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(Chest. 1999;115:218-223.)
© 1999 American College of Chest Physicians

Development of Housing Programs to Aid in the Treatment of Tuberculosis in Homeless Individuals: A Pilot Study*

Philip A. LoBue, MD; Robert Cass; Diana Lobo; Kathleen Moser, MD and Antonino Catanzaro, MD, FCCP

* From the Division of Pulmonary and Critical Care Medicine (Drs. LoBue and Catanzaro), University of California, San Diego Medical Center, and the Tuberculosis Control Program (Mr. Cass, Ms. Lobo, and Ms. Moser), San Diego County Department of Health Services.


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 References
 
Study objectives: To describe our experience with novel supervised housing programs developed to aid in the treatment of tuberculosis (TB) in homeless individuals, including a preliminary analysis of their effectiveness and estimate of potential cost savings.

Design: Retrospective chart review.

Setting: A county TB control program.

Methods: The San Diego County TB Control Program's computer database was used to identify homeless individuals placed in one of two supervised housing programs for treatment of TB [Young Men's Christian Association (YMCA), for noninfectious patients, or Bissell House, for infectious patients]. Charts for all these patients were reviewed and information regarding their demographics, underlying medical conditions, therapy, microbiologic markers of response to therapy, hospitalizations, and participation in supervised housing programs was recorded.

Measurements and results: The sputum culture conversion and treatment completion rates for those housed in the YMCA were 100 and 84.6%, respectively. Of the patients in the Bissell House program, 100% had converted their smear and culture. In addition, all patients in this program completed an adequate course of supervised therapy. These rates of microbiologic conversion and treatment completion compare favorably with historical data from San Diego County and other locations. Estimated cost savings for placing medically stable infectious patients in the Bissell House for respiratory isolation and supervised treatment were estimated to be $27,034 per patient.

Conclusions: Use of supervised housing to aid in treatment of TB in the homeless appears to be effective and results in substantial cost savings. A larger multicenter study should be considered to confirm these findings and better quantify the cost-effectiveness of such programs.

Key Words: directly observed therapy • homelessness • supervised housing • tuberculosis


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 Conclusion
 References
 
The resurgence of tuberculosis (TB) in the United States in the 1980s and early 1990s has been well documented.1 This problem was particularly severe in cities such as New York where the TB case rate nearly tripled over a 15-year period from the late worsening social and economic conditions, most

notably homelessness. In fact in one study of 224 1970s to the early 1990s.2 Among the factors contributing to this resurgence were the HIV epidemic, the decline in funding for TB control programs, and worsening social and economic conditions, most notably homelessness. In fact in one study of 224 consecutive patients with TB admitted to a large city public hospital, 68% were homeless or lived in an unstable housing situation.3 Of these, 178 were discharged with anti-TB therapy, 89% of which were subsequently lost to follow-up and did not complete treatment. Failure to complete treatment not only leads to morbidity and mortality in the individual patient but also to the spread of the disease to others in the community. In addition, partial treatment of TB can result in the dreaded complication of multiple drug resistance (MDR), a phenomenon that became widespread in several US cities during the 1980s and early 1990s.2

Major efforts have been directed at controlling these public health problems with some success. Among the factors cited for improving the situation are better use of effective, short course treatment regimens, better institutional infection control measures, and perhaps, most importantly, the increased use of directly observed therapy (DOT).2 Even with these improvements, the problem of TB among the homeless remains significant. In a study of TB in homeless men in New York, 53% failed to complete therapy despite being in a DOT program.4 Burman et al5 reported in a Denver, CO, study that 18% of that city's DOT program patients were noncompliant with DOT and homelessness was a significant risk factor for noncompliance.

