Quality of drug-resistant tuberculosis care: Gaps and solutions

Abstract

Drug-resistant forms of tuberculosis (DR-TB) are a significant cause of global morbidity and mortality and the treatment of DR-TB is characterized by long and toxic regimens that result in low rates of cure. There are few formal studies documenting the quality of DR-TB treatment services provided globally, but the limited data that do exist show there is a quality crisis in the field. This paper reviews current issues impacting quality of care in DR-TB, including within the areas of patient-centeredness, safety, effectiveness and equity. Specific issues affecting DR-TB quality of care include: 1) the use of regimens with limited efficacy, significant toxicity, and high pill burden; 2) standardized treatment without drug susceptibility testing; 3) non-quality assured medications and drug stock outs; 4) lack of access to newer and repurposed drugs; 5) high rates of adverse events coupled with minimal monitoring and management; 6) care provided by multiple providers in the private sector; 7) depression, anxiety, and stress; and 8) stigma and discrimination. The paper discusses potential ways to improve quality in each of these areas and concludes that many of these issues arise from the traditional “public health approach” to TB and will only transformed when a human-rights based approach is put into practice.

Decentralized Care for Rifampin-Resistant Tuberculosis, Western Cape, South Africa

“…Additional outreach efforts such as mobile clinics have facilitated RR TB diagnosis. However, because mobile clinics might not be staffed in the same location each day, they are unable to administer SLDs, suggesting that broader access to new oral second-line TB drugs is needed in these settings ( 17 ).…”

Preparedness of outpatient health facilities for ambulatory treatment with all-oral short DR-TB treatment regimens in Zhytomyr, Ukraine: a cross-sectional study

“…Availability of ancillary medicines, psychosocial assessment, and essential ART-monitoring services like viral load at implementation sites are minimum conditions for roll-out of new DR-TB treatment according to WHO [ 3 ]. Absence of these services hampers delivery of quality DR-TB care [ 3 , 10 ]. Some benefits of TB-decentralisation are undone if patients need to travel separately to access ancillary medicines, ART or electrocardiography.…”

“…In 2018, only one third of estimated patients with drug-resistant tuberculosis (DR-TB) were initiated on second-line regimens, and only 56% among them were treated successfully [ 2 ]. Despite gaps in strategies to treat and retain patients, limited studies examine the quality of routine DR-TB care, including access to patient-centred services, quality of treatment monitoring, follow-up of adverse events and psychosocial services [ 3 ]. There is ample evidence supporting community-based ambulatory DR-TB care over prolonged hospitalisation, with ambulatory care showing better treatment outcomes, more patient satisfaction and a lower cost [ 4 – 8 ].…”

Preparedness of outpatient health facilities for ambulatory treatment with all-oral short DR-TB treatment regimens in Zhytomyr, Ukraine: A cross-sectional study

“…Availability of ancillary medicines, psychosocial assessment, and essential ART-monitoring services like viral load at implementation sites are minimum conditions for roll-out of new DR-TB treatment according to WHO (3). Absence of these services hampers delivery of quality DR-TB care (3,10). Some bene ts of TB-decentralisation are undone if patients need to travel separately to access ancillary medicines, ART or electrocardiography.…”

“…In 2018, only one third of estimated patients with drug-resistant tuberculosis (DR-TB) were initiated on second-line regimens, and only 56% among them were treated successfully (2). Despite gaps in strategies to treat and retain patients, limited studies examine the quality of routine DR-TB care, including access to patient-centred services, quality of treatment monitoring, follow-up of adverse events and psychosocial services (3). There is ample evidence supporting community-based ambulatory DR-TB care over prolonged hospitalisation, with ambulatory care showing better treatment outcomes, more patient satisfaction and a lower cost (4)(5)(6)(7)(8).…”