Using automated pharmacy records to assess the management of tuberculosis

Methods in public health services and systems research: a systematic review

CONTEXT

Public Health Services and Systems Research (PHSSR) is concerned with evaluating the organization, financing, and delivery of public health services and their impact on public health. The strength of the current PHSSR evidence is somewhat dependent on the methods used to examine the field. Methods used in PHSSR articles, reports, and other documents were reviewed to assess their methodologic strengths and challenges in light of PHSSR goals.

EVIDENCE ACQUISITION

A total of 364 documents from the PHSSR library met the inclusion criteria as empirical and based in the U.S. After additional exclusions, 327 of these were analyzed.

EVIDENCE SYNTHESIS

A detailed codebook was used to classify articles in terms of (1) study design; (2) sampling; (3) instrumentation; (4) data collection; (5) data analysis; and (6) study validity. Inter-coder reliability was assessed for the codebook; once it was found reliable, the available empirical documents were coded.

CONCLUSIONS

Although there has been a dramatic increase in the amount of published PHSSR recently, methods used remain primarily cross-sectional and descriptive. Moreover, although appropriate for exploratory and foundational work in a new field, these approaches are limiting progress toward some PHSSR goals. Recommendations are given to advance and strengthen the methods used in PHSSR to better meet the goals and challenges facing the field.

Biologics and infections: lessons from tumor necrosis factor blocking agents

In the decade since tumor necrosis factor α (TNF-α) antagonists were first approved for clinical use, they have proven invaluable for the treatment of specific types of chronic inflammation. Currently licensed TNF blockers fall into two classes, monoclonal antibody (or antibody fragments) and soluble receptor. Although they are equally effective in rheumatoid arthritis and psoriasis, important differences have emerged with regard to efficacy in granulomatous inflammation and risks of granulomatous infections, particularly tuberculosis. This article focuses on recent studies that inform prevention and management of infections in this susceptible patient population.

Infectious complications of tumor necrosis factor blockade

PURPOSE OF REVIEW

Our understanding of the infection risks posed by tumor necrosis factor (TNF) antagonists has continued to evolve in the 10 years since these drugs were first introduced. This review summarizes recent data regarding infection risk, examines potential structure-function relationships that may account for the differences, and discusses their implications with regard to tuberculosis prevention and management.

RECENT FINDINGS

Recent prospective studies have confirmed the risk of tuberculosis reactivation posed by TNF antibodies to be several fold greater than soluble TNF receptor. Certolizumab pegol, a monovalent anti-TNF Fab' fragment appears to share this risk, despite its lack of Fc and its inability to cross-link transmembrane TNF. Screening and initiation of treatment for latent tuberculosis (TB) infection can greatly reduce the TB risk of anti-TNF treatment in western countries. However, alternative strategies to prevent TB because of new transmission may be required as these therapies become available worldwide. Current recommendations for withdrawal of anti-TNF therapy when TB is diagnosed place patients at risk for paradoxical worsening because of recovery of TNF-dependent inflammation. Recent case reports suggest reinstitution of TNF blockade may be safe and effective adjunctive treatment in such cases, but prospective studies are needed to confirm these observations.

SUMMARY

TNF blockers have transformed treatment of several chronic inflammatory conditions. Further research is needed to determine how best to prevent and manage their infectious complications and to determine their potential adjunctive therapeutic role in chronic infection diseases.

The medication Adherence and Blood Pressure Control (ABC) trial: A multi-site randomized controlled trial in a hypertensive, multi-cultural, economically disadvantaged population

The Medication Adherence and BP Control Trial (ABC Trial) is a randomized, controlled, multi-site, medication adherence and blood pressure (BP) control trial in an economically disadvantaged and multi-cultural population of hypertensive patients followed in primary care practices. To date, no other such trial has been published in which objective measures of adherence (electronic pill bottles) were used to assess the effectiveness of these behavioral interventions for hypertension. This study tested a combination of commercially-available interventions that can be easily accessed by health care providers and patients, and therefore may provide a real-world solution to the problem of non-adherence among hypertensives. The aim of the ABC Trial was to test the effectiveness of a stepped care intervention in improving both medication adherence to an antihypertensive medication regimen and BP control. Step 1 of the intervention employed home Self-BP Monitoring (SBPM); at this stage, there were two arms: (1) Usual Care (UC) and (2) Intervention. At Step 2, patients in the intervention arm whose BP had not come under control after 3 months were further randomized to one of two conditions: (1) continuation of SBPM (alone) or (2) continuation of SBPM plus telephone-based nurse case management (SBPM+NCM). Electronic Medication Event Monitoring (MEMS) was the primary measure of medication adherence, and in-office BP was the primary measure of hypertension control. We present an overview of the study design, details of the administrative structure of the study and a description of clinical site recruitment, patient recruitment, and follow-up assessments.

