Tuberculosis in the veterans healthcare system: a six-year review and evaluation of programme effectiveness

The Department of Veterans Affairs operates a large, centrally administered health care system consisting of 173 hospitals and 4 free standing outpati ent clinics nationwide with approximately 945 115 hospital discharges, 24.2 million outpatient visits, and 2.86 million persons served annually over t he time frame of the review. The purpose of the study was to define whether such a system could effect timely change in the incidence of tuberculosis (TB) using centralized programme planning and flexible field implementation . A retrospective review of the number of newly diagnosed cases of active T B treated at veterans health care facilities between 1 October 1990 and 30 September 1997 was determined by using a standardized annual case census. Intervention included implementation of the must current guidelines for the prevention of transmission of TB in the community and hospital setting, in cluding administrative and engineering controls and a change in personal pr otective equipment. Centrally directed programme guidance, education, and f unding were provided for field use in health care facilities of widely vary ing size and complexity. The numbers of total reported cases of TB decreased significantly (P < 0.00 1) throughout the veterans health care system (nationally and regionally), with the case rate decreasing at a rate significantly greater than that see n in the USA as a whole (P < 0.0001). TB associated with multi-drug resista nce (isoniazid and rifampin) and HIV coinfection also significantly decreas ed over the study period. Therefore, a large, centrally administered health care system can effectively combat a re-emerging infectious disease and ma y also demonstrate a successful outcome greater than seen in other, perhaps less organized health care settings.