Caveat Emptor? Meta-Analysis of Studies Comparing Self-Observed Therapy and Directly Observed Therapy for Tuberculosis

Pasipanodya and Gumbo compared self-administered therapy (SAT) with directly observed therapy (DOT) to determine the proportion of cases with microbiologic failure, relapse, and acquired drug resistance among a pooled cohort of 12 482 persons with tuberculosis from 10 independent studies [1]. The concept of DOT first emerged as a potential therapeutic alternative to resource-intensive hospitalization [2]. Shortly after the introduction of oral antibiotics and during a time when the prevalence of tuberculosis exceeded the availability of hospital beds, well-organized, provider-supervised ambulatory care became the only viable option [2, 3]. However, it was unclear if such therapy could achieve the same success rate as long-term hospitalization. Randomized trials from the late 1950s demonstrated similar patient outcomes to those of hospitalization [3, 4], and thus resources began to shift away from sanatorium-era approaches to clinic-based approaches that have since evolved into the accepted standard of practice for tuberculosis management with DOT. Today similar resource restrictions have forced tuberculosis programs to rethink this strategy and consider less resource-intensive alternative approaches. The polarizing debate and controversy about DOT efficacy is not new [5, 6] and Pasipanodya and Gumbo are not the first to use metaanalysis to seek evidence for consensus [7, 8].