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

Abstract

Background: Private 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.

Methods: Retrospective 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.

Results: Of 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.

Conclusions: The 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.

Keywords: Delayed diagnosis; Patient care; Private sector; Public sector; Time-to-treatment.

Fig. 1

Conceptual illustration of definitions of delays (adapted from Van Wyk et al. 2011)

Fig. 2

Kaplan-Meier curves for TB patients with pulmonary involvement in Victoria from 2002 to 2015. a Health system delay. b Diagnostic delay to first CXR. c Treatment initiation delay 1

Fig. 3

Kaplan-Meier curves for extrapulmonary TB patients in Victoria from 2002 to 2015. a Health system delay. b Diagnostic delay to first CXR

Fig. 4

Kaplan-Meier curves for TB patients in Victoria. a Patient delay 2012–2015. b Laboratory delay 2011–2015. c Treatment initiation delay 2 2002-2015