What Patient Factors Predict Physicians’ Decision Not to Treat Latent Tuberculosis Infection in Tuberculosis Contacts?

Abstract

ObjectiveThe study aimed to determine factors that are associated with physicians’ decision to offer treatment for latent tuberculosis infection (LTBI) in contacts of patients with tuberculosis.MethodsWe performed a nested case-control study in a cohort of contacts of patients with pulmonary tuberculosis who had a tuberculin skin test (TST) ≥ 10 mm. Cases were those who were offered treatment for LTBI. Controls were randomly selected from those who were not offered treatment for LTBI by the reviewing physician. Odds ratios were estimated by multivariate logistic regression.ResultsThere were 195 cases and 279 controls. The following factors were significantly (positively or negatively) associated with being offered LTBI treatment in the multivariate analysis: female gender (OR 2.9; 95% CI 1.6–5.5), TST conversion (OR 3.9; 2.0–7.9), TST > 20 mm (OR 4.1; 1.8–9.1, for TST of 21–30 mm and OR 7.9; 2.6–23.8, for TST >30 mm), sputum smear positive index case (OR 12.7; 4.5–36.1), being overseas-born and immigration more than 2 years ago (OR 0.1; 0.06–0.3), being a health care worker (OR 0.2; 0.1–0.6), being a non-household contact of the TB index case (OR 0.3; 0.2–0.6) and age >35 years (OR 0.2; 0.1–0.5 for age 35 to 54.9 years and OR 0.04; 0.01–0.2 for age ≥55 years). Previous BCG vaccine and chest x-ray findings were not significantly associated with physicians’ decision to offer treatment for LTBI.ConclusionsMost factors that influenced physicians’ decisions on treatment for LTBI were based on evidence of an association with risk of developing TB or risk of having an adverse reaction to treatment for LTBI. However, the decreased likelihood of offering treatment for LTBI to people born overseas, men and health care workers, was apparently not based on any evidence of risk. Efforts should be made to ensure that these groups are given access to treatment for LTBI.

Yield of tuberculosis contact investigations in Amsterdam: opportunities for improvement

“…However, almost half of the contacts diagnosed with LTBI did not start on preventive treatment. A study conducted in Sydney, Australia, by DOBLER et al [16] showed that physicians' decisions to offer LTBI treatment may be correlated with factors associated with an increased risk of developing tuberculosis, such as young age and being a close contact of an index case. Unfortunately we were not able to determine whether these contact factors influenced physicians' decisions on treatment or whether patients' refusal was associated with starting treatment.…”

Preventive therapy for latent tuberculosis infection—the promise and the challenges

“…Potential barriers to the uptake of LTBI testing and treatment include reluctance of providers to prescribe LTBI treatment (for example because of fear of facilitating the development of drug resistance with monotherapy, 99 or because the health providers are not convinced that the benefits of LTBI treatment outweigh the potential risk from adverse effects 100,101 ), reluctance of people with LTBI to undergo a prolonged course of treatment for an asymptomatic condition that may never progress to active TB disease, lack of trained and experienced medical staff, and lack of availability of single drugs in some low-and middle-income countries in which only combination therapy for treatment of active TB is readily available.…”

Clinicians’ cognitive biases: a potential barrier to implementation of evidence-based clinical practice

“…Physicians may not prescribe evidence-based preventive treatments because they are more afraid of the risk of potential adverse effects from treatments than the higher risks of morbidity and mortality associated with the disease (eg, preventive tuberculosis treatment in patients with latent infection,4 anticoagulation for atrial fibrillation in high-risk patients5).…”