Tuberculosis hospitalization expenditures per patient from private health insurance claims data, 2010-2014

Extrapulmonary tuberculosis in China: a national survey

OBJECTIVES

Extrapulmonary tuberculosis (EPTB) is not a notifiable infectious disease in China but is a heavy burden on public health. However, the epidemic situation of EPTB nationwide is unclear. This study aimed to investigate the magnitude and main subtypes of EPTB in China.

METHODS

We conducted a national cross-sectional study with multistage, stratified cluster random sampling during 2020-2021. We calculated proportions of EPTB in all patients with TB by organs. Logistic regression models were used to estimate odds ratios by characteristics.

RESULTS

A total of 6843 patients with TB were included. Of them, 24.6% were patients with EPTB, and the proportion of EPTB solo was 21.3%. Higher EPTB burden was observed in children, female patients, clinically diagnosed patients, provincial-level and prefectural-level health facilities, and Central and West China. EPTB occurred most frequently in respiratory (35.5%), musculoskeletal (15.8%), and peripheral lymphatic (15.8%) systems with top three subtypes, including tuberculous pleurisy (35.0%), spinal TB (9.8%) and cervical tuberculous lymphadenopathy (7.9%). With the increase of age, proportion of peripheral lymphatic TB decreased, and proportion rank of genitourinary TB rose.

CONCLUSION

It is essential to strengthen the diagnosis and treatment capacity for EPTB in primary medical facilities. EPTB should be added to the National Tuberculosis Program as a notifiable disease.

The Case for Integrating Health Systems to Manage Noncommunicable and Infectious Diseases in Low- and Middle-Income Countries: Lessons Learned From Zambia

Noncommunicable diseases (NCDs) are the leading cause of death in the world, and 80% of all NCD deaths occur in low- and middle-income countries (LMICs). The COVID-19 pandemic has demonstrated that patients with NCDs are at increased risk of becoming severely ill from the virus. Disproportionate investment in vertical health programs can result in health systems vulnerable to collapse when resources are strained, such as during pandemics. Although NCDs are largely preventable, globally there is underinvestment in efforts to address them. Integrating health systems to collectively address NCDs and infectious diseases through a wide range of services in a comprehensive manner reduces the economic burden of healthcare and strengthens the healthcare system. Health system resiliency is essential for health security. In this article, we provide an economically sound approach to incorporating NCDs into routine healthcare services in LMICs through improved alignment of institutions that support prevention and control of both NCDs and infectious diseases. Examples from Zambia's multisector interventions to develop and support a national NCD action plan can inform and encourage LMIC countries to invest in systems integration to reduce the social and economic burden of NCDs and infectious diseases.

Interferon gamma release assay tests are associated with persistence and completion of latent tuberculosis infection treatment in the United States: Evidence from commercial insurance data

Background

Risk-targeted testing and treatment of latent tuberculosis infection (LTBI) is a critical component of the United States’ (US) tuberculosis (TB) elimination strategy, but relatively low treatment completion rates remain a challenge. Both treatment persistence and completion may be facilitated by diagnosing LTBI using interferon gamma release assays (IGRA) rather than tuberculin skin tests (TST).

Methods

We used a national sample of administrative claims data to explore associations diagnostic test choice (TST, IGRA, TST with subsequent IGRA) and treatment persistence and completion in persons initiating a daily dose isoniazid LTBI treatment regimen in the US private healthcare sector between July 2011 and March 2014. Associations were analyzed with a generalized ordered logit model (completion) and a negative binomial regression model (persistence).

Results

Of 662 persons initiating treatment, 327 (49.4%) completed at least the 6-month regimen and 173 (26.1%) completed the 9-month regimen; 129 (19.5%) persisted in treatment one month or less. Six-month completion was least likely in persons receiving a TST (42.2%) relative to persons receiving an IGRA (55.0%) or TST then IGRA (67.2%; p = 0.001). Those receiving an IGRA or a TST followed by an IGRA had higher odds of completion compared to those receiving a TST (aOR = 1.59 and 2.50; p = 0.017 and 0.001, respectively). Receiving an IGRA or a TST and subsequent IGRA was associated with increased treatment persistence relative to TST (aIRR = 1.14 and 1.25; p = 0.027 and 0.009, respectively).

