| |
TB Notes Newsletter
Return to Main Menu - TB Notes
3, 2008
No. 3, 2008
Surveillance, Epidemiology,
and Outbreak Investigations
Branch Updates
TBESC Task Order 12 Update:
Primary Care Management of LTBI and TB Disease among Foreign-born
Populations: A Study of Barriers and Facilitators
Project Overview:
CDC, Seattle and King County Public Health
Department, and the University of Washington have completed a 3-year
study about the facilitators and barriers associated with the
primary-care management of latent and active TB among immigrant
populations. National surveillance data indicate that the highest
incidence of TB disease within the United States occurs in recent
immigrants from Mexico, the Philippines, and Vietnam. Effective TB
control strategies require that primary care providers be adept at
identifying active TB as well as managing persons with latent TB
infection (LTBI).
The objectives of this study were to-
- Conduct formative research to describe the factors influencing the
efficient management of latent and active TB among primary care
providers caring for immigrants from Mexico, the Philippines, and
Vietnam;
- Design, implement, and assess the impact of an educational
intervention to improve LTBI management in primary care; and
- Assess the effectiveness of this intervention on altering
knowledge and attitude of primary care providers regarding LTBI
testing and treatment.
Methods:
This study was implemented in two phases. In Phase I,
qualitative interviews were conducted, including focus groups and
individual interviews with health care providers to elucidate
aspects of primary care practice that impact TB testing and
treatment management. Participants had to have practiced in primary
care medicine (e.g., internal medicine, family practice, pediatrics,
women’s health), have 3 or more years of medical experience, have
practiced in their current setting at least 1 year, and have a
patient population of at least 25% foreign-born individuals.
A total of 80 health care providers were interviewed. Major themes
were identified by three reviewers and used to shape Phase II of
this study. For the second phase (i.e., the intervention phase), a
1-hour didactic session was developed that integrated national and
local TB epidemiology and reviewed the nuances of LTBI testing and
treatment. A pre-intervention assessment composed of knowledge
questions on the epidemiology of TB within the United States, risk
groups for LTBI, interpretation of the tuberculin skin test, and
LTBI treatment was administered to a group of primary care providers
who did not participate in Phase I of this study.
The didactic session was presented by a local TB control expert to
these primary care providers. A post-intervention assessment was
administered to each participant 2 to 4 weeks after the didactic
session. A comparison of pre- and post-intervention responses was
used to assess the effectiveness of this intervention on changing
the knowledge and attitudes of primary care physicians with regard
to LTBI testing and treatment. The assessment tool and the didactic
session materials can be found at www.ethnomed.org.
Preliminary Results:
A total of 92 primary care providers
participated in Phase II (intervention phase) of this study. The
mean age of participants was 47 years, of whom 52% were male and 64%
were foreign born. Eighty percent of participants were either
medical doctors (MDs) or doctors of osteopathic medicine (DOs), and
55% practiced in a federally qualified health center. Only 55%
reported having some form of TB training in the past.
Responses to the knowledge questions showed that the intervention
increased the provider’s knowledge about patients who are at added
risk for LTBI, particularly those who are HIV infected, and those
who have the co-morbid conditions of renal failure, diabetes, and
silicosis. The providers showed increased knowledge in the
interpretation of the tuberculin skin test, especially in the
settings of HIV, previous BCG vaccination, and recent exposure to an
individual with active TB. Clinicians were updated to the fact that
isoniazid, the mainstay for LTBI treatment, can be offered to all
age groups who have latent infection if they have no other
contraindications to the treatment.
In the pre-intervention assessment, over 70% agreed that provision
of free isoniazid for LTBI treatment, a reliable treatment tracking
system, better co-management of patients with the local TB clinic,
and a public health effort to educate their patients were “very
important.”
Private practice physicians were more concerned about reimbursement
for LTBI care, more likely to agree that insurance reimbursement
impacted the care they delivered for LTBI, and more likely to be
concerned about the financial implications of LTBI. In federally
qualified health centers and public hospitals, physicians encouraged
persons with LTBI to take treatment, even though LTBI conceptually
was difficult to explain to their patients. Resources for billing
and nursing support were more available to federally qualified
health center clinicians and public sector clinicians than for
private physicians.
Conclusions:
An intervention to improve primary care providers’
knowledge about LTBI testing and treatment among primary care
providers for high-risk foreign-born groups was shown to increase
key measures of knowledge. Measures of attitude generally endorsed
the importance of LTBI, and indicated that LTBI was difficult to
manage and required additional resources. A subgroup analysis of
practice type revealed that private practice physicians worried more
about finances and that reimbursement issues affected their care as
compared to community-based clinicians. The intervention did not
alter these attitudes, nor was it designed to do so. Future
interventions to change attitudes toward LTBI testing and treatment
should address these unique concerns of clinicians based on their
practice settings.
—Submitted by Jenny Pang, MD, MPH,
Seattle and King County Public Health Prevention,
and Carey Jackson, MD, MPH, MA
University of Washington School of Medicine, Dept of General
Internal Medicine
13th Semiannual Meeting of the Tuberculosis Epidemiologic
Studies Consortium (TBESC)
The 13th Semiannual Meeting of the Tuberculosis Epidemiologic
Studies Consortium (TBESC) convened July 16–17, 2008, in Seattle,
Washington. The primary purpose of the TBESC is to conduct
epidemiologic, behavioral, economic, laboratory, and operational
research in TB prevention and control.
Over 80 persons participated in the meeting; attendees included
CDC staff, TBESC principal investigators, project coordinators, and
project-specific personnel. TBESC members and CDC staff presented
results and gave updates on the status of ongoing research projects
and activities.
Presentations included the following:
- Research gaps related to TB transmission
- Modeling of TB rates and implications for future research
- The draft Strategic Plan and ideas for new research
- Administrative updates on consortium-related activities
- Update on the Semiannual Tuberculosis Advisory Review (STAR)
process
- Updates from the Publication and Presentations and External
Relations Committees
- Update from the Translating Research into Practice (TRiP)
Workgroup
In addition, spirited discussions were held at the meeting
regarding the focus of future TBESC research; TBESC will undergo a
recompetition in 2010. Ideas are currently being generated as to the
scope and direction of TBESC projects. At the meeting, members also
discussed the Strategic Planning Workgroup, whose purpose is to
select a research concept that will provide a unifying focus for TB
research in the next several years.
When not attending the meeting, TBESC attendees enjoyed Seattle’s
scenery, blue skies, and mild weather. Planning for the 14th
semiannual meeting, scheduled for February 4–5, 2009, in Atlanta, is
currently underway.
For more
information on the TBESC.
—Reported by Brian Sizemore, MBA
TBESC Project Manager
Div of TB Elimination
Last Updated: 10/7/2008
Last Reviewed: 05/18/2008
Content Source: Division of Tuberculosis Elimination
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
|
