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Importance: Elimination of tuberculosis (TB) disease in the US hinges on the ability of tests to detect individual risk of developing disease to inform prevention. The relative performance of 3 available TB tests-the tuberculin skin test (TST) and 2 interferon-γ release assays (IGRAs; QuantiFERON-TB Gold In-Tube [QFT-GIT] and SPOT.TB [TSPOT])-in predicting TB disease development in the US remains unknown. Objective: To compare the performance of the TST with the QFT-GIT and TSPOT IGRAs in predicting TB disease in high-risk populations. Design, Setting, and Participants: This prospective diagnostic study included participants at high risk of TB infection (TBI) or progression to TB disease at 10 US sites between 2012 and 2020. Participants of any age who had close contact with a case patient with infectious TB, were born in a country with medium or high TB incidence, had traveled recently to a high-incidence country, were living with HIV infection, or were from a population with a high local prevalence were enrolled from July 12, 2012, through May 5, 2017. Participants were assessed for 2 years after enrollment and through registry matches until the study end date (November 15, 2020). Data analysis was performed in June 2023. Exposures: At enrollment, participants were concurrently tested with 2 IGRAs (QFT-GIT from Qiagen and TSPOT from Oxford Immunotec) and the TST. Participants were classified as case patients with incident TB disease when diagnosed more than 30 days from enrollment. Main Outcomes and Measures: Estimated positive predictive value (PPV) ratios from generalized estimating equation models were used to compare test performance in predicting incident TB. Incremental changes in PPV were estimated to determine whether predictive performance significantly improved with the addition of a second test. Case patients with prevalent TB were examined in sensitivity analysis. Results: A total of 22â¯020 eligible participants were included in this study. Their median age was 32 (range, 0-102) years, more than half (51.2%) were male, and the median follow-up was 6.4 (range, 0.2-8.3) years. Most participants (82.0%) were born outside the US, and 9.6% were close contacts. Tuberculosis disease was identified in 129 case patients (0.6%): 42 (0.2%) had incident TB and 87 (0.4%) had prevalent TB. The TSPOT and QFT-GIT assays performed significantly better than the TST (PPV ratio, 1.65 [95% CI, 1.35-2.02] and 1.47 [95% CI, 1.22-1.77], respectively). The incremental gain in PPV, given a positive TST result, was statistically significant for positive QFT-GIT and TSPOT results (1.64 [95% CI, 1.40-1.93] and 1.94 [95% CI, 1.65-2.27], respectively). Conclusions and Relevance: In this diagnostic study assessing predictive value, IGRAs demonstrated superior performance for predicting incident TB compared with the TST. Interferon-γ release assays provided a statistically significant incremental improvement in PPV when a positive TST result was known. These findings suggest that IGRA performance may enhance decisions to treat TBI and prevent TB.
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Infecções por HIV , Tuberculose , Humanos , Masculino , Feminino , Adulto , Testes de Liberação de Interferon-gama , Teste Tuberculínico , Tuberculina , Estudos Prospectivos , Tuberculose/diagnóstico , Tuberculose/epidemiologiaRESUMO
BACKGROUND: Adverse childhood experiences (ACEs) can have severe negative impacts on childhood and adult health via worsened school engagement and educational outcomes. This study seeks to identify the relative importance of various ACEs in predicting school engagement. METHODS: We analyzed data from the National Survey of Children's Health for school-aged children (ages 6-17) for 2018 and 2019. The primary outcome was school engagement, measured through three variables: repeating a grade, doing required homework, and caring about doing well in school. We conducted three logistic regression models with dominance analyses to identify the relative importance of ACE variables in predicting school engagement outcomes. RESULTS: In unadjusted and adjusted dominance analyses, parental incarceration was the most important ACE in predicting repeating a grade. Living in a household in which it was hard to cover basics like food or housing was the most important ACE in predicting doing required homework and caring about doing well in school. DISCUSSION: Our study points toward the large influence of out-of-school factors on school engagement. Parental incarceration and economic hardship, the most important predictors of engagement, are issues that can be addressed and mitigated through policy interventions. With limited funds available for education and public health interventions, it is crucial that these two ACEs be priority considerations when developing policy. A multi-faceted approach that reduces the incarcerated population, encourages economic well-being, and emphasizes early-childhood education has the potential to significantly improve school engagement in vulnerable populations and ultimately advance social equity.
