Management and treatment outcomes of tuberculous patients, eastern Paris, France, 2004

BACKGROUND

France was one of the few European countries without a national tuberculosis (TB) treatment outcome monitoring system until 2007.

OBJECTIVE

To examine TB management and treatment outcomes in the eastern Paris region, and to identify patient- and management-dependent factors affecting treatment outcome.

METHODS

This retrospective study focused on all cases of microbiologically confirmed Mycobacterium tuberculosis cases diagnosed in 2004 in the eastern Paris region, one of the areas of France with the highest frequency of TB.

RESULTS

Treatment outcomes of 629 identified cases (males 69.6%, median age 37 years, socio-economically disadvantaged 44%, foreign-born 78%) were as follows: treatment success 70.1% (95%CI 66.5-73.7), treatment interruption 4.9% (95%CI 3.2-6.6), loss to follow-up 15.0% (95%CI 12.2-17.8), death 5.7% (95%CI 3.9-7.9), transfers 4.3% (95%CI 3.5-5.1). Non-completion of treatment was associated with sputum smear positivity, injection drug use, non-adherence and irregular follow-up in univariate analysis, and with irregular follow-up and non-adherence in multivariate analysis. Duration of TB treatment and follow-up medical visits were not applied as recommended in more than a third of cases.

CONCLUSION

The treatment success rate observed in this study (70.1%) is below the World Health Organization target of 85%, and requires the implementation and evaluation of interventions to increase treatment success rates.

[Evaluation of prescription practices and of the rational use of medicines in Niger]

With the aim of evaluating an essential drugs and costs recovery program in Niger, rational drug use and prescribing patterns were studied in 19 health centers in Tahoua region. Drug use indicators were measured by retrospective and prospective surveys, achieved before and after a training intervention for nurses in using national standard treatments guideline. In the first study period, 627 retrospective randomized prescriptions and 295 prospective prescriptions in successive consultations were collected, and in the second period, ten months later, 665 and 274 prescriptions, respectively. Findings were compared between the two periods, and discussed in regard to referentials and data from other studies. The average number of drugs per prescription increased from 2.96 to 3.14 (p < 0.01) between the two periods, and the percentage of prescriptions with injections from 29.9 to 36.6% (p < 0.02), whereas the percentage of prescriptions containing antibiotics decreased from 75.2 to 68% (p < 0.01). These values were higher than regional or international standards, which were 2 for the average of drugs 17% for the injections and 50% for the antibiotics. Prescribing in essential and generic names of the national drug list was very close to 100% for the two periods. The average cost of prescriptions increased from 437 to 553 francs CFA (p < 0.001), which was higher than the calculated reference cost of 400 francs, but lower than data in literature. Correct prescriptions according to standard treatment guideline were only around 50%, in the two retrospective surveys. The averages of consultation time were 5.4 and 6.1 minutes for the two prospective surveys respectively, and dispensing times were 3.1 and 3.4 minutes, longer than those noticed in most of other studies in developing countries. Prescribed drugs were actually dispensed in almost 100% of the cases during the two periods. Drugs were properly labeled in 92.8% of the cases in the first period survey, and in 89.7% of the cases in the second (p < 0.03), whereas the percentage of patients who knew the correct dosage for drugs delivered increased from 64.4% to 75.5% (p < 0.01). Drug formularies and treatment guidelines were available in all facilities except in one case. Key drug availability ratio at the time of visit were good, in spite of a regression from 97.6 to 85.6% between the two periods. Improving drug purchasing and communal management in the health centers, this program contributed to the availability of essentials generic drugs delivered in a satisfactory way to the patients, and to set up a favorable professional environment for the nurses. On the other hand, the training courses seemed to have a limited impact on prescribing patterns for the nurses. However, better availability of drugs, as well as dispatching courses on the two retrospective surveys periods, could have underestimated this impact. Increasing prescription cost, although remaining compatible with costs recovery of drugs, was probably caused by the negative evolution of some indicators: abusive use of injections, higher number of drugs prescribed, few prescriptions according to standard treatment. These bad habits, often the most dangerous, justify undertaking actions of adapted formation, but also of communication with the patients, which should be regularly evaluated. For that, it will be necessary to have more qualitative indicators, helpful for the assessment of most efficient therapeutic attitude, tempting to value the global impact of these actions on health populations in developing countries.