DISCUSSION: THE DNP-PREPARED NURSE AND THEIR COMMUNITIES OF PRACTICE

LatentTuberculosisInfectionTestingandTreatmentataFederallyQualifiedHealthCenterinSouthernCaliforniawk4.docx

Home >Nursing homework help >DISCUSSION: THE DNP-PREPARED NURSE AND THEIR COMMUNITIES OF PRACTICE

Latent Tuberculosis Infection Testing and Treatment at a Federally Qualified Health Center in Southern California : A Quality Improvement Project

Truax, Fayette Nguyen PhDLow, Julie MDMochizuki, Tessa MPHAsfaha, Setie MPHNguyen, Tu Ngoc DNPCarson, Michael MSPMKatrak, Shereen MD, MPHShah, Neha MD, MPHNguyen, Duc DO

ShareCiteReuse PDF

Article

PDF

Complete Reference

Abstract

Background:

A key strategy to eliminate tuberculosis (TB) in the United States is to increase latent tuberculosis infection (LTBI) screening, testing, and treatment among non–US-born Asian populations.

Purpose:

The purpose was to increase LTBI screening, testing, and treatment at a community clinic.

Methods:

Retrospective baseline LTBI data were retrieved through electronic medical record review. Interventions included adoption of standardized TB risk assessment, training providers to use shorter LTBI treatment regimens, and use of a care coordinator. Chart abstraction to examine outcomes was conducted postintervention at 4 months.

Results:

In 2017, only 3 patients (7%) with LTBI were started on treatment. At 4 months postintervention, 28 (72%) patients with LTBI were started on treatment, of which 27 (96%) were placed on 3- to 4-month regimens.

Conclusions:

Training for providers and changes to clinic workflow, including use of a care coordinator, can help increase LTBI screening, testing, and treatment in community clinics.

Non–US-born Asians in the United States are disproportionately affected by tuberculosis (TB) disease compared with other racial groups.1 Among non–US-born Asians, Vietnam consistently remains one of the top 3 Asian countries with the most TB cases reported since 2014.1 At the national level, it is estimated that more than 13 million people living in the United States have latent tuberculosis infection (LTBI), of whom 73% are non–US-born.2Elimination of TB in the United States will not be achieved without treating the large reservoir of LTBI in non–US-born populations. Progression of LTBI to active TB disease is the main contributor to cases of TB in the United States.3 The current recommendation from the US Preventive Services Task Force emphasizes adopting an approach to routinely screen and test higher-risk individuals for LTBI by focusing on specific racial and ethnic subgroups such as non–US-born Asians.2 , 4 Targeted testing for LTBI in high-risk populations along with using the currently recommended short-course treatment regimen with once-weekly isoniazid-rifapentine for 12 weeks (3HP) was found to be an efficient way to reduce TB incidence and utilize the available resources.5 Routine LTBI screening and testing of non–US-born populations at local community and private clinics remain suboptimal, in part, due to the lack of awareness of LTBI risk factors and best practices of clinicians.6In 2018, 82% of 2092 TB cases in California arose from progression of untreated LTBI to active TB disease, 12% were from recent transmission, and only 6% of the cases represented TB disease present on entry to the United States (imported).7 More than half (53%) of California's TB cases occurred among non–US-born Asians in 2018, with Vietnam in the top 3 countries.7 Orange County, California, has a long history of being home to the largest non–US-born Vietnamese population since the late 1970s. The California Department of Public Health TB Control Branch applied the National Health and Nutrition Examination Survey data to the Orange County population and estimated more than 200 000 people in Orange County with LTBI, which equates to 1 in 6 non–US-born persons in the County.8 In 2019, the Orange County non–US-born Vietnamese TB rate was 25.8 cases per 100 000, which is higher than all other Orange County non–US-born groups.8There are multiple barriers to increasing routine LTBI screening, testing, and treatment in primary care clinics. First, it is not known whether community and private providers are following the Centers for Disease Control and Prevention (CDC) guidelines to routinely screen non–US-born patients for risk factors of TB, such as recent travel to TB endemic regions or recent arrival from a country with high TB burden. Second, adherence of these providers to national guidelines for LTBI testing may not be consistent due to the lack of training available. Third, interferon gamma release assay (IGRA) is the recommended blood test per US guidelines and should be used in place of tuberculin skin test (TST) for diagnosing LTBI in the non–US-born population, because among many non–US-born persons, BCG vaccination may affect their TST results.9 , 10 Because the IGRA has a higher specificity over the TST for LTBI identification, the IGRA is a better choice for non–US-born persons.9 In a systematic review, it was concluded that the IGRA yielded far fewer false-positive results than the TST.9Finally, providers may not be aware of therapies for LTBI other than 6 to 9 months of isoniazid. In 2020, new guidelines for the treatment of LTBI were made available by the CDC and included recommendations for LTBI treatment, preferentially with 3- to 4-month rifamycin-based therapies, including both 3HP, and 4 months of daily rifampin (4R).11 To increase LTBI testing in the community, provider training is an efficient way to quickly bring providers up to date on the recommendations for LTBI screening, testing, and treatment.The purpose of this quality improvement project was to improve the screening, testing, and treatment of LTBI among a non–US-born Vietnamese population through provider training, adoption of a standard TB risk assessment tool, and enabling of on-site blood draw for IGRA at a local community clinic in Orange County, California. The project involved a partnership between 3 entities: a local Federally Qualified Health Center community clinic, the Orange County Health Care Agency Pulmonary Disease Services, and the California Department of Public Health TB Control Branch.

