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Hospitalizations due to tuberculosis: a 3 year observational study

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Hospitalizations due to tuberculosis: a 3 year observational study

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Content TB Hospitalizations 1
Hospitalizations due to Tuberculosis:
A 3 year Observational Study
By
Prashant Patel
A Thesis presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In partial fulfillment of the
Requirements of the Degree
Master of Science
(Clinical and Biomedical Investigations) May 2015
TB Hospitalizations 2
Dedication
To my family, mentors and patients
TB Hospitalizations 3
Acknowledgements
The work in this thesis has been made possible by great help from my mentors Dr. Bharat
Chaudry, Dr. Brenda Jones and Dr. Stanley Azen. I thank all of them for their kind help, support
and guidance.
TB Hospitalizations 4
Table of Contents
Dedication ...................................................................................................................................... 2
Acknowledgements ....................................................................................................................... 3
List of Figures................................................................................................................................ 5
List of Tables ................................................................................................................................. 6
Abstract.......................................................................................................................................... 7
Background ............................................................................................................................... 7
Methods...................................................................................................................................... 7
Results ........................................................................................................................................ 7
Conclusion ................................................................................................................................. 8
Introduction................................................................................................................................... 9
Methods........................................................................................................................................ 10
Study Design............................................................................................................................ 10
Database................................................................................................................................... 11
Statistical Analyses.................................................................................................................. 12
Results .......................................................................................................................................... 12
Patient Characteristics ........................................................................................................... 13
Hospital Characteristics ......................................................................................................... 13
Utilization Patterns ................................................................................................................. 13
Discussion..................................................................................................................................... 23
References.................................................................................................................................... 27
Addendum A................................................................................................................................ 29
TB Hospitalizations 5
List of Figures
Figure A : Rate of TB cases per 100,000 population— United States, 2011 ............................... 16
Figure B : TB cases among U.S.-born and foreign-born persons................................................. 16
Figure C : TB vs non-TB case Admissions .................................................................................. 17
Figure D : TB Admissions from 2009 to 2011 ............................................................................. 17
Figure E : Admissions by Gender................................................................................................ 18
Figure F : Admissions by Race..................................................................................................... 18
