PUBLIC HEALTH BRIEFS
A Combined Health Department-Medical School Rural Outpatient Tuberculosis Program THOMAS H. PEIRCE, MD, GEORGE K. YORK, BA, GIBBE H. PARSONS, MD, VICKIE SPANNAGEL, RN, GLEN A. LILLINGTON, MD, AND CARROLL E. CROSS, MD
Introduction Adequate chemotherapy has largely eliminated surgical treatment for tuberculosis1' 2 and, will almost certainly render patients non-infective within a period of several weeks.3-6 This advance has led to the phasing out of tuberculosis sanatoria7 and has introduced the use of general hospitals for initial short-term treatment periods8 with subsequent referral to an outpatient program. In one rural California county this change was facilitated by merging resources of the County Health Department Tuberculosis Central Program with the Pulmonary Disease Section of a state medical school.
Treatment ofTuberculosis in a Rural County Yolo County is a rural agricultural county in the north central valley of California. The county has an area of 1,035 square miles and a population which has grown steadily from 77,000 in 1964 to 105,000 in 1974. Prior to 1971, all patients with tuberculosis were sent to a tuberculosis sanatorium located 80 miles from the county and remained there until three consecutive monthly sputum samples were negative on culture. In 1972, a program of general hospital and outpatient care was instituted under the combined auspices of the Pulmonary Disease Section of the University of California, Davis School of Medicine and the Yolo County Health Department. The County is now divided into two clinic areas 20 miles apart. One of the clinics is situated beside the Yolo County General Hospital, where some patients are admitted for initial work-up, tuberculosis education, and institution of a satisfactory treatment regimen. The director of public health has responsibility for tuberculosis control in the county. He contracts annually with the University of California School of Medicine for the treatment of known cases of tuberculosis, and the supervision of programs for education, prophylaxis and case-finding. Clinics and inpatient consultation rounds are held bimonthly and are attended by a pulmonary staff physician, pulmonary fellows, and public health nurses. Interns, residents, medical students, and family nurse practitioners atFrom the Department of Internal Medicine, University of Califomia (Davis), Sacramento Medical Center. Address reprint
requests to Dr. T. H. Peirce, Public Health Bldg. #27, Section of Pulmonary Medicine, Sacramento Medical Center, 2221 Stockton Blvd., Sacramento, CA 95817. This paper, submitted to the Journal August 25, 1975, was revised and accepted for publication November 1, 1976.
AJPH March, 1977, Vol. 67, No. 3
tend for two to three months on a rotational basis. When a tuberculosis case is first diagnosed, the public health nurse, in consultation with social workers and the pulmonary physician, decides whether a period of initial hospitalization is advisable. Patient education and establishment of a satisfactory therapeutic regimen is then undertaken, primarily by the public health nurse, in the inpatient or outpatient setting. As far as possible, the public health nurse who follows the patient in the hospital is also responsible for outpatient follow-up. This may require up to three home visits weekly, depending on the therapeutic regimen and the patient's compliance with medication orders. The incidence of tuberculosis in the U.S. and in Yolo County between 1964 and 1975 is shown in Figure 1. Approximately one-third of the Yolo County cases occur in migrant workers and/or in patients addicted to alcohol. Since the inception of the outpatient program in 1972, the incidence of tuberculosis has not changed significantly. However, as shown in Figure 2, the average hospital stay per patient has dropped precipitously, from 150 days per patient in 1971 to 10 days per patient in 1974. The latter figure reflects the fact that since 1972, only 40 per cent of new tuberculosis patients have been admitted to hospital at all, and that hospitalization periods are much shorter.
o- -o- .o U. S.
30
25
INCIDENCE 20 OF TUBERCULOSIS
(cases/yeor/ 100,000) 1 5
101 5
~.-. .YOLO COUNTY
I~~~~~~~ 'I
I',, / i
A \6\
At
,
/
\
\I Y
1964 65 66 67 68 69 70 71 72 73 74 7r5 YEAR FIGURE 1-Incidence of Tuberculosis in the United States and Yolo County, California, 1964-1975. (The arrow denotes the year of inception of an ambulatory care program in Yolo County.)
