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 ID: 373184
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Slide1
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 HealthSlide2
Background
Private
medical providers (PMPs)
provide majority of care for 1/3 of patients with tuberculosis (TB) in California
increasing trend as of 2009
Affordable Care Act may further increase PMP role in TB patient care
Local health departments (LHDs) maintain responsibility for oversight
P
roportion 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 improvementSlide3
Provider Types* in California, by LHD, 2003-2008
*proportion of patients cared for by both PMP and HD not shownSlide4
Objective
Determine whether patient characteristics explain indicator performance differences between patients managed by PMPs and LHDsSlide5
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
characteristicsSlide6
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
Culture Conversion
Documented 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
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 incarcerationSlide7
ResultsSlide8
No Documented Culture Conversion ≤70 Days
Selected
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)
<0.001Slide9
No Documented Culture Conversion ≤70 Days
Multivariable Model Results
Patient
Characteristic
Relative Risk
95% 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 – 0.66Slide10
SAT in Patients with Indications for DOT
Selected
Univariable
Analysis Results
Patient
Characteristic
All Patients
N (%)
SAT
n
(%)
P value
ALL PATIENTS
6824 (100)
746 (11)
--
PMP managed
2271 (33)
568 (25)
< 0.001
N
o 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)
0.005Slide11
SAT in Patients with Indications for DOT
Multivariable Model Results
Patient
Characteristic
Odds
Ratio
95% CI
PMP managed
8.45
8.84 – 11.44
N
o 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 – 0.52Slide12
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 indicationsSlide13
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 associationsSlide14
California Interventions to Improve
PMP-Managed
TB Patient
Care (1)
TB Indicators Project (TIP)
Partnership between state and 14 local TB
c
ontrol programs with highest TB incidence in California
Culture Conversion and DOT/SAT among most-selected indicators
Outcomes improved after TIP interventions in most
LHDsSlide15
California Interventions to Improve
PMP-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 conversionSlide16
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 DOTSlide17
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 careSlide18
Acknowledgements
Anne Cass
Alex Golden
Linda Johnson
Lisa
Pascopella
Fei
Fei
Qin
For more information, please contact
Melissa
Ehman
:
mehman@cdph.ca.gov