Figure G : Admissions by Payer ................................................................................................... 19
Figure H : Admissions by Income ................................................................................................ 19
Figure I : Hospital Teaching Status .............................................................................................. 20
Figure J : Hospital Location.......................................................................................................... 20
Figure K : Hospital Bed Size ........................................................................................................ 21
Figure L : Hospital Region ........................................................................................................... 21
Figure M : Length of Stay............................................................................................................. 22
Figure N : Average Charges ......................................................................................................... 22
TB Hospitalizations 6
List of Tables
Table 1: Hospitalized Patients Characteristics.............................................................................. 14
Table 2: Hospital Characteristics.................................................................................................. 15
Table 3: Utilization Patterns ......................................................................................................... 15
TB Hospitalizations 7
Abstract
Background
Contemporary data regarding characteristics of patients hospitalized for tuberculosis (TB) appears to be lacking. The purpose of this study was to describe characteristics of patients
hospitalized with TB.
Methods
We queried the Nationwide Inpatient Sample Database from 2009 to 2011 and identified
patients with primary Diagnosis of TB. We then compared the characteristics of stay principally
for TB with all other hospitalizations. We studied patient demographic characteristics(age, sex,
race, primary expected payer, median household income for zip codes), hospital characteristics
(teaching status, location, bed size, and region) and Utilization characteristics (Admission
source, Disposition, Length of stay, Total charges).
Results
20,245 hospitalizations (Weighted estimate) were attributed primarily to TB. There were
far more hospitalizations for TB for Men(64.81%) and Non-whites (76.8%). Uninsured patients
accounted for 20.86% of TB stays, though they made up only 5.31% of other hospitalizations.
Majority of TB admissions were in teaching hospitals (65.62%), Urban Hospitals (95.8%) or
large hospitals (68.51%). Emergency Department was the major admission source (65.61%).
2.99% of patients with TB admissions died during the hospital course compared to 1.88% for all
other admissions. Average Length of stay for TB admissions was 13.72 days - almost three
times that of non-TB admissions. Similarly, average total charges for TB admission of $70,181
was more than twice that of non-TB admissions.
TB Hospitalizations 8
Conclusion
Though TB treatment is provided mainly on an outpatient basis, it still remains a major
source of hospital service utilization. Hospitalization data for TB provides valuable information
that can help targeted public health planning efforts.
Keywords: Tuberculosis, Nationwide Inpatient Sample, Utilization, Length of Stay, Charges.
TB Hospitalizations 9
Introduction
Tuberculosis (TB) is an airborne-transmitted infectious disease caused by
Mycobacterium tuberculosis. TB has been a leading health problem and remains a major cause
of death worldwide. It is estimated that one-third of the world’s total population are infected with
TB bacilli and there are1.2–1.5 million deaths in 2010("World Health Organization global
tuberculosis control 2011,"). Globally, the mortality rate (excluding deaths among HIV-positive
people) has fallen by 45% between 1990 and 2013. Not all infected individuals develop the
disease. For many years, the infection can remain latent, asymptomatic and non-infectious.
However, the infection can reactivate at any time and this occurs in up to 10% of cases. In high-
income industrialized nations, the epidemiology of TB has changed, with immigrants from
endemic countries now constituting a major proportion of new TB cases.(Abarca Tomás et al.,
2013) Clinically TB is diagnosed with chest X-ray and presence of bacteria in sputum.
Treatment of TB requires multi drug regimen for several months determined by resistance profile
of bacteria. However adherence to treatment might be low(Ho, 2004).Though in the United
States, active TB disease usually can be treated successfully, with an extended therapeutic course
