Can Patient Navigators Help Potential TB Patients Navigate the Diagnostic and Treatment Pathways? An Implementation Research from India

Navigating the Indian health system is a challenge for people with tuberculosis (TB) symptoms. The onus of organizing care is on the patient and their families alone. Factors like gender discrimination and opportunity costs further aggravate this. As a result, people may not complete the diagnostic and treatment pathway even though they experience poor health. Navigators can aid in the pathway’s completion. We implemented two projects in India—a public sector intervention in Bihar, with a population of 1.02 million, and a private sector intervention in Andhra Pradesh (AP), with a population of 8.45 million. Accredited Social Health Activists (ASHAs) of the public health system in Bihar and local field officers in AP facilitated the patients’ navigation through the health system. In Bihar, ASHAs accompanied community-identified presumptive TB patients to the nearest primary health center, assisted them through the diagnostic process, and supported the patients throughout the TB treatment. In AP, the field officers liaised with the private physicians, accompanied presumptive patients through the diagnosis, counseled and started treatment, and followed-up with the patients during the treatment. Both projects recorded case-based data for all of the patients, and used the yield and historical TB notifications to evaluate the intervention’s effect. Between July 2017 and December 2018, Bihar confirmed 1650 patients, which represented an increase of 94% in public notifications compared to the baseline. About 97% of them started treatment. During the same period in AP, private notifications increased by 147% compared to the baseline, and all 5765 patients started treatment. Patient navigators support the patients in the diagnostic and treatment pathways, and improve their health system experience. This novel approach of involving navigators in TB projects can improve the completion of the care cascade and reduce the loss to follow-up at various stages.

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Prediagnostic loss to follow-up in an active case finding tuberculosis programme: a mixed-methods study from rural Bihar, India

BMJ Open ◽

10.1136/bmjopen-2019-033706 ◽

2020 ◽

Vol 10 (5) ◽

pp. e033706 ◽

Cited By ~ 3

Author(s):

Tushar Garg ◽

Vivek Gupta ◽

Dyuti Sen ◽

Madhur Verma ◽

Miranda Brouwer ◽

...

Keyword(s):

Mixed Methods ◽

Health System ◽

Health Workers ◽

Case Finding ◽

Diagnostic Evaluation ◽

Active Case Finding ◽

Loss To Follow Up ◽

The Public ◽

Active Case

ObjectiveTo quantify the prediagnostic loss to follow-up (PDLFU) in an active case finding tuberculosis (TB) programme and identify the barriers and enablers in undergoing diagnostic evaluation.DesignExplanatory mixed-methods design.SettingA rural population of 1.02 million in the Samastipur district of Bihar, India.ParticipantsBased on their knowledge of health status of families, community health workers or CHWs (called accredited social health activist or locally) and informal providers referred people to the programme. The field coordinators (FCs) in the programme screened the referrals for TB symptoms to identify presumptive TB cases. CHWs accompanied the presumptive TB patients to free diagnostic evaluation, and a transport allowance was given to the patients. Thereafter, CHWs initiated and supported the treatment of confirmed cases. We included 13 395 community referrals received between January and December 2018. To understand the reasons of the PDLFU, we conducted in-depth interviews with patients who were evaluated (n=3), patients who were not evaluated (n=4) and focus group discussions with the CHWs (n=2) and FCs (n=1).Outcome measuresProportion and characteristics of PDLFU and association of demographic and symptom characteristics with diagnostic evaluation.ResultsA total of 11 146 presumptive TB cases were identified between January and December 2018, out of which 4912 (44.1%) underwent diagnostic evaluation. In addition to the free TB services in the public sector, the key enablers were CHW accompaniment and support. The major barriers identified were misinformation and stigma, deficient family and health provider support, transport challenges and poor services in the public health system.ConclusionFinding the missing cases will require patient-centric diagnostic services and urgent reform in the health system. A community-oriented intervention focusing on stigma, misinformation and patient support will be critical to its success.

