Can Primary Care Drive Tuberculosis Elimination? Increasing Latent Tuberculosis Infection Testing and Treatment Initiation at a Community Health Center with a Large Non-U.S.-born Population

Abstract

Community health centers (CHC) play a key role in latent tuberculosis infection (LTBI) testing and treatment. We performed a retrospective analysis of LTBI testing and treatment among pediatric and adult patients at a CHC with a large non-U.S.-born (USB) population during a series of quality improvement (QI) interventions from 2010 to 2019. Among 124,695 patients with primary care visits, 40% of patients were tested for tuberculosis (TB) infection and among those tested, 20% tested positive, including 39% of adults aged 50–79 years. Compared to adults aged 18–49 years, children aged 6–17 had increased odds of LTBI testing and treatment initiation [odds ratio and 95% confidence interval 3.23 (3.10, 3.36) and 1.41 (1.12, 1.79), respectively], while age ≥ 65 was associated with lower odds of both testing and treatment initiation. Over the analysis period, coinciding with unfunded QI interventions intended to reduce barriers to LTBI care, there was a significant increase in the proportion of patients receiving LTBI testing for both adults (6% to 47%, p < 0.001) and children (23% to 80%, p < 0.001). During the analysis period, there was also a significant increase in the proportion of patients receiving prescriptions for LTBI treatment, as well as provider use of evidence-based strategies including rifamycin-based treatment. Our study suggests that primary care interventions can reduce barriers to LTBI treatment and drive TB elimination.

Factors Associated with Treatment Prescription to Pulmonary Tuberculosis Contacts in Catalonia (2019–2021): A Population-Based Epidemiological Study

“…LTBI treatment decisions regarding migrants from countries with high TB incidence continues to be challenging, as the rate of active TB development over the long term appears to be higher in migrants with detected TB infection [ 20 , 21 ]. While Tang et al [ 19 ] reported no association between migrant status and LTBI treatment prescription, our results suggesting that Catalan physicians take migrant status into account when prescribing treatment corroborates findings for a study carried out among new migrants in Montreal [ 22 ].…”

“…The bivariate analysis revealed that treatment was more frequently prescribed to children and adolescents (aged 0–5 and 6–17 years) and less frequently prescribed to individuals aged 35 years and older, a result that corroborates that reported for Australia by Dobler et al [ 18 ]. In one US study by Tang et al [ 19 ] carried out at a community health center, LTBI treatment was most frequently prescribed to contacts aged 6–17 years and less frequently to contacts older than 50 years. However, our multivariate analysis pointed to a significant association between no treatment prescription only for the contact group aged ≥55 years.…”

Community treatment of latent tuberculosis in child and adult refugee populations: outcomes and successes

“…Most importantly, in the 12 years since opening their clinic, TB incidence among migrants screened at the clinic had decreased by 61%. In another study of a large community health center caring for over 124,000 patients, of which a large proportion comprised non-US-born immigrants, a number of electronic record and education interventions were implemented in order to reduce barriers to LTBI identification and management ( 38 ). These led to increased LTBI screening and treatment over a 10-year period.…”

Screening for Latent Tuberculosis Infection Among Non–US-Born Adults in the US

“…One recent study documenting the latent tuberculosis care cascade at a federally qualified health center serving a predominantly immigrant community found that using interferon-gamma release assays over tuberculin skin tests increased testing among eligible non–US-born adults from 6% in 2010 to 47% in 2019. Over the same period, increased adoption of shorter rifamycin-based regimens over longer isoniazid monotherapy regimens correlated with an increase in primary care clinicians prescribing treatment, from 22% to 56% . Scaling up these strategies has the potential to substantially improve tuberculosis outcomes in the US.…”

“…The lack of standardized codes for billing of LTBI testing for asymptomatic individuals creates financial barriers to the provision of tuberculosis preventive care, particularly for immigrants who rely on Medicare or patients who are older and at higher risk of death if tuberculosis develops. In California, between 17% and 72% of tuberculosis affected individuals older than 65 years rely on Medicare, and those with Medicare are tested for tuberculosis infection 78% less than those with private insurance . Despite tuberculosis being a preventable disease, there are no national quality metrics (eg, Uniform Data System [UDS] and Healthcare Effectiveness Data and Information Set [HEDIS] measures) established for use by community health centers and health plans for tuberculosis prevention.…”