Tuberculosis Treatment Managed by Providers outside the Public Health Department: Lessons for the Affordable Care Act

Abstract

IntroductionTuberculosis (TB) requires at least six months of multidrug treatment and necessitates monitoring for response to treatment. Historically, public health departments (HDs) have cared for most TB patients in the United States. The Affordable Care Act (ACA) provides coverage for uninsured persons and may increase the proportion of TB patients cared for by private medical providers and other providers outside HDs (PMPs). We sought to determine whether there were differences in care provided by HDs and PMPs to inform public health planning under the ACA.MethodsWe conducted a retrospective, cross-sectional analysis of California TB registry data. We included adult TB patients with culture-positive, pulmonary TB reported in California during 2007–2011. We examined trends, described case characteristics, and created multivariate models measuring two standards of TB care in PMP- and HD-managed patients: documented culture conversion within 60 days, and use of directly observed therapy (DOT).ResultsThe proportion of PMP-managed TB patients increased during 2007–2011 (p = 0.002). On univariable analysis (N = 4,606), older age, white, black or Asian/Pacific Islander race, and birth in the United States were significantly associated with PMP care (p<0.05). Younger age, Hispanic ethnicity, homelessness, drug or alcohol use, and cavitary and/or smear-positive TB disease, were associated with HD care. Multivariable analysis showed PMP care was associated with lack of documented culture conversion (adjusted relative risk [aRR] = 1.37, confidence interval [CI] 1.25–1.51) and lack of DOT (aRR = 8.56, CI 6.59–11.1).ConclusionWhile HDs cared for TB cases with more social and clinical complexities, patients under PMP care were less likely to receive DOT and have documented culture conversion. This indicates a need for close collaboration between PMPs and HDs to ensure that optimal care is provided to all TB patients and TB transmission is halted. Strategies to enhance collaboration between HDs and PMPs should be included in ACA implementation.

Tuberculosis Knowledge, Awareness, and Stigma Among African-Americans in Three Southeastern Counties in the USA: a Qualitative Study of Community Perspectives

“…While the ACA could evolve to play a larger role in TB services, most notably the shift of TB care towards private medical providers (PMP), to date it has had little impact in this area [46]. However, a recent study concluded that TB patients under PMP care were less likely to receive the level of recommended care that TB cases routinely receive at public health departments such as directly observed therapy and documented culture conversion, cornerstones of public health practice with proven utility in stemming TB [47]. A major change in the public health system has been the constriction of funds for TB programs [48] due to the US economic crisis which was most intense in 2008.…”

Patient support for tuberculosis patients in low-incidence countries: A systematic review

“…Publications were from the USA [ 29 , 31 , 53 , 64 , 65 , 35 , 36 , 41 , 42 , 44 , 46 , 47 , 50 ], the UK [ 9 , 43 , 51 , 54 , 57 , 61 ], Spain [ 30 , 32 , 38 , 40 ], Japan [ 52 , 56 , 59 ], Turkey [ 37 , 48 , 63 ], Canada [ 34 , 62 ], Australia [ 39 ], Greece [ 49 ], Italy [ 45 ], the Netherlands [ 28 ], New Zealand [ 60 ], Norway [ 58 ], Saudi Arabia [ 66 ] and Switzerland [ 33 ]. One study was multi-national, participating countries being Armenia, Australia, Central African Republic, India, Philippines, South Africa, Swaziland, Uganda and the UK [ 55 ].…”

“…Of the 40 publications on TB patient support, 36 included treatment supervision options [ 9 , 28 , 39 – 48 , 30 , 49 , 50 , 52 – 54 , 56 – 60 , 31 , 62 , 64 – 67 , 32 , 33 , 35 – 38 ] (19 as the sole patient support intervention [ 9 , 29 , 39 , 41 , 42 , 45 , 48 , 50 , 58 , 64 , 30 – 33 , 35 – 38 ]), 12 included SE support [ 34 , 43 , 61 , 62 , 46 , 47 , 52 , 53 , 56 , 57 , 59 , 60 ] (1 as the sole intervention [ 61 ]), 11 included PE support [ 34 , 40 , 62 , 51 , 53 – 57 , 59 , ...…”

A systematic synthesis of direct costs to treat and manage tuberculosis disease applied to California, 2015

“…Due to data limitations we could not stratify our cost analysis by public versus private sector, which may be an important distinction. The impact of the changing health care system on the costs of TB care may be substantial, as some care traditionally provided by public health clinics shifts to primary care and community clinics [ 15 ]. Finally, this analysis did not take into account upward pressures on costs such as anti-TB drug shortages in the US [ 16 ].…”