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Papers by Sarah Kiskadden-Bechtel
Senior Project submitted to The Division of Languages and Literature of Bard College
Voices in bioethics, Feb 1, 2016
JAMA Network Open, 2022
IMPORTANCE Electronic directly observed therapy (DOT) is used increasingly as an alternative to i... more IMPORTANCE Electronic directly observed therapy (DOT) is used increasingly as an alternative to in-person DOT for monitoring tuberculosis treatment. Evidence supporting its efficacy is limited. OBJECTIVE To determine whether electronic DOT can attain a level of treatment observation as favorable as in-person DOT. DESIGN, SETTING, AND PARTICIPANTS This was a 2-period crossover, noninferiority trial with initial randomization to electronic or in-person DOT at the time outpatient tuberculosis treatment began. The trial enrolled 216 participants with physician-suspected or bacteriologically confirmed tuberculosis from July 2017 to October 2019 in 4 clinics operated by the New York City Health Department. Data analysis was conducted between March 2020 and April 2021. INTERVENTIONS Participants were asked to complete 20 medication doses using 1 DOT method, then switched methods for another 20 doses. With in-person therapy, participants chose clinic or community-based DOT; with electronic DOT, participants chose live video-conferencing or recorded videos. MAIN OUTCOMES AND MEASURES Difference between the percentage of medication doses participants were observed to completely ingest with in-person DOT and with electronic DOT. Noninferiority was demonstrated if the upper 95% confidence limit of the difference was 10% or less. We estimated the percentage of completed doses using a logistic mixed effects model, run in 4 modes: modified intention-to-treat, per-protocol, per-protocol with 85% or more of doses conforming to the randomization assignment, and empirical. Confidence intervals were estimated by bootstrapping (with 1000 replicates). RESULTS There were 173 participants in each crossover period (median age, 40 years [range, 16-86 years]; 140 [66%] men; 80 [37%] Asian and Pacific Islander, 43 [20%] Black, and 71 [33%] Hispanic individuals) evaluated with the model in the modified intention-to-treat analytic mode. The percentage of completed doses with in-person DOT was 87.2% (95% CI, 84.6%-89.9%) vs 89.8% (95% CI, 87.5%-92.1%) with electronic DOT. The percentage difference was −2.6% (95% CI, −4.8% to −0.3%), consistent with a conclusion of noninferiority. The 3 other analytic modes yielded equivalent conclusions, with percentage differences ranging from −4.9% to −1.9%. CONCLUSIONS AND RELEVANCE In this trial, the percentage of completed doses under electronic DOT was noninferior to that under in-person DOT. This trial provides evidence supporting the (continued) Key Points Question Is electronic directly observed therapy (DOT) noninferior to in-person DOT in supporting medication adherence for tuberculosis treatment? Findings In this randomized, 2-period crossover noninferiority trial of 216 patients with tuberculosis, the modified intention-to-treat analysis estimate of the percentage of medication doses staff observed patients ingest with in-person DOT was 87.2% vs 89.8% with electronic DOT. The percentage difference between DOT methods was −2.6%, which was less than the noninferiority margin of 10% at a statistically significant level. Meaning These findings suggest that electronic DOT was noninferior to in-person DOT when employed by a tuberculosis program that has historically implemented in-person DOT successfully.
Voices in Bioethics, Oct 18, 2016
Medical tourism widens the sphere of available medical care beyond a single country's borders... more Medical tourism widens the sphere of available medical care beyond a single country's borders. Patients who voluntarily leave their home country to seek treatment in other countries typically do so out of perceived medical necessity; these procedures—which are often poorly covered by insurance—range from mandatory heart surgery, to kidney or other organ transplants. In conflict-laden countries like Israel, organ donation rates "are among the lowest in the developed world, about one-third the rate in Western Europe,"[1] giving rise to advertisements for transplants due to inherent shortage.[2] Although rabbis offer different opinions about whether organ transplantation should be permissible under Jewish law, Israeli citizens have been known to venture as far as South Africa to undergo illegal kidney transplants.[3] Clearly, there is palpable incentive for Israeli citizens to receive organ transplants; questions remain, however, regarding whether and how these organs are...
