The Department of Veterans Affairs operates a large, centrally administered health care system
consisting of 173 hospitals and 4 free standing outpatient clinics nationwide with approximately
945115 hospital discharges, 24·2 million outpatient visits, and 2·86 million persons served
annually over the 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 TB 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 most current guidelines for the prevention of
transmission of TB in the community and hospital setting, including administrative and
engineering controls and a change in personal protective equipment. Centrally directed
programme guidance, education, and funding were provided for field use in health care
facilities of widely varying size and complexity.
The numbers of total reported cases of TB decreased significantly (P < 0·001) throughout the
veterans health care system (nationally and regionally), with the case rate decreasing at a rate
significantly greater than that seen in the USA as a whole (P < 0·0001). TB associated with
multi-drug resistance (isoniazid and rifampin) and HIV coinfection also significantly decreased
over the study period. Therefore, a large, centrally administered health care system can
effectively combat a re-emerging infectious disease and may also demonstrate a successful
outcome greater than seen in other, perhaps less organized health care settings.