Long-term hospitalization for tuberculosis control. Experience with a medical-psychosocial inpatient unit
L. Singleton, M. Turner, R. Haskal, S. Etkind, M. Tricarico and E. Nardell
Division of Tuberculosis Prevention and Control, Massachusetts Department of Public Health, Boston 02130, USA. Linda.Singleton@state.ma.us
CONTEXT: Patients with tuberculosis (TB) who are nonadherent to therapy or
have complicated medical or social problems pose a threat to public health.
In some cases, hospitalization may be a necessary component of a
comprehensive TB control program. OBJECTIVE: To describe experience with a
new inpatient program for TB control. DESIGN: Retrospective review.
SETTING: Eighteen-bed, secure, TB treatment unit in a state public health
hospital providing a spectrum of acute and chronic care services. PATIENTS:
Patients with known or suspected TB who were unable to be treated as
outpatients and were hospitalized from 1990 through 1995. INTERVENTIONS:
Voluntary or involuntary hospitalization, with medical, psychosocial, and
legal services. MAIN OUTCOME MEASURES: Admissions, treatment completion,
and disposition. RESULTS: A total of 166 patients with a confirmed
diagnosis of TB accounted for 214 hospitalizations for TB. The mean age was
42 years, 132 (79.5%) were men, 84 (50.6%) were nonwhite, and 45 (27.1%)
were foreign born. At the time of admission, 58 patients (34.5%) were
homeless, 116 (69.9%) had a history of abuse of alcohol or other drugs, and
46 (31.7%) were positive for human immunodeficiency virus. The mean length
of stay was 119.7 days (median, 70 days; range, 7-656 days), and was higher
among homeless patients than nonhomeless patients (168.8 vs 93.4 days). Of
48 patients (28.9%) who were admitted involuntarily, 21 required long-term
confinement under court order. Admission indications (not mutually
exclusive) changed over 5 years: nonadherence decreased (95% to 34%),
medical complexity increased (14% to 77%), short-term isolation increased
(19% to 39%), and involuntary admission decreased (54% to 13%). Of 157
patients with positive cultures for Mycobacterium tuberculosis, 36 (23.1%)
were resistant to at least 1 drug, including 16 who were multidrug
resistant. A total of 123 patients (74.7%) were discharged to an outpatient
setting to complete therapy, 40 (24.1%) required inpatient care to complete
therapy, and 3 died (1 from TB) before discharge. CONCLUSIONS: A high
proportion of patients with TB who failed outpatient therapy completed
treatment in a combined medical and psychosocial inpatient unit. During the
5-year study period, involuntary admissions decreased and most patients
completed therapy as outpatients. In Massachusetts, this program plays an
important role in protecting public health and in providing specialized
medical management for patients to complete therapy in a safe and
supportive environment.
