Upload
baldric-hubbard
View
215
Download
2
Embed Size (px)
Citation preview
Culture Conversion and Self-Administered Therapy in Privately Managed Tuberculosis
Patients
Melissa Ehman MPH, Jennifer Flood MD MPH, Pennan Barry MD MPH
Tuberculosis Control Branch, Division of Communicable Disease Control, Center for Infectious Diseases, California Department of Public Health
Background• Private medical providers (PMPs) provide majority of
care for 1/3 of patients with tuberculosis (TB) in California increasing trend as of 2009Affordable Care Act may further increase PMP role in
TB patient care
• Local health departments (LHDs) maintain responsibility for oversight
• Proportion of cases cared for by PMPs varies widely between LHDs, from 3% to 100%
• Differences in indicator results between LHD- and PMP-managed patients point to possible differences in care, and opportunities for improvement
Provider Types* in California, by LHD, 2003-2008
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%Alameda
Contra Costa
FresnoSacramento
Kern
Los AngelesMonterey
Orange
San Bernardino
San Diego
San Francisco
San Joaquin
San MateoSanta Clara
Stanislaus Tulare
Ventura
Yolo
HD %
PMP%
*proportion of patients cared for by both PMP and HD not shown
Objective
Determine whether patient characteristics explain indicator performance differences between patients managed by PMPs and LHDs
Methods• Study population: TB cases counted in California during
2003, 2004, 2005, 2006, 2008• Data sources: RVCT, and Office of AIDS Registry Match
Data for California• TB cases were stratified according to provider type
“LHD” or “PMP/Other”• Exclusions
– “Both” provider type: variation in reporting across LHDs– Diagnosed at death: provider type not routinely reported
• Associations between PMP care and indicator outcomes modeled using multivariable regression, adjusting for patient demographic and clinical characteristics
Study Indicators
First two indicators chosen for inclusion based on:– Public health impact of TB control activity– Known differences in results between PMP and LHD patients
on univariable analysis
1. Culture ConversionDocumented sputum culture conversion to negative within 70 days of treatment start, for sputum culture-positive TB patients who do not die during the first 70 days of treatment
2. Inappropriate Self-Administered Therapy (SAT)Patients receiving only SAT, of those starting treatment and for whom DOT is indicated under California guidelines:
AIDS, drug-resistance, previous TB, culture conversion >60 days, cavitary TB, sputum smear-positive TB, homelessness, drug use, age <18 years, recent incarceration
Results
No Documented Culture Conversion ≤70 DaysSelected Univariable Analysis Results
Patient Characteristic
All Patients
N (%)
No CC ≤70d n (%)
P value
ALL PATIENTS 6328 (100) 1850 (29) --
Age 0-4 years 7 (0.1) 5 (71) 0.026
Any MDR 74 (1.2) 30 (41) 0.030
PMP managed 1849 (29) 730 (39) <0.001
Disseminated disease 109 (1.7) 40 (37) 0.084
Cavitary disease 1712 (28) 580 (34) <0.001
Born in United States 1144 (18) 390 (34) <0.001
Homeless or drug/alcohol use 1155 (18) 379 (33) 0.003
HIV positive 148 (2.3) 45 (30) 0.752
Female 2238 (35) 584 (26) <0.001
DOT for ≥10 weeks 3935 (62) 951 (24) <0.001
No Documented Culture Conversion ≤70 DaysMultivariable Model Results
Patient CharacteristicRelative
Risk95% Confidence
Interval (CI)
Age 0-4 years 2.19 1.24 – 3.86
PMP managed 1.56 1.45 – 1.68
Any MDR 1.72 1.35 – 2.19
Disseminated disease 1.27 1.003 – 1.63
Cavitary disease 1.26 1.16 – 1.36
Homeless or drug/alcohol use 1.17 1.29 – 1.06
Born in United States 1.12 1.02 – 1.23
HIV positive 1.01 0.78 – 1.31
Female 0.87 0.80 – 0.95
DOT for ≥10 weeks 0.61 0.56 – 0.66
SAT in Patients with Indications for DOTSelected Univariable Analysis Results
Patient Characteristic
