Patient care pathways under the model of integrating tuberculosis service with general hospitals in China

Diagnostic delay, treatment duration and outcomes since the implementation of integrated model of tuberculosis control and their associated factors in a county in East China

OBJECTIVE

This study assesses the diagnostic delay, treatment duration and treatment outcomes of tuberculosis (TB) patients since the implementation of the integrated model of TB control in a county in eastern China. It further identifies factors associated with diagnostic delay and treatment duration in the integrated model.

METHODS

We collected data through the Chinese Tuberculosis Information Management System (TBIMS) for Cangnan County in Zhejiang Province. Chi-square and Mann-Whitney tests were adopted to identify factors associated with duration of treatment and treatment delay for TB patients within the integrated model. Multiple regression analysis was subsequently performed to confirm the identified factors.

RESULTS

In the integrated model from 2012 to 2018, the median health system delay was maintained at 1 day, and the median patient delay decreased from 14 to 9 days and the median total delay decreased from 15 to 11 days. In addition, the proportion of patients who experienced patient delay > 14 days and total delay > 28 days decreased from 49% to 35% and from 32% to 29% respectively. However, the proportion of patients who had health system delay > 14 days increased from 0.2% to 13% from 2012 to 2018. The median treatment duration increased from 199 to 366 days and the number of TB patients lost to follow-up showed an overall upward trend from 2012 to 2018. The multivariable regression analysis indicated that migrant TB patients and TB patients initially diagnosed in hospitals at the prefectural level and above tended to experience total delay > 28 days (p < 0.001). Linear regression analysis confirmed that new TB patients>60 years tended to have longer treatment duration (p < 0.05).

CONCLUSIONS

While our study may suggest the potential of the integrated model in early detection and diagnosis of TB, it also suggests the importance of strengthening supervision and management of designated hospitals to optimize the treatment duration and improve retention of patients in TB care. Enhancing health education for TB patients, especially amongst migrant patients, and training in TB identification and referral for non-TB doctors are also key for early TB detection and diagnosis in the integrated model.

Factors associated with diagnostic delay in recurrent TB

Background

Recurrent tuberculosis (TB) contributes to the burden of TB. The study was designed to explore the time of diagnostic delay and risk of delay in patients with recurrent TB in China.

Methods

A total of 13,334 patients with new and recurrent TB registered in Yulin a city in China were included. The Kaplan-Meier survival curve was employed to estimate the median delay time. The mixed-effects survival model was used to identify the correlates associated with diagnostic delay. The outcome of interest in the model was"being diagnosed".

Results

We found that 6.5% of cases with TB were attributed to recurrence. The median delay time of recurrent TB cases (73 days) was more than twice as long as that of new TB (35 days). Individuals with recurrent TB had a higher risk of diagnostic delay than new TB (HR, 0.5, 95%CI, 0.5–0.6). Factors associated with diagnostic delay differed between new TB and recurrent TB cases. Immigrants (HR, 0.5, 95%CI, 0.3–0.9), cases notified by way of recommendation (HR, 0.6, 95%CI, 0.4–0.9) and diagnosed at TB dispensary (HR, 0.4, 95%CI, 0.3–0.6) were associated with a higher risk of a longer delay for recurrent TB cases.

Conclusions

The proportion of TB cases attributed to recurrence was high. Patients with recurrent TB had a longer delay time and a higher risk of diagnostic delay. Further interventions to improve diagnostic delay should focus on screening for TB in immigrants, improving public health services at the lowest healthcare level and update of TB diagnosis and management model.

Over- and under-treatment of TB patients in Eastern China: an analysis based on health insurance claims data

Objective

Poor compliance with existing guidelines for tuberculosis (TB) care and treatment is an issue of concern in China. We assessed health service use by TB patients over the entire treatment process and compared it to the recommended guidelines.

Methods

We collected insurance claims data in three counties of one province of Eastern China. Patient records with a diagnosis of ‘pulmonary TB’ in 2015 and 2016 were extracted. Treatment duration, number of outpatient (OP) visits and hospital admissions, as well as total cost, out‐of‐pocket (OOP) payments and effective reimbursement rates were analysed.

Results

A total of 1394 patients were included in the analysis. More than 48% received over the 8 months of treatment that TB guidelines recommend, and over 28% received less. 49% of Urban and Rural Resident Basic Medical Insurance (URRBMI) TB patients were hospitalised while 30% of those with Urban Employee Basic Medical Insurance (UEBMI) had at least one admission. Median total cost for patients with hospital admission was almost 10 times that of patients without. By comparison, the average OOP was 5 times higher. UEBMI patients had a shorter treatment period, more outpatient visits but considerably fewer hospital admissions than URRBMI patients.

Conclusions

We found an alarming extent of TB over‐ and under‐treatment in our study population. There is an urgent need to improve compliance with treatment guidelines in China and to better understand the drivers of divergence. Extending the coverage of health insurance schemes and increasing reimbursement rates for TB outpatient services would seem to be key factors in reducing both the overall cost and financial burden on patients.

Pathways to diabetic care at hospitals in rural Eastern Uganda: a cross sectional study

Background

Prompt access to appropriate treatment reduces early onset of complications to chronic illnesses. Our objective was to document the health providers that patients with diabetes in rural areas seek treatment from before reaching hospitals.

Methods

Patients attending diabetic clinics in two hospitals of Iganga and Bugiri in rural Eastern Uganda were asked the health providers they went to for treatment before they started attending the diabetic clinics at these hospitals. An exploratory sequential data analysis was used to evaluate the sequential pattern of the types of providers whom patients went to and how they transitioned from one type of provider to another.

