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Ku JH, Fischer H, Qian LX, Li K, Skarbinski J, Shaw S, Bruxvoort KJ, Lewin BJ, Spence BC, Tartof SY. Latent tuberculosis infection testing practices in a large U.S. integrated healthcare system. Clin Infect Dis 2024:ciae015. [PMID: 38207124 DOI: 10.1093/cid/ciae015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 12/27/2023] [Accepted: 01/09/2024] [Indexed: 01/13/2024] Open
Abstract
PURPOSE Tuberculosis (TB) is a public health threat with >80% of active TB in the U.S. occurring due to reactivation of latent tuberculosis infection (LTBI). We may be under-screening those with high risk for LTBI and over-testing those at lower risk. A better understanding of gaps in current LTBI testing practices in relation to LTBI test positivity is needed. METHODS This study, conducted between 01/01/2008 and 12/31/2019 at Kaiser Permanente Southern California, included individuals ≥18 years of age without a history of active TB. We examined factors associated with LTBI testing and LTBI positivity. RESULTS Among 3,816,884 adults (52% female, 37% White, 37% Hispanic, mean age 43.5 years [S.D. 16.1]), 706,367 (19%) were tested for LTBI, among whom 60,393 (9%) had ≥1 positive result. Among 1,211,971 individuals meeting ≥1 screening criteria for LTBI, 210,025 (17%) were tested for LTBI. Factors associated with higher adjusted odds (aOR) of testing positive included male sex [aOR: 1.32, 95% CI:1.30-1.35], Asian/Pacific Islander [2.78, 2.68-2.88], current smoking [1.24, 1.20-1.28], diabetes [1.13, 1.09-1.16], hepatitis B [1.45, 1.34-1.57], hepatitis C [1.54, 1.44-1.66], and birth in a country with an elevated TB rate [3.40, 3.31-3.49]). Despite being risk factors for testing positive for LTBI, none of these factors were associated with higher odds of LTBI testing. CONCLUSIONS Current LTBI testing practices may be missing individuals at high risk of LTBI. Additional work is needed to refine and implement screening guidelines that appropriately target testing for those at highest risk for LTBI.
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Affiliation(s)
- Jennifer H Ku
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Heidi Fischer
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Lei X Qian
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Kris Li
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Jacek Skarbinski
- Division of Research, Kaiser Permanente Northern California, Oakland, California USA
| | - Sally Shaw
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Katia J Bruxvoort
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Bruno J Lewin
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Brigitte C Spence
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Sara Y Tartof
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
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Fischer H, Qian L, Li Z, Garba S, Bruxvoort KJ, Skarbinski J, Ku JH, Lewin BJ, Mahale PS, Shaw SF, Spence BC, Tartof SY. Prior Screening for Latent Tuberculosis Among Patients Diagnosed With Tuberculosis Disease: Missed Opportunities? Open Forum Infect Dis 2023; 10:ofad545. [PMID: 38023560 PMCID: PMC10651207 DOI: 10.1093/ofid/ofad545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 10/30/2023] [Indexed: 12/01/2023] Open
Abstract
Background California has the largest number of tuberculosis (TB) disease cases in the United States. This study in a large California health system assessed missed opportunities for latent tuberculosis (LTBI) screening among patients with TB disease. Methods Kaiser Permanente Southern California patients who were ≥18 years old with membership for ≥24 months during the study period from 1 January 2008 to 31 December 2019 were included. Prior LTBI test (tuberculin skin test or interferon-γ release assay) or diagnosis code prior to TB disease diagnosis was assessed among patients with observed TB disease (confirmed by polymerase chain reaction and/or culture). In the absence of current treatment practices, more patients screened for LTBI may have developed TB disease. We estimated hypothetical TB disease cases prevented by multiplying LTBI progression rates by the number of LTBI-positive patients prescribed treatment. Results A total of 1289 patients with observed TB disease were identified; 148 patients were LTBI positive and 84 were LTBI negative. Patients not prescreened for LTBI made up 82.0% of observed TB disease cases (1057/1289). Adding the hypothetical maximum estimate for prevented cases decreased the percentage of patients who were not prescreened for LTBI to 61.7% [1057/(1289 + 424)]. Conclusions One-fifth of patients were screened for LTBI prior to their active TB diagnosis. Assuming the upper bound of cases prevented through current screening, almost 62% of TB disease patients were never screened for LTBI. Future work to elucidate gaps in LTBI screening practices and to identify opportunities to improve screening guidelines is needed.