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Experiências Adversas da Infância , Adolescente , Humanos , Criança , Estudos Transversais , Instituições Acadêmicas , Escolaridade , PobrezaRESUMO
BACKGROUND: Individuals on immunosuppressive therapies experience greater morbidity and mortality due to vaccine-preventable illnesses, but there are low rates of adherence to immunization guidelines within this population. OBJECTIVE: To determine the effectiveness of clinician-led education, patient-centered dialogue, and immediately available immunization on influenza vaccination uptake in patients taking immunosuppressive therapies. METHOD: We used a controlled before-and-after quasi-experimental design to evaluate our quality improvement intervention occurring from September 2019 to March 2020, with follow-up through July 2020. The study included 2 dermatology practices wherein nursing staff offered influenza vaccination during patient rooming (standard care). Within each practice, clinicians either implemented the intervention or provided only standard care. Patients received the intervention or standard care depending on the clinician they visited. Patients seen at the 2 clinics during the intervention period were included in analyses if they were taking or newly prescribed immunosuppressant medication at the time of their visit. We examined influenza immunization status for 3 flu seasons: 2017-2018 (preintervention), 2018-2019 (preintervention), and 2019-2020 (intervention). INTERVENTION: Immunosuppressed patients initially declining an influenza vaccine were provided dermatologist-led education on the benefits of immunization. Dermatologists explored and addressed individual patients' immunization concerns. Influenza vaccination was then offered immediately postdialogue. RESULTS: Analyses included 201 dermatology patients who were prescribed or currently taking immunosuppressive medication (intervention group [72.6%], comparison group [27.4%]). During the intervention period, 91.1% of the intervention group received influenza vaccination compared to 56.4% of the comparison group. Vaccination trends from 2018-2019 (preintervention) to 2019-2020 (intervention) differed significantly between groups (χ2 = 22.92, P < .001), with greater improvement in the intervention group. In 2019-2020, influenza vaccination was more likely in the intervention group relative to the comparison group (odds ratio: 16.22, 95% confidence interval: 5.55-47.38). In the subset of patients that had never received an influenza vaccine, influenza immunization in 2019-2020 was more common in the intervention group (75.8%, 25/33) relative to the comparison group (13.3%, 2/15, P < .001). CONCLUSION: The intervention successfully addressed vaccine hesitancy and improved influenza immunization rates in an immunosuppressed population receiving care from a specialty clinic. Implementing a similar model across specialty clinics may improve vaccination rates for influenza, coronavirus disease 2019, and other vaccine-preventable illnesses in other populations.
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COVID-19 , Vacinas contra Influenza , Influenza Humana , Humanos , Vacinas contra Influenza/uso terapêutico , Influenza Humana/tratamento farmacológico , Influenza Humana/prevenção & controle , Vacinação , Hesitação VacinalRESUMO
BACKGROUND: Tuberculosis (TB) elimination within the United States will require scaling up TB preventive services. Many public health departments offer care for latent tuberculosis infection (LTBI), although gaps in the LTBI care cascade are not well quantified. An understanding of these gaps will be required to design targeted public health interventions. METHODS: We conducted a cohort study through the Tuberculosis Epidemiologic Studies Consortium (TBESC) within 15 local health department (LHD) TB clinics across the United States. Data were abstracted on individuals receiving LTBI care during 2016-2017 through chart review. Our primary objective was to quantify the LTBI care cascade, beginning with LTBI testing and extending through treatment completion. RESULTS: Among 23 885 participants tested by LHDs, 46% (11 009) were male with a median age of 31 (interquartile range [IQR] 20-46). A median of 35% of participants were US-born at each site (IQR 11-78). Overall, 16 689 (70%) received a tuberculin skin test (TST), 6993 (29%) received a Quantiferon (QFT), and 1934 (8%) received a T-SPOT.TB; 5% (1190) had more than one test. Among those tested, 2877 (12%) had at least one positive test result (3% among US-born, and 23% among non-US-born, Pâ <â .01). Of 2515 (11%) of the total participants diagnosed with LTBI, 1073 (42%) initiated therapy, of whom 817 (76%) completed treatment (32% of those with LTBI diagnosis). CONCLUSIONS: Significant gaps were identified along the LTBI care cascade, with less than half of individuals diagnosed with LTBI initiating therapy. Further research is needed to better characterize the factors impeding LTBI diagnosis, treatment initiation, and treatment completion.
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Tuberculose Latente , Tuberculose , Humanos , Masculino , Estados Unidos/epidemiologia , Feminino , Tuberculose Latente/diagnóstico , Tuberculose Latente/tratamento farmacológico , Tuberculose Latente/epidemiologia , Estudos de Coortes , Saúde Pública , Teste Tuberculínico , Testes de Liberação de Interferon-gamaRESUMO
ABSTRACT: More than 70% of tuberculosis (TB) cases diagnosed in the United States (US) occur in non-US-born persons, and this population has experienced less than half the recent incidence rate declines of US-born persons (1.5% vs 4.2%, respectively). The great majority of TB cases in non-US-born persons are attributable to reactivation of latent tuberculosis infection (LTBI). Strategies to expand LTBI-focused TB prevention may depend on LTBI positive non-US-born persons' access to, and ability to pay for, health care.To examine patterns of health insurance coverage and usual sources of health care among non-US-born persons with LTBI, and to estimate LTBI prevalence by insurance status and usual sources of health care.Self-reported health insurance and usual sources of care for non-US-born persons were analyzed in combination with markers for LTBI using 2011-2012 National Health and Nutrition Examination Survey (NHANES) data for 1793 sampled persons. A positive result on an interferon gamma release assay (IGRA), a blood test which measures immunological reactivity to Mycobacterium tuberculosis infection, was used as a proxy for LTBI. We calculated demographic category percentages by IGRA status, IGRA percentages by demographic category, and 95% confidence intervals for each percentage.Overall, 15.9% [95% confidence interval (CI)â=â13.5, 18.7] of non-US-born persons were IGRA-positive. Of IGRA-positive non-US-born persons, 63.0% (95% CIâ=â55.4, 69.9) had insurance and 74.1% (95% CIâ=â69.2, 78.5) had a usual source of care. IGRA positivity was highest in persons with Medicare (29.1%; 95% CI: 20.9, 38.9).Our results suggest that targeted LTBI testing and treatment within the US private healthcare sector could reach a large majority of non-US-born individuals with LTBI. With non-US-born Medicare beneficiaries' high prevalence of LTBI and the high proportion of LTBI-positive non-US-born persons with private insurance, future TB prevention initiatives focused on these payer types are warranted.