In the 1980s and early 1990s, problems with TB control among the homeless, similar to those described above, also occurred in San Diego County. The first major effort to deal with this problem was the implementation of essentially universal use of DOT among the homeless, which went into effect in 1992. However, based on subsequent experience and studies such as the ones cited above, it was recognized that DOT alone may not be sufficient to ensure completion of therapy among homeless individuals.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 Conclusion
 References
 
Origins and Development of the Housing Programs
In the early 1990s, a task force of 13 local private and government agencies, including the San Diego Department of Health Services (SDDHS), the American Lung Association of San Diego and Imperial Counties (ALASDIC), and the St. Vincent de Paul Village, was formed to address the problem of homelessness in San Diego County. The consortium of local agencies, led by the St. Vincent de Paul Village, submitted a joint application for a "Solutions" grant. "Solutions," a United States Department of Housing and Urban Development funded program, solicited applications for funding from homeless providers (not specifically for TB) through a notice of funding availability. The grant application was subsequently approved and funded for a total of $9.0 million for 5 years. The consortium recognized that TB was a major problem among the homeless. It allocated $105,199 (for 5 years, approximately $21,000 per year) of the $9.0 million grant for development and implementation of a supervised housing program to aid in the treatment of TB. After exploring various housing options for TB patients, the consortium entered into an agreement with the local Young Men's Christian Association (YMCA) hostel. Under this agreement the YMCA devoted six single-occupancy rooms to the housing of patients with TB. SDDHS maintained responsibility for providing DOT and case management for all individuals housed in the YMCA. The new program was instituted in mid 1994. Patients were deemed eligible to enter the program if they were homeless, carried a diagnosis of active or suspected TB, and were considered to be very low risk for infectiousness as demonstrated by three negative sputum acid-fast bacillus (AFB) smears on 3 consecutive days.

Because the YMCA was not an appropriate site for infectious individuals, a second housing option, known as the Bissell House, was developed. This project, begun in 1996, was developed jointly by ALASDIC and SDDHS. Infectious TB patients who were medically appropriate to initiate or continue TB treatment on an outpatient basis, but who did not have suitable housing were eligible for this program. The housing unit consisted of a detached cottage in a residential complex. The patient was required to remain in the cottage at all times until given clearance to do otherwise by SDDHS personnel. Compliance was monitored by visits from SDDHS personnel, an on-site manager, and an electronic monitoring device, which was attached to the patient's ankle. Failure to comply with SDDHS policies and procedures resulted in the removal of the patient from the Bissell House to an acute care hospital or other appropriate setting. SDDHS and the San Diego County Housing and Community Development Departments provided the majority of funding for the Bissell House.

Review of Patient Records
Using the San Diego County TB Control Program's computer database, all cases of TB in homeless individuals for the year 1995 (the first full year the YMCA program was in place) were identified. A patient was considered homeless if he/she met the Centers for Disease Control and Prevention (CDC) definition for homelessness at any time while under treatment. According to the CDC, a person is homeless if he/she "is not paying rent, does not own a home or is not steadily living with friends or relatives." Charts for all these patients were reviewed in detail to obtain the following information: patient's age, sex, race, country of origin, HIV status, AFB smear, culture and sensitivity results, site of TB, treatment regimen, duration of treatment, culture conversion, interruptions in therapy, number of hospital admissions, and whether the therapy was considered complete. (Treatment was considered complete if the patient completed a treatment regimen that was in accordance with the 1994 American Thoracic Society/CDC guidelines.6 ) In addition, medical records were reviewed for all individuals housed in the Bissell House between April 1996 and November 1997. These data were recorded anonymously using the patient's medical record number, for identification. This study was reviewed and approved by the Human Subjects Committee of the University of California-San Diego (UCSD) Medical Center.

Cost Information
Cost figures for the YMCA program, Bissell House, DOT, and UCSD hospital admissions were obtained from SDDHS records. These data were used to estimate cost savings.