257
PUBLIC HEALTH BRIEFS
350 300
2501 AVERAGE HOSPITAL 200 STAY (days/patient)
150-
100 _ 50-
I
1964 65 66 67 68 69 70 71 72 73 74 75 YEAR FIGURE 2-Average Hospital Stay per Patient with Tuberculosis in Yolo County, 1964-1975. (The arrow denotes the year of inception of an ambulatory program in Yolo County.)
Table I shows the estimated costs for the care of an average patient with tuberculosis in Yolo County in 1971 and 1974; the expense of an efficiently administered outpatient program is far less than the expense of prolonged sanatoria care. In Yolo County a portion of the funds spent previously to support long-term hospitalizations is now utilized to employ two extra public health nurses, who have helped to intensify case-finding, patient education, and home care follow-up programs, as well as administering a greatly increased INH prophylactic program.
Discussion The new tuberculosis control program provides several distinct advantages to the tuberculosis patient. First, the TABLE 1-Actual Difference in Cost of Treating a Case of Tuberculosis in Yolo County in 1971 and 1974. Therapeutic Regimen
1971
1974
$6,000 150 days at sanatorium @ $40/day 10 days at a local general hospital 2 days acute @ $85 plus $650 8 days extended care @ $60 $60 2 home visits @ $30 $420 14 home visits @ $30 $360 18 clinic visits @ $20 $480 24 clinic visits @ $20 $6,420 $1,550 TOTAL Drugs, radiology and laboratory tests are similar for the two years per case treated.
258
time that the patient must spend in a hospital is markedly decreased, although the quality and efficacy of outpatient care of tuberculosis has been shown to be comparable to the older method of prolonged hospitalization.9' 10 Secondly, any necessary hospitalization is now done close to home and family. A minority of "problem" cases, frequently alcoholics, are treated in the general hospital for up to four weeks. They are then discharged home or to a "board and care" type of environment where they receive three home visits per week for drug administration by the public health nurse. By gaining the confidence of these patients rather than following the previous policy of incarceration in a sanitorium, we have found them much more amenable to treatment, although loss to follow-up still remains a problem. In Yolo County, as elsewhere, many tuberculosis patients are treated at public expense; hence the cost of care should be a public concem. The wide differences in cost among the various treatment regimens, together with evidence indicating that prolonged hospitalization is no more effective than ambulatory treatment, emphasize that the use of the former for the majority of patients with active tuberculosis is poor economic practice. It is important for people involved in the treatment of tuberculosis to assess the scientific evidence that ambulatory care is indeed a distinct advantage. However, this evidence is by no means universally accepted;11' 12 17 states use sanatoria exclusively,13' 14 and there remains resistance to renovation of tuberculosis treatment programs. An important ancillary benefit of a combined medical school-public health tuberculosis program is the provision of first-hand experience for professionals of both programs to interrelate in an organized and changing health care delivery system. Medical schools have been accused of failing to emphasize the principles of preventive and community health care. This failure is understandable, considering that most clinical teaching is provided in university hospital centers. The involvement of medical students, interns, residents, and fellows in a community public health program broadens their educational base and increases their interest and understanding of the problems of public health maintenance. Many local public health departments have been resistant to changes for fear of displeasing the local medical establishment and have been in a measure guilty of zealously guarding their administrative responsibilities for community preventive health and communicable disease services. It would seem that merger and shared responsibilities of some programs with medical school teaching and service programs would well serve the receivers of certain health care delivery systems. It has been demonstrated that public health tuberculosis programs in areas near medical schools is one area where this can be readily and efficiently accomplished. REFERENCES 1. Johnson, R. F., and Wildrick, K. H. State of the art review: The impact of chemotherapy on the care of patients with tuberculosis. Amer. Rev. Resp. Dis., 109:636-664, 1974. 2. Newman, R., Doster, B. E., Murray, F. J., and Woolpert, S. F.
