“Think. Test. Treat TB” in Action: An Innovative Primary Care and Public Health Partnership to Improve Tuberculosis Prevention and Care

Abstract

Tuberculosis (TB) elimination in the United States hinges on large-scale TB screening, testing, and preventive treatment of individuals at risk for TB disease. However, the path from TB screening to TB preventive therapy (TPT) completion is not straightforward and relies on collaboration between public health departments and primary care providers to deliver quality TB services. North East Medical Services (NEMS) is a federally qualified community health center in the San Francisco Bay Area that provides primary care services to a large low-income Asian immigrant population at increased risk for TB infection and disease. To address a gap in primary care guidance on how to manage a patient who is asymptomatic and TB screening test–positive with abnormal chest imaging, NEMS and the San Francisco Department of Public Health TB Clinic, with support from the California Department of Public Health and University of California, San Francisco as partners, collaborated to utilize both provider education and radiology, laboratory, and electronic health record (EHR) systems modifications as decision aids for TB risk stratification of patients for home collection TB sputum evaluation and/or TB clinic referral before TPT is offered. A multidisciplinary group made up of local provider stakeholders from TB public health, infectious disease, pulmonary care, and primary care was convened in August 2022 to develop novel primary care workflows surrounding asymptomatic patients’ abnormal chest imaging following a positive TB screening test. This new strategy, rolled out from August to December 2022, included trainings for radiologists and laboratory staff in addition to primary care providers, EHR modifications to support TB evaluation, and standardized TB radiology language to enhance clinical communication. The TB risk stratification algorithm and associated EHR modifications and trainings supported provider decision-making and led to a significant improvement in the quality of TB diagnostic evaluation; notably, the number and proportion of complete sputum evaluation from preimplementation to postimplementation of the strategy increased (21% [20 of 95] in 2022 vs. 63% [85 of 135] in 2023, P < 0.05). Through this multipronged approach, this community health center simplified TB prevention workflows for primary care providers and streamlined the provider decision-making process to refer patients at higher risk for developing TB disease to the TB clinic.