Clinical and Health Affairs
An Innovative Model for Tuberculosis Control: An Academic Medical Center–Public Health Department Partnership
By Prathibha Varkey, M.D., M.P.H., M.H.P.E., Samar Harris, M.B.B.S., Larry Edmonson, M.P.H., Kevin McCoy, B.S.N., R.N., P.H.N., Timothy Aksamit, M.D., and Michael D. Brennan, M.D.
Abstract
Between 1996 and 1999, the incidence rate of active tuberculosis (TB) in Olmsted County, Minnesota, increased by 365%—from 3.4 cases per 100,000 population to 15.8 per 100,000 people. The need for early detection and treatment of TB, efficient care delivery, and cost containment led to the establishment in 2001 of an innovative centralized TB clinic. The clinic was established through a collaboration between Mayo Clinic and the Olmsted County Public Health Department. Following its inception, conversion rates for sputum-positive culture increased from 69.2% to 92%, and the percentage of patients taking part in directly observed therapy increased from 20.8% to 94.6%. Because of successful medical outcomes and acceptance by patients, providers, and the community, the clinic model lends itself to replication elsewhere in the United States.
The incidence of tuberculosis (TB) in the United States has been decreasing steadily over the last few years.1 However, the proportion of cases occurring among foreign-born persons in this country increased from 27% in 1991 to 49% in 2001.2,3 In 2001, five states including Minnesota reported that more than 70% of their annual TB cases occurred among foreign-born persons.2 Several factors have contributed to this increase. For one, the total number of immigrants has increased. Second, the proportion of immigrants arriving from countries where the incidence of TB is three to 25 times higher than it is in the United States has grown.4 Finally, cultural and language barriers can result in delays in diagnosis and treatment.5
Between 1996 and 1999, the incidence rate of active TB in Olmsted County, Minnesota, increased by 365%—from 3.4 cases to 15.8 cases per 100,000 population (Figure 1). The need for early detection and efficient, cost-effective treatment of TB led to the establishment of a centralized TB clinic by Mayo Clinic and the Olmsted County Public Health Department. This article describes key features of that clinic and the impact it has had on the management and control of TB in Olmsted County.
The TB Clinic Model
The TB clinic is located in the Olmsted County Public Health Department (OCPHD) building, which is a familiar place for many refugees, as many of them have their initial health screenings done there. The clinic has capabilities to diagnose and initiate treatment of patients with TB at the first visit. Services provided include screening tuberculin skin tests, Quantiferon Gold TB blood tests, chest radiography, phlebotomy, sputum induction, and treatment and management of latent TB infection (LTBI) as well as active TB, including directly observed therapy (DOT) and contact tracing. The facility has a chest X-ray and processing equipment, a ventilated sputum induction station, a phlebotomy station, three negative-pressure rooms, a physician-nurse conference room, an electronic medical record system, and a digital radiography system that allows for wireless transfer of images to Mayo Clinic for almost immediate interpretation.
Public health staff work with new immigrants to familiarize them with the U.S. health care system, schedule medical appointments, and provide interpretation services for their appointments as necessary. Mayo Clinic is responsible for providing the clinic with physician, radiological, and diagnostic laboratory expertise, while the OCPHD provides public health infrastructure, public health nurses, a radiology technician, a laboratory technician, interpreters, clinical space, and support for DOT.
The cost of treating patients without insurance is absorbed jointly by Mayo Clinic and the OCPHD. Some reimbursement is sought for patients on Medical Assistance. All medications are provided by the state of Minnesota. Gift cards purchased with Minnesota Department of Health grant money are provided as incentives for patients with active TB to comply with DOT. In addition, outreach workers may take medications to patients’ homes, workplaces, or schools, if necessary.
What the Clinic Has Accomplished
Data on the outcomes for the TB clinic including frequency of patients seen and treated were obtained from the OCPHD and the Minnesota Department of Health. Between April 2001, the month the clinic opened, and December 2005, a total of 55 cases of active TB were diagnosed, three of which were multi-drug resistant. One patient died from other medical causes prior to beginning TB treatment. Treatment completion rates increased from 91.8% before the opening of the clinic to 94.4% (Table). Similarly, conversion rates for positive sputum cultures increased from 69.2% to 92%. The number of visits for DOT increased from 30 in 2000 to 1,172 in 2005 (Figure 2), and the percentage of patients receiving DOT increased from 20.8% to 94.6%. During the same period, 1,032 patients with latent TB were started on treatment; the LTBI treatment completion rate was 86.4%.
Discussion
The TB clinic was founded on the principles articulated in the Institute of Medicine’s report “Ending Neglect” on eliminating TB in the United States. The report suggests that new TB treatment and prevention strategies must include “centralization of resources to improve access and deliver more efficient clinical, epidemiological, case management, and laboratory services” in order to provide the safest, most effective therapy in the shortest time.6 Very little has been published on similar centralized models for the management of TB in an entire county.
Prior to the start of the TB clinic, TB care in Olmsted County was provided by physicians in different settings. The Olmsted County TB Clinic is innovative in that it centralizes TB care and case management. Its success is reflected in the significant changes in sputum culture conversion and number of patients participating in DOT. Close collaboration between the medical and public health sectors facilitates translation of public health knowledge into mainstream clinical practice, providing effective preventive care and treatment to a much broader population. This type of collaboration also makes it possible for clinicians to have a greater impact than they would have caring for individual patients. And by working together, the two organizations are able to share costs and improve efficiency.7 Although the cost-effectiveness of the Olmsted County model has not been studied, a similar cooperative model between a group of infectious disease specialists and a county public health department in Pierce County, Washington, saved that county at least $390,000 per year for the care of TB patients.8
Conclusion
Tuberculosis continues to flourish in poor and underserved regions of the world where public health capabilities are either nonexistent or ineffective. Neither public health departments nor academic medical centers alone can provide the full array of services needed to identify and treat patients who arrive in this country with the disease. Establishing a centralized TB clinic that draws on the resources of both groups may be the most effective way to test for and treat TB. Further studies are essential to determine the cost-effectiveness of this model. MM
Prathibha Varkey is an associate professor of medicine, preventive medicine, and medical education in the Division of Preventive and Occupational Medicine at Mayo Clinic College of Medicine. Samar Harris is an internal medicine resident at the University of Columbia-Missouri. Larry Edmonson is director of disease prevention and control for Olmsted County Public Health Services. Kevin McCoy is coordinator of the TB clinic in the Olmsted County Public Health Department. Timothy Aksamit is an assistant professor of medicine in the Division of Pulmonary and Critical Care Medicine at Mayo Clinic College of Medicine. He directs the TB clinic in the Olmsted County Public Health Department. Michael Brennan is a professor of medicine in the Division of Endocrinology at Mayo Clinic College of Medicine.
The authors would like to thank Mary Wellik, R.N., M.P.H., and Michael Schryver who assisted with the inception of the TB clinic.
References
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