Rifampin in the initial treatment of pulmonary tuberculosis, Amer. Rev. Resp. Dis., 109:216-232, 1974. AJPH March, 1977, Vol. 67, No. 3
PUBLIC HEALTH BRIEFS 3. Gunnels, J. J., Bates, J. F., Swindoll, H. Infectivity of sputumpositive tuberculous patients on chemotherapy. Amer. Rev. Resp. Dis., 109:323-330, 1974. 4. Kamart, S. R., Dawson, J. J., Devadatta, S., Fox, W., Janardhanam, B., Radhakrisha, S., Ramakrishan, C. V., Somasundaram, R. R., Stott, H., Velu, S. A controlled study of the influence of segregation of tuberculosis in a five-year period in close family contacts in South India. Bull. W.H.O. 34:517-532, 1966. 5. Riley, R. L., Mills, C. C., O'Grady, F., Sultan, L. U., Wittstadt, F., Shivpuri, D. N. Infectiousness of air from a tuberculosis ward. Amer. Rev. Resp. Dis., 85:511-525, 1962. 6. Bates, J. H., and Stead, W. W. Effect of chemotherapy on infectiousness of tuberculosis. New Engl. Journal Med., 290:459460, 1974. 7. Dandoy, S., and Elman, S. B. Current status of general hospital use for tuberculous patients in the United States. Amer. Rev. Resp. Dis., 106:580-586, 1972.
8. Reagan, W. P. Treatment of tuberculosis in the general hospital. Clin. Notes Resp. Dis., 11 (4):3-16, 1973. 9. Dandoy, S., and Hansen, R. Tuberculosis care in general hospitals, Arizona's experience, Amer. Rev. Resp. Dis. Vol. 112:757-763, 1975. 10. McConville, J. H., Rapoport, M. I. Tuberculosis management in the mid-1970's. 11. Oatway, W. H. Early discharge of patients with active tuberculosis? Amer. Rev. Resp. Dis., 109:320-322, 1974. 12. Bates, J. H. Ambulatory treatment of tuberculosis-An idea whose time has come. Amer. Rev. Resp. Dis., 109:317-319, 1974. 13. Reichman, L. B. Tuberculosis care: When and where? Ann. Int. Med., 80:402-406, 1974. 14. Dandoy, S., Wiggins, K. Current status of general hospital use for patients with tuberculosis in the United States: An update. Amer. Rev. Resp. Dis. 110:442-445, 1974.
1977 Graduate Summer Session in Epidemiology University of Minnesota The Twelfth Graduate Summer Session in Epidemiology sponsored by the Epidemiology Section of the American Public Health Association and the Association of Teachers of Preventive Medicine will be presented at the University of Minnesota in Minneapolis through the School of Public Health, Health Sciences Center and the Nolte Center for Continuing Education during the three-week period from June 19 to July 9, 1977. These summer graduate sessions are designed primarily for teachers in medical schools, but postdoctoral fellows, graduate students and residents in departments of preventive medicine and other medical school departments may qualify. Similarly teachers, post-doctoral fellows and graduate students in schools of public health, dentistry and veterinary medicine are eligible as are qualified personnel of federal, state and local health agencies. The summer session in 1977 will follow the pattern previously established. In addition to the two basic courses in Fundamentals of Epidemiology and Fundamentals of Biostatistics several of the previously presented courses will be offered. These include, the Epidemiology of Cancer, Epidemiology of Cardiovascular Diseases, Epidemiology of Infectious Diseases, Genetics and Epidemiology, Epidemiology of Injuries and Principles and Methods of Epidemiologic Research. Three new courses will be presented: Development of and Perspectives in Epidemiology, Hospital Epidemiology and Infection Control, and Epidemiology of Diseases Due to Drugs and Other Therapies. Tuition for the 3-week session will be approximately $350$400. Special rates for food and lodging in dormitories have been arranged. Grants for tuition and stipends may become available but prospective registrants should explore other sources of funding as soon as possible. Should a grant for this purpose be realized, high priority applicants with financial hardship will be given consideration. Such individuals will also have to be non-federally employed U.S. citizens who are not concurrently on another federal stipend. No reimbursement will be made for travel. A $25 deposit, credited to tuition, should accompany applications. Receipt of the deposit will constitute evidence of intent to attend. Refund of deposit will be made if the application is not accepted or if applicant's plans change before May 16. Further information and application forms for the 1977 session may be obtained by writing to Dr. Leonard M. Schuman, Director, Graduate Summer Session in Epidemiology, University of Minnesota School of Public Health, A1- 1 17 Unit A Health Sciences Building, 515 Delaware St. S.E., Minneapolis, MN 55455.
