Patient and provider delay in tuberculosis suspects from communities with a high HIV prevalence in South Africa: A cross-sectional study

BMC Infectious Diseases Patient and provider delay in tuberculosis suspects from communities with a high HIV prevalence in South Africa: A cross-sectional study Graeme Meintjes 1 2 Hennie Schoeman 2 Chelsea Morroni 0 Douglas Wilson 2 Gary Maartens 3 0 Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town , Anzio Road, Observatory, 7925 , South Africa 1 GF Jooste Hospital , Duinefontein Road, Manenberg, 7764 , South Africa 2 Division of Infectious Diseases, Department of Medicine, Faculty of Health Sciences, University of Cape Town , Anzio Road, Observatory, 7925 , South Africa 3 Division of Clinical Pharmacology, Department of Medicine, Faculty of Health Sciences, University of Cape Town , Anzio Road, Observatory, 7925 , South Africa Background: Delay in the diagnosis of tuberculosis (TB) results in excess morbidity and mortality, particularly among HIV-infected individuals. This study was conducted at a secondary level hospital serving communities with a high HIV prevalence in Cape Town, South Africa. The aim was to describe patient and provider delay in the diagnosis of TB in patients with suspected TB requiring admission, and to determine the risk factors for this delay and the consequences. Methods: A cross-sectional study was conducted. Patients admitted who were TB suspects were interviewed using a structured questionnaire to assess history of their symptoms and health seeking behaviour. Data regarding TB diagnosis and outcome were obtained from the medical records. Bivariate associations were described using student's T-tests (for means), chi-square tests (for proportions), and Wilcoxon rank-sum tests (for medians). Linear regression models were used for multivariate analysis. Results: One hundred twenty-five (125) patients were interviewed. In 104 TB was diagnosed and these were included in the analysis. Seventy of 83 (84%) tested were HIV-infected. Provider delay (median = 30 days, interquartile range (IQR) = 10.3-60) was double that of patient delay (median = 14 days, IQR = 7-30). Patients had a median of 3 contacts with formal health care services before referral. Factors independently associated with longer patient delay were male gender, cough and first health care visit being to public sector clinic (compared with private general practitioner). Patient delay 14 days was associated with increased need for transfer to a TB hospital. Provider delay 30 days was associated with increased mortality. Conclusion: Delay in TB diagnosis was more attributable to provider than patient delay, and provider delay was associated with increased mortality. Interventions to expedite TB diagnosis in primary care need to be developed and evaluated in this setting. - Background Delay in diagnosis is an important contributor to the excess morbidity and mortality of tuberculosis (TB) in HIV-infected people [1,2]. Delay in the diagnosis of TB in HIV-infected individuals has a greater impact on mortality and morbidity when compared with HIV-uninfected individuals because TB presents more commonly with dissemination [3] and disease progression is more rapid [4]. In addition, HIV disease progression is accelerated and viral load increased by TB [5-7] and a delayed TB diagnosis exacerbates this [8]. There are increased costs associated with a delayed diagnosis, both to the patient in terms of lost employment and visits to the health care system and to the health care system in terms of additional clinic visits and the need for hospitalisation. Also, a delay in diagnosis means that the untreated individual remains an infectious risk in the community for longer, contributing to increased TB transmission [9]. This study quantified diagnostic delay, associated factors, and consequences in patients requiring admission with suspected TB to a community-based secondary level hospital serving communities with a high HIV prevalence in Cape Town, South Africa (GF Jooste Hospital). The hospital serves a population of 1.3 million people. During the study period the main community served by the hospital had an antenatal HIV prevalence of 27% and a TB incidence of 1416/100 000 per annum. Methods This was a cross-sectional study. Data were collected using an interviewer-administered semi-structured questionnaire. All TB suspects who were admitted to the medical wards at GF Jooste Hospital between February and September 2003 were approached while in the ward for participation. Most of the TB diagnostic work-up in this setting takes place at government-funded public sector primary care facilities. Ill patients requiring admission are referred to the hospital by these facilities or by a private general practitioner (GP). The study was conducted prior to antiretroviral therapy (ART) being available in the public sector in South Africa and no patients in the study were on ART. There was also no isoniazid (INH) preventive therapy programme in the public or private sector. Patients 18 years or older were recruited. Exclusion criteria were treatment for TB within the preceding 6 months, confusion, and being a TB suspect solely on the basis of suspected TB meningitis. Patients were not recruited if admitted over weekends or during the two periods of leave taken by the interviewer. Participants gave written consent. The interviews were conducted by a trained interviewer in the patient's home language. Data on patients' socio-demographic and economic profile, symptoms, timing of seeking medical attention and type of health provider visited, and knowledge, attitudes and beliefs (KAB) were collected. The KAB questions were openended and the answers were coded into categories for analysis. Patients with an unknown HIV serostatus were offered HIV testing with pre- and post- test counselling upon completion of the interview. The test for HIV, using the Abbott Determine HIV-1/2, was conducted in a laboratory. Those with a previous diagnosis of HIV at another institution were not retested as long as this diagnosis was documented in the referral letter. Data regarding TB diagnosis and outcome were obtained from the medical records. The main inclusion criterion was a TB suspect, defined as referral from a primary care facility for diagnostic work-up for TB or in whom the admitting doctor suspected TB. Patients were followed up to assess whether the final diagnosis made by the admitting doctors was TB, but no attempt was made to influence their diagnostic process. The diagnosis of TB was divided into three categories: possible, probable and definite. The diagnosis was regarded as possible if both the clinical picture and radiological findings were assessed by a senior clinician to be compatible with TB, but microscopy and culture were negative or not done. Probable TB was diagnosed if acid fast bacilli (AFBs) were found on microscopy of any sample, or if granulomas were detected on histological or cytological examination. Definit (...truncated)