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The Role of Patient Navigators in Ambulatory Care: Overview of Systematic Reviews

10.21203/rs.3.rs-506357/v1 ◽

2021 ◽

Author(s):

Hannah Budde ◽

Gemma Williams ◽

Juliane Winkelmann ◽

Laura Pfirter ◽

Claudia Bettina Maier

Keyword(s):

Health Services ◽

Health System ◽

Ambulatory Care ◽

Systematic Reviews ◽

Patient Navigation ◽

Transitional Care ◽

Emergency Department Visits ◽

Patient Navigators

Abstract Background: Patient navigators have been introduced across various countries to enable timely access to healthcare services and ensure completion of diagnosis and follow-up of care. There is an increasing amount of evidence on the positive effect of patient navigation for patients. The aim of this study was to analyse the evidence on patient navigation interventions in ambulatory care and to evaluate their effects on individuals and health system outcomes.Methods: An overview of reviews was conducted, based on a prespecified protocol. All patients in ambulatory care or transitional care setting were included in this review as long as it was related to the role of patient navigators. The study analysed all roles of patient navigators covering a wide range of health professionals such as physicians, nurses, pharmacists, social workers as well as lay health workers or community-based workers with no or very limited training. Studies including patient-related measures and health system-related outcomes were eligible for inclusion. A rigorous data collection was performed in multiple data bases. After reaching an inter-rater agreement, title and abstract screening was independently performed. Of an initial 8362 search results a total of 673 articles were eligible for full-text screening. An extraction form was used to analyse the nine included review.Results: Nine systematic reviews were included covering various patient navigation roles in cancer care, disease screening and transitional care. Seven systematic reviews primarily tailored services to ethnic minorities or other disadvantaged groups. Patient navigators performed tasks such as providing education and counselling, translations, home visits, outreach, scheduling of appointments and follow-up. Six reviews identified positive outcomes in expanding access to care, in particular for vulnerable patient groups. Two reviews on patient navigation in transitional care reported improved patient outcomes and hospital readmission rates and mixed evidence on quality of life and emergency department visits.Conclusions: Patient navigators have shown to expand access to screenings and health services for vulnerable patients or population groups who tend to underuse health services.

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The impact of smoking on tuberculosis treatment outcomes: a meta-analysis

The International Journal of Tuberculosis and Lung Disease ◽

10.5588/ijtld.19.0002 ◽

2020 ◽

Vol 24 (2) ◽

pp. 170-175 ◽

Cited By ~ 3

Author(s):

E. Y. Wang ◽

R. A. Arrazola ◽

B. Mathema ◽

I. B. Ahluwalia ◽

S. R. Mase

Keyword(s):

Cigarette Smoking ◽

Treatment Outcomes ◽

Meta Analysis ◽

Current Evidence ◽

Cochrane Library ◽

Loss To Follow Up ◽

Tb Treatment ◽

The Impact ◽

Culture Conversion

BACKGROUND: Cigarette smoking contributes to tuberculosis (TB) epidemiology. However, limited evidence exists on how smoking impacts TB treatment outcomes such as treatment loss to follow-up and culture conversion.METHODS: This meta-analysis assessed current evidence of the impact of active cigarette smoking on TB treatment outcomes. PubMed, Scopus, Embase, and the Cochrane Library were searched for English-language articles published from database inception through 2017. Articles addressing active pulmonary TB and cigarette smoking were identified and data abstracted. Smokers were defined as those who smoked every day or some days at the time of interview/diagnosis. Non-smokers did not smoke at the time of interview/diagnosis. Unfavorable outcomes included any outcome other than cure or completion of TB treatment. Three different data sets were examined: 8 articles addressing unfavorable treatment outcomes, 9 analyzing only treatment loss to follow-up, and 5 addressing delayed smear or culture conversion. Studies that had <20 subjects or that addressed only populations with comorbidities were excluded.RESULTS: We identified 1030 studies; 21 studies fulfilled the inclusion/exclusion criteria. Smokers had greater odds of unfavorable outcomes (pooled odds ratio [pOR] 1.23, 95%CI 1.14–1.33), delayed smear or culture conversion (pOR 1.55, 95%CI 1.04–2.07), and treatment loss to follow-up (pOR 1.35, 95%CI 1.21–1.50).CONCLUSION: Cigarette smoking is associated with negative treatment results and delayed conversion to negative smear or culture, suggesting smoking is an important factor for consideration in TB elimination efforts.

