Prior Screening for Latent Tuberculosis Among Patients Diagnosed With Tuberculosis Disease: Missed Opportunities?
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PROVIDER: S-EPMC10651207 | biostudies-literature | 2023 Nov
REPOSITORIES: biostudies-literature
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Project description:BackgroundCardiovascular disease (CVD) is the leading cause of death in women in every major developed country and in most emerging nations. Complications of pregnancy, including preeclampsia, indicate a subsequent increase in cardiovascular risk. There may be a primary care provider knowledge gap regarding preeclampsia as a risk factor for CVD. The objective of our study is to determine how often internists at an academic institution inquire about a history of preeclampsia, as compared to a history of smoking, hypertension and diabetes, when assessing CVD risk factors at well-woman visits. Additional aims were (1) to educate internal medicine primary care providers on the significance of preeclampsia as a risk factor for CVD disease and (2) to assess the impact of education interventions on obstetric history documentation and screening for CVD in women with prior preeclampsia.MethodsA retrospective chart review was performed to identify women ages 18-48 with at least one prior obstetric delivery. We evaluated the frequency of documentation of preeclampsia compared to traditional risk factors for CVD (smoking, diabetes, and chronic hypertension) by reviewing the well-woman visit notes, past medical history, obstetric history, and the problem list in the electronic medical record. For intervention, educational teaching sessions (presentation with Q&A session) and education slide presentations were given to internal medicine physicians at clinic sites. Changes in documentation were evaluated post-intervention.ResultsWhen assessment of relevant pregnancy history was obtained, 23.6% of women were asked about a history preeclampsia while 98.9% were asked about diabetes or smoking and 100% were asked about chronic hypertension (p < 0.001). Education interventions did not significantly change rates of screening documentation (p = 0.36).ConclusionOur study adds to the growing body of literature that women with a history of preeclampsia might not be identified as having increased CVD risk in the outpatient primary care setting. Novel educational programming may be required to increase provider documentation of preeclampsia history in screening.
| S-EPMC7528479 | biostudies-literature
Project description:BackgroundIn Morocco, of the estimated 29,000 people living with HIV in 2011, only 20% were aware of their HIV status. More than half of diagnoses were at the AIDS stage. We assumed that people who were unaware of their infection had contacts with the healthcare system for HIV indicators that might prompt the healthcare provider to offer a test. The aim was to assess missed opportunities for HIV testing in patients newly diagnosed with HIV who accessed care in Morocco.MethodsA cross-sectional study was conducted in 2012-2013 in six Moroccan HIV centers. Participants were aged ≥18, and had sought care within 6 months after their HIV diagnosis. A standardized questionnaire administered during a face-to-face interview collected the patient's characteristics at HIV diagnosis, HIV testing and medical history. Contacts with care and the occurrence of clinical conditions were assessed during the 3 years prior to HIV diagnosis. Over this period, we assessed whether healthcare providers had offered HIV testing to patients with HIV-related clinical or behavioral conditions.ResultsWe enrolled 650 newly HIV-diagnosed patients (median age: 35, women: 55%, heterosexuals: 81%, diagnosed with AIDS or CD4 < 200 cells/mm3: 63%). During the 3 years prior to the HIV diagnosis, 71% (n = 463) of participants had ≥1 contact with the healthcare system. Of 323 people with HIV-related clinical conditions, 22% did not seek care for them and 9% sought care and were offered an HIV test by a healthcare provider. The remaining 69% were not offered a test and were considered as missed opportunities for HIV testing. Of men who have sex with men, 83% did not address their sexual behavior with their healthcare provider, 11% were not offered HIV testing, while 6% were offered HIV testing after reporting their sexual behavior to their provider.ConclusionsAmong people who actually sought care during the period of probable infection, many opportunities for HIV testing, based on at-risk behaviors or clinical signs, were missed. This highlights the need to improve the recognition of HIV clinical indicators by physicians, further expand community-based HIV testing by lay providers, and implement self-testing to increase accessibility and privacy.
