Evaluating Tuberculosis Case Detection via Real-Time Monitoring of Tuberculosis Diagnostic Services

Abstract

Rationale: Tuberculosis case-detection rates are below internationally established targets in high-burden countries. Real-time monitoring and evaluation of adherence to widely endorsed standards of tuberculosis care might facilitate improved case finding. Objectives: To monitor and evaluate the quality of tuberculosis casedetection and management services in a low-income country with a high incidence of tuberculosis. Methods: We prospectively evaluated tuberculosis diagnostic services at five primary health-care facilities in Uganda for 1 year, after introducing a real-time, electronic performance-monitoring system. We collected data on every clinical encounter, and measured quality using indicators derived from the International Standards of Tuberculosis Care. Measurements and Main Results: In 2009, there were 62,909 adult primary-care visits. During the first quarter of 2009, clinicians referred only 21% of patients with cough greater than or equal to 2 weeks for sputum smear microscopy and only 71% of patients with a positive sputum examination for tuberculosis treatment. These proportions increased to 53% and 84%, respectively, in the fourth quarter of 2009. The cumulative probability that a smear-positive patient with cough greater than or equal to 2 weeks would be appropriately evaluated and referred for treatment rose from 11% to 34% (P 5 0.005). The quarterly number of tuberculosis cases identified and prescribed treatment also increased four-fold, from 5 to 21. Conclusions: Poor adherence to internationally accepted standards of tuberculosis care improved after introduction of real-time performance monitoring and was associated with increased tuberculosis case detection. Real-time monitoring and evaluation can strengthen health systems in low-income countries and facilitate operational research on the effectiveness and sustainability of interventions to improve tuberculosis case detection.

Investigating Barriers to Tuberculosis Evaluation in Uganda Using Geographic Information Systems

“…18,19 In this analysis, we sampled all patients who presented to health centers with cough of more than 2 weeks' duration and underwent sputum examination as part of a TB diagnostic evaluation. We excluded those receiving follow-up monitoring and care for a previous diagnosis of TB.…”

Pre-treatment loss to follow-up in tuberculosis patients in low- and lower-middle-income countries and high-burden countries: a systematic review and meta-analysis

“…Two studies included patients who were either smear-or culture-positive. 29,30 In some studies smear positivity was defined as at least 1 25,27,28,30,35,41,42 or at least 2 [22][23][24]34 positive smears, whereas others did not provide any definition. 10,21,26,[31][32][33][36][37][38][39][40] A study from South Africa stratified rates of reported pre-treatment loss to followup by smear status (smear-positive or smear-negative but culture-positive), 23 whereas another study, also from South Africa, reported on pre-treatment loss to follow-up in tuberculosis patients whose diagnosis was established clinically and/ or bacteriologically.…”

“…In the remaining 4 studies, patients with a diagnosis of tuberculosis were identified as part of ongoing epidemiological surveillance 30 or were prospectively recruited for follow-up from a chest clinic 33,40 or from primary-health-care centres. 41 The recruitment periods ranged from 3 months 24,34,36 to 90 months. 30 Only 9 studies [22][23][24][25]27,29,31,36,37 applied a cut-off for time since diagnosis -ranging from 1 month to 3 months -to define pretreatment loss to follow-up.…”

“…Studies that reported on data from a single clinical site 21,22,26,29,31,33,35,40 had higher rates of pre-treatment loss to follow-up (range: 14-38%) than studies reporting on national or regional data (range: 4-25%). 10,[23][24][25]27,28,30,32,34,[36][37][38][39]41,42 In total, 10 studies 10,24,25,[30][31][32][33][34]38,40 attempted to trace tuberculosis patients with pre-treatment loss to follow-up (Table 4). One of them did not detail the tracing method used.…”

Opinião dos profissionais de saúde sobre os serviços de controle da tuberculose

“…(9) Because patients with tuberculosis have contact with other individuals, the World Health Organization recommends prophylaxis in, recording of, and control of those who had direct contact with such patients as a strategy for detecting new cases; this strategy includes the request for tests to investigate contacts. (10,11) Health professionals need to explain clearly how the exam will be done and its importance for the patient and contacts in helping to completely eliminate the disease in the community. (3) Therefore, the professional needs to completely understand the disease, in order the patient trust on his/her guidance.…”