Patient and health care system delays in pulmonary tuberculosis diagnosis in a low-incidence state.

SETTING: Tuberculosis (TB) patients reported to the Maryland Department of Health and Mental Hygiene from 1 June 2000 to 30 November 2001. OBJECTIVE: To determine the extent of delayed diagnosis of TB and to assess patient and provider factors associated with delays. DESIGN: A prospective cohort study. RESULTS: Median patient, health care and total delays were 32, 26 and 89 days, respectively, for 158 patients. Non-white (relative hazard [RH] 0.62; 95% CI 0.39-0.98) and less educated (RH 0.43; 95% CI 0.26-0.72) patients had longer patient delays. English-speaking patients (RH 0.40; 95% CI 0.24-0.68) had increased health care delays, as did patients who received a diagnosis of a respiratory illness and non-TB antibiotics (RH 0.69; 95% CI 0.49-0.96) prior to a TB diagnosis. Patients first presenting to a private physician (51 days) rather than a hospital emergency room (18 days; RH 1.87; 95% CI 1.05-3.33) or public health clinic (10 days; RH 1.79; 95% CI 1.21-2.63) had longer health care delays. When a TB diagnostic tool (chest radiograph or AFB culture) was utilized, a more rapid diagnosis of TB was made. CONCLUSION: Education of the patient population about TB symptoms might reduce delays. Increased physician awareness of the current epidemiology of TB and better use of available diagnostic tools will reduce delays and may reduce TB transmission.     

Risk factors for delay in the diagnosis and treatment of tuberculosis at a referral hospital in Rwanda.

SETTING: Kigali University Hospital, the main referral centre for TB in Rwanda. OBJECTIVE: To evaluate delays in the diagnosis and treatment of tuberculosis (TB) and associated risk factors. DESIGN: Prospective data collection of patients treated for pulmonary TB (PTB) or extra-pulmonary TB (EPTB) between June and September 2006. RESULTS: Of 104 patients with a mean age of 35 years (range 17-84) recruited into the study, 62% were HIV-positive. EPTB was diagnosed in 60 cases. The median total, health care and patient delays were respectively 57, 28 and 25 days. The health system delay before referral was significantly longer than the delay at our institution (18 vs. 6 days, P<0.0001). Risk factors for a longer health system delay at our institution were smear-negative PTB or EPTB (OR 5.12) and a trial of antibiotics (OR 2.96). The latter was also found to significantly prolong total delay (OR 2.85), as did rural residence (OR 4.86). No significant association was found between patient delay and age, sex, profession or health insurance status. CONCLUSION: Smear-negative PTB and EPTB were associated with longer health system delays. A trial of antibiotics significantly increased the health system delay. Its use, recommended by the World Health Organization in case of smear-negative TB and EPTB in developing countries, needs validation at the tertiary health care level.     

Factors associated with patient and health system delays in the diagnosis of tuberculosis in South India.

OBJECTIVES: To investigate the factors associated with delay in 1) care-seeking (patient delay), and 2) diagnosis by health providers (health system delay), among smear-positive tuberculosis patients, before large-scale DOTS implementation in South India. METHODS: New smear-positive patients were interviewed using a structured questionnaire. RESULTS: Among 531 participants, the median patient, health system and total delays were 20, 23 and 60 days, respectively. Twenty-nine per cent of patients delayed seeking care for > 1 month, of whom 40% attributed the delay to their lack of awareness about TB. Men postponed seeking care for longer periods than women (P = 0.07). In multivariate analysis, the patient delay was greater if the patient had initially consulted a government provider (adjusted odds ratio [AOR] 2.2, P < or = 0.001), resided at a distance >2 km from a health facility (AOR 1.6, P = 0.04), and was an alcoholic (AOR 1.6, P = 0.04). Health system delay was >7 days among 69% of patients. Factors associated with health system delay were: first consultation with a private provider (AOR 4.0, P < 0.001), a shorter duration of cough (AOR 2.6, P = 0.001), alcoholism (P = 0.04) and patient's residence >2 km from a health facility (AOR 1.8, P = 0.02). The total delay resulted largely from a long patient delay when government providers were consulted first, and a long health system delay when private providers were consulted first. CONCLUSION: Public awareness about chest symptoms and the availability of free diagnostic services should be increased. Government and private physicians should be educated to be aware about the possibility of tuberculosis when examining out-patients. Effective referrals for smear microscopy should be developed between private and public providers.     

Treatment seeking behaviour of smear-positive tuberculosis patients diagnosed in Burkina Faso.

