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01.12.2017 | Research article | Ausgabe 1/2017 Open Access

BMC Health Services Research 1/2017

High pre-diagnosis attrition among patients with presumptive MDR-TB: an operational research from Bhopal district, India

BMC Health Services Research > Ausgabe 1/2017
Hemant Deepak Shewade, Arun M Kokane, Akash Ranjan Singh, Manoj Verma, Malik Parmar, Ashish Chauhan, Sanjay Singh Chahar, Manoj Tiwari, Sheeba Naz Khan, Vivek Gupta, Jaya Prasad Tripathy, Mukesh Nagar, Sanjai Kumar Singh, Pradeep Kumar Mehra, Ajay MV Kumar
Wichtige Hinweise

Electronic supplementary material

The online version of this article (doi:10.​1186/​s12913-017-2191-6) contains supplementary material, which is available to authorized users.
An erratum was published to correct author’s name.
Both contributed equally and are the joint primary/first authors
An erratum to this article is available at http://​dx.​doi.​org/​10.​1186/​s12913-017-2252-x.



Pre-diagnosis attrition needs to be addressed urgently if we are to make progress in improving MDR-TB case detection and achieve universal access to MDR-TB care. We report the pre-diagnosis attrition, along with factors associated, and turnaround times related to the diagnostic pathway among patient with presumptive MDR-TB in Bhopal district, central India (2014).


Study was conducted under the Revised National Tuberculosis Control Programme setting. It was a retrospective cohort study involving record review of all registered TB cases in Bhopal district that met the presumptive MDR-TB criteria (eligible for DST) in 2014. In quarter 1, Line Probe Assay (LPA) was used if sample was smear/culture positive. Quarter 2 onwards, LPA and Cartridge-based Nucleic Acid Amplification Test (CbNAAT) was used for smear positive and smear negative samples respectively. Pre-diagnosis attrition was defined as failure to undergo DST among patients with presumptive MDR-TB (as defined by the programme).


Of 770 patients eligible for DST, 311 underwent DST and 20 patients were diagnosed as having MDR-TB. Pre-diagnosis attrition was 60% (459/770). Among those with pre-diagnosis attrition, 91% (417/459) were not identified as ‘presumptive MDR-TB’ by the programme. TAT [median (IQR)] to undergo DST after eligibility was 4 (0, 10) days. Attrition was more than 40% across all subgroups. Age more than 64 years; those from a medical college; those eligible in quarter 1; patients with presumptive criteria ‘previously treated – recurrent TB’, ‘treatment after loss-to-follow-up’ and ‘previously treated-others’; and patients with extra-pulmonary TB were independent risk factors for not undergoing DST.


High pre-diagnosis attrition was contributed by failure to identify and refer patients. Attrition reduced modestly with time and one factor that might have contributed to this was introduction of CbNAAT in quarter 2 of 2014. General health system strengthening which includes improvement in identification/referral and patient tracking with focus on those with higher risk for not undergoing DST is urgently required.
Additional file 1: Dataset; Description of file: This file contains all the variables of all the study particpiants that were collected during record review. (XLS 399 kb)
Additional file 2: Codebook/Data documentation sheet; Description of file: This file contains details of the fields including values (codes) and value labels. (XLSX 16 kb)
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