Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA.
Center for Tuberculosis Research, Johns Hopkins University, Baltimore, MD, USA.
Lancet Infect Dis. 2021 Aug;21(8):1175-1183. doi: 10.1016/S1473-3099(20)30732-5. Epub 2021 Mar 23.
A high index of suspicion is needed to initiate appropriate testing for tuberculosis due to its protean symptoms, yet health-care providers in low-incidence settings are becoming less familiar with the disease as rates decline. We aimed to estimate delays in tuberculosis diagnosis and treatment at the US national level between 2008 and 2016.
In this retrospective observational cohort study, we repurposed private insurance claims data provided by Aetna (Connecticut, USA), to measure health-care delays in tuberculosis diagnosis in the USA in 2008-16. Active tuberculosis was determined by diagnosis codes and the filling of anti-tuberculosis treatment prescriptions. Health-care delays were defined as the duration between the first health-care visit for a tuberculosis symptom and the initiation of anti-tuberculosis treatment. We assessed if delays varied over time, and by patient and system variables, using multivariable regression. We estimated household tuberculosis transmission and respiratory complications after treatment initiation.
We confirmed 738 active tuberculosis cases (incidence 1·45 per 100 000 person-years) with a median health-care delay of 24 days (IQR 10-45). Multivariable regression analysis showed that longer delays were associated with older age (8·4% per 10 year increase [95% CI 4·0 to 13·1]; p<0·0086) and non-HIV immunosuppression (19·2% [15·1 to 60·0]; p=0·0432). Presenting with three or more symptoms was associated with a shorter delay (-22·5% [-39·1 to -2·0]; p=0·0415), relative to presenting with one symptom, as did use of chest imaging (-24·9% [-37·9 to -8·9]; p<0·0098), tuberculosis nucleic acid amplification tests (-19·2% [-32·7 to -3·1]; p=0·0241), and care by a tuberculosis specialist provider (-17·2% [-33·1 to -22·3]; p<0·0087). Longer delays were associated with an increased rate of respiratory complications even after controlling for patient characteristics, and an increased rate of secondary tuberculosis among dependents.
In the USA, the median health-care delay for privately insured patients with tuberculosis exceeds WHO-recommended levels of 21 days (3 weeks). The results suggest the need for health-care provider education on best practices in tuberculosis diagnosis, including the use of molecular tests and the maintenance of a high index of suspicion for the disease.
US National Institutes of Health.
由于结核病的症状多种多样，因此需要高度怀疑才能进行适当的检测，但随着发病率的下降，低发病率地区的医疗服务提供者对该病的了解越来越少。我们旨在估计 2008 年至 2016 年期间美国全国结核病诊断和治疗的延迟。
在这项回顾性观察队列研究中，我们重新利用了 Aetna（美国康涅狄格州）提供的私人保险索赔数据，以衡量 2008-16 年美国结核病诊断中的医疗保健延迟。活动性结核病通过诊断代码和抗结核治疗处方的填写来确定。医疗保健延迟定义为首次出现结核病症状至开始抗结核治疗之间的持续时间。我们使用多变量回归评估了随时间变化的情况，以及患者和系统变量的变化。我们估计了家庭内结核病传播和治疗后呼吸道并发症的发生率。
我们确认了 738 例活动性结核病病例（发病率为每 100000 人年 1.45 例），中位医疗保健延迟为 24 天（IQR 10-45）。多变量回归分析表明，年龄较大（每增加 10 岁增加 8.4%[95%CI 4.0 至 13.1]；p<0.0086）和非 HIV 免疫抑制（19.2%[15.1 至 60.0]；p=0.0432）与较长的延迟相关。与仅出现一种症状相比，出现三种或更多症状与较短的延迟相关（-22.5%[-39.1 至-2.0]；p=0.0415），使用胸部成像（-24.9%[-37.9 至-8.9]；p<0.0098），结核核酸扩增检测（-19.2%[-32.7 至-3.1]；p=0.0241），以及由结核病专科医生提供护理（-17.2%[-33.1 至-22.3]；p<0.0087）也与较短的延迟相关。即使在控制患者特征后，较长的延迟与呼吸道并发症的发生率增加有关，并且与依赖者中继发性结核病的发生率增加有关。
在美国，私人保险结核病患者的医疗保健延迟中位数超过了世界卫生组织建议的 21 天（3 周）。结果表明，需要对医疗保健提供者进行结核病诊断最佳实践的教育，包括使用分子检测和保持对该病的高度怀疑。
美国国立卫生研究院。