SETTING: Yalgado Ouedraogo University Health Centre and National Tuberculosis Centre, Ouagadougou, Burkina Faso. OBJECTIVE: To identify causes and circumstances leading to delays in the diagnosis of sputum-positive tuberculosis (TB). DESIGN: A cross-sectional study conducted between October and December 2001. Data were collected on reasons for consulting and admission to hospital, health units visited and diagnoses. RESULTS: Before obtaining a diagnosis, 24.5% of patients had visited a public health unit, 31% had visited a private health unit, 31% had treated themselves and 6% had visited a traditional healer. In total, 16% of visits to the National Tuberculosis Centre and the Yalgado Ouedraogo University Health Centre were initiated by the patients themselves, 43% by a relative and 41% by a health worker. The average delay to diagnosis was 4 months. Only 24.5% of patients had undergone smear microscopy compared to 44.2% who had undergone chest X-ray. The majority of patients came from the outskirts of Ouagadougou. CONCLUSION: Delays in TB diagnosis seem to be due to the lack of awareness of patients and the incompetence of some health workers. Training and supervision of staff and TB information campaigns targeted at the population (transmission, symptoms and treatment) will improve TB control in Burkina Faso.     

Assessing health seeking behaviour among tuberculosis patients in rural South Africa.

SETTING: South Africa's rural Northern Province. OBJECTIVES: To examine patterns of health seeking behaviour among hospitalised tuberculosis patients. DESIGN: Information on personal characteristics, health seeking behaviour and delays to presentation and hospitalisation was collected from hospitalised TB patients. Analysis of rates was used to investigate factors associated with delay. RESULTS: Among 298 patients, median total delay to hospitalisation was 10 weeks, with patient delay contributing a greater proportion than service provider delay. Patients more often presented initially to public hospitals (41%) or clinics (31 %) than to spiritual/traditional healers (15%) or private GPs (13%). Total delay was shorter amongst those presenting to hospitals than those presenting to clinics (rate ratio 1.33, 95%CI 1.13-1.85), with a significantly smaller proportion of the total delay attributable to the health service provider (18% vs. 42%). Those exhibiting a conventional risk profile for TB (migrants, alcohol drinkers, history of TB) were diagnosed most quickly by health services, while women remained undiagnosed for longer. CONCLUSION: Considerable delay exists between symptom onset and treatment initiation among pulmonary tuberculosis patients. While a substantial delay was attributable to late patient presentation, an important, preventable period of infectiousness was caused by the failure of recognised clinical services to diagnose tuberculosis among symptomatic individuals.     

Patient and health system delays in the diagnosis and treatment of tuberculosis in Southern Taiwan.

SETTING: Tainan city, Tainan county and 13 townships of Kaohsiung county, Southern Taiwan. OBJECTIVE: To measure delays in the diagnosis and treatment of sputum-positive tuberculosis (TB) and to determine factors associated with delays in seeking health care (patient delay) and in starting anti-tuberculosis treatment (health system delay). DESIGN: A population-based patient interview study. RESULTS: Median patient delay was 7 days (range 0-730). Median health system delay was 23 days (range 0-489), 13 for smear-positive patients and 37 for smear-negative patients (P < 0.005). Median total delay was 44 days (range 0-730). Age <65 years was associated with longer patient delay. Negative smear, absence of haemoptysis, not having a chest radiograph at the first medical consultation and visiting clinics for first consultation were associated with a longer health system delay. Age <65 years, negative smear and cough as the only presenting symptom were associated with longer total delay. CONCLUSION: Patient delay was substantially shorter than health system delay. To reduce health system delay, clinics need to be involved and the referral mechanism must be strengthened. Physicians should maintain high alert for TB and perform prompt sputum smear examinations.     

Health seeking behaviour and diagnosis for pulmonary tuberculosis in an HIV-epidemic mountainous area of Thailand.