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Atenção à Saúde/economia , Emigrantes e Imigrantes/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Tuberculose Latente/epidemiologia , Adolescente , Adulto , Idoso , Criança , Estudos Transversais , Atenção à Saúde/estatística & dados numéricos , Feminino , Acessibilidade aos Serviços de Saúde , Humanos , Incidência , Cobertura do Seguro/tendências , Testes de Liberação de Interferon-gama/métodos , Tuberculose Latente/diagnóstico , Tuberculose Latente/prevenção & controle , Masculino , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Mycobacterium tuberculosis/imunologia , Inquéritos Nutricionais/métodos , Prevalência , Estados Unidos/epidemiologia , Adulto JovemRESUMO
BACKGROUND: There is excess amenable mortality risk and evidence of healthcare quality deficits for persons with serious mental illness (SMI). We sought to identify sociodemographic and clinical characteristics associated with variations in two 2015 Healthcare Effectiveness Data and Information Set (HEDIS) measures, antipsychotic medication adherence and preventive diabetes screening, among Medicaid enrollees with serious mental illness (SMI). METHODS: We retrospectively analyzed claims data from September 2014 to December 2015 from enrollees in a Medicaid specialty health plan in Florida. All plan enrollees had SMI; analyses included continuously enrolled adults with antipsychotic medication prescriptions and schizophrenia or bipolar disorder. Associations were identified using mixed effects logistic regression models. RESULTS: Data for 5502 enrollees were analyzed. Substance use disorders, depression, and having both schizophrenia and bipolar disorder diagnoses were associated with both HEDIS measures but the direction of the associations differed; each was significantly associated with antipsychotic medication non-adherence (a marker of suboptimal care quality) but an increased likelihood of diabetes screening (a marker of quality care). Compared to whites, blacks and Hispanics had a significantly greater risk of medication non-adherence. Increasing age was significantly associated with increasing medication adherence, but the association between age and diabetes screening varied by sex. Other characteristics significantly associated with quality variations according to one or both measures were education (associated with antipsychotic medication adherence), urbanization (relative to urban locales, residing in suburban areas was associated with both adherence and diabetes screening), obesity (associated with both adherence and diabetes screening), language (non-English speakers had a greater likelihood of diabetes screening), and anxiety, asthma, and hypertension (each positively associated with diabetes screening). CONCLUSIONS: The characteristics associated with variations in the quality of care provided to Medicaid enrollees with SMI as gauged by two HEDIS measures often differed, and at times associations were directionally opposite. The variations in the quality of healthcare received by persons with SMI that were identified in this study can guide quality improvement and delivery system reform efforts; however, given the sociodemographic and clinical characteristics' differing associations with different measures of care quality, multidimensional approaches are warranted.
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Antipsicóticos , Diabetes Mellitus , Adulto , Antipsicóticos/uso terapêutico , Florida , Humanos , Medicaid , Adesão à Medicação , Estudos Retrospectivos , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Risk-targeted testing and treatment of latent tuberculosis infection (LTBI) is a critical component of the United States' (US) tuberculosis (TB) elimination strategy, but relatively low treatment completion rates remain a challenge. Both treatment persistence and completion may be facilitated by diagnosing LTBI using interferon gamma release assays (IGRA) rather than tuberculin skin tests (TST). METHODS: We used a national sample of administrative claims data to explore associations diagnostic test choice (TST, IGRA, TST with subsequent IGRA) and treatment persistence and completion in persons initiating a daily dose isoniazid LTBI treatment regimen in the US private healthcare sector between July 2011 and March 2014. Associations were analyzed with a generalized ordered logit model (completion) and a negative binomial regression model (persistence). RESULTS: Of 662 persons initiating treatment, 327 (49.4%) completed at least the 6-month regimen and 173 (26.1%) completed the 9-month regimen; 129 (19.5%) persisted in treatment one month or less. Six-month completion was least likely in persons receiving a TST (42.2%) relative to persons receiving an IGRA (55.0%) or TST then IGRA (67.2%; p = 0.001). Those receiving an IGRA or a TST followed by an IGRA had higher odds of completion compared to those receiving a TST (aOR = 1.59 and 2.50; p = 0.017 and 0.001, respectively). Receiving an IGRA or a TST and subsequent IGRA was associated with increased treatment persistence relative to TST (aIRR = 1.14 and 1.25; p = 0.027 and 0.009, respectively). CONCLUSIONS: IGRA use is significantly associated with both higher levels of LTBI treatment completion and treatment persistence. These differences are apparent both when IGRAs alone were administered and when IGRAs were administered subsequent to a TST. Our results suggest that IGRAs contribute to more effective LTBI treatment and consequently individual and population protections against TB.
