Patient pathway analysis of tuberculosis diagnostic delay: a multicentre retrospective cohort study in China

Abstract

Objectives: Delay in diagnosis of tuberculosis (TB) is an important but under-appreciated problem. Our study aimed to analyse the patient pathway and possible risk factors of long diagnostic delay (LDD). Methods: We enrolled 400 new bacteriologically diagnosed patients with pulmonary TB from 20 hospitals across China. LDD was defined as an interval between the initial care visit and the confirmation of diagnosis exceeding 14 days. Its potential risk factors were investigated by multivariate logistic regression and multilevel logistic regression. Hospitals in China were classified by increasing size, from level 0 to level 3. TB laboratory equipment in hospitals was also evaluated. Results: The median diagnostic delay was 20 days (IQR: 7e72 days), and 229 of 400 patients (57.3%, 95% CI 52.4e62.1) had LDD; 15% of participants were diagnosed at the initial care visit. Compared to level 0 facilities, choosing level 2 (OR 0.27, 95%CI 0.12e0.62, p 0.002) and level 3 facilities (OR 0.34, 95%CI 0.14

Association between diagnostic delay and prognosis of pulmonary tuberculosis in Shandong, China: a retrospective study

“…Long DD may generate a high mycobacterial load and increased Mycobacterium tuberculosis (M.tb) excretion, leading to high positive smear rates. Additionally, individuals inevitably come into contact with undiagnosed TB patients who may carry M.tb, thus increasing TB transmission [11,30].…”

“…TB can result in chronic lung injury, with anti-TB treatments confirmed as a highrisk factor for pulmonary function deterioration [40]. Patients with a TB treatment history were more likely to suffer other respiratory disorders, which may have been confused with a TB diagnosis [11,38].…”

“…Several studies reported that DD in PTB patients was common in China, and caused low decline of PTB incidence [3,6,[11][12][13][14][15]. In addition, the COVID-19 pandemic partly disrupted TB services, resulting in an increase in DD [16].…”

Time-trend analysis of tuberculosis diagnosis in Shenzhen, China between 2011 and 2020

“…Considering the different factors affecting the patient and hospital, the interval of the diagnosis delay was divided into two parts—the delay in the care-seeking of the patient (patient delay) and the diagnosis in the hospital (hospital delay). A patient delay occurred if the interval between the onset of symptoms and the first care-seeking was more than 30 days, and a hospital delay occurred if it took more than 14 days from the patient's first care-seeking to diagnosis ( 3 , 10 ). In terms of case-finding, ‘active case-finding' included X-ray screening of TB close contacts and physical examinations of employees or elderly people, whereas ‘passive case-finding' included care-seeking of symptomatic patients and referrals from primary care.…”

“…Delays in the diagnosis of TB often lead to exacerbations, increased mortality, and further community transmission ( 2 ). The lack of bacteriological tests and drug-resistance screening, which is the gold standard for the diagnosis of pulmonary TB, is an important cause of the diagnosis delay ( 3 ). The commonly used sputum smear method has low sensitivity (40–0%) and the period for sputum culture is long (4–8 weeks), while molecular diagnostic technologies, such as GeneXpert, not only improve the detection sensitivity (>90%) but also shorten the detection time (0–1 days) ( 4 ).…”