老美接受LTBI treatment的人，不到一半完治，和duration成正比
This study shows that although acceptance of LTBI treatment is relatively high (83%), the proportion completing is low (47%). When the product of these two proportions is calculated, we see that completion was achieved by only 39% of persons who were offered LTBI treatment. The major risk factor for noncompletion was being prescribed the 9-month INH regimen. As shown in Figure 1, when the proportions completing the three most commonly prescribed regimens are compared, it can be seen that there is an inverse relationship between length of the regimen prescribed and the proportion completing treatment. The increased completion that we observed with the 4-month rifampin regimen is consistent with previous reports.[18–20] It is of interest to note that if completion of the 9-month regimen were defined as completion of at least 6 months of INH, the noncompletion rate of the 9-month regimen, 42.9%, would have been almost identical to that of the 6-month regimen, 44.8%. Thus, prescribing the longer course seems neither to greatly encourage nor discourage patients from completing 6 months of INH.
In addition to using regimens of shorter duration, another strategy for increasing completion suggested by the results of this study is targeting of populations at higher risk of failing to complete treatment. Such populations include residents in congregate settings (nursing homes, homeless shelters, jails, and prisons), injection drug users, and employees of hospitals and nursing homes. Some of these populations are recognized to include many difficult-to-reach subjects,[1] but health-care workers could be targeted by adherence programs in the workplace. Unfortunately, only 336/1994 (16.9%) of the patients receiving LTBI treatment in this study were members of these groups, so improvement in completion among these populations might not translate to a substantial overall improvement.
On the other hand, if strategies to improve completion in populations with low rates of completion cannot be implemented, focusing screening efforts on populations with better rates of completion might more efficiently use program resources. Such populations include those in contact with patients with infectious TB, persons younger than 15 years of age, and foreign-born persons during their first year in the United States/Canada. Such a strategy would have the additional advantage of targeting the group with the highest rates of TB disease of all foreign-born persons in the United States.[23–26] Moreover, specialized programs that are designed to be culturally sensitive have been shown to be successful in reaching such populations.[27]
We did not find significant differences in completion of LTBI treatment by race, sex or birth outside the United States, or between those who had received bacillus Calmette-Guérin (BCG) vaccination and those who had not, as has been reported by others.[12,14,16,17] Moreover, characteristics of the treating clinic and the patient experience at the clinic were not associated with completion. Thus, factors that have been reported to be associated with completion in single-clinic studies may not be generalizable to the United States as a whole.
More than 20% of those initiating treatment stopped it within 1 month of starting; this amounts to one-third of all those who failed to complete treatment. It is possible that some of those failing to complete in the first month may have been individuals who were unwilling to refuse the offer of treatment, but who never intended to initiate it. Thus, acceptance rates may not be as encouraging as they appear. In addition, because more than one-half of those who did not complete stopped within 2 months after starting, close follow-up of patients during the first 2 months with prompt intervention to encourage completion among those stopping treatment might pay substantial dividends.
Our study has several limitations. First, not all clinics that were selected for the study agreed to participate, and clinics that did not participate differed from those that did participate. Although we were able to adjust for some of these differences in the analysis, our results may still reflect unmeasured or uncorrected bias. Second, clinics that treated fewer than 10 persons per year for LTBI were excluded. Thus, it is possible that large numbers of small clinics and practices, each treating a small number of persons each year, could represent a substantial number of LTBI diagnoses and courses of treatment that were missed by our survey. Based on our informal understanding of the relative importance assigned to LTBI treatment by primary care physicians and infectious diseases specialists, we doubt that this is the case. Third, some charts were ineligible or could not be located. Such charts might be expected to have been more likely to represent patients who declined or did not complete treatment. To the extent that this occurred, our proportions of acceptance and completion may be overestimates.
