March 14, 2000
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TB Therapy Requires Experts, Hopkins Investigation Finds
A study by infectious disease experts at Johns Hopkins concludes thatpublic health doctors do a far better job of treating tuberculosis (TB)than private-practice physicians. Results strongly suggest that privatedoctors are responsible for most of the drug-resistant TB cases emerging inthe United States, the study's authors say.
"In the United States, TB is now uncommon enough and its treatment complex enough that it should only be treated by an expert," says Richard Chaisson, M.D., a professor of medicine and senior author of the study that appears in the March issue of Chest. "If this is not feasible, there needs to be training and adequate support in monitoring private physicians so that they make fewer errors."
In the United States, the number of TB cases has dropped substantially inrecent years, and many doctors have little experience with treating thedisease properly. Antibiotics normally knock out the bacillus that causesTB, but without the proper combination of drugs for the proper amount oftime, some bacilli become drug resistant, worsening the problem andcomplicating treatment. Good TB therapy generally requires a six month drug regimen involving four drugs.
For several years, researchers have known that patients treated at clinicsrun by public health departments have better outcomes than patients treated by private physicians. They didn't know, however, whether the clinics werebetter at treating their patients or whether the patients whoreceived care at the clinics were just better at taking their medications.
To examine the treatment conundrum, experts at Hopkins collected the filesof all infectious TB cases reported in Baltimore between January 1994 andDecember 1995. Excluding cases diagnosed after death and those withincomplete medical files, they examined the records of the remaining 110cases, 34 treated by private physicians and 76 at the Tuberculosis Clinicat the Baltimore City Health Department.
The researchers found that 15 percent of the total had serious errors intheir treatment for TB and that private physicians treated 77 percent ofthese patients. Of those who were treated erroneously, eight patientsreceived inadequate doses of anti-TB drugs, four were put on inappropriatecombinations of drugs, three were not treated for the full six months, andtwo were put on inadequate dosages as well as not treated long enough.
"Inappropriate treatment generally reflected a lack of familiarity with thetreatment guidelines," said Chaisson. "Because in the United States, TB isso uncommon, most doctors will not see a single case of TB in any givenyear, whereas a city's health department may see up to 100 cases in a year.You can't expect a private physician to be up on all the guidelinescompared to a group that sees TB patients all the time."
According to Chaisson, the most efficient way to avoid treatment errors andthe development of drug-resistant strains is to have all TB patientstreated by a health department or by those specializing in TB treatment. Ifthis is not possible, he says, private physicians who treat TB patientsshould be monitored.
"In the last few years, it has been shown that for any illness where thereis a degree of complexity in treatment, experienced physicians providebetter care than inexperienced physicians," said Chaisson. "This is anothercase."
For more information on TB, visit the Hopkins TB Web site athttp://www.hopkins-tb.org.
Other authors of the study include Sudeep N. Rao, M.B.B.S.; AnuradhaMookerjee, M.D., M.S., M.P.H.; and Olugbenga Obasanjo, M.D.
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