METHODS

Retrospective baseline data

To determine baseline LTBI screening and treatment practices, 2 subsets of de-identified data were retrieved from the clinic's electronic medical record (EMR) system by project coordinators. No personal health information was gathered for this project. The measurement was a query of all charts with either a TST or an IGRA ordered in 2017 using billing data. Each electronic chart with a TST- or IGRA-positive test result was reviewed further to identify whether chest radiographs and LTBI treatment were ordered according to the CDC recommendation.

Baseline survey

All clinic providers from the participating community clinic were invited to attend the LTBI training offered on-site. Before the training started, providers were asked to fill out a 20-question survey that used Likert scale–type questions to assess knowledge and attitudes toward LTBI testing and treatment, including understanding of at-risk groups, appropriate testing, treatment regimens, and perceived importance of LTBI treatment to patients' overall health. Providers were asked to rate their level of agreement/disagreement with statements related to key beliefs about LTBI best practices, and self-efficacy and intention to follow these practices, in order to identify key barriers to providing LTBI care. The survey was previously piloted among primary care providers (n = 37) at 8 clinics throughout the state of California. In October 2018, the Orange County TB controller conducted a 1-hour LTBI training session for 8 clinic medical providers, which included 6 physicians, 1 nurse practitioner, and 1 physician assistant. The session included the following topics: (1) recommendation for using the IGRA blood test for LTBI screening; (2) recommendation of prescribing the shorter 3HP or 4R LTBI treatment regimens; and (3) the introduction of the California state TB risk assessment form to be used for patient screening. Posttraining, phone consultations with the TB controller were available to clinic providers for questions related to LTBI testing and treatment. In addition to the training, as part of the quality improvement project, LTBI educational handouts for patients, posters in the waiting rooms, and new risk assessments were provided to the clinic.

Interventions for clinic

Immediately following the training provided by public health officials, a new process for screening LTBI risk factors was adopted and implemented. The California TB risk assessment form, developed by California Department of Public Health, was added to the routine annual physical visits for medical assistants to ask patients. The chief medical officer agreed to have the TB risk assessment form implemented as part of patient intake to improve patient workflow. During the project implementation phase, the TB risk assessment form was completed by medical assistants using paper copies. A few months later, the questions were embedded into the clinic's new EMR system. All patients with at least one positive risk factor on the assessment form were recommended to have an IGRA blood test ordered instead of the traditional TST to assess for LTBI. To improve patients' adherence on obtaining the blood test, public health partners connected the community clinic to a nearby laboratory that allowed the IGRA blood test to be drawn at the community clinic. Providers were then encouraged to order the 3HP treatment for patients with positive laboratory results for LTBI. Finally, a part-time student nurse practitioner volunteer was assigned to be an LTBI care coordinator and assisted the clinic staff in implementing the TB risk assessment, keeping track of the negative and positive results including patients' LTBI treatment completion status, and coordinating patient follow-up as needed.

Postintervention data

Statistical analysis

Data were entered into REDCap12 and analyzed using SAS version 9.4 (2013; SAS Institute Inc., Cary, North Carolina).

RESULTS

Demographics

This quality improvement project was conducted at a large community clinic that served patients who identify as racial and/or ethnic minorities. In 2018, the clinic had 10 755 (85.5%) patients identified as Asian. Approximately 75.5% of the patients at this clinic preferred a language other than English.13 During the project implementation stage from the beginning of November 2018 to February 2019, there were 684 adult physical visits at this facility, of which 542 (79.2%) were identified as Vietnamese clients.

Survey results for providers

Altogether, 10 health care providers were invited to the training session. Of the 10 providers, only 8 (73%) were able to attend the training session. All providers were of Vietnamese descent. The 20-question survey regarding the knowledge, attitude, and beliefs (KAB survey) related to screening and treating patients for LTBI was administered at the beginning of the training session. All providers agreed testing and treating patients for LTBI born in countries with an elevated TB rate would improve their patients' long-term health. Only 50% of the providers strongly agreed that they were comfortable prescribing LTBI drug regimens other than 9 months of isoniazid therapy. Knowledge, attitudes, and beliefs related to LTBI treatment varied slightly among providers screened (see Supplemental Digital Content, Table, available at: http://links.lww.com/JNCQ/A870 ). A follow-up KAB survey was planned at the 1-year follow-up training; however, the training could not be scheduled because of the pandemic restrictions at the time. Despite the challenges, there were major improvements from all providers related to the increase in screening, testing, and treatment of LTBI immediately after the training occurred ( Table).

Table. Comparison of LTBI Testing and Treatment Practices at Baseline and Postintervention Full Size Table
	Baseline (2017), n (%)	4 mo Postintervention (2019), n (%)
Test for LTBI ordered a	276	199
TST only	270	10
IGRA b	6	189
Test result available	226 (82)	174 (87)
TST only c	220	9
IGRA	6	165
New positive result d	42 (19)	39 (22)
TST only	42	0
IGRA	0	39
Chest radiographs completed	40 (95)	28 (72)
Treatment started	3 (7)	28 (72)
INH	3	1
3HP	0	26
4R	0	1
Treatment completed	0	7 documented completion; 17 prescriptions provided

Abbreviations: 4R, 4 months of rifampin; IGRA, interferon-gamma release assay; INH, LTBI treatment with isoniazid; LTBI, latent tuberculosis infection; 3HP, 3 months of short-course combination of once-weekly isoniazid-rifapentine; TST, tuberculin skin test.

a Four patients in the postintervention cohort had an LTBI test but reported prior treatment of tuberculosis and were therefore excluded from further follow-up.

b Six patients in the postintervention cohort had both TST and IGRA ordered.

c One patient in the postintervention cohort had both TST and IGRA ordered, with TST negative and IGRA not completed.

d Two patients in the postintervention cohort had a positive TST and negative IGRA and were excluded from the new positive group.

Retrospective baseline data

Results for baseline and 4-month postintervention data are presented in the Table. In 2017, a total of 276 LTBI tests were ordered. Because no risk assessments were performed at baseline, it is unknown whether a risk factor was present for those tested. However, on the basis of the aggregate data reviewed for 2017, LTBI testing was primarily ordered for school or work clearance. Of the tests ordered, 270 (98%) were TST only, rather than the preferred IGRA; 6 patients were given the IGRA. Altogether, there were 42 (19%) positive results for LTBI and 3 (7%) patients with LTBI were placed on treatment; none received the preferred 3- to 4-month regimens. No treatment completion was documented in the patient charts.

Four-month postintervention data

At 4 months postintervention, data related to LTBI screening, testing, and treatment from November 2018 through February 2019 were collected to assist the TB controller in identifying areas that may need additional intervention. Data collected included the number of TB risk assessments completed; the number of IGRAs, TSTs, chest radiographs ordered; and the number of patients prescribed LTBI medication. A second set of postintervention data was planned to be collected in January 2020; unfortunately, data collection at this time point was not completed because of the COVID-19 pandemic. Altogether, 285 TB risk assessments were completed in this 4-month period following intervention including patients who were scheduled for physicals and sick visits. Of the 285 TB risk assessments completed, 279 (98%) were positive for the risk factor “birth, travel, or residence in a country with an elevated TB rate.” Of those, 270 (97%) reported no previous treatment of tuberculosis.

DISCUSSION

This quality improvement project led to the development of a successful partnership between the state and county public health department and a local community clinic to improve screening, testing, and treatment of LTBI in a high-risk population. Prior to the provider training and clinic interventions, routine screening for LTBI at the community clinic was not a standard practice and testing was ordered primarily when requested by patients for work or school as noted from the data extraction regarding LTBI practices in 2017. Non–US-born Vietnamese patients, who compose the majority of the patient population at the clinic, were not routinely screened or tested for TB despite their history of immigrating from a high TB incidence country or frequent travel to and from Vietnam. In 2017, baseline data indicated only 6 IGRAs ordered for that year. At 4 months postintervention in 2019, there were 189 patients with IGRAs ordered and 10 patients who had only TSTs ordered ( Figure). From this cohort, there were a total of 39 (22%) positive IGRA results, of which 28 (72%) patients were placed on LTBI treatment. Of the 28 patients placed on treatment, 27 (96%) were prescribed the preferred 3HP or 4R regimens recommended by public health officials ( Table).

Figure.

Key steps in the LTBI care cascade at baseline and 4 months postintervention. a No risk assessments were performed at baseline; therefore, it is unknown whether a risk factor was present for those tested. Nonpreferred LTBI practice = use of TST instead of IGRA; prescription of 6 to 9 months of isoniazid instead of 3 months of short-course combination of once-weekly isoniazid-rifapentine (3HP) or 4 months of rifampin. LTBI, indicates latent tuberculosis infection; TST, tuberculin skin test; IGRA, interferon-gamma release assay.In 2018, prior to the provider training, the community clinic chief medical officer was asked by the team if their staff were aware of the California TB risk assessment form that was available online. The providers admitted they had no knowledge of the TB risk assessment form. During the training, the providers confirmed they were not aware of the current CDC recommendations for LTBI testing and treatment of high-risk populations. As a result, there were few treatments started for LTBI and no documented treatment completions at baseline despite a high prevalence of LTBI in the clinic population. Since the partnership, the community clinic has integrated the TB risk assessment form into its clinic workflow to routinely screen patients during annual visits and when risk factors are present. Although the COVID-19 pandemic impacted data collection and conclusions about sustainability of these outcomes, 4-month postintervention data suggest that there was a substantial increase in patients receiving preferred IGRAs and starting treatment with a preferred 3- to 4-month LTBI regimen. These results reflect a significant change in providers' behavior posttraining. Based on the KAB survey results, providers at this community clinic were supportive of testing and treating LTBI in their patient population. Our results supported their intention as noted by medical providers ordering more IGRA blood tests over the TST postintervention. In addition, enabling on-site blood draw for the IGRA at the community clinic was helpful in increasing testing for a population that often does not have consistent transportation or ability to attend multiple clinic visits. The support received by the community clinic from the partnership enabled patients to get their IGRA blood test drawn at their home clinic, which likely helped reduce the number of patients who could be lost to follow-up. In addition, community providers in this project were trained to prescribe the shorter LTBI treatment regimen recommended by the CDC. Our postintervention data saw a major shift of providers switching from the 6- to 9-month isoniazid regimen to 3- to 4-month regimens, primarily 3HP. This shorter course is strongly preferred as the standard treatment of healthy individuals with LTBI; studies have shown increased adherence and treatment completion for 3HP compared with longer regimens.14Community providers play an important role in implementing and sustaining an LTBI program since they already have their patients' trust. They can ensure the implementation of TB risk assessment on annual visits and perform LTBI testing as needed. For IGRA-positive results, they can initiate LTBI short-course treatment and monitor until treatment completion, which is the most cost-effective way to prevent TB disease.15 Other staff members in the clinic such as medical assistants or interns can make a difference in the patients' LTBI success rate as well. For this quality improvement project, a part-time volunteer nurse practitioner student was assigned to assist clinic staff to implement the TB risk assessment as well as follow-up on laboratory results. Clinic staff found the LTBI care coordinator support to be valuable during the postintervention phase. By the end of the project, public health officials recommended the community clinic to designate at least one clinic staff to be the LTBI care coordinator to follow up on IGRA laboratory results, schedule patients' follow-up appointments, and monitor patients for adherence and drug side effects through follow-up phone calls. A large study found patients who missed the first return visit for LTBI treatment to be at high risk for treatment noncompletion.16 The LTBI care coordinator can also address any concerns or fears that may prevent successful treatment.Public health partners plan on returning to the community clinic for a refresher LTBI training session. More guidance will be given to providers at this refresher course, reemphasizing the importance of screening all non–US-born patients. In addition, the survey on clinic providers' knowledge completed at the initial training session will be presented at the refresher session. There will be time allotted for an open discussion session to address all providers' concerns or questions related to LTBI screening and treatment. The county will also invite an outside Vietnamese health care provider with a TB background to the training session to help address questions related to the Vietnamese culture. Incentives such as continuing education units can be offered for providers attending the training. Although this quality improvement project took place at a single clinic, and methods preclude measuring the impact of each intervention, our experience suggests that a program of interventions that include training for medical providers, changes to clinic workflow, and a part-time LTBI patient coordinator can increase LTBI screening, testing, and treatment in community clinics serving patients at high risk of TB infection. This package of interventions will require partnership between clinics and local and state TB programs but can be implemented with few additional resources or funding.

Limitations

For the 9-month postintervention data, project coordinators were not able to retrieve and review the entire set of data that were queried because of several barriers. First, the community clinic had multiple audits during that time frame; therefore, clinic administrators asked the TB team to return in 3-month time after the audits were completed. When the team returned in early 2020, the team was given only a few days of data collection. Because of the COVID-19 pandemic in 2020, several community providers were reassigned to COVID-19 duties and the clinic only operated at half capacity during that time. At the first peak of the pandemic in spring of 2020, the community clinic closed to become a COVID-19 testing site for the community. In addition, the 1-year provider LTBI follow-up training that was scheduled for summer of 2020 was postponed because of COVID-19 priorities.

CONCLUSION

To support the national goal of TB elimination in the United States, LTBI among high-risk populations such as non–US-born Asians must be treated to prevent reactivation of LTBI. Community clinics serving these populations are the ideal place for screening, testing, and treating patients for LTBI. Medical providers in the communities have an advantage over other entities such as public health departments to take on this role because they have preexisting and ongoing relationships with their patients. A program of interventions that include training for medical providers on more effective screening using the IGRA blood test, use of shorter LTBI treatment regimens such as 3HP or 4R, incorporation of routine TB risk assessment to the annual physical visit, and an addition of a part-time LTBI care coordinator can increase LTBI testing and treatment in community clinics. Further interventions such as EMR clinician reminders and additional EMR fields to capture completion of treatment, and repeat measurements of testing and treatment practices may be needed to sustain optimal practice over time. This quality improvement project was implemented using few external resources and could be replicated in clinics serving other high-risk populations including non–US-born Asian patients.

REFERENCES

· 1.

Centers for Disease Control and Prevention. Reported Tuberculosis in the United States, 2018. US Department of Health and Human Services; 2019. Accessed June 1, 2020. https://cdc.gov/tb/statistics/reports/2018/national_data.htm [Context Link]

· 2.