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Antituberculosos/uso terapêutico , Isoniazida/uso terapêutico , Tuberculose Latente/diagnóstico , Tuberculose Latente/tratamento farmacológico , Adolescente , Adulto , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Seguro Saúde , Testes de Liberação de Interferon-gama , Tuberculose Latente/epidemiologia , Masculino , Pessoa de Meia-Idade , Estados Unidos/epidemiologia , Adulto JovemRESUMO
To improve latent tuberculosis infection treatment completion rates, Tarrant County Public Health began providing after-dusk home delivery of a 12-dose latent tuberculosis infection regimen of weekly rifapentine plus isoniazid administered via directly observed preventive therapy during Ramadan, a month of prayer and daytime fasting observed by Muslims. In unadjusted difference-in-difference logistic regression analyses (n = 148), Muslim patients had lower treatment completion rates than non-Muslim patients during Ramadan prior to program implementation (68.8% vs 95.4%), whereas rates were comparable postimplementation (95.7% vs 96.4%; difference-in-difference P = .011). Similar results were found after adjusting for age and gender (pre: 71.4% vs 94.8%; post: 95.5% vs 96.3%; P = .032). These findings provide evidence of the need for and effectiveness of programmatic innovations tailored to the varying cultural norms of the widely diverse populations served by public health authorities and suggest that culturally competent clinical care may advance population health goals.
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Assistência à Saúde Culturalmente Competente , Tuberculose Latente , Refugiados , Humanos , Islamismo , Isoniazida , Tuberculose Latente/diagnóstico , Tuberculose Latente/terapiaRESUMO
OBJECTIVE: To use hospital-level data from the US to determine whether private patient rooms (PPRs) are associated with fewer in hospital-acquired methicillin-resistant Staphylococcus aureus (HA-MRSA) infections. METHODS: We retrospectively analyzed Texas Inpatient Public Use Data with discharges between September 2015 and August 2016 merged with American Hospital Association annual survey data. We used negative binomial regression to estimate the association between the proportion of PPRs within a hospital and the count of discharges with HA-MRSA infections, adjusting for potentially confounding variables. RESULTS: We analyzed data for 340 hospitals and 2,670,855 discharges. HA-MRSA incidence within these hospitals was 386 per 100,000 discharges (95% CI: 379, 393) and, on average, 62.73% (95% CI: 58.99, 66.46) of rooms in these hospitals were PPRs. PPRs were significantly associated with fewer HA-MRSA infections (unadjusted IRR = 0.973, 95% CI: 0.968, 0.979; adjusted IRR = 0.992, 95% CI: 0.991, 0.994; p<0.001 for both); at the hospital level, as the percentage of PPRs increased, HA-MRSA infection rates decreased. This association was non-linear; in hospitals with few PPRs there was a stronger association between PPRs and HA-MRSA infection rate relative to hospitals with many PPRs. CONCLUSION: We identified 0.8% fewer HA-MRSA infections for each 1% increase in PPRs as a proportion of all rooms, suggesting that private rooms provide substantial protection from HA-MRSA. Small changes may not induce significant improvements in HA-MRSA incidence, and hospitals seeking tangible benefits in HAI reduction likely need to markedly increase the proportion of PPRs through large-scale renovations. The effect of private rooms is disproportionate across hospitals. Hospitals with proportionately fewer PPRs stand to gain the most from adding additional PPRs, while those with an already high proportion of PPRs are unlikely to see large benefits. Our findings enable hospital administrators to consider potential patient safety benefits as they make decisions about facility design and renovation.
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Infecção Hospitalar/epidemiologia , Staphylococcus aureus Resistente à Meticilina , Quartos de Pacientes/organização & administração , Infecções Estafilocócicas/epidemiologia , Infecção Hospitalar/prevenção & controle , Feminino , Hospitais , Humanos , Incidência , Masculino , Estudos Retrospectivos , Infecções Estafilocócicas/prevenção & controle , Texas , Estados UnidosRESUMO
BACKGROUND: Factors that affect latent tuberculosis infection (LTBI) treatment completion in the US have not been well studied beyond public health settings. This gap was highlighted by recent health insurance-related regulatory changes that are likely to increase LTBI treatment by private sector healthcare providers. We analyzed LTBI treatment completion in the private healthcare setting to facilitate planning around this important opportunity for tuberculosis (TB) control in the US. METHODS: We analyzed a national sample of commercial insurance medical and pharmacy claims data for people ages 0 to 64 years who initiated daily dose isoniazid treatment between July 2011 and March 2014 and who had complete data. All individuals resided in the US. Factors associated with treatment completion were examined using multivariable generalized ordered logit models and bivariate Kruskal-Wallis tests or Spearman correlations. RESULTS: We identified 1072 individuals with complete data who initiated isoniazid LTBI treatment. Treatment completion was significantly associated with less restrictive health insurance, age < 15 years, patient location, use of interferon-gamma release assays, non-poverty, HIV diagnosis, immunosuppressive drug therapy, and higher cumulative counts of clinical risk factors. CONCLUSIONS: Private sector healthcare claims data provide insights into LTBI treatment completion patterns and patient/provider behaviors. Such information is critical to understanding the opportunities and limitations of private healthcare in the US to support treatment completion as this sector's role in protecting against and eliminating TB grows.
