Tuberculosis Contact Investigations--United States, 2003-2012.

Mycobacterium tuberculosis is transmitted through the air from an infectious patient (index patient) to other persons (contacts) who share space. Exposure to M. tuberculosis can result in tuberculosis (TB) disease or latent TB infection (LTBI), which has no clinical symptoms or radiologic evidence of disease. The cycle of transmission can be ended by isolating and treating patients with TB disease, examining contacts, and treating LTBI to prevent progression to TB disease. CDC systematically collects aggregate data on contact investigations from the 50 states, the District of Columbia (DC), and Puerto Rico. Data from 2003-2012 were analyzed for trends in yields from contact investigations, in terms of numbers of contacts elicited and examined and the estimated number of TB cases averted through treatment of LTBI among contacts in 2012. During 2003-2012, the number of TB cases decreased, while the number of contacts listed per index patient with contacts elicited increased. In 2012, U.S. public health authorities reported 9,945 cases of TB disease (1) and 105,100 contacts. Among these contacts, 84,998 (80.9%) were examined; TB was diagnosed in 532 (0.6%) and LTBI in 15,411 (18.1%). Among contacts with LTBI, 10,137 (65.8%) started treatment, and 6,689 (43.4% of all contacts with LTBI) completed treatment. By investigating contacts in 2012, an estimated 128 TB cases (34% of all potential cases) over the initial 5 years were averted, but an additional 248 cases (66%) might have been averted if all potentially contagious TB patients had contacts elicited, all contacts were examined, and all infected contacts completed treatment. Enhancing contact investigation activities, particularly by ensuring completion of treatment by contacts recently infected with M. tuberculosis, is essential to achieve the goal of TB elimination.

Tuberculosis treatment managed by providers outside the Public Health Department: lessons for the Affordable Care Act.

INTRODUCTION: Tuberculosis (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. METHODS: We 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). RESULTS: The 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). CONCLUSION: While 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.

Improved outcomes found after implementing a systematic evaluation and program improvement process for tuberculosis.

California's state and local tuberculosis (TB) programs collaborated to develop the Tuberculosis Indicators Project (TIP), a program evaluation and improvement process. In TIP, local and state staff review data, identify program gaps, implement plans to improve local TB program performance, and evaluate outcomes. After 10 years of project implementation, indicator performance changes and patient outcomes were measured. Eighty-seven percent of participating programs showed a performance increase in targeted indicators after three years compared with 57% of comparison groups. Statistically significant performance change was more common in the intervention local health departments (LHDs) than in comparison groups. The most notable performance changes were in the contact investigation and case management indicators. These results indicate that this systematic evaluation and program improvement project was associated with improved LHD TB control performance and may be useful to inform improvement projects in other public health programs.

Developing and using performance measures based on surveillance data for program improvement in tuberculosis control.

California state and local tuberculosis (TB) programs used a systematic process to develop a set of indicators to measure and improve program performance in controlling TB. These indicators were the basis for a quality improvement process known as the TB Indicators Project. Indicators were derived from guidelines and legal mandates for clinical, case management, and surveillance standards and were assessed using established criteria. The indicators were calculated using existing surveillance data. The indicator set was field tested by local programs with high TB morbidity and subsequently revised. Collaboration with key stakeholders at all stages was crucial to developing useful and accepted indicators. Data accessibility was a critical requirement for indicator implementation. Indicators most frequently targeted for performance improvement were those perceived to be amenable to intervention. Indicators based on surveillance data can complement other public health program improvement efforts by identifying program gaps and successes and monitoring performance trends.

Can I find a doctor? Availability of primary care physicians in the San Francisco Bay Area.

OBJECTIVES: Primary care physicians function as "gatekeepers" in many managed care systems. With the rapid growth of managed care enrollment, it is crucial that patients have adequate access to primary care physicians. We investigated factors associated with new-patient appointment availability of primary care physicians in the San Francisco Bay Area. STUDY DESIGN: Observational cohort. POPULATION: Cross-sectional survey of primary care physician offices in 2 San Francisco Bay Area counties (n=438). OUTCOMES MEASURED: New-patient appointment availability. RESULTS: Seventy-five percent of primary care physicians participating in managed care had an appointment available for a new patient. Appointments were more likely to be available with primary care physicians who had been in practice for 10 years or less (odds ratio [OR]=4.2; 95% confidence interval [CI], 1.7-10.3), compared with more established physicians; and with primary care physicians who had graduated from a medical school outside of the United States (OR=3.5; 95% CI, 1.7-7.3), compared with US graduates. Appointments within 30 days were less available with female primary care physicians (OR=0.4; 95% CI, 0.2-0.7) than for male primary care physicians. CONCLUSIONS: The limited availability of appointments for new patients may create barriers to primary care in the San Francisco Bay Area, a region with high managed-care penetration.