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Incidence of Suicide Attempts in Madrid: Characteristics of the Attempts and Response of the Health System

European Psychiatry ◽

10.1016/s0924-9338(09)71037-5 ◽

2009 ◽

Vol 24 (S1) ◽

pp. 1-1

Author(s):

M. Miret ◽

C. Morant ◽

R. Nuevo ◽

M. Jiménez ◽

M. Reneses ◽

...

Keyword(s):

Public Health ◽

Suicidal Ideation ◽

Health System ◽

Suicide Attempts ◽

Public Health Problem ◽

Public Hospitals ◽

Prevention Measures ◽

The Public ◽

Emergency Units

Background:Suicide is a serious public health problem. In 2005, 793 people were hospitalized in Madrid due to suicide attempt. However, most of the attempts do not require hospitalization and patients are discharged after the intervention in the emergency units. With the aim to implement local policies to prevent suicide, it is important to know the whole spectrum of suicide attempts that contact emergency units in Madrid.Aims:To explore the incidence of suicide attempts assisted in the public health system in Madrid and to analyze their characteristics and the response of the health system.Method:Clinical reports of all patients attempting suicide were analyzed during 4 months in 4 general public hospitals (covering 44.7% of the whole population) in the Community of Madrid.Results:1009 suicide attempts committed by 921 people (66.2% women) were collected, with an incidence of 34.3 people per 100.000 in 4 months. 57 people (6.2%) committed more than one attempt (range 2 to 10, mean=2.5 ± 1.3). After the emergency intervention 71.9% of the patients were discharged, 25.3% hospitalized, 2.6% fled, and 0.2% died. Regarding suicidal ideation, 7.5% presented very high levels during evaluation, while 13.1% had high levels, 20.3% moderate and 47.3% had no suicidal ideation.Conclusion:Compared with other European countries, our findings show moderate incidence of suicide attempts, most of which were mild, treated in the emergency units and derived to outpatient psychiatric follow-up. These results suggest places to develop and implement prevention measures.Funded by Instituto de Salud Pública de Madrid.

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Patient and health system factors associated with pretreatment loss to follow up among patients diagnosed with tuberculosis using Xpert® MTB/RIF testing in Uganda

10.21203/rs.2.17693/v3 ◽

2020 ◽

Author(s):

Stella Zawedde-Muyanja ◽

Achilles Katamba ◽

Adithya Cattamanchi ◽

Barbara Castelnuovo ◽

Yukari C Manabe

Keyword(s):

