Missed Opportunities for TB Investigation in Primary Care Clinics in South Africa: Experience from the XTEND Trial

Abstract

Setting40 primary health clinics (PHCs) in four provinces in South Africa, June 2012 –February 2013.ObjectiveTo determine whether health care worker (HCW) practice in investigating people with TB symptoms was altered when the initial test for TB was changed from smear microscopy to Xpert MTB/RIF.DesignCross-sectional substudy at clinics participating in a pragmatic cluster randomised trial, Xpert for TB: Evaluating a New Diagnostic "XTEND", which evaluated the effect of Xpert MTB/RIF implementation in South Africa.MethodsConsecutive adults exiting PHCs reporting at least one TB symptom (defined as any of cough, weight loss, night sweats and fever) were enrolled. The main outcome was the proportion who self-reported having sputum requested by HCW during the clinic encounter just completed.Results3604 adults exiting PHCs (1676 in Xpert arm, 1928 in microscopy arm) were enrolled (median age 38 years, 71.4% female, 38.8% reported being HIV-positive, 70% reported cough). For 1267 participants (35.2%) the main reason for attending the clinic was TB symptom(s).Overall 2130/3604 (59.1%) said they reported their symptom(s) to HCW. 22.7% (818/3604) reported having been asked to give sputum for TB investigation. Though participants in the Xpert vs. microscopy arm were more likely to have sputum requested by HCW, this was not significantly different: overall (26.0% [436/1676] vs 19.8% [382/1928]; adjusted prevalence ratio [aPR] 1.31, [95% CI 0.78–2.20]) and when restricted to those presenting at clinics due to symptoms (49.1% [260/530] vs 29.9% [220/737]; aPR 1.38 [0.89–2.13]) and those reporting being HIV-positive (29.4% [190/647] vs 20.8% [156/749]; aPR 1.38[0.88–2.16]).Those attending clinic due to TB symptoms, were more likely to have sputum requested if they had increasing number of symptoms; longer duration of cough, unintentional weight loss and night sweats and if they reported symptoms to HCW.ConclusionsA large proportion of people exiting PHCs reporting TB symptoms did not get tested. Implementation of Xpert MTB/RIF did not substantially change the probability of testing for TB. Better systems are needed to ensure that opportunities to identify active TB among PHC attendees are not missed.

Higher cost of implementing Xpert<SUP>®</SUP> MTB/RIF in Ugandan peripheral settings: implications for cost-effectiveness

“…Consistent with prior studies performed under conditions of greater resource availability, 19,26 we found that implementation of Xpert in Uganda (a country with fewer resources and outside a trial setting) led to few incremental TB diagnoses relative to the current standard based on sputum smear. We augment this understanding by correlating diagnostic outcomes with the incremental cost of Xpert, which constituted over 60% of diagnostic costs in sites utilizing Xpert.…”

Missed opportunities for diagnosis and treatment in patients with tuberculosis symptoms: a systematic review

“…The proportions of participants who reported having been screened for TB symptoms in the three exit interview studies were 0.60 (2130/3604), [30] 0.50 (622/1255), [15] and 0.04 (16/423) [9] respectively ( Figure 3A). The proportion of symptomatic attendees offered a diagnostic investigation (data available for 13 studies), was highly variable, ranging from 0.05 to 0.84 (median 0.38 [IQR: 0.22 to 0.45]) ( Figure 3B).…”

Missed opportunities for diagnosis and treatment in patients with tuberculosis symptoms: a systematic review

“…We excluded 12 articles: two because the data applicable to the review was already included in the authors' other included publication, [15,16] two because data were not original to research manuscripts (one commentary and one systematic review), [7,17] seven studies because they did not report data that could be mapped to our pre-defined patient categories, and one because it was a community-based study. [18][19][20][21][22][23][24] Description Of Studies The 14 eligible studies were published between 2000 and 2018 and reported data from India, [25][26][27][28][29] South Africa, [9,[30][31][32] Kenya, [33] Thailand, [34] China, [35] Vietnam [36] and Ghana [37] (Table 1).…”