of a combination of antibiotics, often using directly observed therapy (DOT). In United States,
the epidemiology of tuberculosis has undergone a fundamental transformation: since 2002, the
majority of TB patients are among foreign-born persons. Figure A shows the rate of tuberculosis
(TB) cases in the United States, during 2011. Compared with the national TB case rate of 3.4
cases per 100,000 population, TB rates in reporting areas ranged widely, from 0.7 in Maine to
9.3 in Alaska (median: 2.4). Figure B shows the number and rate of tuberculosis (TB) cases
among U.S.-born and foreign-born persons, by year, reported in the United States during 1993-
TB Hospitalizations 10
2011. Among U.S.-born persons, the number and rate of TB cases declined in 2011. The 3,929
TB cases in U.S.-born persons (37.5% of all cases in persons with known national origin) were a
9.9% decrease compared with 2010 and a 77.5% decrease compared with 1993. It is to be noted
that this information is based on cases reported to National Tuberculosis Surveillance System
which uses a different ‘case definition’ (discussed later in this article). Among the foreign-born
in the U.S., undocumented people are largely from countries with a moderate or high prevalence
of TB. These individuals present unique challenges for the elimination of TB in the US(Moua,
Guerra, Moore, & Valdiserri, 2002).
Although TB is primarily treated on an outpatient basis, it is not uncommon for
community hospitals to have patients admitted with diagnosis of TB. This may include initial
hospitalizations due to symptoms leading to further workup and diagnosis of TB as well as
hospitalizations due to complications of TB and/or its treatment. Several studies have been
published characterizing epidemiology of TB patients. However most epidemiologic studies in
industrialized nations are restricted to small sample size.(Khan et al., 2008). Hence, we queried
data from a large database to characterize the patients hospitalized with TB in the United States
for years 2009 to 2011.
Methods
Study Design
We used an administrative database to conduct a cross-sectional study characterizing
hospitalizations for TB in the United States from 2009 to 2011. Records with principal discharge
diagnosis of TB were selected for further analyses.
TB Hospitalizations 11
Database
The Nationwide Inpatient Samper(NIS) is part of the Healthcare Cost and Utilization
Project (HCUP), sponsored by the Agency for Healthcare Research and Quality (AHRQ),
formerly the Agency for Health Care Policy and Research. The NIS is the largest all-payer
inpatient care database that is publicly available in the United States, containing data from
approximately 8 million hospital stays annually from about 1,000 hospitals sampled to
approximately a 20-percent stratified sample of U.S. community hospitals.("HCUP-US NIS
Overview,"). Community hospitals have been defined as short-term, non-federal, general and
other hospitals, excluding hospital units of other institutions (e.g. Prisons). They exclude
rehabilitation and long term acute care facilities. Data from the NIS has been used previously to
identify, track and analyze national trends in health care utilization, access, charges, quality and
outcomes.(Bekelis, Missios, MacKenzie, Labropoulos, & Roberts, 2015; Goel et al., 2015;
Walkey, Lagu, & Lindenauer, 2015) The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-
9-CM) is based on the World Health Organization's Ninth Revision, International Classification
of Diseases (ICD-9). ICD-9-CM is the official system of assigning codes to diagnoses and
procedures associated with hospital utilization in the United States. The National Center for
Health Statistics (NCHS) and the Centers for Medicare and Medicaid Services are the U.S.
governmental agencies responsible for overseeing all changes and modifications to the ICD-9-
CM.("ICD - ICD-9-CM - International Classification of Diseases, Ninth Revision, Clinical
Modification,") The principal diagnosis is defined as the condition, after study, which occasioned the
admission to the hospital.("ICD 9-CM Guidelines,")
TB Hospitalizations 12
The Clinical Classifications Software (CCS) for ICD-9-CM is a diagnosis and procedure
categorization scheme developed as part of the Healthcare Cost and Utilization Project (HCUP),
a Federal-State-Industry partnership sponsored by the Agency for Healthcare Research and
Quality. The ICD-9-CM's multitude of codes - over 14,000 diagnosis codes and 3,900 procedure
codes - are collapsed into a smaller number of clinically meaningful categories that are
sometimes more useful for presenting descriptive statistics than are individual ICD-9-CM
codes.("HCUP-US Tools & Software Page,") For this study, TB was defined as the following