We conclude that the most important advance that could improve the effectiveness of LTBI treatment would be a regimen of shorter duration. The 4-month rifampin regimen and the 3-month regimen of daily INH plus rifampin are both shorter regimens with better completion rates, but the 4-month rifampin regimen has not had efficacy evaluated in a large prospective trial, whereas the 3-month regimen of INH plus rifampin has only been conclusively demonstrated to be effective in HIV-infected persons,[28] and is not recommended for use in the United States. Another 3-month regimen, once weekly rifapentine plus INH, has been shown to be well tolerated and lead to improved completion.[29] The efficacy of this regimen compared with the 9-month INH regimen is currently being studied by the Tuberculosis Trials Consortium.[30] If this regimen is as effective as the 9-month INH regimen, its widespread adoption might lead to substantially improved treatment completion rates and result in prevention of more cases of TB.
https://docs.google.com/fileview?id=0B278nGJMQBk7NTI0ODY4OTAtMzc2NS00NmY3LTk5MzAtMGE3MTU1YWY4ZDRh&hl=zh_TW
In addition to using regimens of shorter duration, another strategy for increasing completion suggested by the results of this study is targeting of populations at higher risk of failing to complete treatment. Such populations include residents in congregate settings (nursing homes, homeless shelters, jails, and prisons), injection drug users, and employees of hospitals and nursing homes. Some of these populations are recognized to include many difficult-to-reach subjects,[1] but health-care workers could be targeted by adherence programs in the workplace. Unfortunately, only 336/1994 (16.9%) of the patients receiving LTBI treatment in this study were members of these groups, so improvement in completion among these populations might not translate to a substantial overall improvement.
On the other hand, if strategies to improve completion in populations with low rates of completion cannot be implemented, focusing screening efforts on populations with better rates of completion might more efficiently use program resources. Such populations include those in contact with patients with infectious TB, persons younger than 15 years of age, and foreign-born persons during their first year in the United States/Canada. Such a strategy would have the additional advantage of targeting the group with the highest rates of TB disease of all foreign-born persons in the United States.[23–26] Moreover, specialized programs that are designed to be culturally sensitive have been shown to be successful in reaching such populations.[27]
We did not find significant differences in completion of LTBI treatment by race, sex or birth outside the United States, or between those who had received bacillus Calmette-Guérin (BCG) vaccination and those who had not, as has been reported by others.[12,14,16,17] Moreover, characteristics of the treating clinic and the patient experience at the clinic were not associated with completion. Thus, factors that have been reported to be associated with completion in single-clinic studies may not be generalizable to the United States as a whole.
More than 20% of those initiating treatment stopped it within 1 month of starting; this amounts to one-third of all those who failed to complete treatment. It is possible that some of those failing to complete in the first month may have been individuals who were unwilling to refuse the offer of treatment, but who never intended to initiate it. Thus, acceptance rates may not be as encouraging as they appear. In addition, because more than one-half of those who did not complete stopped within 2 months after starting, close follow-up of patients during the first 2 months with prompt intervention to encourage completion among those stopping treatment might pay substantial dividends.
Our study has several limitations. First, not all clinics that were selected for the study agreed to participate, and clinics that did not participate differed from those that did participate. Although we were able to adjust for some of these differences in the analysis, our results may still reflect unmeasured or uncorrected bias. Second, clinics that treated fewer than 10 persons per year for LTBI were excluded. Thus, it is possible that large numbers of small clinics and practices, each treating a small number of persons each year, could represent a substantial number of LTBI diagnoses and courses of treatment that were missed by our survey. Based on our informal understanding of the relative importance assigned to LTBI treatment by primary care physicians and infectious diseases specialists, we doubt that this is the case. Third, some charts were ineligible or could not be located. Such charts might be expected to have been more likely to represent patients who declined or did not complete treatment. To the extent that this occurred, our proportions of acceptance and completion may be overestimates.
We conclude that the most important advance that could improve the effectiveness of LTBI treatment would be a regimen of shorter duration. The 4-month rifampin regimen and the 3-month regimen of daily INH plus rifampin are both shorter regimens with better completion rates, but the 4-month rifampin regimen has not had efficacy evaluated in a large prospective trial, whereas the 3-month regimen of INH plus rifampin has only been conclusively demonstrated to be effective in HIV-infected persons,[28] and is not recommended for use in the United States. Another 3-month regimen, once weekly rifapentine plus INH, has been shown to be well tolerated and lead to improved completion.[29] The efficacy of this regimen compared with the 9-month INH regimen is currently being studied by the Tuberculosis Trials Consortium.[30] If this regimen is as effective as the 9-month INH regimen, its widespread adoption might lead to substantially improved treatment completion rates and result in prevention of more cases of TB.
https://docs.google.com/fileview?id=0B278nGJMQBk7NTI0ODY4OTAtMzc2NS00NmY3LTk5MzAtMGE3MTU1YWY4ZDRh&hl=zh_TW
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