Showing papers by "Donald A. Goldmann published in 2022"
TL;DR: In this article , the use of interferon gamma release assays (IGRAs) for diagnosis of tuberculosis infection in children was reported to increase substantially between 2015 and 2021.
Abstract: US guidelines recommend interferon gamma release assays (IGRAs) for diagnosis of tuberculosis infection in children. In this retrospective cohort study, IGRA use in children 2–17 years of age increased substantially between 2015 and 2021. Testing in inpatient/subspecialty settings (vs. primary care), public (vs. private) insurance, lower age and non-English preferred language were associated with increased odds of receiving an IGRA.
TL;DR: In this article , the authors conducted a retrospective cohort study of children (age <18 years) screened for TB within 2 Boston-area health systems between January 2017 and May 2019.
TL;DR: Haberer et al. as discussed by the authors conducted a retrospective cohort study of LTBI in children 0-17 years old who were prescribed outpatient treatment in two Boston-area health systems from 2017-2019.
Abstract: Abstract Background Location and type of clinic where pediatric latent TB infection (LTBI) care is provided are associated with treatment completion and retention in care. Prior research has not evaluated joint clinical management occurring between care settings. Understanding care transfer dynamics and accessibility of clinics can inform pediatric LTBI care service delivery. Methods We conducted a retrospective cohort study of LTBI in children 0-17 years old who were prescribed outpatient treatment in two Boston-area health systems from 2017-2019. We defined “initial clinical setting” (categorized as primary care or TB/infectious diseases clinic) as the location where the first LTBI medication was prescribed. Through chart review, we determined if care was transferred to a different (“final”) clinic setting during treatment. We calculated driving time between a child’s home address and initial and final treatment clinics. The primary outcome was frequency of care transfer after starting treatment. In a secondary analysis, we used two multivariable logistic regression models (adjusted for age, sex, and use of rifamycin-based treatment) to evaluate associations between completion and distance to and type of initial and final treatment clinic. Results We identified 142 children who started LTBI treatment as outpatients; 110 started treatment in primary care clinics and 32 in TB/infectious diseases clinics. Overall, 20/142 (14%) transferred TB care to a different clinic after starting treatment. A total of 101/142 (71%) patients completed treatment. Neither initial treatment location nor driving time to initial clinic were significantly associated with treatment completion (Table 1). However, final treatment in a TB clinic was associated with higher odds of treatment completion than final treatment in a primary care clinic (aOR 2.71 [95%CI 1.06-6.91], P=0.04); time to clinic was not associated with completion (Table 2). Figure 1. Patient transfers after starting LTBI treatment.Table 1. Initial treatment location: Univariable and multivariable analysis of factors associated with treatment completion. 1Adjusted for time to clinic and location of initial treatment as well as age, sex, and use of rifamycin-based treatment.Table 2. Final treatment location: Univariable and multivariable analysis of factors associated with treatment completion. 1Adjusted for time to clinic and location of final treatment as well as age, sex, and use of rifamycin-based treatment. Conclusion Among children with LTBI in a large metropolitan area, more patients received treatment in primary care clinics than in TB clinics. Care transfers were relatively uncommon after starting treatment. A TB clinic as a final treatment location was associated with increased odds of treatment completion. Disclosures Jessica Haberer, MD, MS, Merck: Advisor/Consultant|Natera: Stocks/Bonds.
TL;DR: In this paper , the authors performed a retrospective cohort study of interferon-gamma release assays (IGRAs) use in patients <2 years old in 2 large Boston healthcare systems.
Abstract: Background: Interferon-gamma release assays (IGRAs) are approved for children ≥2 years old to aid in diagnosis of Mycobacterium tuberculosis (TB) infection and disease. Tuberculin skin tests (TSTs) continue to be the recommended method for diagnosis of TB infection in children <2 years, in part due to limited data and concern for high rates of uninterpretable results. Methods: We performed a retrospective cohort study of IGRA use in patients <2 years old in 2 large Boston healthcare systems. The primary outcome was the proportion of valid versus invalid/indeterminate IGRA results. Secondary outcomes included concordance of IGRAs with paired TSTs and trends in IGRA usage over time. Results: A total of 321 IGRA results were analyzed; 308 tests (96%) were valid and 13 (4%) were invalid/indeterminate. Thirty-seven IGRAs were obtained in immunocompromised patients; the proportion of invalid/indeterminate results was significantly higher among immunocompromised (27%) compared with immunocompetent (1%) patients (P < 0.001). Paired IGRAs and TSTs had a concordance rate of 64%, with most discordant results in bacille Calmette-Guérin–vaccinated patients. The proportion of total TB tests that were IGRAs increased over the study period (Pearson correlation coefficient 0.85, P < 0.001). Conclusions: The high proportion of valid IGRA test results in patients <2 years of age in a low TB prevalence setting in combination with the known logistical and interpretation challenges associated with TSTs support the adoption of IGRAs for this age group in certain clinical scenarios. Interpretation of IGRAs, particularly in immunocompromised patients, should involve consideration of the broader clinical context.