All Patients
N (%)
SATn (%)
P value
ALL PATIENTS 6824 (100) 746 (11) --
PMP managed 2271 (33) 568 (25) < 0.001
No culture conversion ≤ 60 days 2027 (42) 300 (15) <0.001
History of TB 622 (9.2) 78 (13) 0.174
INH or Rifampin resistance 783 (14) 97 (12) 0.128
Long-term care facility 213 (3.1) 23 (11) 0.948
HIV positive 201 (2.9) 17 (8.4) 0.254
Age < 18 years 863 (13) 70 (8.1) 0.005
Cavitary disease 1823 (29) 129 (7.1) <0.001
Sputum smear-positive 3839 (63) 212 (5.7) <0.001
Homeless or drug/alcohol use 1498 (22) 81 (5.4) <0.001
Correctional facility 204 (3.0) 10 (4.9) 0.005
SAT in Patients with Indications for DOTMultivariable Model Results
Patient Characteristic Odds Ratio 95% CI
PMP managed 8.45 8.84 – 11.44
No culture conversion ≤ 60 days 1.67 1.29 – 2.15
Born in United States 1.39 1.02 – 1.90
History of TB 0.77 0.49 – 1.20
Cavitary disease 0.52 0.39 – 0.70
INH or Rifampin resistance 0.48 0.31 – 0.74
Age < 18 years 0.46 0.22 – 0.97
HIV positive 0.45 0.18 – 1.14
Correctional facility 0.26 0.10 – 0.67
Homeless or drug/alcohol use 0.25 0.16 – 0.39
Smear positive 0.23 0.18 – 0.30
Long-term care facility 0.18 0.07 – 0.49
Disseminated disease 0.17 0.06 – 0.52
Summary
Documented Sputum Culture Conversion ≤ 70 Days• After adjustment for confounders, PMP-managed TB
patients less likely to culture convert, vs. LHD-managed • Patients with MDR TB or cavitary disease less likely to
document culture conversion ≤ 70 days• Patients receiving ≥ 10 weeks of DOT more likely to
document culture conversion ≤ 70 days
SAT When DOT Is Indicated• PMP-managed TB patients more likely to receive SAT
throughout treatment when DOT is indicated• Patients slow to culture convert more likely to receive
SAT, vs. those with other DOT indications
Limitations
• Preliminary results• Caution for interpretation at local level
– Reporting of provider type varies across LHDs– Influence of patient characteristics may also vary
• Unmeasured confounders, e.g., comorbidities and culture conversion
• Odds ratios are likely overestimates of magnitude of true associations
California Interventions to ImprovePMP-Managed TB Patient Care (1)
TB Indicators Project (TIP) • Partnership between state and 14 local TB control
programs with highest TB incidence in California• Culture Conversion and DOT/SAT among most-selected
indicators• Outcomes improved after TIP interventions in most LHDs
California Interventions to ImprovePMP-Managed TB Patient Care (2)
State TB Program Interventions• Fact sheets on DOT and culture conversion
– targeted to PMPs
LHD TB Program Interventions• Letter to PMP at diagnosis
– outlining standards of care and LHD role• Provide DOT and sputum collection for PMP patients• Regular case management conferences
– identify patients not on DOT or without documented culture conversion
Conclusions
When other characteristics are taken into account,
PMP-managed patients are at higher risk for:• not having a documented, timely culture conversion • receiving SAT when DOT is indicated
When TB patients cannot be managed by the LHD, strategies to ensure a consistent level of TB care for PMP patients are needed
Outcomes might improve by LHD overseeing culture conversion and providing DOT
Next Steps• Sensitivity analysis of culture conversion
within 70 vs. 60 days• Assess additional indicators of interest
• Completion of therapy, to inform feasibility of improving performance
• Deaths during therapy, to avert preventable deaths in the future
• Include new surveillance fields:• Comorbidities• Patients receiving only inpatient care
• Measure effectiveness of specific LHD interventions to improve outcomes for patients under PMP care
Acknowledgements
• Anne Cass• Alex Golden• Linda Johnson• Lisa Pascopella• Fei Fei Qin
For more information, please contact Melissa Ehman: [email protected]