No equal opportunity for NY smear-positives
The key: High volume, plus lab that never sleeps
Whether for managing outbreaks or simply for day-to-day business, New York State’s Fast Track program is a hit, users say. The creator of the program, Max Salfinger, MD, director of the state’s clinical mycobacteriology laboratory, says Fast Track provides fast, free identification and susceptibility testing, exclusively for smear-positive specimens.
"I can’t tell you how important and helpful an asset it’s been," says Rachel Strickof, MPH, an epidemiologist with the state Department of Health. In 1996, the program added the MTB Direct Test to its arsenal of capabilities; and turnaround time for susceptibility tests averages about two weeks, from date of receipt to date of reporting, Strickof says.
Though it uses state-of-the-art technology, Salfinger says the program is feasible from a cost standpoint because with 115 institutions enrolled, it generates enough volume to make it possible to keep the lab open and running seven days a week.
The program was born in 1993, after Salfinger, who was new on the job, decided to conduct a survey to see what fellow lab directors were up to. "The result was not good," he says. "Eighty percent of the testing load was not being processed with gold-standard procedures."
Plus, there was the inevitable range in capability in what various labs could do, with the result that some hospitals were waiting months for identification, as specimens slowly made their way from one lab level to the next.
Salfinger concluded he had only two choices. "You spend millions of dollars to upgrade the labs; or you focus on the highly infectious, smear-positive patients and centralize them." He chose the second course.
Not everyone sees the point. "We do direct tests at the state lab if we urgently need the data," says Sue Etkind, MS, Massachusetts’ state TB controller. "But it doesn’t make economic sense for us to [fast track] all smear-positive patients." Besides, most of the time, getting results back quickly doesn’t make any practical difference, Etkind says. "We start everyone on four-drug therapy anyway."
As Salfinger sees it, there are a host of benefits, including advantages for the public health, hospitals, and patients.
Knowing right away that a smear-positive specimen is, in fact, M. tuberculosis can be of critical importance. But even when the identification results in a negative answer, there are benefits, he says. Hospitals save money, by avoiding keeping patients in expensive respiratory isolation rooms unnecessarily.
Patients are spared being placed on drugs they don’t need a scenario more frequent than one expects in Salfinger’s jurisdiction, given that the proportion of mycobacterial infections that turn out not to be nontuberculous is 50% in New York City and 30% in New York State.
Putting such patients on four drugs they don’t need may put them at particular risk for adverse reactions and interactions, says Salfinger. Such patients are likely to be suffering from a variety of diseases and often are already taking many other drugs. For such patients, the dent in quality of life caused by adding more drugs to an already crowded medication regimen shouldn’t be underestimated, he adds.
From a purely administrative standpoint, the arrangement also has its satisfactions, Salfinger says.
"Whatever changes we make in our procedures immediately effects all 115 institutions," he says. "I don’t have to discuss it with lab directors or hospital administrators. I don’t have to beg these institutions for more money to make changes. I just do it."
Just because a state has instituted centralized testing at the state lab doesn’t mean they get the fast turnaround times he does, adds Salfinger. This, he adds, is where prioritizing comes in: "The key is to say No equal opportunity’ for TB specimens!"
Lab can stay open 7 days a week
The addition of the direct test, which is only used as an adjunct, is not critical to the "fast" component of Fast Track, Salfinger explains. Rather, the important factor is generating enough volume to make it feasible to keep the lab open seven days a week.
Several of Salfinger’s colleagues pointedly mention having sighted their boss in the lab at every conceivable hour of the day and night; but even without his presence, the lab is always running. Incoming specimens are received seven days a week, culture identifications are set up five or six days a week, and susceptibility testing is begun or analyzed seven days a week.
To keep up the speed, Salfinger has applied special touches to events at the end of the line. As soon as results become available, they are dispatched with a triple whammy-approach that includes a fax, a telephone call, and a written copy of results.
The same day, Salfinger also loads the lab report data into the TB control data base, accomplishing the reporting and making the data instantly available to all concerned parties. The arrangement enhances communication "between the TB controller, the treating physician, and the laboratory," he says. "And they need to be in touch!"
Only Florida has copied program so far
Although he is a tireless crusader for the Fast Track model, so far only Florida has installed its own fast-track laboratory program. There are several reasons this is so, Salfinger says.
For one thing, unless a state is centralized, there may not be sufficient influence at the top to galvanize jurisdictions into action; attempts to introduce fast-tracking procedures in states that operate on a decentralized model have sputtered and died, he says, for the simple reason that local jurisdictions accustomed to autonomy are reluctant to give up control.
In addition, states without strict licensing procedures lack the whip needed to crack over existing facilities, with the result that lab directors may be more apt to coast along with the status quo.
Finally, there’s the matter of ego. "It takes [swallowing] a bit of pride," Salfinger says. Hospitals that regard themselves as equipped with the latest of everything must say, "We could do it on our own, but we don’t have the volume. . . . Besides, even the fancy labs in New York City have enrolled! So yes, we will sign up, too."
They can take comfort in knowing they’re doing the right thing, Strickof says. "All laboratories of all hospitals cannot and probably should not have the inherent ability to do in-house the full spectrum of tests using the latest technology," she says. "If you see one TB case a year, you can’t justify the expense. And you won’t have the expertise, either."
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