CCS diagnosis: ‘1 Tuberculosis’. Similar approach has been adopted in previously published
statistical brief.(Holmquist, Russo, & Elixhauser).
Statistical Analyses
We used SAS Version 9.4(SAS Institute Inc., Cary, North Carolina) for analyses.
Weighted values of patient level observations were generated to produce a nationally
representative estimate of the entire US population of hospitalized patient. Differences between
categorical variables were tested using chi-square test and differences between continuous
variables were tested using Wilcoxon-Mann-Whitney test. A p value < 0.05 was considered
statistically significant.
Results
Between 2009 and 2011, there were 20,245 hospitalizations in US that had TB listed as a
primary diagnosis. The number of hospitalizations declined from 7399 in 2009 to 5749 in 2011.
Overall this represented a small percent of a total of 112 million hospitalizations in those 3 years.
(Figure C and Figure D).
TB Hospitalizations 13
Patient Characteristics
The average age of patient at time of admission was 48.5 years. Demographic
characteristics of TB related stays compared to all other hospitalizations is shown in Table 1.
Difference between TB admissions and non-TB admissions was statistically significant (p<0.05) for all demographic variables we examined. This included Gender, Race, Primary payer source
and median household income for the zip codes in which patient resided. Men compromised
64.81% of TB related stays as compared to only 42.05% of non-TB related stays (Figure E).
Minorities (Black 23.16%; Hispanic 26.99%; Asian/Pacific Islander 17.21; others 9.44%) compromised majority of TB related stays unlike all other hospitalizations(Figure F). 20.86% of
TB related stays was in uninsured patients compared to only 5.31% of uninsured other diagnoses
related hospitalizations(Figure G). Similarly, 59.59% of TB related hospitalization was noted in
patients living in zip codes with median household income below the 50
th
percentile for the
nation(Figure H).
Hospital Characteristics
Characteristics of hospitals for all TB related stays compared to all other hospitalizations
is shown in Table 2. The difference between TB cases and nonTB cases was statistically
significant (p<0.05) for each of the hospital characteristics we examined such as teaching status,
location, bed size and region. Majority of TB related stays were in teaching hospital (65.62%),
urban location (95.8%) and large hospitals (68.51%) (Figure I, Figure J, Figure K).
Utilization Patterns
Admission source and Disposition for these two groups of patients is shown in Table 3.
Almost 2/3
rd
of the patients with TB were admitted from emergency departments. As shown in
Figure M, the average length of stay was considerably higher for TB hospitalizations compared
TB Hospitalizations 14
to all other admissions (13.72 days vs 4.54 days, p<0.05). Moreover, the mean total charges
were more than double for TB admissions than those for non-TB admissions ($70,181 vs
$32,807, p<0.05)(Figure N). Finally, mortality for hospitalized TB patients was significantly
higher than non-TB admissions (2.99% vs 1.88%, p<0.05) Table 1: Hospitalized Patients Characteristics
TB Admissions All Others
(Weighted Estimates) n = 20,245 n = 112,000,000
Gender p < 0.0001
†
Male 64.81* 42.05
Female 35.19 57.95
Race p < 0.0001
White 23.2 65.75
Black 23.16 14.86
Hispanic 26.99 12.55
Asian/Pacific Islander 17.21 2.58
Other 9.44 4.25
Primary Payer p < 0.0001
Medicare 23.91 38.04
Medicaid 25.09 20.51
Private Insurance 19.19 32.33
Self-Pay 20.86 5.31
Other 10.95 3.81
Median Household
Income
p < 0.0001
0-25th Percentile 36.93 28.94
26th to 50th Percentile
(Median) 22.46 25.63
51st to 75th Percentile 21.86 24.38
76th to 100th Percentile 18.75 21.05
*Values are given as percent.
† Calculated using χ2 test.
TB Hospitalizations 15
Table 2: Hospital Characteristics
TB Admissions All Others
(Weighted Estimates) n = 20,245 n = 112,000,000
Teaching Status p < 0.0001
†
Teaching 65.62* 47.56
Nonteaching 34.38 52.44
Location p < 0.0001
Rural 4.2 11.93
Urban 95.8 88.07
Bedside p < 0.0001
Small 8.25 11.63
Medium 23.24 24.29
Large 68.51 64.08
Region p < 0.0001
Northeast 23.46 19.31
Midwest 11.77 22.73
South 38.53 38.22
West 26.23 19.74
*Values are given as percent.
† Calculated using χ2 test.
Table 3: Utilization Patterns
TB Admissions All Others
(Weighted Estimates) n = 20,245 n = 112,000,000
Admission Source Emergency Department 65.61* 38.98
Another Hospital 3 3.66
Other health facility, including
long term care
2.19 2.38
Court/Law enforcement 2.32 0.12
Routine, birth and other 26.88 54.85
Disposition of
Patient
Routine 74.24 71.4
Transfer to Short-term facility 3.26 2.13
Transfer other : Includes SNF,
ICF, another type of facility
9.53 13.12
Home Health Care 7.85 10.45
Died 2.99 1.88
