Introduction

1. Missed Opportunities for Timely Diagnosis and Treatment of Active and Latent Tuberculosis in Patients within Denver Health and HospitalsE. Baron, MD 2, R. Belknap, MD 1,2, D. McEwen 1, L. Yun, MD,MSPH 1 and R. Reves, MD,MSc 1,2. 1 Denver Public Health, Denver, CO, United States and 2 University of Colorado Health Sciences Center, Denver, CO, United States. ABSTRACT METHODS RESULTS RESULTS Introduction Tuberculosis (TB) incidence rates are low in Colorado (average 2.6 per 100,000 over the past 3 years), therefore TB elimination efforts need to focus on identifying high-risk populations. Community Health Centers (CHC) affiliated with Denver Health and Hospitals serve over 100,000 persons yearly, 28% of whom are foreign-born. TB control priorities for primary care providers include timely diagnosis of active TB and latent TB infection (LTBI). Methods We reviewed active TB cases from 2001 to 2003 who received care through CHC. The CHC users registry was used to estimate denominators for TB rate calculations per 100,000 person-years. Provider delay was defined as > 3 visits for TB symptoms over at least 30 days. Missed opportunity for TB prevention was defined as a patient in primary care > 3 months who had risk for infection (eg. foreign-born) and/or risk for progression (eg. medical risk factors) but never completed LTBI testing and treatment. Results We identified 55 cases of active TB (42 foreign-born) for an overall incidence rate of 15.5. TB rates in the foreign-born and U.S.-born patient populations were 43.0 and 5.1, respectively. 16 patients (29%) had a delay in TB diagnosis; most had 4-6 visits over a median of 6 months. Missed opportunities for prevention through diagnosis and treatment of LTBI were identified for 8 of 25 patients (32%) who had established primary care prior to TB diagnosis. Conclusions Denver CHC provides medical care for many foreign-born persons at high risk for TB. Missed opportunities for timely diagnosis and treatment of active and latent TB are common. These findings support the need for an expanded role of CHC in TB elimination efforts. • Setting • Community health clinics (CHC) and Denver Metro TB Clinic (Denver Public Health Department) operating as part of the Denver Health and Hospital Authority, the agency providing medical & public health services to residents of Denver County • Ten CHC provide primary care to ~ 118,000 patients per year • Study Population • Public health records reviewed for patients diagnosed with active TB in Denver County 1/1/2000 - 12/31/2003. • DHHA medical record cross-match used to identifiy patients with > 1 visit for primary care site in CHC prior to TB diagnosis • Population served by CHC estimated by number of patients with > 1 visit for each year • Populations by country of birth available for 2003 & estimated by applying 2003 proportions to age-ethnicity categories for 2001 & 2002 • Study Definitions • Provider Delay : diagnosis > 1 month and > 3 clinical encounters for symptoms (fever, cough, weight loss, hemoptysis, lymphadenopathy etc.) • Preventable Cases:patients in primary care > 3 months before TB diagnosis, who had risk for TB infection and risk for progression, but who were not testing or treated for latent TB Table 3: Characteristics of Potentially Preventable Cases FB = foreign-born; DM = diabetes; ESRD = end-stage renal disease CONCLUSIONS BACKGROUND • The rate of TB in patients receiving primary care through the CHCs was higher than the average rate for Colorado (15.5 vs 2.6) • The overall rate ratio for Foreign-born patients was 8.4 times higher than U.S.-born patients (however, among patients > 60, the rate ratio was 1.0) • Delayed diagnosis was common (29% of cases) and was most often associated with lymphatic TB when a fine needle aspiration or excision was deferred for an imaging study but also occurred in 6 patients who had smear (+) pulmonary TB • Patients who have latent TB and are thus potentially preventable cases receive care through community health clinics • If primary care providers routinely assessed risk factors for TB infection and/or progression, they may be more likely to diagnose active TB early and to prevent cases through latent TB treatment • Achieving TB elimination will require primary care providers working with public health agencies to establish community based programs for latent TB testing and treatment • Important roles for primary care providers in U.S. TB elimination efforts •  Early diagnosis & public health reporting of active TB •  Timely initiation of effective treatment to stop transmission • Targeted testing & treatment of latent TB infection to prevent new cases • Unique role for primary care providers in community-based health centers identified in IOM report Ending Neglect (Objectives I-D and II-A) •  Serve populations at higher risk for TB • Need training in diagnosis & treatment of latent & active TB • Partnerships with public health recommended • Status of TB elimination in Colorado • Low-incidence state for TB: rate 2.6 cases/105/year over 3 years but rates not declining •  Case rates remain high in homeless & foreign-born persons •  Community health centers known to serve TB high-risk populations RESULTS Of 173 TB cases over 3 years, 55 were in patient who had received care at CHC before TB diagnosis. Patients with TB were more likely male, Asian & foreign-born. OBJECTIVES Assess TB control activities in community health centers in Denver, Colorado 1. Estimate the incidence of TB in patients receiving care in community health centers 2. Evaluate the timeliness of provider diagnosis of TB 3. Identify potentially preventable TB cases among patients in primary care