Health system delay in pulmonary tuberculosis treatment in a country with an intermediate burden of tuberculosis: a cross-sectional study

Abstract

BackgroundDelayed diagnosis and treatment of tuberculosis increase both the severity of the disease and the duration of infectivity. A number of studies have addressed the issue of health system delays in the treatment of tuberculosis, but mostly in countries with a high or low incidence of the disease. Our understanding of delay is quite limited in settings with an intermediate burden of tuberculosis. We explore the duration and factors associated with delays in the Croatian health system which has free health care and a sufficient network of health services providing tuberculosis diagnosis and care.MethodsA total of 241 consecutive adults with culture-confirmed pulmonary tuberculosis were interviewed in seven randomly selected Croatian counties and their medical records were evaluated. A health system delay was defined as the number of days from the first consultation with a physician to the initiation of anti-tuberculosis treatment. A long delay was defined as a period exceeding the median delay, while an extreme delay was considered to be above the 75th percentile delay.ResultsThe median health system delay was 15 days while the 75th percentile was 42 days (the 5th and 95th percentile being 1 and 105 days respectively). Almost 30% of tuberculosis patients remained undiagnosed for more than 30 days after the initial health care visit. Female patients (p = 0.005), patients with a negative sputum smear (p = 0.002) and patients having symptoms other than the usual ones (0.027) were found to be in significant correlation with a long delay. In a multivariate model, a long delay remained associated with the same variables (p = 0.008, p = 0.003, and p = 0.037, respectively).A significant association was demonstrated between both the female gender (p = 0.042) and a negative sputum smear (p < 0.001) and extreme delay, while only a negative sputum smear (p < 0.001) remained significant in the multivariate analysis.ConclusionsOur findings suggest that some groups of tuberculosis patients experienced a health system delay. In such a setting where tuberculosis incidence is decreasing, which leads to a lack of physician experience and expertise, training in tuberculosis is required. Such measure may be useful in reducing the number of missed opportunities for tuberculosis diagnosis.

Patients’ and health system’s delays in the diagnosis and treatment of new pulmonary tuberculosis patients in West Gojjam Zone, Northwest Ethiopia: a cross-sectional study

“…Similar findings were observed in other countries [21, 28]. Diagnosis of PTB in the study zone is based on the national TB diagnostic and treatment guideline [18].…”

Factors Contributing to Treatment Delay Among Pulmonary Tuberculosis Patients in Melaka

“…A study in Iran produced the same findings (Yazdani-Charati et al, 2017). This was in contrast with findings in studies by (Zhang et al, 2017;Gebreegziabher et al, 2016;Jurcev-Savicevic et al, 2013;WHO, 2006), showing that patients with PTB smear negative had been significantly associated with treatment delay. The extreme distribution of PTB smear positive (88%) is a possible explanation why the types of PTB were not a significant factor.…”

“…This is in line with studies by (Yazdani-Charati et al, 2017;Said et al, 2017). These were different from studies by (Jurcev-Savicevic et al, 2013;Ukwaja et al, 2013), that revealed both men and women were significant factors. In this study, 50% of male patients were unemployed, in contrast with other studies as employed male patients were associated with treatment delay.…”

Delays in presentation and diagnosis of pulmonary tuberculosis: a retrospective study of a tertiary health service in Western Melbourne, 2011–2014

“…Previous studies have arbitrarily nominated a certain number of days from onset of symptoms to differentiate ‘delayed’ from ‘acceptable’ time periods; the number of days constituting ‘delayed diagnosis’, however, has varied widely. Definitions of total delay have varied from 28 to 98 days; patient delays have been defined variously from 30 to 60 days, and health system delays from 7 to 56 days …”

“…Previous studies have arbitrarily nominated a certain number of days from onset of symptoms to differentiate 'delayed' from 'acceptable' time periods; the number of days constituting 'delayed diagnosis', however, has varied widely. Definitions of total delay have varied from 28 to 98 days [5][6][7][8][9][10] ; patient delays have been defined variously from 30 to 60 days, 7,8,10 and health system delays from 7 to 56 days. 7,8,10,11 Since the last study of delayed diagnosis in Australia 15 years ago, 9 there have been major sociodemographic changes in the Australian population and new rapid tests for TB based on nucleic acid detection.…”