Missed Opportunities in the Diagnosis of Tuberculosis Meningitis. (1st February 2023)

• Record Type: Journal Article
• Authors: Simmons, Niamh; Olsen, Margaret A; Buss, Joanna; Bailey, Thomas C; Mejia-Chew, Carlos
• Is Part Of: Open forum infectious diseases. Volume 10:Number 2(2023)
• Publication Date: 2023-02-01
• Subjects: tuberculosis meningitis -- missed opportunity -- TB -- mortality; Communicable diseases -- Periodicals; Medical microbiology -- Periodicals; Infection -- Periodicals; 616.9
• DOI: 10.1093/ofid/ofad050
• Languages: English
• ISSNs: 2328-8957

Abstract

Abstract: Background: Tuberculosis meningitis (TBM) has high mortality and morbidity. Diagnostic delays can impact TBM outcomes. We aimed to estimate the number of potentially missed opportunities (MOs) to diagnose TBM and determine its impact on 90-day mortality. Methods: This is a retrospective cohort of adult patients with a central nervous system (CNS) TB International Classification of Diseases, Ninth/Tenth Revision (ICD-9/10) diagnosis code (013*, A17*) identified in the Healthcare Cost and Utilization Project, State Inpatient and State Emergency Department (ED) Databases from 8 states. Missed opportunity was defined as composite of ICD-9/10 diagnosis/procedure codes that included CNS signs/symptoms, systemic illness, or non-CNS TB diagnosis during a hospital/ED visit 180 days before the index TBM admission. Demographics, comorbidities, admission characteristics, mortality, and admission costs were compared between those with and without a MO, and 90-day in-hospital mortality, using univariate and multivariable analyses. Results: Of 893 patients with TBM, median age at diagnosis was 50 years (interquartile range, 37–64), 61.3% were male, and 35.2% had Medicaid as primary payer. Overall, 407 (45.6%) had a prior hospital or ED visit with an MO code. In-hospital 90-day mortality was not different between those with and without an MO, regardless of the MO coded during an ED visit (13.7% vs 15.2%, P = .73) or a hospitalization (28.2% vs 30.9%, P = .74). Independent risk of 90-day in-hospital mortality was associated with older age, hyponatremia (relative risk [RR], 1.62; 95% confidence interval [CI], 1.1–2.4; P = .01), septicemia (RR, 1.6; 95% CI, 1.03–2.45; P = .03), and mechanical ventilation (RR, 3.4; 95% CI, 2.25–5.3; P < .001) during the index admission. Conclusions: Approximately half the patients coded for TBM had a hospital or ED visit in the previous 6 months meeting the MO definition. We found no association between having an MO for TBM and 90-day in-hospital mortality. Abstract : In this large cohort of patients with tuberculosis meningitis, 45.6% of patients had a hospital or emergency department visit in the previous 6 months coded for missed opportunity. 90-day mortality was associated with older age, hyponatremia, septicemia, and mechanical ventilation.