While all people are susceptible to infection with TB, the majority of cases occur in men, minorities, and the socially disadvantaged. Our results are consistent with these previous epidemiologic data.
This study extends previous insights, and shows that men continue to be at greater risk and that most of the patients admitted to the hospital with TB were racial minorities, residents of regions with lowhouse-hold incomes, and had publicly funded or no health insurance.
Despite available effective therapy, people hospitalized for TB in the present study had an unaccept-ably high mortality rate. The in-hospital mortality rate for TB hospital admissions (4.9%) was more than double the mortality rate for all other hospital admissions (2.4%), including those for other chronic illnesses, such as COPD (2.5%), cystic fibrosis (1.6%), or asthma (0.4%). We identified several predictors of in-hospital mortality in a multivariate regression analysis, including emergency department admissions, older age, and comorbid illness.
The source of admission to the hospital is an indicator of access to continuity care and also an indicator of acuity of illness. We expected that patients who had been admitted to the hospital through the emergency department were likely to be sicker at time of presentation, and to have experienced delayed treatment and/or had limited access to primary care. Despite public health efforts and DOT, patients with TB were admitted to the hospital through the emergency department 57% of the time. Although we have accounted for several factors that are associated with limited access to care such as health insurance status, race, and income, the hospital admission source remained a significant predictor of mortality. In a previous study, unemployment, concern about cost, uncertainty about where to get care, anticipated long waiting time in the physician’s office or a long wait for an appointment, fear of immigration authorities, and belief in the efficacy of self-treatment were shown to be significantly associated with delays in seeking care among symptomatic patients with TB. Furthermore, individuals who are homeless, mentally disturbed, or alcoholic may lack the motivation or concern about their health status and may seek medical care too late to be cured. In fact, delayed treatment has been linked previously to higher mortality rates in patients with TB.’’ Thus, actual or perceived access barriers to health care may play a significant role in high TB mortality. Public health policy aimed at decreasing these barriers and encouraging patients to seek care early in their illness should be intensified. Because urban and teaching hospitals carry most of the burden of hospital care, and because publicly funded health-care programs (ie, Medicare and Medicaid) provide care for almost half of patients hospitalized for TB, the expansion of governmental programs that are aimed at education about, prevention of, and early identification of TB seems to be justified,