Culture Conversion and Self-Administered Therapy in Privately Managed Tuberculosis Patients

1. 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

2. 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 • 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

3. Provider Types* in California, by LHD, 2003-2008 *proportion of patients cared for by both PMP and HD not shown

4. Objective Determine whether patient characteristics explain indicator performance differences between patients managed by PMPs and LHDs

5. 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

6. 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 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 • 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

7. Results

8. No Documented Culture Conversion ≤70 DaysSelected Univariable Analysis Results

9. No Documented Culture Conversion ≤70 DaysMultivariable Model Results

10. SAT in Patients with Indications for DOTSelected Univariable Analysis Results

11. SAT in Patients with Indications for DOTMultivariable Model Results

12. Summary Documented Sputum Culture Conversion ≤ 70 Days • After adjustment for confounders, PMP-managed TB patientsless likely to culture convert, vs. LHD-managed • Patients with MDR TB or cavitary diseaseless likely to document culture conversion ≤ 70 days • Patients receiving ≥ 10 weeks of DOT more likelyto 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. Acknowledgements • Anne Cass • Alex Golden • Linda Johnson • Lisa Pascopella • FeiFei Qin For more information, please contact Melissa Ehman: mehman@cdph.ca.gov