Background
Meeting
the challenge of tuberculosis (TB) elimination will require adopting new models
of delivering patient-centered care customized to diverse settings and
contexts. In areas of low incidence with cases spread out across jurisdictions
and large geographic areas, a “virtual” model is attractive. However, whether
“virtual” clinics and telemedicine deliver the same outcomes as face-to-face
encounters in general and within the sphere of public health in particular, is
unknown. This evidence is generated here by analyzing outcomes between the
“virtual” and “outpatient” public health TB clinics in Alberta, a province of
Western Canada with a large geographic area and relatively small population.
Methods
In
response to the challenge of delivering equitable TB services over long
distances and to hard to reach communities, Alberta established three public
health clinics for the delivery of its program: two outpatient serving major
metropolitan areas, and one virtual serving mainly rural areas. The virtual
clinic receives paper-based or electronic referrals and generates directives
which are acted upon by local providers. Clinics are staffed by dedicated
public health nurses and university-based TB physicians. Performance of the two
types of clinics is compared between the years 2008 and 2012 using 16 case
management and treatment outcome indicators and 12 contact management
indicators.
Findings
In
the outpatient and virtual clinics, respectively, 691 and 150 cases and their
contacts were managed. Individually and together both types of clinics met most
performance targets. Compared to outpatient clinics, virtual clinic performance
was comparable, superior and inferior in 22, 3, and 3 indicators, respectively.
Conclusions
Outpatient and virtual public health TB clinics perform
equally well. In low incidence settings a combination of the two clinic types
has the potential to address issues around equitable service delivery and
declining expertise.
Below: TB Prevention and Care Program of Alberta: The organization of TB services in the Province of Alberta, Canada
Below: The age- and sex-adjusted incidence of tuberculosis in Alberta,
1989–2013: The age- and sex-adjusted incidence of TB in Alberta over the 25
years 1989–2013 was estimated in three population groups: Registered or Status
Indians (SI), the foreign-born (FB) and Canadian-born ‘Others’ (CBO). The
population estimates used in the analysis were derived from Canadian censuses
conducted in 1986, 1991, 1996, 2001, and 2006. [5]
After 2006 the long form of the Canadian census, which had previously estimated
the foreign-born population by age and sex, was discontinued. However, it was
noted that in 2001 and 2006 the proportion of the population, other than Status
Indians, that was foreign-born by 5-year age and sex grouping, was relatively
constant. Accordingly, the foreign-born population in 2011 was calculated on
the basis of the proportions in 2006. Inter-censal estimates were estimated
using linear interpolations between censuses; estimates from 2012 and 2013 were
obtained by linear extrapolation. Adjustment of rates was carried out using the
direct method with the total Alberta population as the reference population.
The three-clinic model began in 1999; see red arrow.
Full article at: http://goo.gl/lOQh49
By:
Richard Long, Courtney Heffernan, Mary Lou Egedahl
Faculty of Medicine and
Dentistry, Department of Medicine, University of Alberta, Edmonton, Alberta,
Canada
Richard Long, James Talbot
School of Public Health,
University of Alberta, Edmonton, Alberta, Canada
Zhiwei Gao
Clinical Epidemiology Unit,
Department of Medicine, Memorial University, St. John’s, Newfoundland, Canada
James Talbot
Alberta Health Province of
Alberta, Edmonton, Alberta, Canada
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