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Antituberculosos/uso terapêutico , Tuberculose Latente/tratamento farmacológico , Cooperação do Paciente/estatística & dados numéricos , Adolescente , Adulto , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Revisão da Utilização de Seguros , Tuberculose Latente/epidemiologia , Masculino , Pessoa de Meia-Idade , Setor Privado/estatística & dados numéricos , Fatores Socioeconômicos , Estados Unidos/epidemiologia , Adulto JovemRESUMO
OBJECTIVE: To determine whether latent tuberculosis infection risk factors are associated with an increased likelihood of latent tuberculosis infection testing in the US private healthcare sector. DATA SOURCE: A national sample of medical and pharmacy claims representing services rendered January 2011 through December 2013 for 3,997,986 commercially insured individuals in the US who were 0 to 64 years of age. STUDY DESIGN: We used multivariable logistic regression models to determine whether TB/LTBI risk factors were associated with an increased likelihood of Interferon-Gamma Release Assay (IGRA) or Tuberculin Skin Test (TST) testing in the private sector. PRINCIPAL FINDINGS: 4.31% (4.27-4.34%) received at least one TST/IGRA test between 2011 and 2013 while 1.69% (1.67-1.72%) received a TST/IGRA test in 2013. Clinical risk factors associated with a significantly increased likelihood of testing included HIV, immunosuppressive therapy, exposure to tuberculosis, a history of tuberculosis, diabetes, tobacco use, end stage renal disease, and alcohol use disorder. Other significant variables included gender, age, asthma, the state tuberculosis rate, population density, and percent of foreign-born persons in a county. CONCLUSIONS: Private sector TST/IGRA testing is not uncommon and testing varies with clinical risk indicators. Thus, the private sector can be a powerful resource in the fight against tuberculosis. Analyses of administrative data can inform how best to leverage private sector healthcare toward tuberculosis prevention activities.
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Atenção à Saúde/estatística & dados numéricos , Testes de Liberação de Interferon-gama , Setor Privado/estatística & dados numéricos , Teste Tuberculínico , Tuberculose/diagnóstico , Tuberculose/prevenção & controle , Adolescente , Adulto , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Estados Unidos , Adulto JovemRESUMO
Rationale: More information on risk factors for death from tuberculosis in the United States could help reduce the tuberculosis mortality rate, which has remained steady for more than a decade.Objective: To identify risk factors for tuberculosis-related death in adults.Methods: We performed a retrospective study of 1,304 adults with tuberculosis who died before treatment completion and 1,039 frequency-matched control subjects who completed tuberculosis treatment in 2005 to 2006 in 13 states reporting 65% of U.S. tuberculosis cases. We used in-depth record abstractions and a standard algorithm to classify deaths in persons with tuberculosis as tuberculosis-related or not. We then compared these classifications to causes of death as coded in death certificates. We used multivariable logistic regression to calculate adjusted odds ratios for predictors of tuberculosis-related death among adults compared with those who completed tuberculosis treatment.Results: Of 1,304 adult deaths, 942 (72%) were tuberculosis related, 272 (21%) were not, and 90 (7%) could not be classified. Of 847 tuberculosis-related deaths with death certificates available, 378 (45%) did not list tuberculosis as a cause of death. Adjusting for known risks, we identified new risks for tuberculosis-related death during treatment: absence of pyrazinamide in the initial regimen (adjusted odds ratio, 3.4; 95% confidence interval, 1.9-6.0); immunosuppressive medications (adjusted odds ratio, 2.5; 95% confidence interval, 1.1-5.6); incomplete tuberculosis diagnostic evaluation (adjusted odds ratio, 2.2; 95% confidence interval, 1.5-3.3), and an alternative nontuberculosis diagnosis before tuberculosis diagnosis (adjusted odds ratio, 1.6; 95% confidence interval, 1.2-2.2).Conclusions: Most persons who died with tuberculosis had a tuberculosis-related death. Intensive record review revealed tuberculosis as a cause of death more often than did death certificate diagnoses. New tools, such as a tuberculosis mortality risk score based on our study findings, may identify patients with tuberculosis for in-hospital interventions to prevent death.
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CONTEXT: Targeted identification and treatment of people with latent tuberculosis infection (LTBI) are key components of the US tuberculosis elimination strategy. Because of recent policy changes, some LTBI treatment may shift from public health departments to the private sector. OBJECTIVES: To (1) develop methodology to estimate initiation and completion of treatment with isoniazid for LTBI using claims data, and (2) estimate treatment completion rates for isoniazid regimens from commercial insurance claims. METHODS: Medical and pharmacy claims data representing insurance-paid services rendered and prescriptions filled between January 2011 and March 2015 were analyzed. PARTICIPANTS: Four million commercially insured individuals 0 to 64 years of age. MAIN OUTCOME MEASURES: Six-month and 9-month treatment completion rates for isoniazid LTBI regimens. RESULTS: There was an annual isoniazid LTBI treatment initiation rate of 12.5/100 000 insured persons. Of 1074 unique courses of treatment with isoniazid for which treatment completion could be assessed, almost half (46.3%; confidence interval, 43.3-49.3) completed 6 or more months of therapy. Of those, approximately half (48.9%; confidence interval, 44.5-53.3) completed 9 months or more. CONCLUSIONS: Claims data can be used to identify and evaluate LTBI treatment with isoniazid occurring in the commercial sector. Completion rates were in the range of those found in public health settings. These findings suggest that the commercial sector may be a valuable adjunct to more traditional venues for tuberculosis prevention. In addition, these newly developed claims-based methods offer a means to gain important insights and open new avenues to monitor, evaluate, and coordinate tuberculosis prevention.