AJPH March, 1977, Vol. 67, No. 3
259
A Combined Health Department-Medical School Rural Outpatient Tuberculosis Program THOMAS H. PEIRCE, MD, GEORGE K. YORK, BA, GIBBE H. PARSONS, MD, VICKIE SPANNAGEL, RN, GLEN A. LILLINGTON, MD, AND CARROLL E. CROSS, MD
Introduction Adequate chemotherapy has largely eliminated surgical treatment for tuberculosis1' 2 and, will almost certainly render patients non-infective within a period of several weeks.3-6 This advance has led to the phasing out of tuberculosis sanatoria7 and has introduced the use of general hospitals for initial short-term treatment periods8 with subsequent referral to an outpatient program. In one rural California county this change was facilitated by merging resources of the County Health Department Tuberculosis Central Program with the Pulmonary Disease Section of a state medical school.
Treatment ofTuberculosis in a Rural County Yolo County is a rural agricultural county in the north central valley of California. The county has an area of 1,035 square miles and a population which has grown steadily from 77,000 in 1964 to 105,000 in 1974. Prior to 1971, all patients with tuberculosis were sent to a tuberculosis sanatorium located 80 miles from the county and remained there until three consecutive monthly sputum samples were negative on culture. In 1972, a program of general hospital and outpatient care was instituted under the combined auspices of the Pulmonary Disease Section of the University of California, Davis School of Medicine and the Yolo County Health Department. The County is now divided into two clinic areas 20 miles apart. One of the clinics is situated beside the Yolo County General Hospital, where some patients are admitted for initial work-up, tuberculosis education, and institution of a satisfactory treatment regimen. The director of public health has responsibility for tuberculosis control in the county. He contracts annually with the University of California School of Medicine for the treatment of known cases of tuberculosis, and the supervision of programs for education, prophylaxis and case-finding. Clinics and inpatient consultation rounds are held bimonthly and are attended by a pulmonary staff physician, pulmonary fellows, and public health nurses. Interns, residents, medical students, and family nurse practitioners atFrom the Department of Internal Medicine, University of Califomia (Davis), Sacramento Medical Center. Address reprint
requests to Dr. T. H. Peirce, Public Health Bldg. #27, Section of Pulmonary Medicine, Sacramento Medical Center, 2221 Stockton Blvd., Sacramento, CA 95817. This paper, submitted to the Journal August 25, 1975, was revised and accepted for publication November 1, 1976.
AJPH March, 1977, Vol. 67, No. 3
tend for two to three months on a rotational basis. When a tuberculosis case is first diagnosed, the public health nurse, in consultation with social workers and the pulmonary physician, decides whether a period of initial hospitalization is advisable. Patient education and establishment of a satisfactory therapeutic regimen is then undertaken, primarily by the public health nurse, in the inpatient or outpatient setting. As far as possible, the public health nurse who follows the patient in the hospital is also responsible for outpatient follow-up. This may require up to three home visits weekly, depending on the therapeutic regimen and the patient's compliance with medication orders. The incidence of tuberculosis in the U.S. and in Yolo County between 1964 and 1975 is shown in Figure 1. Approximately one-third of the Yolo County cases occur in migrant workers and/or in patients addicted to alcohol. Since the inception of the outpatient program in 1972, the incidence of tuberculosis has not changed significantly. However, as shown in Figure 2, the average hospital stay per patient has dropped precipitously, from 150 days per patient in 1971 to 10 days per patient in 1974. The latter figure reflects the fact that since 1972, only 40 per cent of new tuberculosis patients have been admitted to hospital at all, and that hospitalization periods are much shorter.
o- -o- .o U. S.
30
25
INCIDENCE 20 OF TUBERCULOSIS
(cases/yeor/ 100,000) 1 5
101 5
~.-. .YOLO COUNTY
I~~~~~~~ 'I
I',, / i
A \6\
At
,
/
\
\I Y
1964 65 66 67 68 69 70 71 72 73 74 7r5 YEAR FIGURE 1-Incidence of Tuberculosis in the United States and Yolo County, California, 1964-1975. (The arrow denotes the year of inception of an ambulatory care program in Yolo County.)
