Variation in tuberculosis treatment outcomes and treatment supervision practices in Uganda

Abstract

Background Variation in healthcare delivery is increasingly recognized as an important metric of healthcare quality. Directly observed therapy (DOT) has been the standard of care for tuberculosis (TB) treatment supervision for decades based on World Health Organization (WHO) guidelines. However, variation in implementation of DOT and associated TB treatment supervision practices remains poorly defined. Methods We collected individual patient data from TB treatment registers at 18 TB treatment units in Uganda including District Health Centers, District Hospitals, and Regional Referral Hospitals. We also administered a survey and did observations of TB treatment supervision practices by health workers at each site. We describe variation in TB treatment outcomes and TB treatment supervision practices. Results Of 2767 patients treated for TB across the 18 clinical sites between January 1 and December 31, 2017, 1740 (62.9%) were men, most were of working age (median 35 years, interquartile range [IQR] 27 – 46), 2546 (92.0%) had a new TB diagnosis, and nearly half (45.9%, n = 1283) were HIV positive. The pooled treatment success proportion was 69.4% (95% confidence interval [CI] 67.8 – 71.1) but there was substantial variation across sites (range 42.6 – 87.6%, I-squared 92.7%, p < 0.001). The survey and observation of TB treatment practices revealed that the majority of sites practice community-based DOT (66.7%, n = 12) and request a family member, who receives no additional training or supervision, to serve as a treatment supporter (77.8%, n = 14). At TB medication refill visits, all sites screen for side effects and most assess adherence via self-report (83.3%, n = 15). Only 7 (38.9%) sites followed-up patients who missed appointments using either phone calls (22.2%, n = 4/7) or community health workers (16.7%, n = 3/7). All 18 sites counseled patients at treatment initiation, but none provided additional counseling at refill visits other than addressing poor adherence or missed appointments. Conclusion There was substantial variation in implementation of DOT, including observation and documentation of daily dosing, training and supervision of treatment supporters, and follow-up for missed clinic visits. Identifying best practices and reducing uncontrolled variation in the delivery of TB treatment is critical to improving treatment outcomes.

Factors associated with poor treatment outcomes among tuberculosis patients in Kyangwali Refugee Settlement, Uganda, 2016–2017

“…different from that in our study [23]. However, a separate study conducted in Kampala, Uganda reported favorable treatment outcomes in 80.0% of TB patients [24].…”

Digital adherence technology for tuberculosis treatment supervision: A stepped-wedge cluster-randomized trial in Uganda

“…During the control period, health facilities continued providing TB treatment supervision in the same manner as before the trial. The community-based DOT model used at the 18 health facilities has been described previously, including the substantial variation in how TB treatment supervision is implemented across the facilities [ 9 ]. All facilities request patients to take their TB medicines under direct observation by a treatment supporter.…”

“…99DOTS implementation AU : Pleasecheckthattheeditstothesentence99DOTimplementatio and health economic outcomes are described in the trial protocol [8]; implementation and health economic outcomes will be reported later. Previous publications have described the trial protocol [8], baseline TB treatment outcomes at the trial sites [9], and the human-centered design process used to adapt the 99DOTS platform to better meet the needs of patients and health workers [10,11].…”

“…Each row corresponds to a patient. The dataset includes 13 columns: intervention group-randomization block (1)(2)(3)(4)(5)(6); health facility-health facility where the patient initiated treatment (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18); health center-type of facility (health center, hospital); trial month-month during which the patient initiated treatment (0-7); study period (control, buffer, intervention); sex; age; HIV status; disease class (bacteriologically confirmed pulmonary TB, clinically diagnosed pulmonary TB); retreatment -patient type (new, retreatment); treated successfully-primary outcome; persisting on treatment-secondary outcome; not lost to follow-up-secondary outcome.…”

Implementation of enhanced 99DOTS for TB treatment supervision in Uganda: An interrupted time series analysis

“…TB treatment support and supervision was provided via community-based DOT at the 12 99DOTS-naïve facilities. The implementation of community-based DOT varied by health facility (8).…”