| S-EPMC7802172 | biostudies-literature
Project description:BackgroundTuberculosis meningitis (TBM) has high mortality and morbidity. Diagnostic delays can impact TBM outcomes. We aimed to estimate the number of potentially missed opportunities (MOs) to diagnose TBM and determine its impact on 90-day mortality.MethodsThis is a retrospective cohort of adult patients with a central nervous system (CNS) TB International Classification of Diseases, Ninth/Tenth Revision (ICD-9/10) diagnosis code (013*, A17*) identified in the Healthcare Cost and Utilization Project, State Inpatient and State Emergency Department (ED) Databases from 8 states. Missed opportunity was defined as composite of ICD-9/10 diagnosis/procedure codes that included CNS signs/symptoms, systemic illness, or non-CNS TB diagnosis during a hospital/ED visit 180 days before the index TBM admission. Demographics, comorbidities, admission characteristics, mortality, and admission costs were compared between those with and without a MO, and 90-day in-hospital mortality, using univariate and multivariable analyses.ResultsOf 893 patients with TBM, median age at diagnosis was 50 years (interquartile range, 37-64), 61.3% were male, and 35.2% had Medicaid as primary payer. Overall, 407 (45.6%) had a prior hospital or ED visit with an MO code. In-hospital 90-day mortality was not different between those with and without an MO, regardless of the MO coded during an ED visit (13.7% vs 15.2%, P = .73) or a hospitalization (28.2% vs 30.9%, P = .74). Independent risk of 90-day in-hospital mortality was associated with older age, hyponatremia (relative risk [RR], 1.62; 95% confidence interval [CI], 1.1-2.4; P = .01), septicemia (RR, 1.6; 95% CI, 1.03-2.45; P = .03), and mechanical ventilation (RR, 3.4; 95% CI, 2.25-5.3; P < .001) during the index admission.ConclusionsApproximately half the patients coded for TBM had a hospital or ED visit in the previous 6 months meeting the MO definition. We found no association between having an MO for TBM and 90-day in-hospital mortality.
| S-EPMC9969738 | biostudies-literature
Project description:IntroductionScreening for interpersonal violence is used in healthcare settings to identify patients experiencing violence. However, using unvalidated screening tools may misclassify patients' experience with violence. The Center for Medicare & Medicaid Innovation adapted a previously validated intimate partner violence screening tool for use in assessing interpersonal violence and retained the tool's original scoring rubric, despite the new tool's broader scope. This study evaluates the scoring system for detecting safety concerns.MethodsThis was a cross-sectional survey of a convenience sample of adult patients and caregivers of pediatric patients at 7 primary care clinics and 4 emergency departments (2018-2019). Surveys included the adapted 4-item Hurt Insult Threat Scream tool. Questions are scored by frequency on a Likert scale (1=never; 5=frequently). Scores of 11-20 are considered positive for safety concerns. Two-sided Fisher's exact tests were used for descriptive analyses. Data analyses occurred in 2019-2020.ResultsOf 1,014 participants, 66 (6.5%) reported any frequency of physical violence. Of these, 54 (81.8%) did not reach the threshold score of 11. Of the 1,014 participants, 93 (9.2%) reported any frequency of physical violence or being threatened with harm; 76 of 93 participants (81.7%) scored <11.ConclusionsUsing the original scoring criteria for the adapted Hurt Insult Threat Scream, >80% of participants reporting physical violence did not screen positive for potential safety concerns. The scoring criteria did not reliably identify participants experiencing or at high risk for violence. To improve patient safety, the adapted Hurt Insult Threat Scream scoring rubric should be updated on the basis of stakeholder input and additional validation studies.
| S-EPMC8558875 | biostudies-literature
Project description:Late presentation to medical care of individuals infected with the human immunodeficiency virus (HIV) is linked to poor outcomes and increased morbidity and mortality. Missed opportunities for a prompt diagnosis are frequently reported among late presenters. We aimed to estimate the proportion of late presenters and missed opportunities in diagnosis among newly diagnosed HIV-positive subjects presenting to a specialty clinic in Lebanon. This is a retrospective chart review of all newly diagnosed adult HIV-positive subjects presenting to clinic from 2012 to 2022. Demographic, laboratory, and clinical data were collected at initial HIV diagnosis or presentation to medical care. We defined late presentation as having a CD4 count < 350 or AIDS-defining event regardless of CD4 count. Advanced disease is defined as having a CD4 count below 200 cells/μL or the presence of an AIDS-defining illness, regardless of the CD4 count. A missed opportunity was defined as the presence of an indicator condition (IC) that suggests infection with HIV/AIDS during 3 years preceding the actual HIV diagnosis and not followed by a recommendation for HIV testing. The proportions for demographic, epidemiological, and clinical characteristics are calculated by excluding cases with missing information from the denominator. Our cohort included 150 subjects (92.7% males; 63.6% men who have sex with men (MSM); 33.3% heterosexuals; median age 30.5 years at diagnosis). 77 (51.3%) were late presenters and 53 (35.3% of all subjects, 68.8% of late presenters) had advanced HIV on presentation. Up to 76.5% of late presenters had a presentation with an HIV-related condition at a healthcare provider without getting HIV test within the previous 3 years. The most frequent ICs were weight loss, generalized lymphadenopathy, constitutional symptoms, and chronic idiopathic diarrhea. Overall mortality rate was 4% (6/150 individuals). All-cause mortality among those who presented with AIDS was 15.4% (6/39 subjects). In our setting, late presentations and missed opportunities for HIV diagnosis are common. In the Middle East, AIDS mortality remains high with a large gap in HIV testing. To effectively influence policies, comprehensive analyses should focus on estimating the preventable health and financial burdens of late HIV presentations. Another concern pertains to healthcare providers' attitudes and competencies.