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Isoniazida/uso terapêutico , Tuberculose Latente/tratamento farmacológico , Tuberculose Latente/prevenção & controle , Adolescente , Adulto , Antituberculosos/economia , Antituberculosos/uso terapêutico , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Revisão da Utilização de Seguros , Cobertura do Seguro/normas , Cobertura do Seguro/estatística & dados numéricos , Isoniazida/economia , Tuberculose Latente/epidemiologia , Masculino , Pessoa de Meia-Idade , Setor Privado/estatística & dados numéricos , Texas/epidemiologiaRESUMO
OBJECTIVE: We used a recent source of nationally representative population data on tuberculosis (TB) infection to characterize concordance between the tuberculin skin test (TST) and the QuantiFERON-TB Gold In-Tube (QFT-GIT) blood test for immigrants in the United States. METHODS: We used TB screening data from the 2011-2012 National Health and Nutrition Examination Survey to examine concordance between the TST and QFT-GIT--an interferon-gamma release assay (IGRA) blood test--for 7,097 U.S. natives, naturalized citizens, and noncitizens. RESULTS: Consistent with prior findings, one in five immigrants in the survey was identified with latent TB infection (LTBI), a rate 14 times higher than for U.S. natives. We also found higher rates of discordant TST/IGRA results among immigrants than among U.S. natives. Unadjusted discordance between TST and IGRA was 3% among U.S. natives (weighted N=5,684,274 of 191,179,213) but ranged up to 19% for noncitizens (weighted N=3,722,960 of 19,377,147). Adjusting for age, sex, and race/ethnicity, noncitizens had more than nine times the odds of having a positive TST result but negative QFT-GIT result compared with U.S. natives. CONCLUSIONS: Our findings suggest that whether and how either of these tests should be deployed is highly context sensitive. Significant discordance in test results when used among immigrants raises the possibility of missed opportunities for harm reduction in this already at-risk population. However, we found little distinction between the tests in terms of diagnostic outcome when used in a U.S. native population, suggesting little benefit to the adoption and use of the QFT-GIT test in place of TST on the basis of test performance alone for this population.
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Emigrantes e Imigrantes/estatística & dados numéricos , Testes de Liberação de Interferon-gama/estatística & dados numéricos , Tuberculose Latente/imunologia , Mycobacterium tuberculosis/imunologia , Teste Tuberculínico/estatística & dados numéricos , Tuberculose Pulmonar/imunologia , Adolescente , Adulto , Idoso , Distribuição de Qui-Quadrado , Criança , Custos e Análise de Custo , Feminino , Humanos , Testes de Liberação de Interferon-gama/economia , Tuberculose Latente/diagnóstico , Tuberculose Latente/epidemiologia , Modelos Logísticos , Masculino , Programas de Rastreamento/economia , Programas de Rastreamento/métodos , Programas de Rastreamento/normas , Pessoa de Meia-Idade , Inquéritos Nutricionais , Radiografia Torácica , Sensibilidade e Especificidade , Teste Tuberculínico/economia , Tuberculose Pulmonar/diagnóstico por imagem , Tuberculose Pulmonar/epidemiologia , Estados Unidos , Adulto JovemRESUMO
OBJECTIVES: We compared mortality among tuberculosis (TB) survivors and a similar population. METHODS: We used local health authority records from 3 US sites to identify 3853 persons who completed adequate treatment of TB and 7282 individuals diagnosed with latent TB infection 1993 to 2002. We then retrospectively observed mortality after 6 to 16 years of observation. We ascertained vital status as of December 31, 2008, using the Centers for Disease Control and Prevention's National Death Index. We analyzed mortality rates, hazards, and associations using Cox regression. RESULTS: We traced 11 135 individuals over 119 772 person-years of observation. We found more all-cause deaths (20.7% vs 3.1%) among posttreatment TB patients than among the comparison group, an adjusted average excess of 7.6 deaths per 1000 person-years (8.8 vs 1.2; P < .001). Mortality among posttreatment TB patients varied with observable factors such as race, site of disease, HIV status, and birth country. CONCLUSIONS: Fully treated TB is still associated with substantial mortality risk. Cure as currently understood may be insufficient protection against TB-associated mortality in the years after treatment, and TB prevention may be a valuable opportunity to modify this risk.
