Critical pathways for TB make difference
Secret of success is more than just DOT
What is keeping tuberculosis cases down in recent years? Case management, say TB experts who have put TB protocols to good use.
Case management goes a long way in explaining why Newark, NJ, reported a 30% decrease in TB cases last year while in nearby Jersey City, which lacks such a program, they had an increase in cases, says Lee Reichman, MD, MPH, director of the National Tuberculosis Center at the New Jersey School of Medicine in Newark.
"The case rates are down by a big chunk, and it’s exciting because we feel it is attributable to case management," he says.
The center is one of three model TB programs established through support from the Centers for Disease Control and Prevention three years ago. It developed a case management program that expands treatment protocols beyond traditional directly observed therapy, preventing fragmentation of care by giving field workers access to the resources and manpower they need to overcome problems they encounter during patient follow-up. (See related story in TB Monitor, September, 1996, p. 103.)
"DOT is fine, but it’s not the entire answer," Reichman tells TB Monitor. "You have to do all these other things, and that is what we have done."
The case management model has been so successful that the center has contracted with the Jersey City health department to transfer its program there, sharing its physician teams and teaching clinicians to be more efficient and effective in prevention and treatment. The center also is presenting TB case management courses in Baltimore, Chicago, Columbus, OH, and Paris.
Case management protocols implemented three years ago at Jackson Memorial Hospital help explain the reduced cases in the Miami area, says Joan Otten, RN, director of the hospital’s TB program. (See related story in TB Monitor, May 1996, pp. 49-51.)
"For us, it has been wonderful," she says. "We use case management internally, and then we use case management on the outside as well in conjunction with the health department."
An effective case management program, such as the one at Jackson Hospital, spells out day-to-day and month-to-month protocols for inpatient and outpatient care, she says. For example, if a patient doesn’t show up for an appointment at the hospital, an outreach worker immediately contacts the health department to find out why. (See a copy of Jackson’s TB pathway in the insert of TB Monitor, May 1996.)
"Health departments will tell you they are doing case management because patients come in, and they have established protocols," Otten says. "However, often they don’t have written protocols and leave it up to the physician to make the determination."
Three months ago, the state requested that the hospital make its TB case management pathway available through its TB hotline, she adds.
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