Public Health ◽

Health Facility ◽

High Volume ◽

Health Facilities ◽

High Rate ◽

Loss To Follow Up ◽

Public Health Facilities ◽

Factors Associated ◽

Tb Treatment

Abstract Background: In 2018, Uganda started only 65% of persons with incident tuberculosis on treatment. Pretreatment loss to follow up is an important contributor to suboptimal treatment coverage. We aimed to describe the patient and health facility-level characteristics associated with pretreatment loss to follow up among patients diagnosed with pulmonary tuberculosis at public health facilities in Uganda. Methods: At ten public health facilities, laboratory register data was used to identify patients aged 15 years who had a positive Xpert®MTB/RIF test. Initiation on TB treatment was ascertained using the clinical register. Factors associated with not being initiated on TB treatment within two weeks of diagnosis were examined using a multilevel logistic regression model accounting for clustering by health facility. Results:From January to June 2018, 510 patients (61.2% male and 31.5% HIV co-infected) were diagnosed with tuberculosis. One hundred (19.6%) were not initiated on TB treatment within two weeks of diagnosis. Not having a phone number recorded in the clinic registers (aOR 7.93, 95%CI 3.93-13.05); being HIV-infected (aOR 1.83; 95% CI: 1.09-3.26) and receiving care from a high volume health facility performing more than 12 Xpert tests per day (aOR 4.37, 95%CI 1.69-11.29) and were significantly associated with pretreatment loss to follow up. Conclusion: In public health facilities in Uganda, we found a high rate of pretreatment loss to follow up especially among TBHIV co-infected patients diagnosed at high volume health facilities. Interventions to improve the efficiency of Xpert® MTB/RIF testing, including monitoring of the TB care cascade should be developed and implemented.

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Understanding pretreatment loss to follow-up of tuberculosis patients: an explanatory qualitative study in Chennai, India

BMJ Global Health ◽

10.1136/bmjgh-2019-001974 ◽

2020 ◽

Vol 5 (2) ◽

pp. e001974 ◽

Cited By ~ 2

Author(s):

Beena E Thomas ◽

Chandra Suresh ◽

J Lavanya ◽

Mika M Lindsley ◽

Amith T Galivanche ◽

...

Keyword(s):

Health System ◽

Healthcare Worker ◽

Qualitative Interviews ◽

Explanatory Model ◽

Group Discussions ◽

Loss To Follow Up ◽

Sputum Microscopy ◽

Worker Absenteeism ◽

Lost To Follow Up

IntroductionPretreatment loss to follow-up (PTLFU)—dropout of patients after diagnosis but before treatment registration—is a major gap in tuberculosis (TB) care in India and globally. Patient and healthcare worker (HCW) perspectives are critical for developing interventions to reduce PTLFU.MethodsWe tracked smear-positive TB patients diagnosed via sputum microscopy from 22 diagnostic centres in Chennai, one of India’s largest cities. Patients who did not start therapy within 14 days, or who died or were lost to follow-up before official treatment registration, were classified as PTLFU cases. We conducted qualitative interviews with trackable patients, or family members of patients who had died. We conducted focus group discussions (FGDs) with HCWs involved in TB care. Interview and FGD transcripts were coded and analysed with Dedoose software to identify key themes. We created categories into which themes clustered and identified relationships among thematic categories to develop an explanatory model for PTLFU.ResultsWe conducted six FGDs comprising 53 HCWs and 33 individual patient or family member interviews. Themes clustered into five categories. Examining relationships among categories revealed two pathways leading to PTLFU as part of an explanatory model. In the first pathway, administrative and organisational health system barriers—including the complexity of navigating the system, healthcare worker absenteeism and infrastructure failures—resulted in patients feeling frustration or resignation, leading to disengagement from care. In turn, HCWs faced work constraints that contributed to many of these health system barriers for patients. In the second pathway, negative HCW attitudes and behaviours contributed to patients distrusting the health system, resulting in refusal of care.ConclusionHealth system barriers contribute to PTLFU directly and by amplifying patient-related challenges to engaging in care. Interventions should focus on removing administrative hurdles patients face in the health system, improving quality of the HCW-patient interaction and alleviating constraints preventing HCWs from providing patient-centred care.

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Factors associated with loss to follow-up among people with tuberculosis in the country of Georgia: a cohort study

Monaldi Archives for Chest Disease ◽

10.4081/monaldi.2021.1705 ◽

2021 ◽

Vol 91 (1) ◽

Author(s):

Natalia Adamashvili ◽

Kristina Akopyan ◽

Nestani Tukvadze ◽

Kostyantyn Dumchev ◽

Yuliia Sereda ◽

...

