title: Tuberculosis treatment managed by providers outside the Public Health Department: lessons for the Affordable Care Act.
abstract: BACKGROUND
  Tuberculosis (TB) requires at least six months of multidrug treatment and necessitates monitoring for response to treatment. Historically, public health departments (HDs) have cared for most TB patients in the United States. The Affordable Care Act (ACA) provides coverage for uninsured persons and may increase the proportion of TB patients cared for by private medical providers and other providers outside HDs (PMPs). We sought to determine whether there were differences in care provided by HDs and PMPs to inform public health planning under the ACA.
  
  
  METHODS
  We conducted a retrospective, cross-sectional analysis of California TB registry data. We included adult TB patients with culture-positive, pulmonary TB reported in California during 2007-2011. We examined trends, described case characteristics, and created multivariate models measuring two standards of TB care in PMP- and HD-managed patients: documented culture conversion within 60 days, and use of directly observed therapy (DOT).
  
  
  RESULTS
  The proportion of PMP-managed TB patients increased during 2007-2011 (p = 0.002). On univariable analysis (N = 4,606), older age, white, black or Asian/Pacific Islander race, and birth in the United States were significantly associated with PMP care (p<0.05). Younger age, Hispanic ethnicity, homelessness, drug or alcohol use, and cavitary and/or smear-positive TB disease, were associated with HD care. Multivariable analysis showed PMP care was associated with lack of documented culture conversion (adjusted relative risk [aRR] = 1.37, confidence interval [CI] 1.25-1.51) and lack of DOT (aRR = 8.56, CI 6.59-11.1).
  
  
  CONCLUSIONS
  While HDs cared for TB cases with more social and clinical complexities, patients under PMP care were less likely to receive DOT and have documented culture conversion. This indicates a need for close collaboration between PMPs and HDs to ensure that optimal care is provided to all TB patients and TB transmission is halted. Strategies to enhance collaboration between HDs and PMPs should be included in ACA implementation.
authors.affiliation: Tuberculosis Control Branch, Division of Communicable Disease Control, Center for Infectious Diseases, California Department of Public Health, Richmond, California, United States of America; Institute of Global Health, Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America.
authors.forename: Melissa
authors.initials: M
authors.lastname: Ehman
authors.affiliation: Tuberculosis Control Branch, Division of Communicable Disease Control, Center for Infectious Diseases, California Department of Public Health, Richmond, California, United States of America.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Flood
authors.affiliation: Tuberculosis Control Branch, Division of Communicable Disease Control, Center for Infectious Diseases, California Department of Public Health, Richmond, California, United States of America.
authors.forename: Pennan M
authors.initials: PM
authors.lastname: Barry
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002140:California / Q000453:epidemiology; D023801:Directly Observed Therapy; D005260:Female; D006282:Health Personnel; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D058991:Patient Protection and Affordable Care Act; D011634:Public Health; D014376:Tuberculosis / Q000188:drug therapy* / Q000453:epidemiology; D014481:United States; D014483:United States Dept. of Health and Human Services; D055815:Young Adult