Quantification of multidrug-resistant M. tuberculosis bacilli in sputum during the first 8 weeks of treatment.

SETTING: Mulago Hospital, Kampala, Uganda.OBJECTIVE: To quantify Mycobacterium tuberculosis in sputum during the first 8 weeks of pulmonary multidrug-resistant TB (MDR-TB) treatment.DESIGN: We enrolled consecutive adults with pulmonary MDR-TB treated according to national guidelines. We collected overnight sputum samples before treatment and weekly. Sputum samples were cultured on Middlebrook 7H11S agar to measure colony-forming units per mL (cfu/mL) and in MGIT™ 960™ media to measure time to detection (TTD). Linear mixed-effects regression was used to estimate the relational change in log10 cfu/mL and TTD.RESULTS: Twelve adults (median age: 27 years) were enrolled. Half were women, and two-thirds were HIV-positive. At baseline, median log10 cfu/mL was 5.1, decreasing by 0.29 log10 cfu/mL/week. The median TTD was 116.5 h, increasing in TTD by 36.97 h/week. The weekly change was greater in the first 2 weeks (-1.04 log10 cfu/mL/week and 120.02 h/week) than in the remaining 6 weeks (-0.17 log10 cfu/mL/week and 26.11 h/week).CONCLUSION: Serial quantitative culture measures indicate a slow, uneven rate of decline in sputum M. tuberculosis over 8 weeks of standardized pulmonary MDR-TB treatment.

Comparison of time to positive and colony counting in an early bactericidal activity study of anti-tuberculosis treatment.

SETTING: Patients with smear-positive, newly diagnosed pulmonary tuberculosis (TB) presenting to the out-patient TB clinic in Kampala, Uganda. OBJECTIVE: To compare colony-forming unit (cfu) counting and time to positive (TTP) in Mycobacteria Growth Indicator Tube (MGIT) culture as measures of early bactericidal activity (EBA). DESIGN: Patients were enrolled in an EBA feasibility study of standard TB chemotherapy. Sixteen-hour overnight sputum collections were obtained before and on days 2, 4, 7, 10, 12 and 14 of treatment for quantitative culture on selective Middlebrook 7H11 agar media and TTP in the MGIT liquid culture system. RESULTS: Log cfu and TTP were correlated over all time points (r(s) = -0.71, P < 0.001). Within-subject (day to day) variation as a percentage of total variation was very similar between the two measures: 25.7% for cfu and 25% for TTP. Mean EBA 0-14, 0-2 and 2-14 measured by TTP were similar to those previously reported. CONCLUSION: TTP measured by an automated, standardized, commercially available culture system correlates with cfu determinations. EBA measured by TTP provides similar information to cfu counting, and is reproducible across sites and in different patient populations. These findings support replacing cfu counting with TTP as the primary measurement in EBA studies.

Impact of an electronic medical record on quality of care in a primary care office.

OBJECTIVE: To determine whether or not implementation of an electronic medical record (EMR) in a primary care office is associated with an increase in completion of preventive care for a general population of adults and children, and for adults with diabetes mellitus. DESIGN: Observational cohort study that compared the change in completion rate of recommended interventions from before to one year after implementation of an EMR. The EMR was designed for direct interaction by providers and included guidelines for preventive care as well as automated prompts for when interventions were due. MEASUREMENTS: Patients were selected from a family medicine teaching practice in Delaware that implemented an EMR in July of 1998. We examined completion of recommended interventions for adults (influenza and pneumococcal immunizations, mammograms and cholesterol screening), children (hepatitis B and varicella immunizations) and adults with diabetes mellitus (monitoring for glycosylated hemoglobin and cholesterol, influenza and pneumococcal immunizations). Completion rates were compared from before to one year after EMR implementation. RESULTS: The number of persons analyzed ranged from 117 for diabetes interventions to 1148 for cholesterol screening. Completion rates increased from before to after EMR implementation for all outcomes studied. The largest increases were seen for mammograms (28.7 percent to 52.5 percent), varicella immunizations (29.6 percent to 55.9 percent), glycosylated hemoglobin (53.0 percent to 80.3 percent) and influenza immunization for persons with diabetes (29.7 percent to 55.1 percent). CONCLUSION: Implementation of a primary care EMR was associated with a substantial increase in completion of recommended preventive care across a broad spectrum of interventions and populations.

The effect of continuity of care on emergency department use.

OBJECTIVE: To examine whether continuity of care with an individual health care provider is associated with the number of hospital emergency department (ED) visits in a statewide Medicaid population. DESIGN: A cross-sectional study based on a 100% sample of Delaware Medicaid claims for 1 year (July 1, 1993, to June 30, 1994). Continuity with a single provider during the year was computed for each participant. SETTING: The state of Delaware. PARTICIPANTS: Continuously enrolled Medicaid clients aged 0 to 64 years who had made at least 3 physician office visits during the study year (N = 11,474). INTERVENTION: None. MAIN OUTCOME MEASURES: Likelihood of making a single ED visit or multiple ED visits during the study year. RESULTS: In multivariate analysis, continuity is associated with a significantly lower likelihood of making a single ED visit (odds ratio, 0.82; 95% confidence interval, 0.70-0.95), and is even more strongly associated with a lower likelihood of making multiple ED visits (odds ratio, 0.65; 95% confidence interval, 0.56-0.76). CONCLUSIONS: This study demonstrates that high provider continuity is associated with lower ED use for the Medicaid population. This suggests that strategies to improve continuity of care may result in lower ED use and possibly reduced health care costs. Such strategies may be more acceptable than current managed care policies that attempt to control costs by denying access to emergency care.