Quality of care for patients evaluated for tuberculosis in the context of Xpert MTB/RIF scale-up

Katherine Farr; Talemwa Nalugwa; Christopher Ojok; Mariam Nantale; Sarah Nabwire; Denis Oyuku; Priya B Shete; Alvina H Han; Katherine Fielding; Moses Joloba; Frank Mugabe; David W Dowdy; Daj Moore; J Lucian Davis; Achilles Katamba; Adithya Cattamanchi

doi:10.1016/j.jctube.2019.100099

Quality of care for patients evaluated for tuberculosis in the context of Xpert MTB/RIF scale-up

J Clin Tuberc Other Mycobact Dis. 2019 Apr 12:15:100099. doi: 10.1016/j.jctube.2019.100099. eCollection 2019 May.

Authors

Katherine Farr^{1

2}, Talemwa Nalugwa³, Christopher Ojok³, Mariam Nantale³, Sarah Nabwire³, Denis Oyuku³, Priya B Shete^{1

2}, Alvina H Han⁴, Katherine Fielding⁵, Moses Joloba⁶, Frank Mugabe⁶, David W Dowdy⁷, Daj Moore⁸, J Lucian Davis^{9

10}, Achilles Katamba³, Adithya Cattamanchi^{1

2}

Affiliations

¹ Division of Pulmonary and Critical Care Medicine, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA.
² Curry International Tuberculosis Center, University of California San Francisco, San Francisco, CA, USA.
³ School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda.
⁴ Columbia College, Columbia University, New York, NY, USA.
⁵ Faculty of Epidemiology and Population Health and TB Centre, London School of Hygiene and Tropical Medicine, London, UK.
⁶ National Tuberculosis and Leprosy Programme, Kampala, Uganda.
⁷ Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
⁸ Faculty of Infectious and Tropical Diseases and TB Centre, London School of Hygiene and Tropical Medicine, London, UK.
⁹ Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA.
¹⁰ Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, New Haven, CT, USA.

Abstract

Rationale: Many high-burden countries are scaling-up Xpert MTB/RIF using a hub-and-spoke model. We evaluated the quality of care for patients undergoing TB evaluation at microscopy centers (spokes) linked to Xpert testing sites (hubs) in Uganda.

Objectives: To characterize the extent to which patients were receiving care in accordance with international and national guidelines.

Methods: We conducted a prospective cohort study of all adults with presumptive pulmonary TB at 24 health centers linked to Xpert testing sites. Health center staff photographed TB registers, and uploaded photos to a secure server bi-weekly. We assessed the proportion of patients (1) initiating testing; (2) completing testing; and (3) treated for confirmed TB within 14 days.

Measurements and main results: Between January to December 2017, 6744 patients underwent evaluation for pulmonary TB. Only 1316 patients had sputum referred for Xpert testing, including 1075/3229 (33.3%) people living with HIV and 241/3515 (6.9%) without HIV. Of 119 patients confirmed to have TB by Xpert testing, 44 (36%) did not initiate treatment. There were significant losses along the entire diagnostic cascade of care, with only 5330/6744 (79.0%) patients having samples referred for sputum-based testing, 2978/5330 (55.9%) patients completing recommended testing if referred, and 313/418 (74.9%) patients initiating treatment within 14 days if confirmed to have TB.

Conclusions: Although coverage of Xpert testing services across Uganda is high, the quality of care delivered to patients undergoing TB evaluation remains poor. Further research is needed to identify health system interventions to facilitate uptake of Xpert testing and high-quality care.

Keywords: Diagnosis; Quality of care; Tuberculosis.

Abstract

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