SETTING: Chiang Rai Hospital, Chiang Rai Province, the epicentre of the human immunodeficiency virus (HIV) in Thailand. OBJECTIVE: To describe the health seeking behaviour among tuberculosis (TB) patients, to measure patient and provider delays and to analyse factors determining these delays. DESIGN: All patients aged over 15 years with new smear-positive pulmonary TB detected in Chiang Rai Hospital (n = 557) were interviewed using a structured questionnaire. RESULTS: The median patient delays for HlV-positive and HIV-negative patients and those whose HIV status was unknown were 10, 15 and 15 days respectively, while provider delays were respectively 7, 7.5 and 10 days. HIV-positive patients suffered more symptoms and had a shorter patient's delay. Risk factors of long patient delay (>21 days) included being HIV-negative, having no health insurance, hill tribe ethnicity, no previous visits to the hospital, and borrowing money for hospital visits. Multivariate logistic analysis suggested that being married or widowed and being HIV-positive led to the shortest patient delay. Provider delay was significantly longer in female patients than male patients. CONCLUSION: Although patient and provider delays were favourably short, certain specific groups require further attention. Hill tribe people should be targeted to improve accessibility to TB treatment. Active case-finding services for people known to be HIV-positive should be encouraged. The reasons for the longer provider delay in female patients require further investigation.     

Patient and health care system delays in Queensland tuberculosis patients, 1985-1998.

SETTING: Queensland tuberculosis (TB) control centre QTCC). OBJECTIVE: To investigate patient and health care system delays in the diagnosis of active TB in Queensland. DESIGN: Analysis of data extracted from the QTCC database and review of charts. Symptomatic patients with bacteriologically or histologically proven TB were considered as a total group and a pulmonary smear-positive (PSP) group. RESULTS: The median patient delays were 29 days (total group) and 30 days (PSP group). The median health care system delays were 22 days (total group) and 11 days (PSP group). There were significant trends towards increasing health care system delays with increasing age and longer residency of migrants in Australia. Health care system delays were significantly longer for females and those aged over 45. Migrants from countries of high TB incidence and indigenous Australians had shorter health care system delays compared to non-indigenous Australians. Common reasons for diagnostic delays of more than 90 days were failure to perform appropriate investigations and misdiagnosis of chest X-rays. CONCLUSION: Physicians need to consider including TB in the differential diagnosis in older age groups and migrants with longer residency in Australia. There should be a low threshold for obtaining chest X-rays and sputum samples in patients with persistent cough.     

Delay in tuberculosis diagnosis and treatment in four provinces of Argentina.

SETTING: Public health care services in the provinces of Buenos Aires, Santa Fe, Jujuy and Santa Cruz, Argentina. OBJECTIVE: To evaluate delays in tuberculosis (TB) diagnosis and treatment and associated risk factors in departments and administrative areas of four Argentine provinces. DESIGN: Cross-sectional survey including retrospective medical record review and patient interviews. RESULTS: A total of 243 patients with smear-positive pulmonary TB and a mean age of 40 years were included in the study. The mean diagnostic delays were as follows: total delay 92.1 days (median 62.0); patient delay 58.8 days (median 31); health service delay 32.6 days (median 12.5). The mean treatment delay was 0.9 days (median 0). Associations were observed between patient delays of >30 days and residence in Jujuy, age >50 years, dependence on transport to the nearest public health service due to distance and presence of cough. The >60-day total diagnosis delay was associated with age >50 years and need for transport to the nearest public health service. CONCLUSION: Diagnostic delay is an important problem in the areas studied, with patient delay being of most concern. Patient delay was associated with age >50 years, dependence on transport to the nearest public health service due to distance and presence of cough.     

Pathways from first health care seeking to diagnosis: obstacles to tuberculosis care in rural China.

OBJECTIVE: To examine health care seeking pathways for patients with tuberculosis (TB) and barriers related to these pathways in counties under the National TB Control Programme in rural China. METHODS: A cross-sectional study was conducted in two counties of east China in 2004-2005. A total of 557 TB patients were recruited and interviewed by physicians at the time of TB diagnosis. RESULTS: Of 557 participants, 13.3% had presented to a specialised county TB dispensary (CTD) directly after onset of symptoms, 31.4% had first sought care at a village health station and 51.2% had visited a township or county hospital first. The proportion of referral by a first health care provider to a CTD was highest in county level hospitals (73.5%) and lowest in village health stations (21.7%). The most prompt pathway from first health care seeking to TB diagnosis was to visit a CTD directly, with a median provider's delay of only one day. There was an increase in provider's delay when more health facilities were involved. CONCLUSION: To improve direct referral from general health care providers, especially village health care workers, to TB specialists would significantly shorten the delays in TB diagnosis in rural China.     

