Ending Neglect The Elimination of Tuberculosis in the United States (2000) / Chapter Skim
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3 Tuberculosis Elimination and the Changing Role of Tuberculosis Control Programs
3 Tuberculosis Elimination and the Changing Role of Tuberculosis Control Programs
Pages 51-85
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From page 51... ...
At the same time health care delivery systems are changing, as there is a trend toward increased privatization of health care and social services and increased use of managed care organizations for the delivery of services. All of these challenges can also create opportunities.
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From page 52... ...
Recommendation 3.3 To make further progress toward the elimination of tuberculosis in regions of the country experiencing low rates of disease, the committee recommends that · Tuberculosis elimination activities be regionalized through a combination of federal and multistate initiatives to provide better access to and more efficient utilization of clinical, epidemiological, and other technical services. · Protocols and action plans be developed jointly by CDC and the states for use by state and local health departments to enable planning for the availability of adequate resources.
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From page 53... ...
Tuberculosis elimination is dependent on the results of this second race, with the best outcome being that it is never run. Strategies to that end include not only aggressive promotion of the vision of tuberculosis elimination but also continual adaptation and evolution of the tuberculosis control program response to an increasingly uncommon disease.
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From page 54... ...
As applied to tuberculosis control programs these responsibilities include · assessment, through regular and systematic collection and analysis of information about the extent of tuberculosis infection and disease in a community and the effectiveness of programs and interventions that will reduce this threat; · policy development, through comprehensive, evidence-based policy formulation that allows equitable and effective distribution of public tuberculosis control resources and complementary private activities; and · assurance that services necessary to achieve tuberculosis control are provided by encouraging and enabling actions by other entities, by requiring such actions through regulation, or by providing services directly. As with tuberculosis control goals, these core functions of tuberculosis control programs will not change as the country moves toward tuberculosis elimination.
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From page 55... ...
For no other disease, however, has this assurance function been translated into so much primary responsibility for the direct provision of medical treatment by the public health system. Data from CDC annual reports on tuberculosis show that since 1993 slightly less than one-half of all tuberculosis patients are treated by health departments and about onequarter each are either managed by private providers or comanaged by private-sector providers and the health department.
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From page 56... ...
The extent to which the private sector is up to the task, particularly with respect to the provision of directly observed therapy, is still a subject of debate. However, unpublished data from CDC show that from 1993 to 1997 the proportion of patients who completed therapy within one year when a year or less of therapy was indicated steadily increased both for patients managed by private providers and for patients managed by the health departments.
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From page 57... ...
In contrast to the provision of diagnostic treatment services to patients with tuberculosis, however, tuberculosis control programs will continue to have direct responsibility for conducting case investigation and contact identification and follow-up, as there is no other appropriate provider of services. The key challenge posed by progress to tuberculosis elimination will be to maintain competency and to develop strategies for ensuring that resources for tuberculosis elimination are available, despite a diminishing and unpredictable demand for services.
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From page 58... ...
These guidelines call for targeted tuberculin skin testing of populations at high risk of infection and the treatment of latent infections for all those found to be infected. The guidelines also introduce short
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From page 59... ...
CROSSCUTTING STRATEGIES In addition to the goal-specific effects on the evolution of tuberculosis control strategies described in the previous section, progress toward tuberculosis elimination will also require crosscutting changes in approach. These changes can be broadly grouped into three categories based on the
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From page 60... ...
One very important core of competency is the group of public health advisers employed by CDC and assigned to work in state and local health departments as direct federal assistance. Most of these individuals began their careers in public health as field workers in sexually transmitted disease, tuberculosis, or other public health programs and have worked in a variety of field and managerial positions.
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From page 61... ...
Special training efforts should be focused on those physicians serving impoverished individuals and new arrivals to the United States, such as physicians in community health centers, migrant health centers and public hospitals, and foreign-trained physicians. Distinct educational programs are also needed for correctional institutions and the U.S.
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From page 62... ...
The recent appropriation of federal bioterrorism dollars for the creation of a Health Alert Network will result in dedicated, high-speed Internet connections, computer hardware and software to take advantage of this resource, and an increased capacity to participate in distance-based learning in most local health departments. These new tools provide a perfect opportunity to increase the "system expertise" in tuberculosis control by making the Internet a site of userfriendly training, education, and reference material.
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From page 64... ...
24~. Understanding cultural barriers to prevention, treatment, and control as well as the incentives and enablers that are most effective in enhancing compliance by specific target groups, such as increasing the return rate for reading of tuberculin skin test results among drug users at
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From page 65... ...
As staff become increasingly inexperienced, such measures will help ensure that the right information is monitored and will allow an ongoing objective assessment of whether tuberculosis control programs are performing adequately. Tuberculosis control is well suited to performance measures, as goals, strategies, and standards of practice are better delineated for tuberculosis than for many other public health programs.
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From page 66... ...
Investigative Guidelines, Instructions, and Templates Increasingly, public health staff called on to investigate tuberculosis may not be experienced or may not have experience with on-site supervision. As is described in detail in Chapter 4, accessible, up-to-date, userfriendly, locally relevant, comprehensive guidelines, including step-bystep instructions, investigative algorithms, and checklists, are currently not available but could provide structure and supervision to inexperienced staff.
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From page 67... ...
