Health system delay in pulmonary tuberculosis treatment in a country with an intermediate burden of tuberculosis: a cross-sectional study

Croatian TB services are integrated in the mainstream national health system and rely on general practitioners/family medicine physicians guiding TB patients through the entire procedure and course of treatment. The availability and network of health services providing TB care and diagnosis are believed to be sufficient in Croatia [6, 9, 10], as revealed in a study on patient delay where the long distance to a health facility was among the very few reasons (1.3% of participants) for delay [8]. A developed network of 14 TB laboratories meets international requirements and each laboratory performs microscopy and culture procedures. The laboratory notification system reports smear-positive results within 24 hours and positive culture results immediately upon cultivation [11]. The Croatian health system allows for as many medical visits as required and for as many tests as the GP finds necessary, free of charge to the patient, in the case of many infectious diseases, including tuberculosis. TB treatment is also free of charge, with the institutional procurement of drugs and an uninterrupted supply of first-line drugs [11]. This explains the common reasons for the health system delay being identified elsewhere [12‐14]. Causative laboratory delays and distances to the health provider were, however, not explored in the present study.

This cross-sectional study was performed in seven Croatian counties between April and December 2006. The idea was to include more than 50% of the Croatian population and more than 50% of TB patients registered in the preceding year. This study was started in eight randomly selected counties out of 21, covering 60.8% of the Croatian population and 53.6% of all registered TB patients in the preceding year. In the course of the study, one county was later excluded along with all interviewees because the investigator was moved to another non-participating county. Therefore, seven counties with 48% of all TB patients and 53.9% of the Croatian population were finally covered. A team of epidemiologists who had been working in TB control interviewed the consecutive TB patients in hospitals or in their homes, and reviewed their medical records within one month of the diagnosis of TB. The questionnaire was pre-tested for clarity and consistency, and modified accordingly. Data on demographic, socioeconomic, a high-risk life style and diagnostic factors were collected. Smoking status was classified as non-smoker, ex-smoker (previously smoking at any time in their lifetime) and current smoker. Data on alcohol consumption were collected during the previous 12 months and the subjects were classified as non-consumer (no alcohol consumption in the last 12 months), ex-consumer (alcohol had been consumed during the last 12 months but the patient had stopped consuming by the time of the interview) and current consumer. Drug use was defined as use of any drug in the lifetime. Other symptoms were all reported symptoms apart from the classic symptoms (a cough with or without blood, fever, weight loss, fatigue, night sweats, and shortness of breath). The body mass index (kg/m²) on the date of the interview was classified as underweight <18.50, normal range 18.50-24.99, and overweight ≥25.00.

The study was approved by the Ethics Committee of Teaching Public Health Institute of Split and Dalmatia County and all patients provided informed written consent.

Cases that were detected through passive case-finding were defined as all adults (aged 15 years and older) with culture-confirmed pulmonary tuberculosis. TB patients who were identified during contact tracing, patients who had no symptoms before the diagnosis (e.g. identified during preoperative procedures), and patients with a previous history of TB treatment were excluded. The said patients had already had TB data recorded in their medical records and it was reasonable to assume that their physicians would have had a higher degree of suspicion when TB symptoms presented again. Such doctors would have thus been more alert and would have acted accordingly.

‘Health system delay’ was defined as the number of days from the first consultation with a physician (either primary care or other) to the initiation of anti-TB treatment. In the absence of a standard definition, ‘long health system delay’ was defined as a period exceeding the median delay observed in the study population, while ‘extreme delay’ was defined as a period exceeding the 75^th percentile delay. We did not separate diagnostic delay from treatment delay since it is standard practice in Croatia to start anti-TB therapy immediately following diagnosis.

It was estimated that 160 participants (80 per group) should be included in this study to achieve an 80% power to detect an odds ratio of 2.5 with an alpha of 0.05. The median and 75^th percentile delays were calculated for all patients and all variables. We compared the distribution of delay ≤ median (or the 75^th percentile) with delay > median (or the 75^th percentile) by performing the Pearson Chi-squared test for all variables. The association of long and extreme delays with different variables was estimated using the crude odds ratios (OR) and 95% confidence intervals (CI). To identify factors independently associated with long and extreme health system delays, a multivariate logistic regression analysis was performed. All variables significant at a univariate level, as well as age groups, were included in the initial logistic regression model. The backward elimination procedure was used to identify the variables remaining in the final model and in the model-building strategies proposed by Hosmer and Lemeshow [15]. All analyses were conducted using Statistica 8.0 computer software (StatSoft Inc., Tulsa, USA). The level of statistical significance was defined as p < 0.05.

From a public health point of view, it is imperative that physicians be better trained in TB, especially in settings where TB incidence is decreasing continuously. Emphasis should be placed on general practitioners/family medicine physicians, since they are the pillar of the health system and since most patients first go to them for treatment. These measures may be useful in reducing the number of missed opportunities for diagnosis and should form part of an approach to eliminate TB in countries with an intermediate tuberculosis burden.