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Affiliation(s)
- Heidi Fischer
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Lei Qian
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Zhuoxin Li
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Saadiq Garba
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
| | - Katia J Bruxvoort
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jacek Skarbinski
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
- Department of Infectious Diseases, Oakland Medical Center, Kaiser Permanente Northern California, Oakland, California, USA
| | - Jennifer H Ku
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Bruno J Lewin
- Department of Family Medicine, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA
- Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
| | - Parag S Mahale
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Sally F Shaw
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Brigitte C Spence
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Sara Y Tartof
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
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Spence BC, Bruxvoort K, Munoz-Plaza C, Shaw S, Navarro M, Chen H, Skarbinski J, Tartof S. Patient-Reported Barriers to Treatment Initiation and Completion for Latent Tuberculosis Infection Among Patients Within a Large Integrated Health Care System in Southern California. J Public Health Manag Pract 2023; 29:345-352. [PMID: 36867508 PMCID: PMC10038844 DOI: 10.1097/phh.0000000000001711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
OBJECTIVE More than 80% of active tuberculosis in the United States is due to reactivation of latent tuberculosis infection (LTBI), which can be prevented via screening and treatment. Treatment initiation and completion rates are low for patients with LTBI in the United States, and the barriers to successful treatment are poorly understood. DESIGN We conducted semistructured qualitative interviews with 38 patients who were prescribed LTBI treatment (9 months isoniazid, 6 months rifampin, or 3 months rifamycin-isoniazid short-course combinations). We used purposeful sampling employing a maximum variation approach to obtain diverse perspectives of patients who did not initiate treatment, who did not complete treatment, and who completed treatment (n = 14, n = 16, and n = 8, respectively). Patients were asked about LTBI knowledge, experience regarding treatment, interactions with providers, and barriers they faced. Using a team coding model (2 coders/analysts), we developed deductively derived (a priori) codes based on our central research questions and inductively derived codes that emerged directly from the data. Analysis of our coding categories and relationships generated a hierarchy of key themes and subthemes. SETTING Kaiser Permanente Southern California. PARTICIPANTS Individuals 18 years or older who received a diagnosis of LTBI and prescribed treatment. MAIN OUTCOME MEASURES LTBI knowledge, attitudes toward LTBI, attitudes toward LTBI treatment, attitudes toward providers, and explanation of barriers. RESULTS Most patients reported having limited knowledge of LTBI. In addition to the duration of treatment, barriers to initiation and completion included perceived lack of support, uncomfortable side effects, and pervasive minimization of the positive impact of treatment on their health. Many patients felt there was little incentive to overcome barriers. CONCLUSIONS Overall, patient experience with LTBI treatment initiation and completion could be improved with patient-centered treatment and more frequent follow-ups.
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Affiliation(s)
- Brigitte C Spence
- Kaiser Permanente Southern California Department of Research and Evaluation, Pasadena, California (Mss Spence, Munoz-Plaza, and Navarro, Drs Shaw and Tartof, and Mr Chen); and University of Alabama Birmingham, Birmingham, Alabama (Dr Bruxvoort)
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Fischer H, Qian L, Skarbinski J, Bruxvoort KJ, Wei R, Li K, Amsden LB, Wood MS, Eaton A, Spence BC, Shaw SF, Tartof SY. Development and validation of a prediction algorithm to identify birth in countries with high tuberculosis incidence in two large California health systems. PLoS One 2022; 17:e0273363. [PMID: 36006985 PMCID: PMC9409495 DOI: 10.1371/journal.pone.0273363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 08/07/2022] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE Though targeted testing for latent tuberculosis infection ("LTBI") for persons born in countries with high tuberculosis incidence ("HTBIC") is recommended in health care settings, this information is not routinely recorded in the electronic health record ("EHR"). We develop and validate a prediction model for birth in a HTBIC using EHR data. MATERIALS AND METHODS In a cohort of patients within Kaiser Permanente Southern California ("KPSC") and Kaiser Permanent Northern California ("KPNC") between January 1, 2008 and December 31, 2019, KPSC was used as the development dataset and KPNC was used for external validation using logistic regression. Model performance was evaluated using area under the receiver operator curve ("AUCROC") and area under the precision and recall curve ("AUPRC"). We explored various cut-points to improve screening for LTBI. RESULTS KPSC had 73% and KPNC had 54% of patients missing country-of-birth information in the EHR, leaving 2,036,400 and 2,880,570 patients with EHR-documented country-of-birth at KPSC and KPNC, respectively. The final model had an AUCROC of 0.85 and 0.87 on internal and external validation datasets, respectively. It had an AUPRC of 0.69 and 0.64 (compared to a baseline HTBIC-birth prevalence of 0.24 at KPSC and 0.19 at KPNC) on internal and external validation datasets, respectively. The cut-points explored resulted in a number needed to screen from 7.1-8.5 persons/positive LTBI diagnosis, compared to 4.2 and 16.8 persons/positive LTBI diagnosis from EHR-documented birth in a HTBIC and current screening criteria, respectively. DISCUSSION Using logistic regression with EHR data, we developed a simple yet useful model to predict birth in a HTBIC which decreased the number needed to screen compared to current LTBI screening criteria. CONCLUSION Our model improves the ability to screen for LTBI in health care settings based on birth in a HTBIC.