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 Conclusion
 References
 
Patient Characteristics
Twenty-five patients in 1995 met the CDC definition of homelessness. The records for 23 of 25 homeless individuals in 1995 were available for review. Thirteen homeless patients were housed in the YMCA in 1995. Ten were not. Demographic data, site of disease, and HIV status for the groups of homeless patients from 1995 are shown in Table 1 . The reasons why 10 homeless individuals from 1995 were not housed in the YMCA are shown in Table 2 . Seven patients have been housed in the Bissell House program since its creation in 1996. Demographic data, site of disease, and HIV status for those individuals are also shown in Table 1 . The individuals in the Bissell House group are completely distinct from the 1995 homeless patients. Although four Bissell House patients were subsequently transferred to the YMCA after they were no longer infectious, this occurred after April 1996. There is no overlap between any patients who appear in the 1995 YMCA group and the Bissell House group. Data from these groups, therefore, have been analyzed separately.


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  		Table 1. Patient Demographics, Site of Disease, and HIV Status: (A) Homeless Patients With TB in San Diego County in 1995 and (B) Homeless Patients With TB in San Diego County Housed in the Bissell House Program Between April 1996 and November 1997

 

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  		Table 2. Reasons Why 10 Homeless Individuals Were Not Housed in YMCA in 1995

 
The majority of patients had TB confined to the lung (> 85%). There were two cases of pulmonary disease due to Mycobacterium bovis in the Bissell House group. There were no cases of rifampin-resistant TB and less than 10% of patients had isoniazid-resistant TB in all groups. The type of therapy used (DOT vs unsupervised) is shown in Table 3 .


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  		Table 3. Type of Therapy and Outcomes: (A) Homeless Patients With TB in 1995 and (B) Homeless Patients With TB Housed in the Bissell House Program Between April 1996 and November 1997

 
Conversion of Sputum Smears, Cultures, and Completion of Therapy
The sputum culture conversion rates for both the YMCA and Bissell House groups were 100% (Table 3 ). The Bissell House group also had a 100% smear conversion rate. Greater than 80% of patients in the YMCA program completed an adequate course of TB treatment. All patients in the Bissell House program completed an adequate course of therapy.

Hospital and Housing Program Stays and Estimated Cost Savings
The number and duration of hospitalizations and duration of stay in the housing programs are shown in Table 4 . The estimated cost savings of isolating infectious patients at the Bissell House compared with isolating them in a hospital are shown in Tables 5 and 6 . Prior to the Bissell House, homeless TB patients remained hospitalized until they were no longer considered infectious as this was the only option available. This was usually done at UCSD Medical Center where San Diego County Medical Services pays a subacute daily room charge of $651.00. The Bissell House has cost the county $55.90 per day resulting in a total cost of $17,776.20 for 318 days of housing. Based on these figures, it is estimated that San Diego County has saved $27,034.54 per patient in housing costs through the Bissell House program.


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  		Table 4. Hospitalizations and Duration of Stay in Housing Programs: (A) Homeless Patients With TB in 1995 and (B) Homeless Patients With TB Housed in the Bissell House Program Between April 1996 and November 1997*

 

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  		Table 5. Estimated Cost Savings From Bissell House

 

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  		Table 6. Bissell House Cost Breakdown

 

   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
Conclusion
 References
 
DOT is the most effective method for treatment of TB and has been shown to reduce relapse rates and acquired drug resistance.7 Nevertheless, there are barriers to successful treatment of TB even when DOT is used. Homelessness is perhaps the most significant of these barriers.4 ,5 We have experienced such difficulties in treating homeless patients in San Diego. For this reason, housing programs were developed in conjunction with the DOT program in order to improve TB treatment in the homeless.

Although the numbers are small, initial results suggest that both the YMCA and Bissell House programs are beneficial. TB treatment in patients in the YMCA program and the Bissell House, as manifested by microbiologic conversion of sputum and completion of therapy, was more successful than that for homeless patients in our prior experience in San Diego and as previously reported in the literature. In the YMCA program only 1 of 13 (7.7%) patients failed to complete therapy. Of patients in the Bissell House program, 100% completed treatment. This compares favorably to failure rates of 53% among homeless patients in a report from New York published in 19944 and with our prior experience. For example, only 48.4% of homeless patients in San Diego were confirmed to have completed therapy in 1993.8 Additionally, in the same year, 33.4 and 41.5% of homeless patients in San Diego did not have documented smear and culture conversion, respectively.8 In comparison, the culture conversion rate for the YMCA and Bissell House programs was 100%. The smear conversion rate for the Bissell House was also 100%.