Results

Out of 496 patients assessed, 248 (50.0%) went first to hospitals, 104 (21.0%) to private clinics, 73 (14.7%) to health centres, 44 (8.9%) to drug shops and 27 (5.4%) to other types of providers like community health workers, neighbours and traditional healers. However, a total of 295 (59.5%) went to a second provider, 99 (20.0%) to a third, 32 (6.5%) to a fourth and 15 (3.0%) to a fifth before being enrolled in the hospitals’ diabetic clinics. Although community health workers, drug shops and household neighbours were utilized by 65 (13.1%) patients for treatment first, nobody went to these as a second provider. Instead patients went to hospitals, private clinics and health centres with very few patients going to herbalists. There is no clear pathway from one type of provider to another.

Conclusions

Patients consult many types of providers before appropriate medical care is received. Communities need to be sensitized on seeking care early from hospitals. Health centres and private clinics need to be equipped to manage diabetes or at least diagnose it and refer patients to hospitals early enough since some patients go to these health centres first for treatment.

Experience of implementing the integrated TB model in Zhejiang, China: a retrospective observational study

BACKGROUND

This study aims to assess the implementation of the TB control program under the integrated model in China where TB diagnosis and treatment is provided in TB designated hospitals.

METHODS

Six counties under the integrated model in Zhejiang were randomly selected. TB referral and tracing was analyzed based on routine TB reporting data between January and December 2009 from county TB dispensaries. Regarding treatment and community management, we conducted face-to-face surveys with 50 new TB patients randomly selected from each county, and reviewed their medical charts.

RESULTS

A total of 7090 persons with presumptive TB were reported in 2009, of whom, 66.7% (4732/7090) were referred by other health facilities to TB designated hospitals, while 80.2% (3795/4732) were successfully referred. In total, 301 patients were surveyed and had a median medical expenditure of US$192. Ten percent (31/301) missed at least one dose during their treatment, and 64.5% (194/301) received direct observation, mostly by family members.

CONCLUSIONS

The integrated model performed better on case referral and community management, but higher medical expenditures than those reported by studies under the dispensary model in China. Clear guidelines should be issued on supervising TB treatment in designated hospitals.

Association between Directly Observed Therapy and Treatment Outcomes in Multidrug-Resistant Tuberculosis: A Systematic Review and Meta-Analysis

Background

Multidrug-resistant tuberculosis (MDR-TB) represents a major obstacle towards successful TB control. Directly observed therapy (DOT) was recommended by WHO to improve adherence and treatment outcomes of MDR-TB patients, however, the effectiveness of DOT on treatment outcomes of MDR-TB patients was mixed in previous studies. We conducted this systematic review and meta-analysis to assess the association between DOT and treatment outcomes and to examine the impact of different DOT providers and DOT locations on successful treatment outcomes in MDR-TB patients.

Methods

We searched studies published in English between January 1970 and December 2015 in major electronic databases. Two reviewers independently screened articles and extracted information of DOT, treatment success rate and other characteristics of studies. Random effects model was used to calculate the pooled treatment success rate and 95% confidence interval (CI). Sub-group analyses were conducted to access factors associated with successful treatment outcomes.

Results

A total of 31 articles 7,466 participants were included. Studies reporting full DOT (67.4%, 95% CI: 61.4–72.8%) had significantly higher pooled treatment success rates than those reporting self-administration therapy (46.9%, 95% CI: 41.4–52.4%). No statistically difference was found among DOT provided by healthcare providers (65.8%, 95% CI: 55.7–74.7%), family members (72.0%, 95% CI: 31.5–93.5%) and private DOT providers (69.5%, 95% CI: 57.0–79.7%); and neither did we find significantly difference on pooled treatment success rates between patients having health facility based DOT (70.5%, 95% CI: 61.5–78.1%) and home-based DOT (68.4%, 95% CI: 51.5–81.5%).

Conclusion

Providing DOT for a full course of treatment associated with a higher treatment success rate in MDR-TB patients.

Barriers to hospital and tuberculosis programme collaboration in China: context matters

BACKGROUND

In many developing countries, programmes for 'diseases of social importance', such as tuberculosis (TB), have traditionally been organised as vertical services. In most of China, general hospitals are required to report and refer suspected TB cases to the TB programme for standardised diagnosis and treatment. General hospitals are the major contacts of health services for the TB patients. Despite the implementation of public-public/private mix, directly observed treatment, short-course, TB reporting and referral still remain a challenge.

OBJECTIVE

This study aims to identify barriers to the collaboration between the TB programme and general hospitals in China.

DESIGN

This is a qualitative study conducted in two purposefully selected counties in China: one in Zhejiang, a more affluent eastern province, and another in Guangxi, a poorer southwest province. Sixteen in-depth interviews were conducted and triangulated with document review and field notes. An open systems perspective, which views organisations as social systems, was adopted.

RESULTS

The most perceived problem appeared to be untimely reporting and referral associated with non-standardised prescriptions and hospitalisation by the general hospitals. These problems could be due to the financial incentives of the general hospitals, poor supervision from the TB programme to general hospitals, and lack of technical support from the TB programme to the general hospitals. However, contextual factors, such as different funding natures of different organisations, the prevalent medical and relationship cultures, and limited TB funding, could constrain the processes of collaboration between the TB programme and the general hospitals.

CONCLUSIONS

The challenges in the TB programme and general hospital collaboration are rooted in the context. Improving collaboration should reduce the potential mistrust of the two organisations by aligning their interests, improving training, and improving supervision of TB control in the hospitals. In particular, effective regulatory mechanisms are crucial to alleviate the negative impact of the contextual factors and ensure smooth collaboration.