Is a Differentiated Care Model needed for Patients with TB? A cohort analysis of risk factors contributing to unfavourable outcomes among TB patients in two states in south India.

Abstract

Background: TB is a preventable and treatable disease. Yet, successful treatment outcomes at desired levels are elusive in many national TB programs, including India. We aim to identify risk factors for unfavourable outcomes to TB treatment, in order to subsequently design a care model that would improve treatment outcomes among these at-risk patients. Methods: We conducted a cohort analysis among TB patients who had been recently initiated on treatment. The study was part of the internal program evaluation of a USAID-THALI project, implemented in select towns/cities of Karnataka and Telangana, south India. Community Health Workers (CHWs) under the project, used a pre-designed tool to assess TB patients for potential risks of an unfavourable outcome. CHWs followed up this cohort of patients until treatment outcomes were declared. We extracted treatment outcomes from patient’s follow-up data and from the Nikshay portal. The specific cohort of patients included in our study were those whose risk was assessed during July and September, 2018, subsequent to conceptualisation, tool finalisation and CHW training. We used bivariate and multivariate logistic regression to assess each of the individual and combined risks against unfavourable outcomes; death alone, or death, lost to follow up and treatment failure, combined as ‘unfavourable outcome’. Results: A significantly higher likelihood of death and experiencing unfavourable outcome was observed for individuals having more than one risk (AOR: 4.19; 95% CI: 2.47-7.11 for death; AOR 2.21; 95% CI: 1.56-3.12 for unfavourable outcome) or only one risk (AOR: 3.28; 95% CI: 2.11-5.10 for death; AOR 1.71; 95% CI: 1.29-2.26 for unfavourable outcome) as compared to TB patients with no identified risk. Male, a lower education status, an initial weight below the national median weight, co-existing HIV, previous history of treatment, drug-resistant TB, and regular alcohol use had significantly higher odds of death and unfavourable outcome, while age >60 was only associated with higher odds of death. Conclusion: A rapid risk assessment at treatment initiation can identify factors that are associated with unfavourable outcomes. TB programs could intensify care and support to these patients, in order to optimise treatment outcomes among TB patients.

Delivery of Community-based Antiretroviral Therapy to Maintain Viral Suppression and Retention in Care in South Africa

“…Studies have shown that among PLHIV with comorbidities, particularly TB, there were benefits to extending intervals between clinic visits and ART pick-ups from pharmacies, however, routine TB screening was still needed and risk assessment at treatment initiation to identify factors associated with poor clinical outcomes was recommended. 24 , 25 Assessment and eligibility criteria may hamper access to the CCMDD program for patients who potentially have the most to gain from adaptive services. Additionally, there is also opportunity to use differentiated care not just for ART delivery, but for providing additional TB prophylaxis and screening that support both TB and HIV control measures.…”

Tuberculosis and comorbidities: treatment challenges in patients with comorbid diabetes mellitus and depression

“…Moreover, the situation gets worse as TB clinics often do not monitor DM blood markers through finger prick glucose testing or H1Abc blood levels, thereby not having the chance to detect uncontrolled DM in patients. 50 Given that it is known that DM comorbid condition is a risk factor for various negative TB outcomes, TB clinics should offer differentiated care for this type of patients, 51 , 52 as it is feasible to manage uncontrolled DM if detected early in TB treatment. All this highlights the importance of monitoring, educating, and counseling when dealing with medication adherence in TB-DM patients.…”