Other, includes AMA 2.14 1.03
*Values are given as percent.
TB Hospitalizations 16
Figure A : Rate of TB cases per 100,000 population— United States, 2011
Source: cdc.gov/mmwr
Figure B : TB cases among U.S.-born and foreign-born persons.
Source: National Tuberculosis Surveillance System). Data are updated as of February 22, 2012.
TB Hospitalizations 17
Figure C : TB vs non-TB case Admissions
Figure D : TB Admissions from 2009 to 2011
TB Hospitalizations 18
Figure E : Admissions by Gender
Figure F : Admissions by Race
65.75
23.2
14.86
23.16
12.55
26.99
2.58
17.21
0.74 1.22
3.51
8.22
0
10
20
30
40
50
60
70
non-TB TB
Percent
Admissions
Hospital Admissions by Race
White Black Hispanic Asian or Pacific Islander Native American Other
TB Hospitalizations 19
Figure G : Admissions by Payer
Figure H : Admissions by Income
38.04
23.91
20.51
25.09
32.33
19.19
5.31
20.86
0.52
2.27
3.29
8.69
0
5
10
15
20
25
30
35
40
non-TB TB
Percent
Admissions
Hospital Admissions by Payer
Medicare Medicaid Private Insurance Self-Pay No Charge Other
TB Hospitalizations 20
Figure I : Hospital Teaching Status
Figure J : Hospital Location
TB Hospitalizations 21
Figure K : Hospital Bed Size
Figure L : Hospital Region
TB Hospitalizations 22
Figure M : Length of Stay
Figure N : Average Charges
TB Hospitalizations 23
Discussion
This is one of the largest study of TB patients describing attributes related to their
hospitalizations. Centers for disease control and prevention (CDC) publishes extensive data
reports on TB. Several of those reports are based on information reported in National TB
Surveillance System. These reported cases are verified and counted annually. TB case definition
for public health surveillance is provided in Addendum A and is distinctly different from one
used in this study. Moreover, CDC also provides tools such as Online Tuberculosis Information
System (OTIS) which is an interactive data system containing information on TB cases reported
to CDC. Users can select criteria to produce specific reports.("CDC | TB | Data and Statistics,") Our method is based entirely on discharge data reported by hospitals and further classified by
ICD9 coding system. We believe the sample for this study remains highly representative of
national estimates due to its large size among other factors. The total number of cases reported to
and by CDC for years 2009, 2010 and 2011 are 11,519, 11,164 and 10,509 respectively. In our
analyses, the trends for hospitalized cases during those three years follows similar downward
trend as can be seen in Figure D. Not all patients with TB during those years would have been
hospitalized and so as expected the hospitalized TB cases during each of those 3 years were
lower than total cases reported by CDC for corresponding years. In our findings, more TB
hospitalizations were seen in men compared to women. This is similar to previous observations
and is thought to reflect more frequent TB exposure in the community among men than women
(Comstock, 1982). In our analyses, nearly 75% of hospitalized patients were minorities and
almost 60% were residing in zip codes with less than median household income. This is similar
to previously published CDC report which suggested that TB disease rates among racial and
ethnic minority groups are 5 to 10 times higher than among whites; these groups comprised 83
TB Hospitalizations 24
percent of all reported TB cases in 2007.("Reported HIV status of tuberculosis patients--United
States, 1993-2005," 2007). TB has traditionally been associated with low socioeconomic status
which may be associated with crowding, poor nutrition, and poor access to medical care, public
assistance, unemployment, and low education.(Cantwell, McKenna, McCray, & Onorato, 1998).
The next section of our analyses provides some useful information about hospital characteristics.
Most TB hospitalizations were in ‘large’, ‘urban’ or ‘teaching’ hospital, which is not largely
unexpected. Hospitals in these categories are known to provide high proportion of care to
patients with publicly funded insurance or no insurance(Hansel, Merriman, Haponik, & Diette,
2004) and are located in more crowded urban locations. Emergency department remains major
admission source for patients with TB. They may have presented as known case of TB leading to
early airborne precautions or may have presented with or without signs and symptoms of TB
leading to a new diagnosis of TB. Length of stay among hospitalized patients with TB is
significantly greater than other patients. This could be due to several factors: delay in diagnoses
and initiation of appropriate treatment, higher acuity/severity of illness of TB patients and lack of
resources for appropriate transition to outpatient care. Not surprisingly, higher length of stay and