Keyword(s):

Cohort Study ◽

Universal Access ◽

Treatment Interruption ◽

Second Line ◽

First Line ◽

Loss To Follow Up ◽

Pulmonary Tb ◽

Factors Associated ◽

Tb Treatment

Despite having universal access to tuberculosis (TB) treatment, loss to follow-up (LFU) rates remain high in Georgia, 6% among drug-susceptible TB (DS-TB) patients (2017 cohort) and 19% among drug-resistant TB (DR-TB) patients diagnosed in 2016. A cohort study was conducted to analyze secondary data from the Georgian National Tuberculosis Surveillance Database. Study population included adult (≥18 y.o.) patients with bacteriologically confirmed pulmonary TB who were enrolled in Georgian National TB program during 2015-2017. The outcome of interest was loss to follow-up, defined as treatment interruption for more than 2 consecutive months. Patients were stratified by treatment profile (first-line drugs or second-line drugs) and survival analysis was performed within the stratified groups. A total of 7860 treatment episodes were identified during 2015-2017 which corresponded to 6696 bacteriologically confirmed pulmonary TB treatment episodes of whom 795 (12%) were LFU. After adjustment, final multivariate analysis showed that male sex (aHR 1.5, 95%CI 1.2-2.0), being diagnosed in Tbilisi (aHR 1.3, 95%CI 1.1-1.6), unemployment at the time of diagnosis (aHR 1.7, 95%Ci 1.2-2.3) and previous history of TB treatment were independent risk factors for LFU (aHR 2.3, 95%CI 1.9-2.8) among patients on first-line drugs. Among patients on second-line drugs being male (aHR 2.0, 95%CI 1.2-3.2), past TB treatment with second-line drugs (aHR 2.2, 95%CI 1.5-3.2) were significantly associated with LFU. LFU rate was high among patients on first-line drugs and second line drugs (10% and 22% respectively). Patients with past TB treatment history should further research to identify factors that lead to treatment interruption in this group. Other factors associated with LFU (being internally displaced person (IDP), being unemployed, and having imprisonment history) were in some level indication of a poor social-economic status, and strengthening approaches for TB care based on patients’ need could be considered in light of this finding.

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Estimating the effect of pretreatment loss to follow up on TB associated mortality at public health facilities in Uganda

PLoS ONE ◽

10.1371/journal.pone.0241611 ◽

2020 ◽

Vol 15 (11) ◽

pp. e0241611

Author(s):

Stella Zawedde-Muyanja ◽

Joseph Musaazi ◽

Yukari C. Manabe ◽

Achilles Katamba ◽

Joaniter I. Nankabirwa ◽

...

Keyword(s):

Public Health ◽

Health Facility ◽

Health Facilities ◽

Vital Status ◽

Loss To Follow Up ◽

Public Health Facilities ◽

Tb Treatment ◽

Health Facility Level ◽

Facility Level

Introduction Tuberculosis (TB) mortality estimates derived only from cohorts of patients initiated on TB treatment do not consider outcomes of patients with pretreatment loss to follow-up (LFU). We aimed to assess the effect of pretreatment LFU on TB-associated mortality in the six months following TB diagnosis at public health facilities in Uganda. Methods At ten public health facilities, we retrospectively reviewed treatment data for all patients with a positive Xpert®MTB/RIF test result from January to June 2018. Pretreatment LFU was defined as not initiating TB treatment within two weeks of a positive test. We traced patients with pretreatment LFU to ascertain their vital status. We performed Kaplan Meier survival analysis to compare the cumulative incidence of mortality, six months after diagnosis among patients who did and did not experience pretreatment LFU. We also determined the health facility level estimates of TB associated mortality before and after incorporating deaths prior to treatment initiation among patients who experienced pretreatment LFU. Results Of 510 patients with positive test, 100 (19.6%) experienced pretreatment LFU. Of these, we ascertained the vital status of 49 patients. In the six months following TB diagnosis, mortality was higher among patients who experienced pretreatment LFU 48.1/1000py vs 22.9/1000py. Hazard ratio [HR] 3.18, 95% confidence interval [CI] (1.61–6.30). After incorporating deaths prior to treatment initation among patients who experienced pretreatment LFU, health facility level estimates of TB associated mortality increased from 8.4% (95% CI 6.1%-11.6%) to 10.2% (95% CI 7.7%-13.4%). Conclusion Patients with confirmed TB who experience pretreatment LFU have high mortality within the first six months. Efforts should be made to prioritise linkage to treatment for this group of patients. Deaths that occur prior to treatment initation should be included when reporting TB mortality in order to more accurately reflect the health impact of TB.

