ACCEPTABILITYofinterferongammareleaseassaysforusein使用干扰素γ释放试验的可接受性40p资.ppt

1、ACCEPTABILITY-of-interferon-gamma-release-assays-for-use-in-使用干扰素释放试验的可接受性-40页PPT资2Background CDC guidelines recommend TB testing for healthcare workers(HCWs)upon hire and periodically thereafter using either Tuberculin skin test(TST)Interferon-gamma release assays(IGRAs),such as QFT-G and T-SPOT IG

2、RAs are relatively new diagnostic tests for TB infection Little known about their acceptability among healthcare providers and patients,specifically HCWsTask Order 18 Objectives To evaluate performance characteristics of QFT and T-SPOT compared with TST for detecting LTBI in HCWs undergoing routine

3、screeningTest result stability over time(i.e.conversion,reversion)ReproducibilityTest,re-test repeatabilityEstimated sensitivity and specificity%of failed testsImpact of TST on IGRA results To determine costs,cost-effectiveness To determine and compare acceptability of tests among participantsDesign

4、 and Population Longitudinal study HCWs undergoing routine LTBI testing 4 sites:Denver,Houston,Baltimore,NYC Inclusion:18 yrs;informed consent;undergoing routine screening Exclusion:Current or prior active TB;TST within 6 months prior to enrollment Target sample size 2500 2,493 completed baseline as

5、sessment5Acceptability Objectives To assess knowledge,attitudes,beliefs,practices,and barriers in the use of IGRAs with respect to:acceptability and usability of testing procedurespatient-provider communication about IGRAsbarriers and facilitators in the use of the IGRAs6Acceptability Components Qua

6、ntitative-collection of quantitative data assessing individual responses of HCWs to research questions Qualitative-formative research utilizing:focus groups with HCWs key informant interviews with providers7 7Quantitative Component8Study Population and Methods The first 100 participants enrolled at

7、each site asked to respond to an acceptability questionnaire Assessment tool consisted of 13 questions designed to elicit attitudes regarding:the use of TSTs and IGRAs confidence in the results of each test likelihood of taking LTBI treatment based on the results of either test9DemographicsAcceptabi

8、lityN=407Median age(range)37(20-73)Gender(female)81.8%Race/Ethnicity Hispanic24.3%African-American15.7%Caucasian52.1%Asian5.7%Other2.2%Foreign-born17.4%BCG vaccinated11.8%HIV-infected0.2%10Work EnvironmentN=407How frequent in-person contact with pts?-never-rare(50%)16.9%11.9%10.6%7.1%53.4%Job locati

9、on past year:-not used for pt care-rare or no TB pts-occasional reports of TB pts-frequent reports of TB pts18.2%28.0%31.2%11.8%11Awareness of Blood TestsHow much heard of blood tests?N=407Have not heard75.2%Heard a little18.9%Heard a lot5.4%Dont know0.3%Prefer not to answer0.3%12Testing ScenariosIf

10、TST+,believe resultYes69.0%No22.4%DK8.4%13Testing ScenariosIfTST+,believe resultTST+,willing to take TLTBIYes69.0%79.4%No22.4%8.1%DK8.4%12.5%14Testing ScenariosIfTST+,believe resultTST+,willing to take TLTBIBlood test+,believe resultYes69.0%79.4%75.7%No22.4%8.1%7.1%DK8.4%12.5%17.2%15Testing Scenario

11、sIfTST+,believe resultTST+,willing to take TLTBIBlood test+,believe resultBlood test+,willing to take TLTBIYes69.0%79.4%75.7%78.9%No22.4%8.1%7.1%6.1%DK8.4%12.5%17.2%14.7%16General Testing PreferencesFactor/ImportanceNoLowNeutralModerateHighSide effects from test5.99.111.830.542.3Accuracy of results1

12、.00.53.410.384.0Amount of time test in use5.49.127.032.925.3Effect on ability to work4.43.79.826.355.0Ability to understand how test works3.45.713.327.350.1Pain of test11.114.026.024.324.1Convenience of test4.47.422.933.931.2Ability to understand what results mean1.51.54.921.470.3Which test HCP reco

13、mmends5.43.713.031.046.4How much test costs to you7.16.120.427.838.1General Testing PreferencesFactor/ImportanceNoLowNeutralModerateHighSide effects from test5.99.111.830.542.3Accuracy of results1.00.53.410.384.0Amount of time test in use5.49.127.032.925.3Effect on ability to work4.43.79.826.355.0Ab

14、ility to understand how test works3.45.713.327.350.1Pain of test11.114.026.024.324.1Convenience of test4.47.422.933.931.2Ability to understand what results mean1.51.54.921.470.3Which test HCP recommends5.43.713.031.046.4How much test costs to you7.16.120.427.838.1Most important factor:accuracy of re

15、sults18BCG VaccinationBCG vaccinationN=407YesNoDKPNTA10.8%81.8%7.1%0.3%BCG vaccinatedN=44Not BCG vaccinatedN=363Importance of test ability to tell if infected -No importance -Low importance -Neutral -Moderate importance -High importance -DK -PNTA0%2.3%2.3%4.6%88.6%2.3%0.0%0%0.6%1.4%11.0%85.1%0.6%1.4

16、%19Test Preference20Test Preference21.4%50.1%23.3%4.9%0.3%Test Preference-ReasonReason prefer TSTN=85Familiarity with test28.2%Convenience24.7%Less invasive/painful23.5%Blood draw is hard3.5%Can see results7.1%Other10.6%Accuracy2.4%Test Preference-ReasonReason prefer TSTN=85Familiarity with test28.2

