Comprehensive case management models for pulmonary tuberculosis

In view of sweeping health and human service reforms around the US and abroad, program performance standards, their measurement, and their application in program accountability have become critical functions. Measuring the performance of healthcare systems has added a new dimension to the evaluation and management of acute care. Multiple-level evaluation approaches - including randomized controlled trials, cohort, case control and retrospective studies, economic modeling and cost-effectiveness analyses, and case studies - will be necessary to persuade diverse groups of stakeholders, particularly when the interventions are multi-faceted. The goal of multi-level evaluation approaches is to develop an internally consistent set of findings that produce a preponderance of evidence in support of a particular management strategy. Such an approach should also eliminate alternative explanations. The management of certain infectious diseases such as pulmonary tuberculosis (TB) has refocused the attention of performance evaluators upon the concept of continuum of care. Multiple-level evaluation approaches consistently underscore a case management approach based on the use of comprehensive, community-based, patient-centered directly observed therapy (DOT) programs for achieving the highest treatment completion rates for patients with pulmonary TB. As lengths of stays in hospitals continue to shorten, it has become apparent that clinical outcomes cannot be measured during the hospitalization episode(s) alone. This paper discusses the evidence-based case management of pulmonary TB, concluding that patient-centered approaches involving DOT provide the most effective care and disease prevention. Health and public healthcare systems should adopt such patient-centered approaches when managing resurgent infectious diseases such as pulmonary TB.