CDC and the states are engaged in the initial development of systems for computerized electronic laboratory reporting (ELR) of notifiable diseases from public and private laboratories directly to public health departments.
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From page 68... ...
In the absence of daily demonstration of need, the historical example of the 1970s showed that there will be pressure to shift tuberculosis control funding to other, more visible priorities, as discussed in the previous chapter. Although the rallying cry for continued categorical funding may continue to resonate loudly in the halls of tuberculosis control programs, as a single message it may not be heard in the larger policy discussion arenas of public health departments, local city councils, or legislative assemblies.
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From page 69... ...
To preserve services in the face of this decreased funding, tuberculosis control programs at the state and local levels must actively search for ways to integrate activities with comparable activities performed by other categorical health department programs. Examples of such activities might include (1)
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From page 70... ...
Pressure on tuberculosis control budgets could also be reduced by establishing directly observed therapy, targeted tuberculin skin test screening, and provision of treatment of latent infection as performance-based standards in the private sector. In 1993, the Medicaid Act was amended to allow states to provide Medicaid eligibility for anyone who tests tuberculin skin test positive and who also meets that state's income eligibility criteria.
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From page 71... ...
Capacity Measures As the numbers of cases of tuberculosis decline, the perceived need for active tuberculosis control programs will become less apparent. Policy makers will lose touch with the issue and health departments may be unsure or unable to effectively articulate their specific resource requirements.
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From page 72... ...
Response to Managed Care The percentage of individuals with tuberculosis who receive care in the private sector is likely to grow, as Medicaid and Medicare recipients are increasingly being enrolled in the health plans of private for-profit insurance companies and managed care organizations. In 1997, the last
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From page 73... ...
Another health sector reform with the potential to significantly affect tuberculosis control is the growing trend toward privatization by local health departments. Privatization, which consists of outsourcing or contracting with private for-profit or not-for-profit organizations to provide
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From page 74... ...
Opportunities On the other hand, managed care and privatization present, at least in theory, opportunities to redefine and strengthen the respective roles of local health departments and private-sector health care organizations in support of a national tuberculosis control and elimination effort. This is attainable if population-based approaches to care are addressed by managed care organizations and other organizations contracting with state or local health departments.
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From page 75... ...
As in the example cited earlier in a box in this chapter describing the experience in Pierce County, Washington, contracts can set performance standards and identify necessary organizational capacities, technical expertise, provider competencies, and the laboratory quality control necessary for private-sector organizations to successfully undertake the treatment and management of tuberculosis patients. Contracts can also can be used to align public and private stakeholders so that tuberculosis control is properly coordinated among these partners and their participating provider and laboratory networks.
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From page 76... ...
CDC, working in conjunction with state and local health departments, professional societies, and voluntary, nongovernmental organizations, has established national standards of care for tuberculosis. These standards are designed to achieve the maximum rate of cure.
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From page 77... ...
Even when the state's health department lacks independent authority, and cooperation with the Division of Insurance has not developed, state or local boards of health usually have legislatively authorized power to establish rules and regulations that require that the state's physicians and hospital providers adhere to specific behavior or treatment standards. This has been successfully accomplished in Colorado and other states where specific statewide treatment standards require the implementation of directly observed therapy for all tuberculosis patients, unless an exemption is granted from the Department of Health.
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From page 78... ...
Importantly, these patient-centered approaches coupled with directly observed therapy and other aspects of case supervision have been shown to be highly effective across a range of geographical and socioeconomic settings, producing treatment completion rates in excess of 90 percent (Bayer et al., 1998~. The provision of incentives without directly observed therapy produces much lower completion rates (Armstrong and Pringle, 1984; Caminero et al., 1996; Cohn et al., 1990; Cowie and Brink, 1990; Dutt et al., 1984; Hong Kong Chest Service/British Medical Research Council, 1984; fin et al., 1993; Menzies et al., 1993; Ormerod et al., 1991; Samuel, 1976; Snider et al., 1998; Valeza and McCougall, 1990; Van der Werf et al., 1990; Wolde et al., 1992~.
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From page 79... ...
Colorado's Department of Health has recently established specific statewide treatment standards that require the implementation of directly observed therapy for all patients identified as having active tuberculosis unless an exemption is obtained from the Department of Health. In situations where directly observed therapy can not be used, fixed-dose drug combinations (containing both isoniazid and rifampin)
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From page 80... ...
Simple sharing of provider inpatient and outpatient care practices on a geographical basis, along with comparing provider comparisons with national practice guidelines, has proved to be a powerful tool for improving quality of patient care.
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From page 81... ...
Partnerships between these providers that serve the most vulnerable populations, local health departments, and managed care organizations would result in improved access to tuberculosis services in the primary care setting. Such partnerships could also involve the wide range of other organizations and providers that provide primary care to those most at risk of developing tuberculosis.
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From page 82... ...
Stayton C, Desvarieux MD, et al., 1998. Directly observed therapy and treatment completion for tuberculosis in the United States: Is universal supervised therapy necessary?
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From page 83... ...
1998. Directly observed therapy for treatment completion of tuberculosis.
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From page 84... ...
1998. Tuberculosis control in a changing health care system: Model contract specifications for managed care organizations.
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From page 85... ...
1989. The tuberculosis clinic.
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