TL;DR: Haberer et al. as discussed by the authors conducted a convergent mixed methods study with physicians in Massachusetts to understand barriers and facilitators to LTBI diagnosis and care, and strategies to improve care.
Abstract: Abstract Background Understanding barriers and facilitators to latent tuberculosis infection (LTBI) diagnosis and care is needed to successfully treat children/adolescents with LTBI in the US. We explored physicians’ perspectives on pediatric LTBI diagnosis and care, and strategies to improve care. Methods We conducted a convergent mixed methods study with physicians in Massachusetts. Participants were purposefully sampled from primary care clinics (n=10), clinics seeing immunocompromised patients (n=2), and TB clinics (n=2). Physicians participated in individual qualitative semi-structured interviews exploring experience and comfort with LTBI care, and perceived barriers and facilitators to care. We used applied thematic analysis to analyze transcripts. Participants completed surveys to assess comfort with LTBI care and volume of LTBI patients in their care. Results Of the 25 physicians invited, 14 participated. Most participants reported “medium” or “high” comfort with current LTBI guidelines; volume of LTBI care varied by physician type (Table 1). Analysis revealed perceived barriers (Figure 1) at four steps of care: 1) identification of risk and testing for LTBI (e.g., family/patient risk perception, physician knowledge gaps), 2) completion of referral after a positive test (e.g., communication barriers), 3) treatment acceptance and initiation (e.g., lack of social support), and 4) treatment adherence and completion (e.g., adolescents’ emerging autonomy). Facilitators such as protocolized screening, counseling strategies, free medication, and telehealth (Figure 2) overcame some barriers. Important emergent themes included: 1) COVID-19 has induced rapid positive and negative changes in LTBI care in primary care clinics; 2) immigrant adolescents are uniquely at risk for disengagement due to lack of social support; and 3) physicians and clinics are ill-equipped to provide TB care for patients’ close contacts, despite knowledge of need for care. Table 1. Volume of patients by clinician type (N=13 respondents)Figure 1. Barriers to LTBI diagnosis and care.Figure 2. Facilitators of LTBI care. Conclusion Lack of perceived risk, family and clinic resource constraints, and accessibility challenges hindered LTBI care; protocolized screening, telehealth, and free medications were among the facilitators that overcame some but not all barriers. These results will inform improvement of LTBI care within and between clinics. Disclosures Jessica Haberer, MD, MS, Merck: Advisor/Consultant|Natera: Stocks/Bonds.
TL;DR: In this article , a cross-sectional study of children ages 0-20 years hospitalized with acute osteomyelitis with a primary or secondary diagnosis was conducted, and the authors used a survey-weighted negative binomial regression to model length of study by race and ethnicity, accounting for clinical and hospital characteristics and socioeconomic status.
Abstract:
Changes in management of bone infections, particularly early transition to oral antibiotic therapy, have decreased length of stay (LOS) for children hospitalized with acute osteomyelitis. However, evaluation of differences in length of stay by race and ethnicity have been limited.
Using the Kids’ Inpatient Database, we conducted a cross-sectional study of children ages 0–20 years hospitalized in 2016 or 2019 with a primary or secondary diagnosis of acute osteomyelitis. Using survey-weighted negative binomial regression, we modeled length of study (LOS) by race and ethnicity, accounting for clinical and hospital characteristics and socioeconomic status. Secondary outcomes included predictors of LOS > 7 days (equivalent to LOS in the highest quartile), central venous catheter (CVC) placement, and time to debridement.
We identified 2,388 patients discharged with acute osteomyelitis. Median LOS was 5 days (IQR 3–7). Black race (adjusted incidence rate ratio [aIRR] 1.15, 95%CI 1.05–1.27), Hispanic ethnicity (aIRR 1.11, 95% CI 1.02–1.21), and other race and ethnicity (aIRR 1.12, 95% CI 1.01–1.23) were associated with longer LOS, compared to White race (Figure 1). Additional factors associated with prolonged LOS were Medicaid/self-pay status (aIRR 1.14, 95% CI 1.07–1.21) and other insurance (aIRR 1.21, 95% CI 1.02–1.45), compared to private insurance; debridement procedure (aIRR 1.31, 95%CI 1.23–1.31); CVC placement (aIRR 1.41, 95% CI 1.31–1.51), and complex chronic condition (aIRR 1.21, 95% CI 1.11–1.33). The odds of Black children experiencing LOS > 7 days was 46% higher compared to White children (aOR 1.46, 95% CI 1.01–2.11; Figure 2). There were no differences by race and ethnicity on odds of CVC placement or time to debridement.
Model is adjusted for hospital location/teaching status, hospital region, year, debridement procedure, CVC placement, complex chronic condition, weekend admission, discharge quarter, hospital bed size, Zip code median income quartile.
Model is adjusted for hospital location/teaching status, hospital region, year, debridement procedure, CVC placement, complex chronic condition, weekend admission, discharge quarter, hospital bed size, Zip code median income quartile.
Black, Hispanic, and other race and ethnicity children with acute osteomyelitis experienced longer LOS than White children. Further research into mechanisms underlying these differences, including social determinants such as access to care or structural racism, may be important to improve care for children with osteomyelitis.
All Authors: No reported disclosures.