The estimated cost savings from the YMCA and especially the Bissell House program also appear to be substantial. It is the policy of SDDHS that infectious patients without suitable housing be admitted to a hospital for isolation. Such patients remain hospitalized until they are no longer considered infectious, often for weeks after their acute medical needs have been met. The Bissell House provides an option for placement as soon as patients are medically stable and a space is available. After the patient converts his/her smear to negative (three negative sputum AFB smears on three consecutive days), he/she can then be transferred to the YMCA program to complete treatment. The stable treatment environment provided by the YMCA and Bissell House programs is expected to result in reduced rates of relapse, acquired drug resistance, and community spread of TB, producing further cost savings above those yielded by decreased hospital stays.


   Conclusion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
References
 
Although the number of patients was small, our data suggest that implementation of housing programs in conjunction with the use of DOT is effective in improving TB therapy outcomes in the homeless. They provide a basis for conducting a larger study of the use of supervised housing in addition to DOT to aid in the treatment of TB in homeless persons. A multicenter study using supervised housing, conducted in inner cities where homelessness and TB are significant problems, should be considered to confirm and quantify the cost-effectiveness of such an approach.


   Acknowledgements
 
ACKNOWLEDGMENT: We acknowledge Elaine Himelfarb of the ALASDIC for her assistance in gathering information for this manuscript and thank Dr. Mel Hovell for critically reviewing this manuscript.


   Footnotes
 
For related material see page 236.

Correspondence to: Philip A. LoBue, MD, Division of Pulmonary and Critical Care Medicine, University of California, San Diego Medical Center, Mail Code 8374, 200 West Arbor Drive, San Diego, CA 92103-8374; e-mail: plobue@ucsd.edu

Abbreviations: AFB = acid-fast bacillus; ALASDIC = American Lung Association of San Diego and Imperial Counties; CDC = Centers for Disease Control and Prevention; DOT = directly observed therapy; MDR = multiple-drug resistant; SDDHS = San Diego Department of Health Services; UCSD = University of California, San Diego; YMCA = Young Men's Christian Association

Received for publication February 13, 1998. Accepted for publication July 31, 1998.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 References
 

  1. . American Thoracic Society. (1992) Control of TB in the United States. Am Rev Respir Dis 146,1623-1633[ISI][Medline]
  2. Freiden, T, Fujiwara, P, Washko, R, et al (1995) TB in New York City—turning the tide. N Engl J Med 333,229-233[Abstract/Free Full Text]
  3. Brudney, K, Dobkin, J (1991) Resurgent TB in New York City. Am Rev Respir Dis 144,745-749[ISI][Medline]
  4. Concato, J, Rom, W (1994) Endemic TB among homeless men in New York City. Arch Intern Med 154,2069-2073[Abstract]
  5. Burman, W, Cohn, D, Rietmijer, C, et al (1997) Noncompliance with directly observed therapy for TB. Chest 111,1168-1173[Abstract/Free Full Text]
  6. . American Thoracic Society. (1994) Treatment of TB and TB infection in adults and children. Am J Respir Crit Care Med 149,1359-1374[Abstract]
  7. Weis, SE, Slocum, PC, Blais, FX, et al (1994) The effect of directly observed therapy on the rates of drug resistance and relapse in TB. N Engl J Med 330,1179-1184[Abstract/Free Full Text]
  8. LoBue, P, Cass, R, Moser, K, et al (1997) Treatment of TB in the homeless in San Diego [abstract]. Am J Respir Crit Care Med 155,A563



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