17、%Less invasive/painful23.5%Convenience24.7%Blood draw is hard3.5%Can see results7.1%Other10.6%Accuracy2.4%Reason prefer blood testN=202Convenience48.0%Accuracy34.2%Convenient/accurate11.4%Other4.0%Not injected with antigen2.5%23Fears of TestsFear ofinjection of fluidN=407blood testN=407Yes10.1%10.1%

18、No88.7%88.7%DK1.0%1.0%PNTA0.3%0.3%24Belief in TestsIf TST+and blood test is negativeN=407TST14.5%Blood test53.6%DK31.5%PTNA0.5%25Belief in TestsIf TST+and blood test is negativeN=407TST14.5%Blood test53.6%DK31.5%PTNA0.5%If TST-and blood test is positiveN=407TST9.8%Blood test54.6%DK35.1%PTNA0.5%26Con

19、clusions Although HCWs indicated preference for IGRAs over the TST and further expressed confidence in IGRA results compared to TST results,the likelihood that HCWs would initiate LTBI treatment based on positive results from either test remained the same.Further studies are needed to determine if I

20、GRA positive results will have any impact on HCWs actual acceptance and completion of LTBI treatment.2727Qualitative Component Focus Groups Key Informant InterviewsRationale for Qualitative Sub-study Provide contextual and anecdotal data to enrich quantitative acceptability data Explore factors infl

21、uencing implementation of LTBI testing and treatment guidelines in occupational health settings HCWs knowledge,attitudes,and practices provider approaches to implementation institutional factors Identify areas for further investigation into LTBI testing and treatment in occupational health settings2

22、8Background Joseph et al(2019)conducted focus groups in 4 healthcare settings exploring HCWs reasons for adherence/nonadherence to occupational health requirements for LTBI testing and treatment Knowledge and attitudes about LTBI and treatment of LTBI influenced HCW adherence to recommendations Inst

23、itutional factors also influential 29Methods Purposive sampling of HCWs and providers experienced in transition from TST to IGRA in serial screening purposive sample is a non-representative sample of a specific sub-population defined by research question Semi-structured interview guides refined afte

24、r initial round of focus groups with providers HCWs recruited through occupational health staff for participation in focus groups Providers recruited directly for individual interviews30Methods(cont)5 focus groups at 3 sites with total of 46 HCWs(7/08-9/09)7 key informant interviews at 2 sites(9/09-

25、4/10)Audio-recorded interviews transcribed and entered in Atlas.ti database for analysis Coding categories determined a priori and as emerged from transcripts Analysis on-going31HCWs Experiences with TB Testing32FactorIGRATSTConvenience of administrationsingle visittwo visitsPerceived drawbacksreluc

26、tance to get blood drawnmisgivings about tuberculin injectionConfidence in methodperceived inherent accuracy of blood testlack of experience w/IGRAsqualitative presentation of resultsadministrator variabilitysubjectivity of interpretationinfluence of BCGfamiliarity w/testCost/Logisticsgeneral unease

27、 about cost of IGRAease of use in the fieldFactors Influencing Preference for Testing MethodHCWs Experiences with TB Testing Factors influencing acceptability are complex accuracy,convenience,implications of cost Perceived consequences of testing repercussions of inaccurate diagnosis in work setting

28、s confusion about LTBI and rationale for its treatment(“why dont they just x-ray everyone?”)misgivings about need for and toxicity of LTBI treatment Need for information about testing rationale and methods in retrospect,desire for more information about testing rationale for new procedures in work s

29、etting information is more valuable when provided in the health care encounter33General HCW Themes HCWs identified conveniences and drawbacks in both TST and IGRAs See IGRAs as potential improvement but misgivings persist:Perceived lack of information about IGRAs Interpretation of test not understoo

30、d Unease concerning cost of IGRA Low awareness of rationale for routine screening in HCWs and treatment of LTBI Range of preferences for education Desire for information that addresses HCWs as patients34Provider Themes Implementation of IGRAs requires increased coordination with other departments an

31、d outside entities “QFT is a clinic within the clinic”Blood draw implies more intensive patient HCW interaction Shift from provider-based to laboratory assessment perceived as beneficial BUT implies loss of provider control over process:“a doctor looking at a patients arm at least sort of knows what

32、 to say to a patient,whereas when they get lab results,sometimes if theyre not really sure what the lab results mean.”35Provider Themes Challenges of interpreting QFT results difficulty of interpreting indeterminate results May be reduced by reliance on actual results,not categorization as negative

33、or positive patient history and consultation with colleagues remain essential to diagnostic process Limited role of IGRAs in treatment for LTBI diagnostic tools are only part of complex interaction between patient and provider distinction between uptake of LTBI treatment(facilitated by use of IGRA)a

34、nd adherence to treatment(multifactorial)Benefit of sharing information about use of IGRAs in routine occupational health settings36Preliminary Qualitative Conclusions Appreciation of potential of IGRAs to detect TB infection HWCs concerns about the overall rationale for LTBI testing and treatment P

35、erceived need for more information about performance of IGRAs Provider decision to recommend treatment based on complex set of factors,of which testing method is a part37AcknowledgementsTO 18 PIs:Chuck Daley,Susan Dorman,Denise GarrettTO 18 SitesBaltimore:Wendy Cronin,Susan Dorman,Bee MunkDenver:Ran

36、dall Reves,Kirsten Wall,Bob BelknapNYC:Neil Shluger,Yael Hirsch-Moverman,Joyce Thomas,Julie FranksTexas:Ed Graviss,Larry TeeterCDCNick DeLuca,Amera Khan,Allison Maiuri,Paul Weinfurter(Westat)Occupational Health Collaborators Jackie Kinnard,Sierra Health,NevadaSusanne Paulson,Nevada Department of HealthJennifer Bunger-Wheeler,Penrose Hospital,ColoradoThank you!39