The health system of Costa Rica

This paper describes the Costa Rican health system which provides health, water and sanitation services. The health component of the system includes a public and a private sector. The public sector is dominated by the Caja Costarricense de Seguro Social (CCSS), an autonomous institution in charge of financing, purchasing and delivering most of the personal health services in Costa Rica. CCSS is financed with contributions of the affiliates, employers and the state, and manages three regimes: maternity and illness insurance, disability, old age and death insurance, and a non-contributive regime. CCSS provides services in its own facilities but also contracts with private providers. The private sector includes a broad set of services offering ambulatory and hospital care. These services are financed mostly out-of-pocket, but also with private insurance premiums. The Ministry of Health is the steward of the system, in charge of strategic planning, sanitary regulation, and research and technology development. Among the recent policy innovations we can mention the establishment of the basic teams for comprehensive health care (EBAIS), the de-concentration of hospitals and public clinics, the introduction of management agreements and the creation of the Health Boards.     

Patient and health service delays in initiating treatment for patients with pulmonary tuberculosis: retrospective cohort study.

SETTING: Catchment population of the North Middlesex University Hospital (NMUH), London, UK. OBJECTIVE: To measure patient and health care delays in treatment of pulmonary tuberculosis. DESIGN: Retrospective cohort study of patients notified with pulmonary tuberculosis between 1 April 2001 and 1 March 2002. RESULTS: The median case finding delays were between 78 and 99 days. Median patient-related delay was between 34.5 and 54 days. Median health care-related delay was 29.5 days. Shorter case finding delays were found in patients born in a high prevalence country, patients presenting first to Accident and Emergency department (A&E), younger patients, and those with sputum smear-positive disease. In those presenting first to A&E, those born in a high prevalence country, and those with sputum-positive disease, this effect was predominantly due to shorter health care delays. Limitations of TB service capacity and organisational factors appeared responsible for up to half of the difference in delay between those presenting to A&E or general practitioners (GPs). CONCLUSION: Patient and health service delays contribute substantially to delays in patients accessing treatment. Considerable reduction in case finding delays may be achieved through changes in the capacity of tuberculosis services, and coordination of associated health services.     

Delays to treatment and out-of-pocket medical expenditure for tuberculosis patients, in an urban area of South America

Short delays to treatment are important for the control of tuberculosis (TB). National Tuberculosis Programmes provide free diagnosis and treatment for smear-positive patients, so that the patients' out-of-pocket medical expenditure could be almost nil. The factors associated with delays in starting treatment, and the pre-treatment out-of-pocket medical expenditure for TB patients, have now been investigated in the Bolivian city of Cochabamba. Bolivia is the Latin American country with the highest incidence of TB. It is covered by a national TB programme that provides free diagnosis and free treatment for smear-positive patients. Structured interviews with 144 smear-positive patients enrolled in this programme revealed median patient, provider and total delays of 3.6, 6.2 and 12.9 weeks, respectively. The total delays were longer for the female patients than for the male, and for patients who consulted private doctors than for the other patients. When the first healthcare provider was a doctor, the median provider delay was 4.9 weeks in the public sector but 7.2 weeks in the private. The median out-of-pocket medical expenditure per patient, which was U.S.$13.2 overall, was much higher for those who consulted a private doctor than for those who did not (U.S.$21.9 v. U.S.$5.4, respectively; P<0.001). It appears that interventions targeting doctors (in both the private and public sectors) are likely to have a larger impact on the shortening of delays in TB treatment than interventions targeting patients. They could also reduce unnecessary out-of-pocket expenditure.     

Planning for PPM-DOTS implementation in urban slums in Kenya: knowledge, attitude and practices of private health care providers in Kibera slum, Nairobi.

SETTING: Kibera, the largest slum in Nairobi, Kenya. OBJECTIVE: To determine the tuberculosis (TB) knowledge, attitude and practices (KAP) of private health care providers (PHCPs) to identify their training needs and willingness to participate in a National Leprosy and Tuberculosis Control Programme (NLTP) guided TB control effort in the slum. DESIGN AND METHODOLOGY: A cross-sectional survey. The KAP of PHCPs was assessed using an interviewer administered questionnaire. RESULTS: Of 75 PHCPs interviewed, the majority (96.0%) were paramedics; 51 (77.1%) did not consider sputum smear microscopy crucial in patients presenting with prolonged cough or when a chest X-ray was suggestive of TB; of 29 (38.7%) who indicated familiarity with the drugs used in TB treatment, 20 (58.5%) would have chosen the NLTP-recommended regimens for the treatment of the various types of TB; 16 (21.3%) PHCPs indicated that they treated TB, six (37.5%) of whom were not familiar with anti-tuberculosis drug regimens. All the PHCPs referred TB suspects to the public sector for diagnosis. CONCLUSION: This study reveals a significant gap in TB knowledge among the PHCPs in Kibera slum. However, given appropriate training and supervision, there is potential for public-private mix for DOTS implementation in this setting.     

