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Multicenter Analysis of Attrition from the Pediatric Tuberculosis Infection Care Cascade in Boston
Jeffrey I Campbell1, Mary Tabatneck2, Mingwei Sun3
1Division of Infectious Diseases, Boston Children's Hospital, Boston, MA.
Insights
Pediatric tuberculosis (TB) testing completion is high, but evaluation and treatment completion remain moderate. Improving care requires transitioning to interferon gamma release assay (IGRA) testing and addressing social determinants of health.
Area of Science:
- Pediatric Infectious Diseases
- Public Health
- Health Services Research
Background:
- Pediatric tuberculosis (TB) infection poses a significant global health challenge.
- Effective care delivery requires understanding and optimizing the entire patient journey, from screening to treatment completion.
- Gaps in the pediatric TB infection care cascade can lead to suboptimal outcomes.
Purpose of the Study:
- To characterize losses within the pediatric TB infection care cascade.
- To identify specific points of failure in TB infection care delivery for children.
- To inform strategies for improving the effectiveness of pediatric TB infection care.
Main Methods:
- Retrospective cohort study of children (<18 years) screened for TB infection.
- Inclusion of patients who received tuberculin skin test (TST) and/or interferon gamma release assay (IGRA) between January 2017 and May 2019.
- Analysis of testing completion, evaluation completion, and treatment completion rates, with associated demographic and clinical factors.
Main Results:
- High testing completion rates (93.9%) were observed among 11,622 children.
- Only 59.3% of eligible patients with positive tests completed evaluation and/or treatment.
- Older age (12-17 years), non-English/Spanish language preference, and IGRA use were associated with higher testing completion.
- Increased social vulnerability and primary care setting for treatment initiation were associated with lower completion rates.
Conclusions:
- While pediatric TB infection testing completion is high, significant losses occur in evaluation and treatment.
- Transitioning to IGRA testing can improve testing completion rates.
- Interventions targeting social determinants of health are crucial for enhancing treatment completion in pediatric TB infection care.
Objective:
To characterize losses from the pediatric tuberculosis (TB) infection care cascade to identify ways to improve TB infection care delivery.
Study Design:
We conducted a retrospective cohort study of children (age <18 years) screened for TB within 2 Boston-area health systems between January 2017 and May 2019. Patients who received a tuberculin skin test (TST) and/or an interferon gamma release assay (IGRA) were included.
Results:
We included 13 353 tests among 11 622 patients; 93.9% of the tests were completed. Of 199 patients with positive tests for whom TB infection evaluation was clinically appropriate, 59.3% completed treatment or were recommended to not start treatment. Age 12-17 years (vs < 5 years; aOR 1.59; 95% CI, 1.32-1.92), non-English/non-Spanish language preference (vs English; aOR, 1.34; 95% CI, 1.02-1.76), and receipt of an IGRA (vs TST, aOR, 30.82; 95% CI, 21.92-43.34) were associated with increased odds of testing completion. Odds of testing completion decreased as census tract social vulnerability index quartile increased (ie, social vulnerability worsened; most vulnerable quartile vs least vulnerable quartile, aOR, 0.77; 95% CI, 0.60-0.99). Odds of completing treatment after starting treatment were higher in females (vs males; aOR, 2.35; 95% CI, 1.14-4.85) and were lower in patients starting treatment in a primary care clinic (vs TB/infectious diseases clinic; aOR, 0.44; 95% CI, 0.27-0.71).
Conclusions:
Among children with a high proportion of negative TB infection tests, completion of testing was high, but completion of evaluation and treatment was moderate. Transitions toward IGRA testing will improve testing completion; interventions addressing social determinants of health are important to improve treatment completion.
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