Health care: caution or cure?

In yesterday’s TB clinic I saw mostly follow-up appointments after initiating TB therapy. One particular encounter left a distinct impression on me. It illustrated the pivotal impact of social determinants of health on patient outcomes.
The patient was a young student who had recently been diagnosed with latent TB from a positive TST but otherwise normal CXRs. She returned to the clinic yesterday for her first follow-up appointment since she started her TB medications one month ago. On presentation, she appeared to be doing well and not experiencing any medication side effects. I inquired a little bit of her background history of how she was diagnosed with latent TB. On review of systems, I couldn’t identify any specific risk factors for contracting TB. I probed further and asked which TB test had confirmed her diagnosis of latent TB. To my surprise, the patient replied that she had never had additional testing beyond her positive TST.
After reviewing the case with my preceptor, we both agreed that the patient should have been offered a confirmatory TB test. However, this test was not covered by OHIP and would cost $90 out of pocket. The patient was clearly at a loss. She was unsure whether she should choose a definitive TB test (with a hefty price tag) or continue to take her 9 months of TB treatment (at no cost). For a student living with overwhelming loans, she clearly struggled to make a decision. In the end, she took the test requisition and agreed to think about it further.

This unique case highlights how social determinants of health directly impact health outcomes. By continuing therapy without confirming her TB diagnosis, we were exposing this young lady to potentially unnecessary TB drug toxicity. Yet because of her difficult financial status, she could not afford to proceed with a confirmatory test. How ironic that our health care system is willing to dole out a pound of cure instead of an ounce of caution.
- AX