Addressing Latent Tuberculosis Infection Treatment Through a Collaborative Care Model With Community Pharmacies and a Health Department

Bernadette Jakeman, PharmD; Stefanie J. Logothetis, PharmD; Melissa H. Roberts, PhD; Amy Bachyrycz, PharmD; Diana Fortune, BSN; Matthew E. Borrego, PhD; Julianna Ferreira, MSN, MPH; Marcos Burgos, MD

Disclosures

Prev Chronic Dis. 2020;17(2):e14 

In This Article

Discussion

This is the first study to evaluate the feasibility of providing LTBI treatment with DOT in a community pharmacy setting as a strategy to improve patient access in collaboration with a state health department. We demonstrated that 3HP can be safely administered in a community pharmacy collaborative care setting and result in high rates of LTBI treatment completion (75% in community pharmacy setting; 77.5% overall). Our LTBI completion rate was similar to rates reported by the NM DOH. In 2017, the NM DOH reported that 374 patients in NM were determined to have LTBI at a DOH clinic location;[26] 167 patients initiated treatment, 107 (64.1%) completed LTBI treatment (New Mexico Department of Health Tuberculosis Prevention Program, 2017, unpublished data). High rates of completion in the community pharmacy setting are likely a result of a variety of accessible pharmacy locations, extended operating hours, and no requirement for scheduled appointments.

In our cohort we found that Hispanic patients were more likely to complete LTBI treatment compared with non-Hispanics. This finding is consistent with those of prior studies,[14,19–21,28,29] but its cause is unclear. However, perception of disease risk has been previously reported as a predictor for LTBI treatment completion,[30] which this study did not assess. These patients may have had an increased perception of risk if they or their family members were born in TB-endemic areas.

We reported high rates of potential ADEs (n = 24; 60%). ADEs, including nausea/vomiting and fatigue, were associated with noncompletion of LTBI treatment in this study. This finding is also consistent with prior studies,[18,21] Most potential medication side effects reported with 3HP were not serious and may have been due to other causes. Most patients were managed through the pharmacy with direct communication and collaboration with the DOH. This resulted in treatment completion in 17 of the 24 patients (71%) that experienced a potential ADE. Pharmacists were able to ensure pyridoxine (vitamin B6) supplementation when appropriate and discuss options to address nausea. Addressing potential ADEs in a community pharmacy setting is an opportunity to increase completion rates before losing patients to follow-up.

WHO describes the importance of accessible and free TB services in their elimination framework.[2] Community pharmacies may be able to offer an additional accessible setting to provide LTBI treatment. To achieve TB elimination, it is important to increase access to treatment in ways that are convenient for patients while also relieving a portion of the burden from the DOH. A total of 41 of the 67 patients who received treatment chose to participate in this study and receive treatment at a community pharmacy site, highlighting patient interest in this treatment setting. With an increase in available community pharmacy sites, it is likely that more patients will have the opportunity to complete treatment.

Data from this pilot project provide important information about LTBI treatment administered in the community pharmacy setting. However, our study has limitations. First, results cannot be generalized outside of New Mexico. This was a pilot study with a small sample in 2 large city settings in New Mexico, which is largely rural and has health care professional shortages and patient socioeconomic barriers. In addition, only a small subset of the total number of pharmacies in the state participated in the study. To minimize this limitation, we included pharmacies that were geographically distributed, including both independent and chain pharmacies. We would not expect the study results to differ significantly if all New Mexico pharmacies offering this public health service had participated. In addition, we only evaluated LTBI treatment with 3HP plus DOT. Another consideration is that this project was supported by a grant, which covered the cost of 3HP medication provided in the community pharmacy. If this public health service is to be sustainably offered to patients at no charge, a mechanism will need to be identified to address the cost of providing this service in the community pharmacy setting. Finally, the success of this program can be attributed to the collaboration with the DOH, in which training and expert consultation was provided.

LTBI treatment with 3HP plus DOT can be safely administered in a community pharmacy collaborative care setting and offers opportunity for improved access to care for patients. High rates of completion in a community pharmacy setting are likely a result of increased access to care through neighborhood pharmacy locations, extended operating hours, and no requirement for scheduled appointments. The largest barrier to LTBI treatment completion was ADEs. Pharmacists can help identify and manage potential ADEs in the community pharmacy setting, which may minimize loss to follow-up.

Comments

3090D553-9492-4563-8681-AD288FA52ACE

processing....