Statistical issues and challenges associated with rapid detection of bio-terrorist attacks

The traditional focus for detecting outbreaks of an epidemic or bio-terrorist attack has been on the collection and analysis of medical and public health data. Although such data are the most direct indicators of symptoms, they tend to be collected, delivered, and analysed days, weeks, and even months after the outbreak. By the time this information reaches decision makers it is often too late to treat the infected population or to react in some other way. In this paper, we explore different sources of data, traditional and non-traditional, that can be used for detecting a bio-terrorist attack in a timely manner. We set our discussion in the context of state-of-the-art syndromic surveillance systems and we focus on statistical issues and challenges associated with non-traditional data sources and the timely integration of multiple data sources for detection purposes.

Pharmacy data for tuberculosis surveillance and assessment of patient management

Pharmacy data help locate tuberculosis cases and assess their management.

Underreporting tuberculosis (TB) cases can compromise surveillance. We evaluated the contribution of pharmacy data in three different managed-care settings and geographic areas. Persons with more than two anti-TB medications were identified by using pharmacy databases. Active TB was confirmed by using state TB registries, medical record review, or questionnaires from prescribing physicians. We identified 207 active TB cases, including 13 (6%) missed by traditional surveillance. Pharmacy screening identified 80% of persons with TB who had received their medications through health plan–reimbursed sources, but missed those treated solely in public health clinics. The positive predictive value of receiving more than two anti-TB medications was 33%. Pharmacy data also provided useful information about physicians' management of TB and patients' adherence to prescribed therapy. Pharmacy data can help public health officials to find TB cases and assess their management in populations that receive care in the private sector.

Predictive value of clinical diagnostic codes for the CDC case definition of pelvic inflammatory disease (PID): implications for surveillance

BACKGROUND

Reporting of pelvic inflammatory disease (PID) from private providers could be incomplete because of time and staff constraints, lack of knowledge of reporting requirements and of case definitions. Reporting burden can be alleviated with the use of administrative data.

GOAL

The goal of this study was to determine the validity of clinical diagnostic codes assigned in electronic medical records (EMR) for identifying PID and their use in enhancing surveillance.

STUDY DESIGN

A random sample of 296 records with a PID International Classification of Diseases, 9th Revision (ICD-9), code (614.9) were reviewed to assess for the presence of the Centers for Disease Control and Prevention (CDC) criteria for the case definition of PID. We used the records meeting the CDC clinical case definition criteria as the reference standard to determine the sensitivity, specificity, and predictive values of various data elements.

RESULTS

Used alone, the positive predictive value (PPV) of ICD-9 code 614.9 for a CDC case definition of PID was 18.1%. The PPV increased to 100% and 56% when the ICD-9 code visit was associated with a positive test for Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT), respectively.

CONCLUSION

In this multispecialty group practice, a positive test for GC and CT coupled with ICD-9 code 614.9 could be used to enhance reporting of cases of PID.

Can managed health care help manage health care-associated infections?

Managed-care organizations have a unique opportunity, still largely unrealized, to collaborate with health-care providers and epidemiologists to prevent health care-associated infections. Several attributes make these organizations logical collaborators for infection control programs: they have responsibility for defined populations of enrollees and for their overall health, including preventive care; they possess unique data resources about their members and their care; and they are able to make systemwide changes in care. Health care-associated infections merit the attention and effort of managed-care organizations because these infections are common, incur substantial illness and costs, and can be effectively prevented by using methods that are unevenly applied in different health-care settings. Both national and local discussions will be required to enable the most effective and efficient collaborations between managed care organizations and health-care epidemiologists. It will be important to articulate clear goals and standards that can be readily understood and widely adopted.