Factors Associated with Failure to Diagnose Acute Pulmonary Tuberculosis in a Public Emergency Department

Abstract

4 Abstract Objective: Emergency department presentation of active pulmonary tuberculosis (TB) can be highly variable and atypical. Appropriate patient stratification may require the assessment of non-clinical criteria. The aim of this study was to determine unique presentation, risk factors and outcomes in the population of TB patients that present to a public emergency department (PED), as well as to identify those factors associated with ED discharge without a diagnosis of TB during a potentially contagious visit. Methods: Epidemiological characteristics were determined for every patient diagnosed with TB in Arizona for 2000-2008. From these, the 1501 presenting in Maricopa County, Arizona for 2000-2008 were selected for further analysis. Presentation at the only PED in the county was determined by retrospective chart review. Potentially contagious TB patients presenting at the PED were analyzed on the basis of the absence or presence of a TB diagnosis during a potentially contagious visit. Results: Of the study population, 150 (12.0% of pulmonary TB patients) presented to the PED within one month of a verified diagnosis of active pulmonary TB. Patients presenting to the public emergency department were more likely to be male, Hispanic, homeless, HIV-positive, current resident of a correctional facility or a long-term care facility, or to have a recent history of substance abuse. Furthermore, PED patients were more likely to have multidrug resistant TB and to die before completion of treatment. Patients reported a median distance of 4.6 miles from their residence to the PED, with only 10.8% reporting a distance of greater than 15 miles. Comparison of potentially contagious TB patient visits demonstrated that patients were significantly less likely to receive a diagnosis of TB when presenting with a traumatic or orthopedic chief complaint, denying cough, hemoptysis, dyspnea, fever or chills, having a normal pulmonary exam and/or chest x-ray, being unresponsive during questioning, or reporting a recent history of both homelessness and excess alcohol use. Baseline sensitivity for the diagnosis of TB during a potentially contagious visit was 78.2%. Modeling revealed an increase in sensitivity to 97.9% if patients were assessed for altered mental status, pulmonary or infectious chief complaint, abnormal vital signs, or history of substance abuse or foreign birthplace. Conclusions: In this study, TB patients presenting to the public 5 emergency department were significantly more likely to have many of the known risk factors for TB, be diagnosed with MDR-TB and die before completion of therapy. Patients with a history of alcohol abuse and homelessness, or lack of signs and symptoms classical for TB were less likely to be diagnosed with TB during a potentially contagious visit. This study adds evidence to the belief that public emergency departments disproportionally care for TB patients and that these patients have a more precarious health status and greater risk for mortality than those who are diagnosed by other facilities.