Diagnostic pathways and direct medical costs incurred by new adult pulmonary tuberculosis patients prior to anti-tuberculosis treatment – Tamil Nadu, India

Abstract

BackgroundTuberculosis (TB) patients face substantial delays prior to treatment initiation, and out of pocket (OOP) expenditures often surpass the economic productivity of the household. We evaluated the pre-diagnostic cost and health seeking behaviour of new adult pulmonary TB patients registered at Primary Health Centres (PHCs) in Vellore district, Tamil Nadu, India.MethodsThis descriptive study, part of a randomised controlled trial conducted in three rural Tuberculosis Units from Dec 2012 to Dec 2015, collected data on number of health facilities, dates of visits prior to the initiation of anti-tuberculosis treatment, and direct OOP medical costs associated with TB diagnosis. Logistic regression analysis examined the factors associated with delays in treatment initiation and OOP expenditures.ResultsOf 880 TB patients interviewed, 34.7% presented to public health facilities and 65% patients sought private health facilities as their first point of care. The average monthly individual income was $77.79 (SD 57.14). About 69% incurred some pre-treatment costs at an average of $39.74. Overall, patients experienced a median of 6 days (3–11 IQR) of time to treatment initiation and 21 days (10–30 IQR) of health systems delay. Age ≤ 40 years (aOR: 1.73; CI: 1.22–2.44), diabetes (aOR: 1.63; CI: 1.08–2.44) and first visit to a private health facility (aOR: 17.2; CI: 11.1–26.4) were associated with higher direct OOP medical costs, while age ≤ 40 years (aOR: 0.64; CI: 0.48–0.85) and first visit to private health facility (aOR: 1.79, CI: 1.34–2.39) were associated with health systems delay.ConclusionThe majority of rural TB patients registering at PHCs visited private health facilities first and incurred substantial direct OOP medical costs and delays prior to diagnosis and anti-tuberculosis treatment initiation. This study highlights the need for PHCs to be made as the preferred choice for first point of contact, to combat TB more efficiently.

Active case finding among marginalised and vulnerable populations reduces catastrophic costs due to tuberculosis diagnosis

“…The effect of ACF on inequity in distribution of catastrophic costs was also not assessed [23]. Although there have been studies on patient costs due to TB care in India [24], studies on catastrophic costs are limited.…”

A double burden of tuberculosis and diabetes mellitus and the role of vitamin D deficiency

“…Second, severe weight loss, decreased appetite and food intake may result in nutrients depletion (33) in general and VDD in particular. Third, TB patients have obviously reduced adipose tissue, which may result in diminished VD reserves (34) . Furthermore, the requirement of VD increases in TB.…”

“…cut off's for serum 25(OH)D of 20ng/mL and 10ng/mL, respectively. Serum leptin and TNF-α levels were highly correlated with BMI (34) , also age, gender may explain variance in their levels in the body (35; 36) . These potential confounders were considered in the present study.…”

“…In recent years, the double burden of tuberculosis and diabetes in low-and middle-income countries has caused intensive concern of international agencies such as the WHO, International Union against Tuberculosis and Lung disease (the Union) and International Diabetes Federation, to provide strategies upon facing this new challenge. The WHO recommended optimized glucose control as part of the management of tuberculosis and diabetes combined patients for improved tuberculosis outcomes (34) . Till now, widely accepted guidelines for the treatment of tuberculosis patients with concurrent diabetes are not available.…”

“…Vitamin D deficiency is a global health problem (29) (30) (31) . High prevalence of vitamin D deficiency and insufficiency has been documented in Europe, China, India, Middle East and South America (30) (32) , even in some areas with very sunny climates, such as Saudi Arabia and India (33) (34) (Figure 1-2).…”