the risk is particularly serious in the hospital-based model where the adverse effects of transmission could be higher (hospitals are crowded so it is easier to infect more people, and those people are likely to have other serious illnesses as well). This is a critical factor to consider when selecting a model of care for a DR-TB patient.
Person-centred treatment support is the method recommended to deliver treatment and support patients in each of the models of care. New ways to deliver person-centred treatment include VST, which can also be considered in any of the models of care presented above. More specific and detailed WHO guidance on how to implement VST and other digital based technologies to monitor adherence to treatment are presented elsewhere (25).