The health system of Honduras

This paper describes the health system of Honduras, including its challenges, structure coverage, sources of financing, resources and stewardship activities. This system counts with a public and a private sector. The public sector includes the Ministry of Health (MH) and the Honduran Social Security Institute (HSSI). The private sector is dominated by a set of providers offering services payed mostly out-of-pocket. The National Health Plan 2010-2014 includes a set of reforms oriented towards the creation of an integrated and plural system headed by the MH in its stewardship role. It also anticipates the creation of a public health insurance for the poor population and the transformation of the HSSI into a public insurance agency which contracts services for its affiliates with public and private providers under a family medicine model.     

Health-seeking behaviour of new smear-positive TB patients under a DOTS programme in Tamil Nadu, India, 2003.

BACKGROUND: Although case detection is above 70% in Tamil Nadu after DOTS implementation, an assessment of the timeliness of patient diagnosis and treatment is still needed. OBJECTIVE: To study the health-seeking behaviour of new smear-positive pulmonary tuberculosis (PTB) patients treated at government facilities. METHODS: New smear-positive patients diagnosed and treated between January and March 2003 in government facilities of randomly selected blocks in Tamil Nadu were interviewed using a semi-structured interview schedule. RESULTS: Of 601 patients interviewed, 65% contacted a provider within 28 days. The first contact was governmental for 47% and non-governmental for 53%. Median total, patient and provider delays were respectively 62, 28 and 28 days; provider delay was 9 days with government and 50 with private provider. In multivariate analysis, patient delay was significantly associated with smoking (P < 0.001) and mode of travel (P < 0.01), and provider delay with first consultation with a private provider (P < 0.001) and distance > 5 km from the health facility (P < 0.01). Twenty-five per cent of patients took more than two actions before diagnosis. CONCLUSION: Community awareness of TB needs to be increased. Greater private sector involvement in the Revised National Tuberculosis Control Programme is essential to reduce provider delay. Referral and sputum transportation to the diagnostic facility should be given priority.     

Help-seeking behavior of marginalized groups: a study of TB patients in Harlem, New York.

SETTING: Harlem Hospital Directly Observed Therapy (DOT) Program, New York City. OBJECTIVE: To identify various pathways to tuberculosis (TB) diagnosis, and determine time to diagnosis and reasons for delay, to ensure rapid diagnosis of TB and prompt initiation of appropriate treatment. DESIGN: Cross-sectional survey of the help-seeking behavior of TB patients within 2 months of their enrollment into DOT from May 2001 to December 2004. RESULTS: The average total delay between symptom onset and a patient's diagnosis of TB was 18 weeks among 39 patients. The average delay to diagnosis attributed to patient delay and health care system delay were 10.5 and 7.5 weeks, respectively. Patients visited on average 1.6 sources of care prior to receiving a TB diagnosis. Foreign-born patients in particular were found to have more complex paths to diagnosis. The most common reason for delaying seeking care reported by patients was that they didn't think it was serious' (29.1%). CONCLUSION: There was a substantial time interval between the onset of symptoms and TB diagnosis due to both patient and health care system delay. Foreign-born status, economic and social factors, and missed opportunities for diagnosis by the health care system played important roles in delaying TB diagnoses for the marginalized patients in this study.     

Gender difference in delays to diagnosis and health care seeking behaviour in a rural area of Nepal.

SETTING: Directly observed treatment for tuberculosis using a short-course regimen (DOTS) was introduced in a rural area of Nepal. All new patients assigned to DOTS from mid-December 1997 to mid-June 1999 were eligible for the study. OBJECTIVE: To examine delays in tuberculosis (TB) diagnosis and compare health care seeking behaviour between men and women. DESIGN: A cross-sectional analysis of patient interviews. RESULTS: Women were found to have a significantly longer total delay before diagnosis of tuberculosis (median 2.3 months for men, 3.3 months for women). When they visited traditional healers first, women had a significantly longer delay than men from the first visit to health care providers to diagnosis (median 1.5 months for men, 3.0 months for women). More women (35%) visited traditional healers before diagnosis than men (18%), and were more likely to receive more complicated charms from traditional healers. Men tended to visit the government medical establishment first if they knew that free TB treatment was available, but women did not. CONCLUSION: Women were more likely to visit and to believe in traditional healers; this might lead to the longer delays experienced before TB diagnosis.