Conclusions

IGRA use is significantly associated with both higher levels of LTBI treatment completion and treatment persistence. These differences are apparent both when IGRAs alone were administered and when IGRAs were administered subsequent to a TST. Our results suggest that IGRAs contribute to more effective LTBI treatment and consequently individual and population protections against TB.

An Unfortunate Case of Reactivation of Tuberculosis in a Postpartum Female

Tuberculosis (TB) is a widely prevalent disease, especially in resource-limited settings. It poses a big burden to the community and is a significant cause of morbidity and mortality in pregnant females due to their immunosuppressed state. During pregnancy, the immune system is suppressed to prevent fetal rejection, and it gets reconstituted postpartum. During this reconstitution phase, reactivation of TB may occur, making it quintessential to test peripartum females for latent TB, especially those belonging to endemic regions. We describe an unfortunate case of reactivation of TB in a postpartum female from Central America.

Number and cost of hospitalizations with principal and secondary diagnoses of tuberculosis, United States

OBJECTIVE

To estimate the number and cost of hospitalizations with a diagnosis of active tuberculosis (TB) disease in the United States.

METHODS

We analyzed the 2014 National In-Patient Sample using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9) codes to identify hospitalizations with a principal (TB-PD) or any secondary discharge (TB-SD) TB diagnosis. We used a generalized linear model with log link and gamma distribution to estimate the cost per TB-PD and TB-SD episode adjusted for patient demographics, insurer, clinical elements, and hospital characteristics.

RESULTS

We estimated 4985 TB-PD and 6080 TB-SD hospitalizations nationwide. TB-PD adjusted averaged $16 695 per episode (95%CI $16 168-$17 221). The average for miliary/disseminated TB ($22 498, 95%CI $21 067-$23 929) or TB of the central nervous system ($28 338, 95%CI $25 836-$30 840) was significantly greater than for pulmonary TB ($14 819, 95%CI $14 284-$15 354). The most common principal diagnoses for TB-SD were septicemia (n = 965 hospitalizations), human immunodeficiency virus infection (n = 610), pneumonia (n = 565), and chronic obstructive pulmonary disease and bronchiectasis (COPD-B, n = 150). The adjusted average cost per TB-SD episode was $15 909 (95%CI $15 337-$16 481), varying between $8687 (95%CI $8337-$9036) for COPD-B and $23 335 (95%CI $21 979-$24 690) for septicemia. TB-PD cost the US health care system $123.4 million (95%CI $106.3-$140.5) and TB-SD cost $141.9 million ($128.4-$155.5), of which Medicaid/Medicare covered respectively 67.2% and 69.7%.

CONCLUSIONS

TB hospitalizations result in substantial costs within the US health care system.

Tuberculosis Test Usage and Medical Expenditures from Outpatient Insurance Claims Data, 2013

Objective

To evaluate TB test usage and associated direct medical expenditures from 2013 private insurance claims data in the United States (US).

Methods

We extracted outpatient claims for TB-specific and nonspecific tests from the 2013 MarketScan® commercial database. We estimated average expenditures (adjusted for claim and patient characteristics) using semilog regression analyses and compared them to the Centers for Medicare and Medicaid Services (CMS) national reimbursement limits.

Results

Among the TB-specific tests, 1.4% of the enrollees had at least one claim, of which the tuberculin skin test was most common (86%) and least expensive ($9). The T-SPOT® was the most expensive among the TB-specific tests ($106). Among nonspecific TB tests, the chest radiograph was the most used test (78%), while chest computerized tomography was the most expensive ($251). Adjusted average expenditures for the majority of tests (≈74%) were above CMS limits. We estimated that total United States medical expenditures for the employer-based privately insured population for TB-specific tests were $53.0 million in 2013, of which enrollees paid 17% ($9 million).

Conclusions

We found substantial differences in TB test usage and expenditures. Additionally, employer-based private insurers and enrollees paid more than CMS limits for most TB tests.