Filling in the gaps: identification of lost opportunities for TB prevention

Purpose: We reviewed current and historic clinical and other records for patients being treated for active TB to identify if and how such records suggest potential opportunities for TB prevention. New or expanded knowledge of how individual and population determinants of health interact with TB risk will allow more efficient and effective development and targeting of strategies against that risk. US public health authorities concur that much or all TB is preventable, whether by primary (prevention of onset by reducing exposure to risk) or secondary (preventing occurrence by treatment to reduce risk) means. Prevention requires a multifactorial approach to address each of the biological, clinical, environmental, social, behavioral, and system determinants of health that together allow TB risk to be avoided entirely or identified and mitigated. Robust treatment of active TB in the US has led to declining TB incidence rates, and many prevention activities take place in various settings. Still, incident TB’s rate of decrease is flattening and new incident TB cases continue to occur. We assume that every newly incident TB patient indicates a missed opportunity for prevention. By identifying factors that led to current TB patients “falling through the cracks” in our otherwise successful public TB prevention programs, we hope to facilitate progress toward the domestic elimination of this serious public health threat. Methods: In a convenience sample from June to July, 2015 we obtained consent for participation from patients under treatment by the Tarrant County Public Health Department Tuberculosis Clinic (TCPH-TBC) for confirmed active TB.. Consenting participants were asked to sign records releases for clinical and other records from TCPH-TBC as well as all other known current and prior health providers. Each record obtained was reviewed by the research fellow and abstracted into a research dataset of standardized elements for analysis for missed opportunities. We defined these as evident clinical risks for the development of active TB disease prior to onset of disease. The study was determined to be exempt status research by UNTHSC’s Office of Research Compliance, IRB # 2015-068. Results: Approximately half (16/33) of all patients in TB treatment at TCPH-TC during the study period consented to take part in the study. Current TCPH-TC administrative or clinical records were obtained for 14 (87.5%) of participants; we obtained at least one historic provider record for another 8 (50%) participants. Among the 14 participants with record reviews , 11 (78.6%) were foreign-born. Insurance status could be identified for 12 (85.7%) participants with records for review,. Most were insured (8/12 or 66.6%) by public or commercial insurance (4 with Medicare/Medicaid, and 4 with commercial insurance). A total of 12 missed opportunities for TB prevention prior to onset of disease (.86/patient analyzed) were identified from available patient records. Conclusions: Retrospective review of available administrative and clinical records of patients treated for TB is a potentially useful and efficient means to identify and target prevention opportunities prior to disease onset. However, the wide-spread, long-term implementation of such efforts require more investigation, as does application of these data to public health efforts.