Senior Project submitted to The Division of Languages and Literature of Bard College
Voices in bioethics, Feb 1, 2016
JAMA Network Open, 2022
IMPORTANCE Electronic directly observed therapy (DOT) is used increasingly as an alternative to i... more IMPORTANCE Electronic directly observed therapy (DOT) is used increasingly as an alternative to in-person DOT for monitoring tuberculosis treatment. Evidence supporting its efficacy is limited. OBJECTIVE To determine whether electronic DOT can attain a level of treatment observation as favorable as in-person DOT. DESIGN, SETTING, AND PARTICIPANTS This was a 2-period crossover, noninferiority trial with initial randomization to electronic or in-person DOT at the time outpatient tuberculosis treatment began. The trial enrolled 216 participants with physician-suspected or bacteriologically confirmed tuberculosis from July 2017 to October 2019 in 4 clinics operated by the New York City Health Department. Data analysis was conducted between March 2020 and April 2021. INTERVENTIONS Participants were asked to complete 20 medication doses using 1 DOT method, then switched methods for another 20 doses. With in-person therapy, participants chose clinic or community-based DOT; with electronic DOT, participants chose live video-conferencing or recorded videos. MAIN OUTCOMES AND MEASURES Difference between the percentage of medication doses participants were observed to completely ingest with in-person DOT and with electronic DOT. Noninferiority was demonstrated if the upper 95% confidence limit of the difference was 10% or less. We estimated the percentage of completed doses using a logistic mixed effects model, run in 4 modes: modified intention-to-treat, per-protocol, per-protocol with 85% or more of doses conforming to the randomization assignment, and empirical. Confidence intervals were estimated by bootstrapping (with 1000 replicates). RESULTS There were 173 participants in each crossover period (median age, 40 years [range, 16-86 years]; 140 [66%] men; 80 [37%] Asian and Pacific Islander, 43 [20%] Black, and 71 [33%] Hispanic individuals) evaluated with the model in the modified intention-to-treat analytic mode. The percentage of completed doses with in-person DOT was 87.2% (95% CI, 84.6%-89.9%) vs 89.8% (95% CI, 87.5%-92.1%) with electronic DOT. The percentage difference was −2.6% (95% CI, −4.8% to −0.3%), consistent with a conclusion of noninferiority. The 3 other analytic modes yielded equivalent conclusions, with percentage differences ranging from −4.9% to −1.9%. CONCLUSIONS AND RELEVANCE In this trial, the percentage of completed doses under electronic DOT was noninferior to that under in-person DOT. This trial provides evidence supporting the (continued) Key Points Question Is electronic directly observed therapy (DOT) noninferior to in-person DOT in supporting medication adherence for tuberculosis treatment? Findings In this randomized, 2-period crossover noninferiority trial of 216 patients with tuberculosis, the modified intention-to-treat analysis estimate of the percentage of medication doses staff observed patients ingest with in-person DOT was 87.2% vs 89.8% with electronic DOT. The percentage difference between DOT methods was −2.6%, which was less than the noninferiority margin of 10% at a statistically significant level. Meaning These findings suggest that electronic DOT was noninferior to in-person DOT when employed by a tuberculosis program that has historically implemented in-person DOT successfully.
Voices in Bioethics, Oct 18, 2016
Medical tourism widens the sphere of available medical care beyond a single country's borders... more Medical tourism widens the sphere of available medical care beyond a single country's borders. Patients who voluntarily leave their home country to seek treatment in other countries typically do so out of perceived medical necessity; these procedures—which are often poorly covered by insurance—range from mandatory heart surgery, to kidney or other organ transplants. In conflict-laden countries like Israel, organ donation rates "are among the lowest in the developed world, about one-third the rate in Western Europe,"[1] giving rise to advertisements for transplants due to inherent shortage.[2] Although rabbis offer different opinions about whether organ transplantation should be permissible under Jewish law, Israeli citizens have been known to venture as far as South Africa to undergo illegal kidney transplants.[3] Clearly, there is palpable incentive for Israeli citizens to receive organ transplants; questions remain, however, regarding whether and how these organs are...