The use of legal action in New York City to ensure treatment of tuberculosis

Background and Methods After an increase in the number of cases of tubercul osis, New York City passed regulations to address the problem of nonadheren ce to treatment regimens. The commissioner of health can issue orders compe lling a person to be examined for tuberculosis, to complete treatment, to r eceive treatment under direct observation, or to be detained for treatment. On the basis of a review of patients' records, we evaluated the use of the se legal actions between April 1993 and April 1995. Results Among more than 8000 patients with tuberculosis, regulatory orders were issued for less than 4 percent. Among patients with a variety of socia l problems, only a minority required regulatory intervention: 10 percent of those with injection-drug use, 16 percent of those with alcohol abuse, 17 percent of those who were homeless, 29 percent of those who used "crack" co caine, and 38 percent of those with a history of incarceration. A total of 150 patients were ordered to undergo directly observed therapy, 139 patient s to be detained during therapy, 12 patients to be examined for tuberculosi s, and 3 patients to complete treatment. These 304 patients had a median of three prior hospitalizations related to tuberculosis and one episode of le aving the hospital against medical advice. Repeatedly noncompliant patients and those who left the hospital against medical advice were more likely th an others to be detained. The median length of detention was 3 weeks for in fectious patients and 28 weeks for noninfectious patients. As compared with patients ordered to receive directly observed therapy, the patients who we re detained remained infectious longer, had left hospitals against medical advice more often, and were less likely to accept directly observed therapy voluntarily. Altogether, excluding those who died or moved, 96 percent of the patients completed treatment, and 2 percent continued to receive treatm ent for multidrug-resistant tuberculosis. Conclusions For most patients with tuberculosis, even those with severe soc ial problems, completion of treatment can usually be achieved without regul atory intervention. Patients were detained on the basis of their history of tuberculosis, rather than on the basis of their social characteristics, an d the less restrictive measure of mandatory directly observed therapy was o ften effective. (N Engl J Med 1999;340:359-66.) (C) 1999, Massachusetts Med ical Society.