resource utilization during hospital stay also explains the higher charges billed by hospitals for
patients with TB than those without TB. Griffith et al previously demonstrated hospital resource
utilization and increased length of stays in TB patients in a municipal hospital in New York.
(Griffiths et al., 1998). The commentary by Brennan that followed the article by Griffith et al
further discussed the merits of both the inpatient and outpatient approach to the diagnosis and
initiation of therapy for TB.(Brennan, 1998). Finally, mortality for hospitalized TB patients
continue to remain high compared to nonTB patients as has been previously demonstrated.
(Hansel et al., 2004). Nature of disease, barriers to healthcare access and lack of concern about
TB Hospitalizations 25
health status among certain populations groups could be few reasons that could explain this.
While advances in medical science leading to novel quick diagnostic methods and treatments of
multi-drug resistant TB may make TB at least less fatal, there could be a scope for improvement
in public health policies to increase awareness about TB and various resources available for
susceptible population subgroups.
This study has several limitations. The database considers each hospitalization as a
separate entry and so it is not possible to separate index cases from readmissions. Hence there
may be a concern that this may lead to overestimation. However, since this study was mainly
focused on studying ‘TB Hospitalizations’ per se, even repeat admissions contribute towards
burden of disease and hence it would be appropriate to include them in analyses. Some
hospitalized patients with TB may have had aggravating conditions such as respiratory failure
which may have occasionally been coded as principal diagnosis even though they may have
arose from TB. Similarly there may have been other scenarios whereby TB may have been coded
as secondary diagnosis. It is to be noted that for each discharger record, up to 25 secondary
diagnoses have been provided in database we used. This may lead to somewhat underestimation
of TB hospitalizations since we only used cases with TB as principal diagnosis. Administrative
databases are increasingly used for healthcare research, however these are susceptible to coding
inaccuracies especially when coding guidelines change over the period of analyses. For the
purpose of this study though, the CCS code for TB and associated ICD9 codes did not change
over the period of analyses based on our understanding. A particular area of interest with several
previously published reports has been to compare TB incidence rates between US born and
Foreign born patients and this information was not available to us with our current data.
TB Hospitalizations 26
In summary, our current study provides vital information about patients hospitalized with
TB. Overall trends related to number of hospitalizations and distribution of disease among
various socioeconomic strata for hospitalized patients show pattern similar to what is known
from other publicly available information but this study provides additional details such as
hospital characteristics, length of stay, total charges, etc. which can be of high value. TB
remains major source of hospital service utilization and hospital discharge data may further aid
in targeting public health efforts towards TB control.
TB Hospitalizations 27
References
Abarca Tomás, B., Pell, C., Bueno Cavanillas, A., Guillén Solvas, J., Pool, R., & Roura, M.
(2013). Tuberculosis in Migrant Populations. A Systematic Review of the Qualitative
Literature. PLoS One, 8(12), e82440. doi: 10.1371/journal.pone.0082440
Bekelis, K., Missios, S., MacKenzie, T. A., Labropoulos, N., & Roberts, D. W. (2015). A
predictive model of hospitalization cost after cerebral aneurysm clipping. J Neurointerv
Surg. doi: 10.1136/neurintsurg-2014-011575
Brennan, P. J. (1998). Hospital-resource utilization and tuberculosis. Infect Control Hosp
Epidemiol, 19(10), 744-746.
Cantwell, M. F., McKenna, M. T., McCray, E., & Onorato, I. M. (1998). Tuberculosis and
race/ethnicity in the United States: impact of socioeconomic status. Am J Respir Crit
Care Med, 157(4 Pt 1), 1016-1020. doi: 10.1164/ajrccm.157.4.9704036
CDC | TB | Data and Statistics. Retrieved January, 18, 2015, from
http://www.cdc.gov/tb/statistics/default.htm
Comstock, G. W. (1982). Epidemiology of tuberculosis. Am Rev Respir Dis, 125(3 Pt 2), 8-15.
Goel, R., Ness, P. M., Takemoto, C. M., Krishnamurti, L., King, K. E., & Tobian, A. A. (2015).
Platelet transfusions in platelet consumptive disorders are associated With arterial
thrombosis and in-hospital mortality. Blood. doi: 10.1182/blood-2014-10-605493
