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. 2018 Mar 27;18(1):142.
doi: 10.1186/s12879-018-3039-3.

Pretreatment loss to follow-up of tuberculosis patients in Chennai, India: a cohort study with implications for health systems strengthening

Beena E Thomas  1 , Ramnath Subbaraman  2   3 , Senthil Sellappan  4 , Chandra Suresh  4 , J Lavanya  5 , Savari Lincy  4 , Agnes Lawrence Raja  4 , B Javeed  4 , S Kokila  4 , S Arumugam  4 , Soumya Swaminathan  6 , Kenneth H Mayer  7   8
Affiliations

Pretreatment loss to follow-up of tuberculosis patients in Chennai, India: a cohort study with implications for health systems strengthening

Beena E Thomas et al. BMC Infect Dis. .

Abstract

Background: Pretreatment loss to follow-up (PTLFU) is a barrier to tuberculosis (TB) control in India's Revised National TB Control Programme (RNTCP). PTLFU studies have not been conducted in India's mega-cities, where patient mobility may complicate linkage to care.

Methods: We collected data from patient registries for May 2015 from 22 RNTCP designated microscopy centers (DMCs) in Chennai and audited addresses and phone numbers for patients evaluated for suspected TB to understand how missing contact information may contribute to PTLFU. From November 2015 to June 2016, we audited one month of records from each of these 22 DMCs and tracked newly diagnosed smear-positive patients using RNTCP records, phone calls, and home visits. We defined PTLFU cases as including: (1) patients who did not start TB therapy within 14 days and (2) patients who started TB therapy but were lost to follow-up or died before official RNTCP registration. We used multivariate logistic regression to identify factors associated with PTLFU.

Results: In the audit of May 2015 DMC registries, out of 3696 patients evaluated for TB, 1273 (34.4%) had addresses and phone numbers that were illegible or missing. Out of 344 smear-positive patients tracked from November 2015 to June 2016, 40 (11.6%) did not start TB therapy within 14 days and 36 (10.5%) started therapy but were lost to follow-up or died before official RNTCP registration, for an overall PTLFU rate of 22.1% (95%CI: 17.8%-26.4%). Of all PTLFU patients, 55 (72.4%) were lost to follow-up and 21 (27.6%) died before starting treatment or before RNTCP registration. In the regression analysis, age > 50 years (OR 2.9, 95%CI 1.4-6.5), history of prior TB (OR 3.9, 95%CI 2.2-7.1), evaluation at a high patient volume DMC (OR 3.2, 95% CI 1.7-6.3), and absence of legible patient contact information (OR 4.5, 95%CI 1.3-15.1) were significantly associated with PTLFU.

Conclusions: In an Indian mega-city, we found a high PTLFU rate, especially in patients with a prior TB history, who are at greater risk for having drug-resistance. Enhancing quality of care and health system transparency is critical for improving linkage of newly diagnosed patients to TB care in urban India.

Keywords: Cascade of care; Health systems research; Implementation science; India; Initial default; Linkage to care; Operations research; Pretreatment loss to follow-up; Quality of care; Tuberculosis.

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Conflict of interest statement

Ethics approval and consent to participate

The research protocol for this study was approved by the Institutional Ethics Committee of the National Institute for Research in TB (NIRT) (FWA00005104) on December 29, 2014 and the Institutional Review Board of Brigham and Women’s Hospital (Partners Healthcare) (FWA00000484) on January 13, 2015. Informed consent for tracking of patients by the study team was waived by these committees, because patient tracking was conducted using RNTCP records, and phone calls and home visits were conducted in conjunction with RNTCP staff. Written informed consent was collected from all PTLFU patients who agreed to participate in the qualitative interviews.

Consent for publication

This manuscript does not contain any individual’s data in any form. Quantitative data were de-identified prior to analysis. The qualitative interview findings are not reported in this manuscript.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
The process of diagnosis and linkage to care for smear-positive tuberculosis patients referred for initial treatment in the outpatient or inpatient setting. TB = tuberculosis; DMC = designated microscopy center; DOT = directly observed therapy; RNTCP = Revised National Tuberculosis Control Programme
Fig. 2
Fig. 2
Protocol for determining study outcomes for smear-positive tuberculosis patients tracked by the field research team. TB = tuberculosis; DMC = designated microscopy center; DOT = directly observed therapy; RNTCP = Revised National Tuberculosis Control Programme
Fig. 3
Fig. 3
Pretreatment loss to follow-up outcomes for 344 tuberculosis patients tracked in Chennai’s government TB program, including patients who failed to start therapy within two weeks and patients who did not get registered in the RNTCP. All percentages are based on the denominator of 344 smear-positive patients tracked. TB = tuberculosis; RNTCP = Revised National TB Control Programme
See this image and copyright information in PMC

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