Case fatality and recurrent tuberculosis among patients managed in the private sector: A cohort study in Patna, India

Abstract

Background A key component of the WHO End TB Strategy is quality of care, for which case fatality is a critical marker. Half of India’s nearly 3 million TB patients are treated in the highly unregulated private sector, yet little is known about the outcomes of these patients. Using a retrospective cohort design, we estimated the case fatality ratio (CFR) and rate of recurrent TB among patients managed in the private healthcare sector in Patna, India. Methods World Health Partners’ Private Provider Interface Agencies (PPIA) pilot project in Patna has treated 89,906 private sector TB patients since 2013. A random sample of 4,000 patients treated from 2014 to 2016 were surveyed in 2018 for case fatality and recurrent TB. CFR is defined as the proportion of patients who die during the period of interest. Treatment CFRs, post-treatment CFRs and rates of recurrent TB were estimated. Predictors for fatality and recurrence were identified using Cox proportional hazards modelling. Survey non-response was adjusted for using inverse probability selection weighting. Results The survey response rate was 56.0%. The weighted average follow-up times were 8.7 months in the treatment phase and 26.4 months in the post-treatment phase. Unobserved patients were more likely to have less than one month of treatment adherence (32.0% vs. 13.5%) and were more likely to live in rural Patna (21.9% vs. 15.0%). The adjusted treatment phase CFR was 7.27% (5.97%, 8.49%) and at 24 months post-treatment was 3.32% (2.36%, 4.42%). The adjusted 24 month post-treatment phase recurrent TB rate was 3.56% (2.54%, 4.79%). Conclusions Our cohort study provides critical estimates of TB patient outcomes in the Indian private sector, and accounts for selection bias. Patients in the private sector in Patna experienced a moderate treatment CFR but rates of recurrent TB and post-treatment fatality were low.

Recurrence of pulmonary tuberculosis in India: Findings from the 2019–2021 nationwide community-based TB prevalence survey

“…The RTB observed in the current survey is high, in terms of absolute numbers, for a country like India. The proportion of RTB patients identified in the survey is slightly higher than proportion of sputum smear positive retreatment patients (24%) as reported in the NTEP [ 8 ] This is higher than the reported proportion of relapse in Zambia and other African counties [ 9 ]. of TB indicate that patients were cured but the underlying medical or social conditions have not been addressed completely.…”

“…proportion of sputum smear positive retreatment patients (24%) as reported in the NTEP [8] This is higher than the reported proportion of relapse in Zambia and other African counties [9]. of TB indicate that patients were cured but the underlying medical or social conditions have not been addressed completely.…”

Barriers to engagement in the care cascade for tuberculosis disease in India: A systematic review of quantitative studies

“…Across 51 studies reporting adjusted analyses including people with drug-susceptible TB, indicators of diagnostic delay or advanced TB—including illness >2 months in 1 study [ 102 ], advanced radiographic (e.g., cavitary) disease in 2 studies [ 102 , 103 ], and smear–positive or microbiologically diagnosed TB (versus smear–negative, extrapulmonary, or clinically diagnosed TB) in 11 studies [ 68 , 70 , 71 , 73 , 76 , 81 , 85 , 87 , 89 , 97 , 104 ]—were associated with unfavorable treatment outcomes (Fig J in the S6 Appendix and Table D in the S4 Appendix ). People with more severe symptoms at treatment initiation were less likely to experience loss to follow-up in 2 studies [ 91 , 105 ], but more likely to experience composite unfavorable TB treatment outcomes in 1 study [ 99 ].…”

“… All studies used multivariable regression and reported adjusted effect estimates [ 66 , 67 , 71 – 73 , 77 , 81 , 84 , 86 , 87 , 89 – 94 , 99 – 105 , 108 – 110 , 123 ]. Estimates greater than 1 represent increased risk of unfavorable outcomes; estimates less than 1 represent decreased risk of unfavorable outcomes.…”

“…Across 9 studies reporting adjusted analyses involving TB recurrence, male sex was associated with TB recurrence in 2 studies [ 95 , 106 ] ( Fig 10 and Table D in the S5 Appendix ); sex had nonsignificant associations in 2 studies [ 81 , 111 ]. Medication nonadherence was associated with TB recurrence in 2 studies [ 95 , 151 ]; adherence had nonsignificant associations in 2 studies [ 81 , 106 ].…”