Griffiths, R. I., Hyman, C. L., McFarlane, S. I., Saurina, G. R., Anderson, J. E., O'Brien, T., . . .
Sierra, M. F. (1998). Medical-resource use for suspected tuberculosis in a New York City
hospital. Infect Control Hosp Epidemiol, 19(10), 747-753.
Hansel, N. N., Merriman, B., Haponik, E. F., & Diette, G. B. (2004). Hospitalizations for
tuberculosis in the United States in 2000: predictors of in-hospital mortality. Chest,
126(4), 1079-1086. doi: 10.1378/chest.126.4.1079
HCUP CCS. Healthcare Cost and Utilization Project (HCUP). November 2014. Agency for
Healthcare Research and Quality, Rockville, MD. Retrieved January, 18, 2015, from
http://www.hcup-us.ahrq.gov/toolssoftware/ccs/ccs.jsp
HCUP Databases. Healthcare Cost and Utilization Project (HCUP). November 2014. Agency
for Healthcare Research and Quality, Rockville, MD. Retrieved January 17, 2015, from
http://www.hcup-us.ahrq.gov/nisoverview.jsp
Ho, M. J. (2004). Sociocultural aspects of tuberculosis: a literature review and a case study of
immigrant tuberculosis. Soc Sci Med, 59(4), 753-762. doi:
10.1016/j.socscimed.2003.11.033
Holmquist, L., Russo, C. A., & Elixhauser, A. Statistical Brief #60. Healthcare Cost and
Utilization Project (HCUP). October 2008. Agency for Healthcare Research and Quality,
Rockville, MD. Retrieved January 18, 2015, from www.hcup-
us.ahrq.gov/reports/statbriefs/sb60.jsp
ICD 9-CM Guidelines. (08/23/2011). Retrieved January, 18, 2015, from
http://www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm
ICD - ICD-9-CM - International Classification of Diseases, Ninth Revision, Clinical
Modification. Retrieved January, 17, 2015, from
http://www.cdc.gov/nchs/icd/icd9cm.htm
TB Hospitalizations 28
Khan, K., Wang, J., Hu, W., Bierman, A., Li, Y., & Gardam, M. (2008). Tuberculosis Infection
in the United States. American Journal of Respiratory and Critical Care Medicine,
177(4), 455-460. doi: 10.1164/rccm.200706-950OC
Moua, M., Guerra, F. A., Moore, J. D., & Valdiserri, R. O. (2002). Immigrant health: legal
tools/legal barriers. J Law Med Ethics, 30(3 Suppl), 189-196.
Reported HIV status of tuberculosis patients--United States, 1993-2005. (2007). MMWR Morb
Mortal Wkly Rep, 56(42), 1103-1106.
Walkey, A. J., Lagu, T., & Lindenauer, P. K. (2015). Trends in Sepsis and Infection Sources in
the United States: A Population Based Study. Ann Am Thorac Soc. doi:
10.1513/AnnalsATS.201411-498BC
World Health Organization global tuberculosis control 2011. Retrieved January, 18, 2015, from
http://www.who.int/tb/publications/global_report/2011/gtbr11_full.pdf
TB Hospitalizations 29
Addendum A
Tuberculosis Case Definition for Public Health Surveillance (Revised May 13, 2009) Clinical Description
A chronic bacterial infection caused by Mycobacterium tuberculosis, usually
characterized pathologically by the formation of granulomas. The most common site of infection
is the lung, but other organs may be involved.
Clinical Case Definition
A case that meets all of the following criteria:
 A positive tuberculin skin test result or positive interferon gamma release assay for M.
tuberculosis
 Other signs and symptoms compatible with tuberculosis (TB) (e.g., abnormal chest
radiograph, abnormal chest computerized tomography scan or other chest imaging study,
or clinical evidence of current disease)  Treatment with two or more anti-TB medications
 A completed diagnostic evaluation
Laboratory Criteria for Diagnosis
 Isolation of M. tuberculosis complex from a clinical specimen, or
 Demonstration of M. tuberculosis complex from a clinical specimen by nucleic acid
amplification test, or
 Demonstration of acid-fast bacilli in a clinical specimen when a culture has not been or
cannot be obtained or is falsely negative or contaminated.

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Creator Patel, Prashant (author)

Core Title Hospitalizations due to tuberculosis: a 3 year observational study

School Keck School of Medicine

Degree Master of Science

Degree Program Clinical and Biomedical Investigations

Publication Date 02/10/2015

Defense Date 01/18/2015

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag charges,length of stay,nationwide inpatient sample,OAI-PMH Harvest,Tuberculosis,utilization

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Chaudry, Bharat (committee chair), Azen, Stanley P. (committee member), Jones, Brenda (committee member)

Creator Email docimg01@yahoo.com,drprashant_md@yahoo.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c3-530997

Unique identifier UC11298454

Identifier etd-PatelPrash-3174.pdf (filename),usctheses-c3-530997 (legacy record id)

Legacy Identifier etd-PatelPrash-3174.pdf

Dmrecord 530997

Document Type Thesis

Format application/pdf (imt)

Rights Patel, Prashant

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA