why has tb and ltbi been under the radar?nid]/8a... · why has tb and ltbi been under the radar?...

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March 13, 2019

(Cover Page)

Bringing Screening and Treatment for LTBI into Primary

Medical Care

Bringing Screening and Treatment for LTBI into Primary

Medical Care

Dr. Lauri Thrupp and Emily Tomich

Myths and Misconceptions about TB and LTBIby Physicians, Providers and Patients in Primary Care Practice

Why has TB and LTBI been under the radar?

Bringing Screening and Treatment for LTBI to Primary Medical Care

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• MYTH: TB is a third world disease– FACT: a) 2,000 cases/yr of active TB in California

b) Estimated >2 million cases of LTBI in California

• MYTH: Everyone from (fill in the blank) country has a positive TST and is “healthy”– FACT: 5-10% lifetime risk of active TB

• MYTH: “I had BCG so I’m protected and the positive PPD is normal”– FACT: a) T-cell reactivity from BCG fades within 2-3 years and booster is unlikely to

affect TST in older age groups

b) Approximately 30% of active TB in California are >65 years

c) Use of IGRA (QFT) can dispel concerns of BCG



• MYTH: Most TB is in foreign-born, but they become infected during overseas visits

– FACT: a) 90% of active TB cases in California were non-US born

b) Of these, 80-85% are reactivation disease in patients residing in California for many years

How do we know these 80% are reactivation disease?

• Pattern of pulmonary lesions do not fit primary disease

• Genotyping of strain doesn’t match other active cases


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• MYTH: I don’t want to take/prescribe 9 months of a toxic drug

– FACT: a) 3HP, 12 weekly doses are equally effective as 9 month Isoniazid with better completion compliance and fewer drug reactions

b) 4 month daily Rifampin has similar results

c) Short course drug therapy can be given SAT rather than DOT and most patients do not require regular office visits


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Most TB in California is preventable by screening

and treatment of LTBI!

Most TB in California is preventable by screening

and treatment of LTBI!


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How to implement?

1. “Routine screening” – e.g., Historical, Syphilis

2. EMR-Era and Influenza – UCIMC Experience– Patients’ automatic EMR prompts, Nurse-driven

– HCW mandated, 2008

3. Cost barriers even for targeted Health-System-wide LTBI screening

4. Exposure case


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Step-wise ImplementationTargeted screening and treatment of non-US born diabetics

1. Why diabetes?

a. 30% of active TB patients in California are diabetic

2. Why are diabetics vulnerable?

a. Increased susceptibility to primary infection

b. Increased susceptibility to reactivation

c. Active disease worsens

d. Slower response to therapy

3. UCI Health Family Health Clinic (FQHC)

a. Ideal site for a pilot project!

b. Stand alone site

c. Large non-US born population


Santa Ana Clinic Statistics

Serve over 20,000 patients

77% Latino

82% are 100% or below the FPL

76% insured through MediCal

13% uninsured

Implementation- Initial Phase

1. Physician Champion: Dr. Emily Dow

2. Baseline Data (2015-2016): Dr. Ruby Gonzalez– Santa Ana Clinic Cohort ≈ 3,500 patients– Non-US born, diabetic patients = 843– Random chart review of 120 non-US born, DM pts– Screened for LTBI (TST and/or QFT) = 10 (7%)– Positive for LTBI = 3/10

3. Education Series: late 2016-2017

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1. LTBI Screening and Treatment Process

2. Identified Barriers and Solutions

3. Tools for Implementation

4. UCI Santa Ana Clinic Results

5. Recommendations for Primary Care Practice


UCI Santa Ana ClinicLTBI Program Process Map

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Barriers to LTBI DiagnosisIntrafacility

• Training of Clinic Staff and New Residents– Solutions:

– LTBI Seminars trained 40+ providers

– Weekly Wednesday Huddles for 15 min prior to afternoon Clinic

– New resident training program

– QuantiFERON-TB added to Diabetes order set


Barriers to LTBI DiagnosisInterfacility

• QuantiFERON-TB samples surpassed 14 hour max transport time– Inconsistency between clinic lab and contracted diagnostic company

• Patients had to complete QuantiFERON-TB at outside lab facility

– Solution: Revised pick up schedule

• Patients not picking up the X-ray order and completing the chest X-ray– Barriers: transportation and time

– Solution: Fax order to radiology center

• Uninsured patients not showing up to the Orange County Health Care Agency– UCI Santa Ana Clinic Provider fills out referral form for uninsured patients for 3HP treatment at

OCHCA

– Solution: Monthly LTBI team conference calls


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Barriers to LTBI Treatment• Providers not following up with 3HP after negative chest X-ray

– Solution: LTBI coordinator remind provider patient is a candidate and to prescribe at upcoming appt

• Patient Education and Take Home Materials– Pamphlets and booklets are not given to patients– Not routinely printed/re-stocked– Solution: LTBI team assess materials and print– LTBI Coordinator reviews medication schedule at Week 0 or Week 1

• LTBI Coordinator is not notified– Patients fall through the cracks and do not receive Week 1 follow up call– Solution: LTBI coordinator checks patients with positive QFT weekly

• Pharmacy requiring DOT– Solution: LTBI Coordinator or provider calling patient’s home pharmacy– CalOptima Patients: Pharmacy will only dispense 1 month supply at a time


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Barriers to Patient Follow-up

• Patients are primarily Spanish speaking– Solution: Spanish fluent volunteer per diem

• Unable to reach patients– Solution: Leave voicemail to call clinic – Leave message about LTBI treatment on patient’s medical record for MA’s

or nurses to reference• If upcoming appointment, message provider to discuss treatment with patient

– Document all unsuccessful calls• After 1 month (or 4 calls) of trying to reach patient with no success, patient is

removed from call list


A Dedicated LTBI CoordinatorRole and Qualifications

Work 3-5 hours per week

Foundational clinical/medical knowledge

Passionate!

Comfortable talking with patients

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Current Clinic

Employee

Current Clinic

Employee

Community Agency Partner

Community Agency Partner

VolunteerVolunteer

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Patient Phone Call Script• Introduce yourself• Confirm patient ID• Assess start of 3HP treatment and compliance

– “Have you started taking the medications?”– “What day did you start? What day of the week do you take your medications?”– “How many pills are you taking?”– “Remember to not drink alcohol”

• Screen for side effects• Questions or concerns regarding treatment• Introduce the LTBI program

– Tell patient you will call in 4 weeks

• Remind patient of any upcoming appointments


LTBI Coordinator: Tools

• Workstation

• Literature for clinic staff and patient education materials

• EMR auto-populated report of patient population– Diabetes order set

• Database to record and track patient phone calls– Excel or EMR

• Access to a secure drive to save database and notes

• Protocol and Call Script

• Symptom Severity Grading Algorithm


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I will take my medication after I eat:

□ Breakfast □ Lunch □Dinner

Mark a check in the box the day you take your medication and

bring this to your next appointment.

I will take my medicine on:

M TU W TH F SA SU

Ex □ □ □ □ □ □ □1 □ □ □ □ □ □ □2 □ □ □ □ □ □ □3 □ □ □ □ □ □ □4 □ □ □ □ □ □ □5 □ □ □ □ □ □ □6 □ □ □ □ □ □ □7 □ □ □ □ □ □ □8 □ □ □ □ □ □ □9 □ □ □ □ □ □ □10 □ □ □ □ □ □ □11 □ □ □ □ □ □ □12 □ □ □ □ □ □ □

Miss a day? You have 2 days to take your missed dose.

Call your doctor or nurse if you miss more than 1 day.

My next clinic visit is:

Bring this document with you to every clinic visit

For questions, call (714)XXX-XXXX

Taking your12 doses of

medication to end TB.

Date Day Time

Name: DOB: MRN: IGRA Date: Result: TST Date: Result: CXR Date: Result:

Congratulations!You completed treatment on: ______________________________Staff signature: ___________________

You have been diagnosed with latent tuberculosis infection (LTBI)

Although you probably don’t feel sick, takingmedication now can protect you and yourfamily from serious illness in the future.

Before starting medication?Review ALL of your current medications with your doctor.

This includes birth control pills, warfarin (Coumadin), diabetes medications, over the counter medications, and supplements.

Avoid alcohol

How do I take my medicine?

Take ALL __ pills at one time each week (but one at a time) for 12 weeks

_ Rifapentinepills (red)

_ Isoniazid pills (white)

_ Vitamin B6

It is important that you complete ALL 12 weeks of medications.

What can I expect while taking medications?Serious side effects are rare. However, some people may need monthly visits and lab draws while ontreatment.

Medications and call the clinic if you have any of the following:

Nausea, vomiting, diarrhea, abdominal pain, or stomach cramps

Fever

Rash or itching

Yellow eyes or skin

Less appetite or no appetite for food

Severe tiredness or weakness

Pain, tingling or numbness in your hands, feet orjoints

Feeling faint, dizzy or lightheaded

Dark colored urine (note: red/orange urine is normal).

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EMR Report Fields

• MRN• Patient Name• Phone• QFT result• QFT date• Last HbA1c• Place of birth• Ethnicity• Age• Sex• Next appointment• Last visit date

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Adverse Events

Symptom Severity

Scale

Adapted from Common Terminology Criteria for Adverse

Events, version 5.0, U.S. Department of Health and

Human Services

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2015-16 Baseline Data

• 843 non US-born, diabetic pts

• 10 pts TST/QFT screened

• 3 pts positive LTBI

• 1 completed other tx (6/9 mo INH)

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• 1116 non-US born, diabetic pts

• 526 pts seen at Santa Ana Clinic

• 128 (24%) were screened for LTBI

• 39 (30%) positive QFT

• 24 (62%) started treatment– 4 (16%) opted for other tx (6/9 mo INH)

• 2 (8%) did not finish 3HP

• 14 (58%) completed 3HP treatment

• 0 recommended to stop 3HP related to adverse events

2018 Results


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Recommendations

• Reserved workstation for the LTBI Coordinator

• Translation services available or bi-lingual LTBI Coordinator

• Direct line or way for patients to contact LTBI Coordinator

• Add QuantiFERON-TB to patient population order set

• Complete QuantiFERON-TB draws and chest X-ray in facility if possible


The LTBI TeamUCI Santa Ana Clinic, Santa Ana, CA

Lauri Thrupp, MD, ID Consultant Emily Dow, MD, Physician-Champion

Orange County Health Care Agency, Santa Ana, CAJulie Low, MD

Mike Carson, MSPM

California Department of Public Health, Richmond, CATessa Mochizuki, MPH

Shereen Katrak, MD, MPHNeha Shah, MD, MPH

Setie Asfaha, MPH

University of California, IrvineSchool of Nursing and School of Medicine

Emily Tomich, BS, BAAndreina Castillo, BAManisha Ati, RN, FNPRuby Gonzalez, MD


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Thank You!


Curry International Tuberculosis CenterCalifornia Department of Public Health, TB Control Branch

Orange County Health Care AgencyUniversity of California, Irvine

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