Assuntos
Sobreviventes/estatística & dados numéricos , Tuberculose/epidemiologia , Adolescente , Adulto , Idoso , Causas de Morte , Centers for Disease Control and Prevention, U.S. , Feminino , Infecções por HIV/epidemiologia , Humanos , Tuberculose Latente/epidemiologia , Masculino , Pessoa de Meia-Idade , Grupos Raciais , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Tuberculose/mortalidade , Estados Unidos , Adulto JovemRESUMO
BACKGROUND: Controlling tuberculosis (TB) infection among occupationally exposed healthcare workers (HCWs) may be challenging. METHODS: We retrospectively reviewed clinical records of HCWs who were exposed to patients diagnosed with infectious TB at King Abdulaziz Medical City, Riyadh, Saudi Arabia, between 2008 and 2010. The collected data included baseline tuberculin skin test (TST) status, potential predictors of TST positivity, postexposure diagnosis of latent TB infection (LTBI), and postexposure compliance with LTBI therapy. RESULTS: Thirteen patients were diagnosed with infectious pulmonary TB during the study period. A total of 298 HCWs met our definition for exposure. Exposed HCWs tended to be female (62.9%), non-Saudi (83.9%), nurses (68.6%), or respiratory therapists (24.0%) working in critical care locations (72.8%). Baseline (preemployment) TST documentation existed for 41.3% (123/298). Among those with documented baseline TSTs, 51.2% (63/123) were positive, representing 21.1% (63/298) of all HCWs. Only 48.9% (115/235) of exposed HCWs who had negative or unknown preexposure TST status had their TST tested after exposure. Approximately 46.1% (53/115) of them were diagnosed with postexposure LTBI, and 92.5% (49/53) of them were prescribed LTBI therapy. Among those, 93.9% (46/49) started LTBI therapy; however, 82.6% (38/46) failed to complete the recommended course. CONCLUSIONS: We found low rates of baseline TST documentation and postexposure screening among exposed HCWs. Compliance with initiating postexposure isoniazid prophylaxis among HCWs was fair, but only a small fraction of those who started prophylaxis completed the recommended course of therapy. These findings suggest substantial opportunities to implement administrative measures to enhance LTBI management among HCWs.
Assuntos
Infecção Hospitalar/diagnóstico , Fidelidade a Diretrizes/estatística & dados numéricos , Transmissão de Doença Infecciosa do Paciente para o Profissional/estatística & dados numéricos , Tuberculose Latente/diagnóstico , Recursos Humanos em Hospital/estatística & dados numéricos , Centros de Atenção Terciária/estatística & dados numéricos , Adulto , Antituberculosos/uso terapêutico , Infecção Hospitalar/tratamento farmacológico , Infecção Hospitalar/transmissão , Feminino , Humanos , Transmissão de Doença Infecciosa do Paciente para o Profissional/prevenção & controle , Tuberculose Latente/tratamento farmacológico , Tuberculose Latente/transmissão , Masculino , Pessoa de Meia-Idade , Exposição Ocupacional/prevenção & controle , Exposição Ocupacional/estatística & dados numéricos , Estudos Retrospectivos , Arábia Saudita/epidemiologia , Teste Tuberculínico/estatística & dados numéricos , Tuberculose Pulmonar/diagnóstico , Tuberculose Pulmonar/tratamento farmacológico , Tuberculose Pulmonar/transmissão , Adulto JovemRESUMO
BACKGROUND: A challenge to effective protection against tuberculosis is to sustain expensive and complex treatment public programs. Potential consequences of program failure include acquired drug resistance, poor patient outcomes, and potentially much higher system costs, however. In contrast, effective efforts have value illustrated by impacts they prevent. We compared the healthcare costs and treatment outcomes among multidrug-resistant tuberculosis (MDR-TB) and non MDR-TB patients in Latvia to identify benefits or costs associated with both. METHODS: We measured and compared costs, healthcare utilization, and outcomes for patients who began treatment through Latvia's TB control program in 2002 using multivariate regression analysis and negative binomial regression. RESULTS: We analyzed data for 92 MDR-TB and 54 non MDR-TB patients. Most (67%) MDR-TB patients had history of prior tuberculosis treatment. MDR-TB was associated with lower cure rates (71% vs. 91%) and greater resource utilization. MDR-TB treatment cost almost $20,000 more than non MDR-TB. CONCLUSION: Up to 2/3 of MDR-TB treated in our sample was preventable at a potential savings of over $1.3 million in healthcare resources as well as substantial individual health.
RESUMO
BACKGROUND: Host pathogen relationships can be classified as allopatric, when the pathogens originated from separate, non-overlapping geographic areas from the host; or sympatric, when host and pathogen shared a common ancestral geographic location. It remains unclear if host-pathogen relationships, as defined by phylogenetic lineage, influence clinical outcome. We sought to examine the association between allopatric and sympatric phylogenetic Mycobacterium tuberculosis lineages and pulmonary impairment after tuberculosis (PIAT). METHODS: Pulmonary function tests were performed on patients 16 years of age and older who had received ≥20 weeks of treatment for culture-confirmed M. tuberculosis complex. Forced Expiratory Volume in 1 min (FEV1) ≥80%, Forced Vital Capacity (FVC) ≥80% and FEV1/FVC >70% of predicted were considered normal. Other results defined pulmonary impairment. Spoligotype and 12-locus mycobacterial interspersed repetitive units-variable number of tandem repeats (MIRU-VNTR) were used to assign phylogenetic lineage. PIAT severity was compared between host-pathogen relationships which were defined by geography and ethnic population. We used multivariate logistic regression modeling to calculate adjusted odds ratios (aOR) between phylogenetic lineage and PIAT. RESULTS: Self-reported continental ancestry was correlated with Mycobacterium. tuberculosis lineage (p<0.001). In multivariate analyses adjusting for phylogenetic lineage, age and smoking, the overall aOR for subjects with allopatric host-pathogen relationships and PIAT was 1.8 (95% confidence interval [CI]: 1.1, 2.9) compared to sympatric relationships. Smoking >30 pack-years was also associated with PIAT (aOR: 3.2; 95% CI: 1.5, 7.2) relative to smoking <1 pack-years. CONCLUSIONS: PIAT frequency and severity varies by host-pathogen relationship and heavy cigarette consumption, but not phylogenetic lineage alone. Patients who had disease resulting from allopatric-host-pathogen relationship were more likely to have PIAT than patients with disease from sympatric-host-pathogen relationship infection. Further study of this association may identify ways that treatment and preventive efforts can be tailored to specific lineages and racial/ethnic populations.