| S-EPMC11004126 | biostudies-literature
Project description:ObjectiveTo identify demographic and clinical factors predictive of having a missed opportunity (MO) for HIV screening.DesignRetrospective cohort study.MethodsElectronic medical records were queried for individuals newly diagnosed with HIV in different sites within a large urban academic medical center in New York City between 2018 and 2022. The primary outcome was having one or more MO for HIV screening within the institution, defined as any encounter at which screening was not performed in the 365 days preceding the HIV diagnosis.ResultsOver one third of new diagnoses had at least one MO in the preceding year. Older individuals, cisgender women and those assigned female sex at birth, and heterosexual individuals were more likely to have at least one MO. An initial CD4 < 200 cells/ul was more likely among men who have sex with women specifically. Most MOs occurred in the emergency department and outpatient settings, with minimal HIV prevention discussions documented during each MO.ConclusionsThese findings suggest that populations perceived to be at lower risk for HIV are more likely to have MOs and possibly late diagnoses, and that universal HIV screening must be implemented into the workflows of emergency department and outpatient settings to facilitate early diagnosis and reduce the incidence of HIV.
| S-EPMC10484428 | biostudies-literature
Project description:BackgroundHospitals often employ Medical Emergency Teams (METs) to respond to patients with acute physiological decline so as to prevent deaths from in-hospital cardiac arrest (IHCA). We determined the frequency of missed opportunities for MET evaluation, defined as no MET evaluation prior to IHCA despite evidence of severe vital sign abnormalities ≥1 hour preceding cardiac arrest.MethodsWithin Get With The Guidelines-Resuscitation, we identified 21,913 patients from 274 hospitals with IHCA on general inpatient or telemetry floors who would be eligible for a MET evaluation prior to IHCA. We determined the proportion of patients with missed opportunities for MET evaluation, defined as no MET evaluation before IHCA despite at least 1 severe vital sign abnormality (pulse >150 or <30, respiratory rate >35 or <8, systolic blood pressure <80, and oxygen saturation <80%) 1, 2, and 4 hours before IHCA. The relationship between a hospital's proportion of missed opportunities for MET evaluation and its risk-standardized rate of survival to discharge for IHCA (derived using hierarchical linear regression models) was then evaluated.ResultsOverall, few (3,814 [17.4%]) patients with IHCA had a preceding MET evaluation, and the odds of a MET evaluation varied by >80% across hospitals (median, 14.6% [interquartile range, 9.1%-22.2%]; median odds ratio, 1.82). Vital sign data were available for 13,115 (72.5%) of the 18,099 patients without MET evaluation. Of these patients, 5,243 (40.0%), 4,078 (31.1%), and 1,767 (13.4%) had at least 1 severe vital sign abnormality ≥1, 2, and 4 hours before IHCA, respectively. Hospitals with the highest proportion of unevaluated patients despite severe vital sign abnormalities 2 and 4 hours preceding cardiac arrest had the lowest IHCA survival rate (correlation of -0.14 [P = .04] and -0.16 [P = .01], respectively).ConclusionsAlthough METs are designed to prevent IHCA, many patients with severe vital sign abnormalities prior to IHCA did not have a MET evaluation, and hospitals with higher rates of unevaluated patients had lower IHCA survival. These findings suggest missed opportunities to efficiently use METs in current practice.
| S-EPMC4908832 | biostudies-literature
Project description:Background and aimScreening for tuberculosis before treating with biologic agents is recommended in patients with immune-mediated inflammatory diseases (IMIDs). We conducted this study to identify adherence to the recommended practice in a real-world setting in Japan.MethodsWe used a community-based insurance claims database in a city in the Greater Tokyo Area in Japan. Between July 2012 and January 2019, we enrolled patients with IMIDs in the age range 15 to 74 years who had initiated biologic therapy. Tuberculosis screening was defined as (a) interferon-γ release assay and/or a tuberculin skin test (IGRA/TST) and (b) IGRA/TST and X-ray and/or CT scan (X-ray/CT) within 2 months before starting biologic agents. We analyzed the proportions of patients who underwent tuberculosis screening and their association with the patient- and treatment-related factors and treatment for latent tuberculosis infection (LTBI).ResultsOf 421 patients presumed to have initiated biologic therapy, 202 (48%) underwent IGRA/TST and 169 (40%) underwent IGRA/TST and X-ray/CT. Patients aged 65 to 74 years were more likely to undergo tuberculosis screening than those aged 45 to 64 years. Compared to infliximab, IGRA/TST was less frequently performed in patients treated with etanercept, adalimumab, golimumab, abatacept, and tocilizumab. Treatment for LTBI was provided to 67 (16%) patients. Proportions of patients receiving LTBI treatment did not significantly differ according to the screening status.ConclusionThere was low adherence to the recommendations for tuberculosis screening and prophylactic treatment before biologic therapy. It is necessary to continue alerting clinical practitioners to the importance of screening for tuberculosis and treatment for LTBI.