Mancuso JD, Diffenderfer JM, Ghassemieh BJ, Horne DJ, Kao TC. The prevalence of latent tuberculosis infection in the United States. Am J Respir Crit Care Med. 2016;194(4):501–509. doi:10.1164/rccm.201508-1683OC [Context Link]

· 3.

Goodell AJ, Shete PB, Vreman R, et al. Outlook for tuberculosis elimination in California: an individual-based stochastic model. PLoS One. 2019;14(4):e0214532. doi:10.1371/journal.pone.0214532 [Context Link]

· 4.

Schwartz NG, Price SF, Pratt RH, Langer AJ. Tuberculosis—United States, 2019. MMWR Morb Mortal Wkly Rep. 2020;69(11):286–289. doi:10.15585/mmwr.mm6911a3 [Context Link]

· 5.

Marks SM, Woodruff RY, Owusu-Edusei K, Asay GRB, Hill AN. Estimates of testing for latent tuberculosis infection and cost, United States, 2013. Public Health Rep. 2019;134(5):522–527. doi:10.1177/0033354919862688 [Context Link]

· 6.

Singer PM, Noppert GA, Jenkins CH. Gaps in federal and state screening of tuberculosis in the United States. Am J Public Health. 2017;107(11):1750–1752. doi:10.2105/AJPH.2017.304076 [Context Link]

· 7.

California Department of Public Health, Tuberculosis Control Branch. Report on tuberculosis in California, 2018. Published 2019. Accessed May 30, 2020. https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/TB-Disease-Data.aspx [Context Link]

· 8.

Orange County Health Care Agency (OCHCA), Pulmonary Disease Services. Tuberculosis fact sheet, 2019. Accessed May 30, 2020. https://www.ochealthinfo.com/civicax/filebank/blobdload.aspx?BlobID=73695 [Context Link]

· 9.

Campbell JR, Krot J, Elwood K, Cook V, Marra F. A systematic review on TST and IGRA tests used for diagnosis of LTBI in immigrants. Mol Diagn Ther. 2015;19(1):9–24. doi:10.1007/s40291-014-0125-0 [Context Link]

· 10.

Lewinsohn DM, Leonard MK, LoBue PA, et al. Official American Thoracic Society/Infectious Diseases Society of America/Centers for Disease Control and Prevention clinical practice guidelines: diagnosis of tuberculosis in adults and children. Clin Infect Dis. 2017;64(2):111–115. doi:10.1093/cid/ciw778 [Context Link]

· 11.

Sterling TR, Njie G, Zenner D, et al. Guidelines for the treatment of latent tuberculosis infection: recommendations from the National Tuberculosis Controllers Association and CDC, 2020. MMRW Recomm Rep. 2020;69(1):1–11. doi:10.15585/mmrw.rr6901a1 [Context Link]

· 12.

Health Resources and Service Administration (HRSA). Health Center Program data. Published 2018. Accessed June 1, 2020. https://bphc.hrsa.gov/uds/datacenter.aspx?q=d&bid=09E01092&state=CA&year=2018 [Context Link]

· 13.

Harris PA, Taylor R, Theilke R, et al. Research Electronic Data Capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377–381. doi:10.1016/j.jbi.2008.08.010 [Context Link]

· 14.

Pease C, Hutton B, Yazdi F, et al. Efficacy and completion rates of rifapentine and isoniazid (3HP) compared to other treatment regimens for latent tuberculosis infection: a systematic review with network meta-analyses. BMC Infect Dis. 2017;17(1):265. doi:10.1186/s12879-017-2377-x [Context Link]

· 15.

Greenway C, Pareek M, Chakra CA, et al. The effectiveness and cost-effectiveness of screening for latent tuberculosis among migrants in the EU/EEA: a systematic review. Euro Surveill. 2018;23(14):17–00543. doi:10.2807/1560-7917.ES.2018.23.14.17-00543 [Context Link]

· 16.

Moro RN, Borisov AS, Saukkonen J, et al. Factors associated with noncompletion of latent tuberculosis infection treatment: experience from the PREVENT TB Trial in the United States and Canada. Clin Infect Dis. 2016;62(11):1390–1400. doi:10.1093/cid/ciw126 [Context Link]