Physicians' perspectives on communication and decision making in clinical encounters for treatment of latent tuberculosis infection

Abstract

The aim of the study was to explore the views of tuberculosis (TB) physicians on treatment of latent TB infection (LTBI), focusing on decision making and communication in clinical practice.20 Australian TB physicians participated in a semistructured interview in person or over the telephone. Interviews were recorded, transcribed and analysed thematically.The study identified challenges that physicians face when discussing treatment for LTBI with patients. These included difficulties explaining the concept of latency (in particular to patients from culturally and linguistically diverse backgrounds) and providing guidance to patients while still framing treatment decisions as a choice. Tailored estimates of the risk of developing TB and the risk of developing an adverse effect from LTBI treatment were considered the most important information for decision making and discussion with patients. Physicians acknowledged that there is a significant amount of unwarranted treatment variation, which they attributed to the lack of evidence about the risk–benefit balance of LTBI treatment in certain scenarios and guidelines that refer to the need for case-by-case decision making in many instances.In order to successfully implement LTBI treatment at a clinical level, consideration should be given to research on how to best address communication challenges arising in clinical encounters.

Absolute risk of tuberculosis among untreated populations with a positive tuberculin skin test or interferon-gamma release assay result: systematic review and meta-analysis

“…Regardless of test used, high rates of tuberculosis were seen among people living with HIV, tuberculosis contacts, prisoners, and people with silicosis, whereas modest rates were seen among recent immigrants or refugees, people requiring dialysis, transplant recipients, and people requiring immunosuppressant drugs. This information should help guide the clinical decisions to test, perform a second test, and treat latent tuberculosis infection in the context of programme priorities and local assessments of feasibility, acceptability, and cost effectiveness 315…”

“…This conflates two different phenomena, which are influenced by different factors: risk of latent tuberculosis infection is determined by local epidemiology, transmission dynamics, and patient history,1314 whereas the risk of progression is determined by time since infection and immunocompetency 2. To help inform decision making by providers and patients,15 we conducted a systematic review and meta-analysis to determine the absolute risk of development of active tuberculosis among different populations of untreated people with a positive TST or IGRA result, or both.…”

Screening for tuberculosis in migrants and visitors from high-incidence settings: present and future perspectives

“…Training of clinicians is required, along with removal of any restrictions in access to healthcare such as those that only allow treatment for emergency care. Discussions about the benefits of LTBI treatment in someone who is completely asymptomatic can be particularly challenging, especially when health beliefs are not aligned with evidence-based Western medicine [79]. Those involved in the care of migrants need to be aware of and address important cultural differences in health beliefs [80].…”

Monitoring tuberculosis contact tracing outcomes in Western Sydney, Australia

“… 35 However, clinical variability in the decision to institute LTBI treatment persists among TB physicians in Australia, 36 including uncertainty about the risk:benefit ratio of LTBI treatment in cases considered to be at low risk of future disease progression. 37 …”