Comparing tuberculosis management under public and private healthcare providers: Victoria, Australia, 2002–2015

Abstract

BackgroundPrivate healthcare providers are important to tuberculosis (TB) management globally, although internationally there are reports of suboptimal management and disparities in treatment commencement in the private sector. We compared the management of TB patients receiving private versus public healthcare in Victoria, an industrialised setting with low tuberculosis (TB) incidence.MethodsRetrospective cohort study: 2002–2015. Private healthcare provision was included as an independent variable in several multivariate logistic and Cox proportional hazard regression models that assessed a range of outcome variables, encompassing treatment commencement delays, management and treatment outcomes.ResultsOf 5106 patients, 275 (5.4%) exclusively saw private providers, and 4714 (92.32%) public. Private care was associated with a shorter delay to presentation (HR 1.36, p = 0.065, 95% CI 1.02–2.00). Private patients were less likely to have genotypic testing (OR 0.66, p = 0.009, 95% CI 0.48–0.90), those with pulmonary involvement were less likely to have a sputum smear (OR 0.52, p = 0.011, 95% CI 0.31–0.86) and provided samples were less likely to be positive (OR 0.54, p = 0.070, 95% CI 0.27–1.05). Private patients with extrapulmonary TB were less likely to have a smear sample (OR 0.7, 95% CI 0.48–0.90, p = 0.009) and radiological abnormalities (OR 0.71, p = 0.070, 95% CI 0.27–1.05). Treatment commencement delays from presentation were comparable for cases with pulmonary involvement and extrapulmonary TB, although public extrapulmonary TB patients received radiological examinations slightly earlier than private patients (HR 0.79, p = 0.043, 95% CI 0.63–0.99) and public patients with pulmonary involvement from high burden settings commenced treatment following an abnormal CXR more promptly than their private counterparts (HR 0.41, p = 0.011, 95% CI 0.21–0.81). Private patients were more likely to receive <4 first-line medications (OR 2.17, p = 0.001, 95% CI 1.36–3.46), but treatment outcomes were comparable between sectors.ConclusionsThe differences we identified are likely to reflect differing case-mix as well as clinician practice. Sputum smear status was an important covariable in our analysis; with its addition we found no significant disparity in the health-system delay to treatment commencement between sectors. Our study highlights the importance of TB programs engaging with private providers, enabling comprehensive data collection that is necessary for thorough and true comparison of TB management and optimisation of care.Electronic supplementary materialThe online version of this article (doi:10.1186/s12879-017-2421-x) contains supplementary material, which is available to authorized users.

Delays in presentation and diagnosis of pulmonary tuberculosis: a retrospective study of a tertiary health service in Western Melbourne, 2011–2014

“…The median duration of delays found in this study align with those found in an international systematic review of the topic in 2009, which included 52 studies and found an average patient delay of 28.7 days and average health system delay of 25 days . Findings are also comparable to the latest studies conducted in Australia on this topic …”

“…The limitations of this study include its retrospective nature, making it vulnerable to recall bias, with data concerning primary outcomes based on hospital records of symptom onset and nature recorded by medical officers rather than directly from patients. It was also limited to a single centre, which raises the possibility that findings are specific for this site; however, it is reassuring that a similar duration of health system delay was found in the recently conducted study by Dale et al 13…”

“…12 Findings are also comparable to the latest studies conducted in Australia on this topic. 9,13 A study published in 2001 9 included 782 symptomatic, culture-positive cases of PTB based on Queensland Tuberculosis Control Centre TB case notification form data between 1985 and 1998. Median patient delay in this study was 29 days and median health system delay was 22 days.…”

“…Despite advances in rapid diagnosis, delays are only marginally shorter than those described 15 years ago. A recently published study by Dale et al 13 involved 5106 Victorian patients identified through notification form data between 2002 and 2015 with PTB and extrapulmonary TB and compared the management of patients receiving private versus public healthcare. The median patient delay was 18 days and median healthcare delay was 22 days in those receiving public healthcare in this cohort.…”

The Use of Fluoroquinolones for Tuberculosis in Victoria between 2011 and 2016

“…The Victorian Tuberculosis Program is the statewide authority responsible for TB public health management, including medication supply and contact tracing [ 12 ]. Notification of all cases of TB is compulsory in both public and private healthcare settings, with case management and outcome records maintained in a central existing electronic public health record system [ 13 ]. This system also includes laboratory diagnostic records, including molecular and phenotypic drug susceptibility testing results.…”