Assuntos
Mycobacterium tuberculosis/fisiologia , Tuberculose Pulmonar/microbiologia , Tuberculose Pulmonar/fisiopatologia , Adolescente , Adulto , Idoso , Análise de Variância , Feminino , Genótipo , Interações Hospedeiro-Patógeno , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Mycobacterium tuberculosis/genética , Razão de Chances , Filogenia , Estudos Prospectivos , Grupos Raciais , Testes de Função Respiratória , FumarRESUMO
BACKGROUND: Disparities in outcomes associated with race and ethnicity are well documented for many diseases and patient populations. Tuberculosis (TB) disproportionately affects economically disadvantaged, racial and ethnic minority populations. Pulmonary impairment after tuberculosis (PIAT) contributes heavily to the societal burden of TB. Individual impacts associated with PIAT may vary by race/ethnicity or socioeconomic status. METHODS: We analyzed the pulmonary function of 320 prospectively identified patients with pulmonary tuberculosis who had completed at least 20 weeks standard anti-TB regimes by directly observed therapy. We compared frequency and severity of spirometry-defined PIAT in groups stratified by demographics, pulmonary risk factors, and race/ethnicity, and examined clinical correlates to pulmonary function deficits. RESULTS: Pulmonary impairment after tuberculosis was identified in 71% of non-Hispanic Whites, 58% of non-Hispanic Blacks, 49% of Asians and 32% of Hispanics (p < 0.001). Predictors for PIAT varied between race/ethnicity. PIAT was evenly distributed across all levels of socioeconomic status suggesting that PIAT and socioeconomic status are not related. PIAT and its severity were significantly associated with abnormal chest x-ray, p < 0.0001. There was no association between race/ethnicity and time to beginning TB treatment, p = 0.978. CONCLUSIONS: Despite controlling for cigarette smoking, socioeconomic status and time to beginning TB treatment, non-Hispanic White race/ethnicity remained an independent predictor for disproportionately frequent and severe pulmonary impairment after tuberculosis relative to other race/ethnic groups. Since race/ethnicity was self reported and that race is not a biological construct: these findings must be interpreted with caution. However, because race/ethnicity is a proxy for several other unmeasured host, pathogen or environment factors that may contribute to disparate health outcomes, these results are meant to suggest hypotheses for further research.
Assuntos
Lesão Pulmonar/microbiologia , Tuberculose Pulmonar/complicações , População Branca , Adulto , Idoso , Estudos de Coortes , Feminino , Disparidades nos Níveis de Saúde , Humanos , Lesão Pulmonar/etnologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Testes de Função Respiratória , Medição de Risco , Tuberculose Pulmonar/etnologiaRESUMO
BACKGROUND: The health impacts of pulmonary impairment after tuberculosis (TB) treatment have not been included in assessments of TB burden. Therefore, previous global and national TB burden estimates do not reflect the full consequences of surviving TB. We assessed the burden of TB including pulmonary impairment after tuberculosis in Tarrant County, Texas using Disability-adjusted Life Years (DALYs). METHODS: TB burden was calculated for all culture-confirmed TB patients treated at Tarrant County Public Health between January 2005 and December 2006 using identical methods and life tables as the Global Burden of Disease Study. Years of life-lost were calculated as the difference between life expectancy using standardized life tables and age-at-death from TB. Years lived-with-disability were calculated from age and gender-specific TB disease incidence using published disability weights. Non-fatal health impacts of TB were divided into years lived-with-disability-acute and years lived-with-disability-chronic. Years lived-with-disability-acute was defined as TB burden resulting from illness prior to completion of treatment including the burden from treatment-related side effects. Years lived-with-disability-chronic was defined as TB burden from disability resulting from pulmonary impairment after tuberculosis. RESULTS: There were 224 TB cases in the time period, of these 177 were culture confirmed. These 177 subjects lost a total of 1189 DALYs. Of these 1189 DALYs 23% were from years of life-lost, 2% were from years lived-with-disability-acute and 75% were from years lived-with-disability-chronic. CONCLUSIONS: Our findings demonstrate that the disease burden from TB is greater than previously estimated. Pulmonary impairment after tuberculosis was responsible for the majority of the burden. These data demonstrate that successful TB control efforts may reduce the health burden more than previously recognized.