| S-EPMC7731986 | biostudies-literature
Project description:BackgroundBarrett's esophagus (BE) is the premalignant lesion of esophageal adenocarcinoma (EAC) and is the target of early detection and prevention efforts for EAC.AimsWe sought to evaluate what proportion and temporal trends of EAC patients had missed opportunities for screening and surveillance of BE.MethodsOur study included 182 patients with EAC at the Michael E. DeBakey VA Medical Center in Houston, Texas, between 02/2005 and 09/2017. We conducted a retrospective audit of patients' medical records for any previous upper endoscopies (EGDs) for screening or surveillance of BE prior to their EAC diagnosis.ResultsThe mean age of the cohort was 67.3 years (SD = 9.5); 99.5% of patients were male, and 85.2% were white. Only 45 patients (24.7%) had EGD at any time prior to the cancer diagnosing EGD, of whom 29 (15.9% of all EAC cases) had an established BE diagnosis. In the 137 patients with no prior EGD, most (63.5%) had GERD or were obese or ever smokers. There were no changes in patterns over time. For the 29 patients with prior established BE, 22 (75.8%) were diagnosed with EAC as a result of surveillance EGD. Patients with prior established BE were more likely to be diagnosed at 0 or I stage (p < 0.001) and managed with endoscopic or surgical modalities (p < 0.001) than patients without prior BE.ConclusionsDespite having established risk factors for BE, the majority of EAC patients had no prior EGD to screen for BE. BE screening may represent the largest missed opportunity to reduce EAC mortality.
| S-EPMC6358496 | biostudies-literature
Project description:BackgroundWe investigated whether polymorphisms in the toll-like receptor genes or gene-gene interactions are associated with susceptibility to latent tuberculosis infection (LTBI) or subsequent pulmonary tuberculosis (PTB) in a Chinese population.MethodsTwo matched case-control studies were undertaken. Previously reported polymorphisms in the toll-like receptors (TLRs) were compared between 422 healthy controls (HC) and 205 LTBI patients and between 205 LTBI patients and 109 PTB patients, to assess whether these polymorphisms and their interactions are associated with LTBI or PTB. A PCR-based restriction fragment length polymorphism analysis was used to detect genetic polymorphisms in the TLR genes. Nonparametric multifactor dimensionality reduction (MDR) was used to analyze the effects of interactions between complex disease genes and other genes or environmental factors.ResultsSixteen markers in TLR1, TLR2, TLR4, TLR6, TLR8, TLR9, and TIRAP were detected. In TLR2, the frequencies of the CC genotype (OR = 2.262; 95% CI: 1.433-3.570) and C allele (OR = 1.566; 95% CI: 1.223-1.900) in single-nucleotide polymorphism (SNP) rs3804100 were significantly higher in the LTBI group than in the HC group, whereas the GA genotype of SNP rs5743708 was associated with PTB (OR = 6.087; 95% CI: 1.687-21.968). The frequencies of the GG genotype of SNP rs7873784 in TLR4 (OR = 2.136; 95% CI: 1.312-3.478) and the CC genotype of rs3764879 in TLR8 (OR = 1.982; 95% CI: 1.292-3.042) were also significantly higher in the PTB group than in the HC group. The TC genotype frequency of SNP rs5743836 in TLR9 was significantly higher in the LTBI group than in the HC group (OR = 1.664; 95% CI: 1.201-2.306). An MDR analysis of gene-gene and gene-environment interactions identified three SNPs (rs10759932, rs7873784, and rs10759931) that predicted LTBI with 84% accuracy (p = 0.0004) and three SNPs (rs3804100, rs1898830, and rs10759931) that predicted PTB with 80% accuracy (p = 0.0001).ConclusionsOur results suggest that genetic variation in TLR2, 4, 8 and 9, implicating TLR-related pathways affecting the innate immunity response, modulate LTBI and PTB susceptibility in Chinese.
| S-EPMC4421918 | biostudies-literature