Expert consultation holds down MDR-TB
Three-year-old Texas program gets high marks
A three-year-old Texas program that encourages physicians treating mono-resistant tuberculosis cases to seek expert consultation appears to be working well, TB control officials say.
Its success is reflected in the way TB patients resistant to rifampin or isoniazid are not acquiring multidrug resistance, a much more serious condition defined as resistance to both isoniazid and rifampin, the so-called "twin pillars" of TB therapy.
"We are now not seeing any acquired multidrug- resistant TB in Texas," says Michael F. Kelley, MD, MPH, chief of the Bureau of Communicable Disease Control of the state’s Department of Health. "I think what we’re doing is right."
After three years of steady decline, cases of multidrug-resistant TB, or MDR-TB, were up slightly in 1996 in Texas; but overwhelmingly, the cases involved primary, not acquired, resistance and occurred among the foreign-born, adds Kelley.
Since the expert-consultation program was launched in October 1993, it has logged over 3,800 calls from physicians and other health care providers, says David Griffith, MD, a pulmonary infectious disease expert at the Center for Infectious Disease Control at the University of Texas in Tyler.
Experts in the field have long pointed to the importance of the role of expert consultation for cases of resistant TB.
A golden opportunity to make a difference
In 1994, there were more than 1,000 patients in the United States with isolates resistant to isoniazid but not rifampin; and over 150 with resistance to rifampin but not isoniazid, says Alan Bloch, MD, MPH, a medical epidemiologist at the Centers for Disease Control and Prevention and a strong advocate for the role of expert consultation in preventing cases of MDR-TB.
The clinical expert can fill a critical role by providing "review of the adequacy of therapy, the care of drug-resistant patients especially those with TB resistance to isoniazid, rifampin, or both and the care of patients who fail to improve," Bloch writes, in a recent article.1 "Such patients should be systematically reviewed in each health jurisdiction." (See related story on the role of clinical experts in preventing MDR-TB, p. 16.)
So far, states have been slow to heed Bloch’s advice.
In New Jersey, the state TB control program is about to announce its own mandate for expert consultation in resistant cases, officials there say. But except for the incipient New Jersey program, the Texas program is probably unique in the nation, says Mack Anders, deputy chief of the Field Services Branch of the Division of TB Elimination at the Centers for Disease Control and Prevention.
"TB treatment is pretty well standardized, but the way people go about implementing guidelines varies," Anders says. In programs with strong linkages to the state TB control office, expert consultation already takes place on an informal basis, Anders concedes; but the extent to which this happens varies enormously from state to state, he says.
By making available and publicizing panels of TB experts, plugging them into toll-free telephone numbers and then injecting a certain amount of arm-twisting, the Texas program (which receives funding from the state legislature) has simply formalized the process. Along with a sharp increase in rates of directly observed therapy, the program appears to be part of a formula that is helping to keep mono-resistant cases from turning into much more complicated cases of multidrug-resistance, says Griffith.
Here is how the Texas program works:
Once the state department of health is notified of a drug-resistant case, a letter is faxed to the treating physician or TB clinic. The case is assigned to a consultant. The physician has three working days to respond by calling one of the experts listed as a consultant. If that doesn’t happen, the consultant calls and offers to help. If the physician declines the offer of help, the recommended action is for the local TB nurse to call the doctor and initiate a consultation. Each case under consultation must be placed on directly observed therapy, Kelley says.
The new program has encountered a few bumps along the way, Kelley concedes. "There’s still some resistance from physicians who aren’t under contract with the health department who objected to having a consultation they didn’t feel they needed or wanted," he says. "We’ve gotten away from the word consultation’; calling it an assessment’ makes it feel not as binding or threatening. But basically, the docs who see most of the TB cases have gotten used to it and don’t have a problem doing it."
Two expedients have helped the medicine go down, say Kelley and Griffith.