257
PUBLIC HEALTH BRIEFS
350 300
2501 AVERAGE HOSPITAL 200 STAY (days/patient)
150-
100 _ 50-
I
1964 65 66 67 68 69 70 71 72 73 74 75 YEAR FIGURE 2-Average Hospital Stay per Patient with Tuberculosis in Yolo County, 1964-1975. (The arrow denotes the year of inception of an ambulatory program in Yolo County.)
Table I shows the estimated costs for the care of an average patient with tuberculosis in Yolo County in 1971 and 1974; the expense of an efficiently administered outpatient program is far less than the expense of prolonged sanatoria care. In Yolo County a portion of the funds spent previously to support long-term hospitalizations is now utilized to employ two extra public health nurses, who have helped to intensify case-finding, patient education, and home care follow-up programs, as well as administering a greatly increased INH prophylactic program.
Discussion The new tuberculosis control program provides several distinct advantages to the tuberculosis patient. First, the TABLE 1-Actual Difference in Cost of Treating a Case of Tuberculosis in Yolo County in 1971 and 1974. Therapeutic Regimen
1971
1974
$6,000 150 days at sanatorium @ $40/day 10 days at a local general hospital 2 days acute @ $85 plus $650 8 days extended care @ $60 $60 2 home visits @ $30 $420 14 home visits @ $30 $360 18 clinic visits @ $20 $480 24 clinic visits @ $20 $6,420 $1,550 TOTAL Drugs, radiology and laboratory tests are similar for the two years per case treated.
258
time that the patient must spend in a hospital is markedly decreased, although the quality and efficacy of outpatient care of tuberculosis has been shown to be comparable to the older method of prolonged hospitalization.9' 10 Secondly, any necessary hospitalization is now done close to home and family. A minority of "problem" cases, frequently alcoholics, are treated in the general hospital for up to four weeks. They are then discharged home or to a "board and care" type of environment where they receive three home visits per week for drug administration by the public health nurse. By gaining the confidence of these patients rather than following the previous policy of incarceration in a sanitorium, we have found them much more amenable to treatment, although loss to follow-up still remains a problem. In Yolo County, as elsewhere, many tuberculosis patients are treated at public expense; hence the cost of care should be a public concem. The wide differences in cost among the various treatment regimens, together with evidence indicating that prolonged hospitalization is no more effective than ambulatory treatment, emphasize that the use of the former for the majority of patients with active tuberculosis is poor economic practice. It is important for people involved in the treatment of tuberculosis to assess the scientific evidence that ambulatory care is indeed a distinct advantage. However, this evidence is by no means universally accepted;11' 12 17 states use sanatoria exclusively,13' 14 and there remains resistance to renovation of tuberculosis treatment programs. An important ancillary benefit of a combined medical school-public health tuberculosis program is the provision of first-hand experience for professionals of both programs to interrelate in an organized and changing health care delivery system. Medical schools have been accused of failing to emphasize the principles of preventive and community health care. This failure is understandable, considering that most clinical teaching is provided in university hospital centers. The involvement of medical students, interns, residents, and fellows in a community public health program broadens their educational base and increases their interest and understanding of the problems of public health maintenance. Many local public health departments have been resistant to changes for fear of displeasing the local medical establishment and have been in a measure guilty of zealously guarding their administrative responsibilities for community preventive health and communicable disease services. It would seem that merger and shared responsibilities of some programs with medical school teaching and service programs would well serve the receivers of certain health care delivery systems. It has been demonstrated that public health tuberculosis programs in areas near medical schools is one area where this can be readily and efficiently accomplished. REFERENCES 1. Johnson, R. F., and Wildrick, K. H. State of the art review: The impact of chemotherapy on the care of patients with tuberculosis. Amer. Rev. Resp. Dis., 109:636-664, 1974. 2. Newman, R., Doster, B. E., Murray, F. J., and Woolpert, S. F.