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Affiliation(s)
- Heidi Fischer
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, United States of America
| | - Lei Qian
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, United States of America
| | - Jacek Skarbinski
- Division of Research, Kaiser Permanente Northern California, Oakland, California, United States of America
- Department of Infectious Diseases, Oakland Medical Center, Kaiser Permanente Northern California, Oakland, California, United States of America
| | - Katia J. Bruxvoort
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, United States of America
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Rong Wei
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, United States of America
| | - Kris Li
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, United States of America
| | - Laura B. Amsden
- Division of Research, Kaiser Permanente Northern California, Oakland, California, United States of America
| | - Mariah S. Wood
- Division of Research, Kaiser Permanente Northern California, Oakland, California, United States of America
| | - Abigail Eaton
- Division of Research, Kaiser Permanente Northern California, Oakland, California, United States of America
| | - Brigitte C. Spence
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, United States of America
| | - Sally F. Shaw
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, United States of America
| | - Sara Y. Tartof
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, United States of America
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, United States of America
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Sites BD, Spence BC, Gallagher J, Beach ML, Antonakakis JG, Sites VR, Hartman GS. Regional anesthesia meets ultrasound: a specialty in transition. Acta Anaesthesiol Scand 2008; 52:456-66. [PMID: 18339151 DOI: 10.1111/j.1399-6576.2008.01604.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Despite its well-known benefits, regional anesthesia has not attained the stature, simplicity, and safety of general anesthesia. Many of the challenges and clinical failures of regional anesthetic techniques can be attributed to fact that neurovascular anatomy is highly variable. Furthermore, current nerve localization techniques provide little or no information regarding the anatomical spread local anesthesia. Recently, ultrasound technology has been utilized by anesthesiologists in an attempt to minimize many of the drawbacks of traditional nerve block techniques. This review article will update the reader on the current status of ultrasound-guided regional anesthesia, provide an evidence-based context, and supply key facts regarding ultrasound physics. In the process, we will also highlight several possible limitations of ultrasound techniques including learning curve issues, costs, and artifact generation.
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Affiliation(s)
- B D Sites
- Department of Anesthesiology, Dartmouth Medical School, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA.
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Sites BD, Beach ML, Spence BC, Wiley CW, Shiffrin J, Hartman GS, Gallagher JD. Ultrasound guidance improves the success rate of a perivascular axillary plexus block. Acta Anaesthesiol Scand 2006; 50:678-84. [PMID: 16987361 DOI: 10.1111/j.1399-6576.2006.01042.x] [Citation(s) in RCA: 136] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Traditional approaches to performing brachial plexus blocks via the axillary approach have varying success rates. The main objective of this study was to evaluate if a specific technique of ultrasound guidance could improve the success of axillary blocks in comparison to a two injection transarterial technique. METHODS Fifty-six ASA physical status I-III patients presenting for elective hand surgery were prospectively randomized to receive an axillary block performed by either a transarterial technique (Group TA) or an ultrasound-guided perivascular approach (Group US). Both groups received a total of 30 ml of 1.5% lidocaine (225 mg) with 5 microg/ml epinephrine. Patients were then evaluated for block onset in specific nerve distributions and whether or not the block acted as a surgical anesthetic. RESULTS Group TA sustained more failures defined as conversion to general anesthesia or the inability to localize the artery [Group TA eight patients (29%) vs. Group US in which 0 patients required conversion to general anesthesia (0%) P < 0.01]. Group US demonstrated a reduction in performance times vs. Group TA (7.9 +/- 3.9 min vs. 11.1 +/- 5.7 min, P < 0.05). By 30 min post-injection, there were no significant differences between groups TA and US in terms of the proportion of patients demonstrating a complete motor or sensory loss. CONCLUSION Ultrasonographic guidance improves the overall success rate of axillary blocks in comparison to a transarterial technique.
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Affiliation(s)
- B D Sites
- Department of Anesthesiology, Dartmouth Medical School, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire 03756, USA.
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