First, when physicians treating a case resistant to first-line drugs ask for "something that’s not normally in the formulary," Kelley declines to release the agent from the pharmacy until the physician cooperates by getting a consultation. In practice, that means doctors are faced with the choice of getting expensive drugs free of charge through the state or forcing their patients to pay for them. "They’re pretty much stuck," says Kelley.
To help make sure physicians actually take the advice they get, experts have adopted the measure of sending a written letter that incorporates a synopsis of the case, and that reiterates the specific recommendations, says Griffith. "The hard copy of the letter, which is referenced to [American Thoracic Society] and CDC guidelines, becomes part of the patient’s record," he says. "That way, the recommendations take on more formality."
Issues that come up during consultations run the gamut from the basics (such as how to read a TB skin test), to problems related to drug interactions and side effects, to complicated decisions about choices of drug regimens, Griffith and Kelley say. "There are 2,500 new cases of TB a year in Texas, and some 40,000 physicians," says Griffith. "Most doctors never see a case of TB in their lives, and the recommendations for treatment aren’t published in the general medical literature. This program is just a handy way to find out how to get going and where to go for more information."
Making sure patients are on adequate regimens is a top priority, Kelley adds. "The thing we’re trying hardest to avoid is the temptation for a doctor to prescribe a weak treatment regimen, often just to avoid having the patient on an injectable drug," he says.
Not all of the calls for expert guidance have to do with TB, Kelley says. "One of the indirect benefits of the program is that we’ve also been treating patents with atypical mycobacteria," he says. "The advantage here is that doctors get very good advice on how to deal with these things, which can be much harder to treat than ordinary TB."
For the consultants involved, the system has proven to be fairly time-consuming, says Griffith. "I make several phone calls and dictate several letters a day," he says. "It’s not an expensive program, but it’s fairly labor-intensive."
In New Jersey, where plans to launch a similar program have been underway for the past seven months, the state’s Model TB Center already serves as a resource for voluntary callers from around the state and beyond, says Eileen Napolitano, deputy director of the New Jersey Medical School’s National Tuberculosis Center. "We get calls from health care providers, nurses, doctors, and from the general public," she says. "In New Jersey, doctors see us as a referral center for patients with compliance problems, drug resistance problems, or medical management problems." The center’s toll-free number [(800) 4TBDOC] logs about 500 calls a year, says Napolitano, about 72% of the calls coming from doctors and other health care workers. Of those, about 15% deal directly with drug-resistant cases.
"We try to identify how the resistance occurred, by constructing a drug-gram up to where we are, and talk about what drugs will be effective and how to give them. We also send current specimens to the CDC or to National Jewish [Hospital in Denver], do susceptibility testing, and send in teams to help with DOT," says Reynard McDonald, MD, the medical director of the center. "By preventing them, you’re also probably preventing an average of five to seven potential [MDR] infections as well."
Although programs that offer expert consultation can’t take all the credit, drug resistance appears to be on the run, McDonald adds. "In New Jersey, we are certainly making a difference," he says. "Resistance isn’t taking nearly the toll we’d feared it would in the late 80s and early 90s."
Weighing the cost and time demanded by such programs against the price of multiple drug resistance makes the benefit clear.
McDonald cites the case of one MDR-TB patient whose case was so notorious, he was featured as a poster at a recent medical convocation. "We tracked him from Jersey City to Washington, to North Carolina, and back to Jersey City," says McDonald. During his Seattle stint alone, the patient racked up bills totaling $80,000. "These [MDR-TB] cases are very, very expensive to care for," he says. "Anytime you can cure a case of MDR-TB, you’re probably preventing five to seven additional infections as well."
Once a patient develops MDR-TB, he’s committed to two years of therapy, the CDC’s Bloch points out. "I think a golden opportunity exists to prevent patients with drug-resistant isolates from progressing to MDR-TB," he says.
Reference
1. Bloch A, Simone P, McCray E, et al. Preventing multidrug-resistant tuberculosis. JAMA 1996; 275:487-489.
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