A Pharmacist-Managed Clinic
A Pharmacist-Managed Clinic
A pharmacist-managed clinic for treating latent tuberculosis infection (LTBI) in health care workers (HCWs) is described.
The hospital-based clinic was begun in 1993 after a review showed that only 0.8% of HCWs at the institution who were prescribed isoniazid for LTBI completed it. The goals of the clinic are to improve HCWs adherence to LTBI treatment, enhance outcomes, and minimize adverse drug reactions. The clinic is staffed by a pharmacist, a medical resident, and a nurse. If an employee is diagnosed with LTBI, he or she is referred to the clinic, where the pharmacist conducts an initial assessment and provides information on medication available for treatment. The worker is then scheduled for monthly follow-up visits with the pharmacist for the first three months of LTBI therapy, during which the pharmacist evaluates treatment adherence and potential adverse effects. Thereafter, the pharmacist interviews the patient monthly by telephone until therapy is complete. HCWs are allowed only a one-month supply of medication with each refill. From June 1993 through June 1997, of 131 employees who started treatment, 122 (93%) completed it. From June 1997 through December 2001, annual therapy completion rates ranged from 90% to 100%. No cases of active tuberculosis have been reported in treated patients, and only nine adverse drug reactions were reported for the 1997 2001 period.
A pharmacist-managed clinic substantially improved rates of treatment completion among HCWs with LTBI.
Tuberculosis remains a significant health problem in the United States; 16,377 cases were reported in 2000. The number of cases of multidrug-resistant tuberculosis has been rising, especially among U.S. residents who were born in countries where tuberculosis is common. Health care workers (HCWs) are at greater risk of contracting tuberculosis than the general public. In addition, many HCWs in the United States were born in other countries, heightening the concern about multidrug-resistant tuberculosis in this population. Health care regulatory agencies may mandate that HCWs must have access to appropriate care for latent tuberculosis infection (LTBI) to minimize the risk of developing active tuberculosis and spreading it to patients and other HCWs. Approximately 10% of persons with a positive tuberculin skin test will develop active tuberculosis without adequate intervention.
It has been shown that nearly 50% of patients in the general population do not take medications as prescribed. Nonadherence to LTBI treatment is likely because persons with LTBI are not clinically symptomatic and may not be motivated to undergo or complete a full course of treatment. Nonadherence to treatment may lead to active tuberculosis and disease transmission and increase the risk of multidrug-resistant tuberculosis. Camins et al. found that only 69 (66%) of 105 HCWs completed isoniazid therapy. The rate of adherence to preventive therapy for tuberculosis ranged from 40% to 60% in a number of studies.
Another significant problem associated with LTBI treatment is adverse drug reactions. A frequency of hepatotoxicity associated with isoniazid therapy ranging from 0.8% to 23% and mortality rates of 0-89 per 100,000 person-years have been reported. The Centers for Disease Control and Prevention (CDC) emphasizes the importance of monitoring liver function during tuberculosis treatment to avoid hepatotoxicity. CDC has reported that 21 patients were hospitalized because of severe liver injury associated with a two-month regimen of rifampin and pyrazinamide for LTBI. Five of these patients died of liver failure. CDC and the American Thoracic Society subsequently revised their treatment guidelines for LTBI and currently recommend careful clinical and laboratory monitoring for patients who must continue taking this two-drug regimen.
People with LTBI have many options for obtaining care, including going to their private physician, a public health facility, or an employer-based health department. Among HCWs, the convenience of receiving treatment for LTBI in the workplace can influence treatment adherence. At Cedars-Sinai Medical Center, a review of employee health service (EHS) medical records for the period from January 1989 to June 1992 revealed that only 1 (0.8%) of 125 employees who were prescribed LTBI therapy completed it. This low adherence rate prompted the director of EHS to ask the pharmacy department to assign a pharmacist to follow up HCWs' isoniazid therapy. Initially, a protocol was created and a small number of HCWs were referred to the designated pharmacist. Growth in the number of referrals prompted the creation of a pharmacist-managed clinic for employees diagnosed with LTBI. The protocol was revised and approved by the medical director of the clinic and EHS.
The use of physician extenders to enhance adherence to treatment regimens and improve treatment outcomes is on the rise in health care organizations. A pharmacist acting as a physician extender can assist clinicians in optimizing tuberculosis therapy to achieve success for particular regimens and minimize toxicity.
In 1993, an LTBI clinic was established at Cedars-Sinai to improve the adherence of HCWs to LTBI treatment, enhance outcomes, and minimize adverse drug reactions.