Rifampin in the initial treatment of pulmonary tuberculosis, Amer. Rev. Resp. Dis., 109:216-232, 1974. AJPH March, 1977, Vol. 67, No. 3
PUBLIC HEALTH BRIEFS 3. Gunnels, J. J., Bates, J. F., Swindoll, H. Infectivity of sputumpositive tuberculous patients on chemotherapy. Amer. Rev. Resp. Dis., 109:323-330, 1974. 4. Kamart, S. R., Dawson, J. J., Devadatta, S., Fox, W., Janardhanam, B., Radhakrisha, S., Ramakrishan, C. V., Somasundaram, R. R., Stott, H., Velu, S. A controlled study of the influence of segregation of tuberculosis in a five-year period in close family contacts in South India. Bull. W.H.O. 34:517-532, 1966. 5. Riley, R. L., Mills, C. C., O'Grady, F., Sultan, L. U., Wittstadt, F., Shivpuri, D. N. Infectiousness of air from a tuberculosis ward. Amer. Rev. Resp. Dis., 85:511-525, 1962. 6. Bates, J. H., and Stead, W. W. Effect of chemotherapy on infectiousness of tuberculosis. New Engl. Journal Med., 290:459460, 1974. 7. Dandoy, S., and Elman, S. B. Current status of general hospital use for tuberculous patients in the United States. Amer. Rev. Resp. Dis., 106:580-586, 1972.
8. Reagan, W. P. Treatment of tuberculosis in the general hospital. Clin. Notes Resp. Dis., 11 (4):3-16, 1973. 9. Dandoy, S., and Hansen, R. Tuberculosis care in general hospitals, Arizona's experience, Amer. Rev. Resp. Dis. Vol. 112:757-763, 1975. 10. McConville, J. H., Rapoport, M. I. Tuberculosis management in the mid-1970's. 11. Oatway, W. H. Early discharge of patients with active tuberculosis? Amer. Rev. Resp. Dis., 109:320-322, 1974. 12. Bates, J. H. Ambulatory treatment of tuberculosis-An idea whose time has come. Amer. Rev. Resp. Dis., 109:317-319, 1974. 13. Reichman, L. B. Tuberculosis care: When and where? Ann. Int. Med., 80:402-406, 1974. 14. Dandoy, S., Wiggins, K. Current status of general hospital use for patients with tuberculosis in the United States: An update. Amer. Rev. Resp. Dis. 110:442-445, 1974.
1977 Graduate Summer Session in Epidemiology University of Minnesota The Twelfth Graduate Summer Session in Epidemiology sponsored by the Epidemiology Section of the American Public Health Association and the Association of Teachers of Preventive Medicine will be presented at the University of Minnesota in Minneapolis through the School of Public Health, Health Sciences Center and the Nolte Center for Continuing Education during the three-week period from June 19 to July 9, 1977. These summer graduate sessions are designed primarily for teachers in medical schools, but postdoctoral fellows, graduate students and residents in departments of preventive medicine and other medical school departments may qualify. Similarly teachers, post-doctoral fellows and graduate students in schools of public health, dentistry and veterinary medicine are eligible as are qualified personnel of federal, state and local health agencies. The summer session in 1977 will follow the pattern previously established. In addition to the two basic courses in Fundamentals of Epidemiology and Fundamentals of Biostatistics several of the previously presented courses will be offered. These include, the Epidemiology of Cancer, Epidemiology of Cardiovascular Diseases, Epidemiology of Infectious Diseases, Genetics and Epidemiology, Epidemiology of Injuries and Principles and Methods of Epidemiologic Research. Three new courses will be presented: Development of and Perspectives in Epidemiology, Hospital Epidemiology and Infection Control, and Epidemiology of Diseases Due to Drugs and Other Therapies. Tuition for the 3-week session will be approximately $350$400. Special rates for food and lodging in dormitories have been arranged. Grants for tuition and stipends may become available but prospective registrants should explore other sources of funding as soon as possible. Should a grant for this purpose be realized, high priority applicants with financial hardship will be given consideration. Such individuals will also have to be non-federally employed U.S. citizens who are not concurrently on another federal stipend. No reimbursement will be made for travel. A $25 deposit, credited to tuition, should accompany applications. Receipt of the deposit will constitute evidence of intent to attend. Refund of deposit will be made if the application is not accepted or if applicant's plans change before May 16. Further information and application forms for the 1977 session may be obtained by writing to Dr. Leonard M. Schuman, Director, Graduate Summer Session in Epidemiology, University of Minnesota School of Public Health, A1- 1 17 Unit A Health Sciences Building, 515 Delaware St. S.E., Minneapolis, MN 55455.
AJPH March, 1977, Vol. 67, No. 3
259