A pharmacist-managed clinic for treating latent tuberculosis infection (LTBI) in health care workers (HCWs) is described.
The hospital-based clinic was begun in 1993 after a review showed that only 0.8% of HCWs at the institution who were prescribed isoniazid for LTBI completed it. The goals of the clinic are to improve HCWs adherence to LTBI treatment, enhance outcomes, and minimize adverse drug reactions. The clinic is staffed by a pharmacist, a medical resident, and a nurse. If an employee is diagnosed with LTBI, he or she is referred to the clinic, where the pharmacist conducts an initial assessment and provides information on medication available for treatment. The worker is then scheduled for monthly follow-up visits with the pharmacist for the first three months of LTBI therapy, during which the pharmacist evaluates treatment adherence and potential adverse effects. Thereafter, the pharmacist interviews the patient monthly by telephone until therapy is complete. HCWs are allowed only a one-month supply of medication with each refill. From June 1993 through June 1997, of 131 employees who started treatment, 122 (93%) completed it. From June 1997 through December 2001, annual therapy completion rates ranged from 90% to 100%. No cases of active tuberculosis have been reported in treated patients, and only nine adverse drug reactions were reported for the 1997 2001 period.
A pharmacist-managed clinic substantially improved rates of treatment completion among HCWs with LTBI.
Tuberculosis remains a significant health problem in the United States; 16,377 cases were reported in 2000. The number of cases of multidrug-resistant tuberculosis has been rising, especially among U.S. residents who were born in countries where tuberculosis is common. Health care workers (HCWs) are at greater risk of contracting tuberculosis than the general public. In addition, many HCWs in the United States were born in other countries, heightening the concern about multidrug-resistant tuberculosis in this population. Health care regulatory agencies may mandate that HCWs must have access to appropriate care for latent tuberculosis infection (LTBI) to minimize the risk of developing active tuberculosis and spreading it to patients and other HCWs. Approximately 10% of persons with a positive tuberculin skin test will develop active tuberculosis without adequate intervention.
It has been shown that nearly 50% of patients in the general population do not take medications as prescribed. Nonadherence to LTBI treatment is likely because persons with LTBI are not clinically symptomatic and may not be motivated to undergo or complete a full course of treatment. Nonadherence to treatment may lead to active tuberculosis and disease transmission and increase the risk of multidrug-resistant tuberculosis. Camins et al. found that only 69 (66%) of 105 HCWs completed isoniazid therapy. The rate of adherence to preventive therapy for tuberculosis ranged from 40% to 60% in a number of studies.
Another significant problem associated with LTBI treatment is adverse drug reactions. A frequency of hepatotoxicity associated with isoniazid therapy ranging from 0.8% to 23% and mortality rates of 0-89 per 100,000 person-years have been reported. The Centers for Disease Control and Prevention (CDC) emphasizes the importance of monitoring liver function during tuberculosis treatment to avoid hepatotoxicity. CDC has reported that 21 patients were hospitalized because of severe liver injury associated with a two-month regimen of rifampin and pyrazinamide for LTBI. Five of these patients died of liver failure. CDC and the American Thoracic Society subsequently revised their treatment guidelines for LTBI and currently recommend careful clinical and laboratory monitoring for patients who must continue taking this two-drug regimen.
People with LTBI have many options for obtaining care, including going to their private physician, a public health facility, or an employer-based health department. Among HCWs, the convenience of receiving treatment for LTBI in the workplace can influence treatment adherence. At Cedars-Sinai Medical Center, a review of employee health service (EHS) medical records for the period from January 1989 to June 1992 revealed that only 1 (0.8%) of 125 employees who were prescribed LTBI therapy completed it. This low adherence rate prompted the director of EHS to ask the pharmacy department to assign a pharmacist to follow up HCWs' isoniazid therapy. Initially, a protocol was created and a small number of HCWs were referred to the designated pharmacist. Growth in the number of referrals prompted the creation of a pharmacist-managed clinic for employees diagnosed with LTBI. The protocol was revised and approved by the medical director of the clinic and EHS.
The use of physician extenders to enhance adherence to treatment regimens and improve treatment outcomes is on the rise in health care organizations. A pharmacist acting as a physician extender can assist clinicians in optimizing tuberculosis therapy to achieve success for particular regimens and minimize toxicity.
In 1993, an LTBI clinic was established at Cedars-Sinai to improve the adherence of HCWs to LTBI treatment, enhance outcomes, and minimize adverse drug reactions.