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Access to colposcopy in the State of São Paulo, Brazil: probabilistic linkage study of administrative data

Cadernos de Saúde Pública ◽

10.1590/0102-311x00304820 ◽

2022 ◽

Vol 38 (1) ◽

Author(s):

Lewis Fletcher Buss ◽

Lise Cury ◽

Caroline Madalena Ribeiro ◽

Gulnar Azevedo e Silva ◽

José Eluf Neto

Keyword(s):

Public Health ◽

Cervical Cancer ◽

Health System ◽

Public Health System ◽

Sao Paulo ◽

The State ◽

São Paulo ◽

The Public ◽

Reference Cohort

Cervical cancer screening is a multistage process, therefore access to both the primary test and subsequent diagnostic procedures is essential. Considering women undergoing screening on the public health system in the State of São Paulo, Brazil, we aimed to estimate the proportion of women accessing colposcopy within six months of an abnormal smear result. We retrieved records from two administrative databases, the Information System on Uterine Cervical Cancer (SISCOLO) that contains smear results and the Outpatient Information System of the Brazilian Unified National Health System (SIA/SUS) that records colposcopies. A reference cohort consisted of women, aged 25 years or older, with an abnormal smear result between May 1, 2014, and June 30, 2014. We excluded prevalent cases. We linked the reference cohort and records in the SIA/SUS extending to December 31, 2014. After excluding prevalent cases, 1,761 women with abnormal cytology results were left. A total of 700 (39.8%) women were linked to a colposcopy record within the follow-up period; this dropped to 671 (38.1%) women when follow-up was censored at six months. We could notice a slightly higher attendance in women living in the metropolitan region of São Paulo compared with residents of the rest of the state. We found no association between colposcopy attendance and age or cytology class. These results emphasize that access to colposcopy in the public health system in São Paulo is limited. This compromises the quality of screening, and the issue needs to be prioritized in service planning.

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‘They are inconveniencing us’ - Exploring how gaps in patient education and patient centred approaches interfere with TB treatment adherence: Perspectives from patients and clinicians in the Free State Province, South Africa.

10.21203/rs.3.rs-15676/v1 ◽

2020 ◽

Author(s):

Nishila Moodley ◽

Amashnee Saimen ◽

Noor Mahomed Zakhura ◽

David Motau ◽

Geoff Setswe ◽

...

Keyword(s):

South Africa ◽

Health Literacy ◽

Treatment Adherence ◽

Treatment Interruption ◽

Social Dimension ◽

Free State ◽

Free State Province ◽

Loss To Follow Up ◽

Tb Treatment

Abstract Background: Tuberculosis (TB) treatment loss to follow up (LTFU) plays an important contributory role to the staggering TB epidemic in South Africa. Reasons for treatment interruption are poorly understood. Treatment interruption appears to be the culmination of poor health literacy of patients and limited health education provided by clinicians. We explored clinician and patient perspectives of the gaps in TB messaging that influence TB treatment LTFU. Methods: We conducted semi-structured in-depth interviews between January and May 2018 with a sample of 15 clinicians managing TB and 7 patients identified as LTFU in public clinics in the Free State Province, South Africa. We used thematic analysis with deductive and inductive approaches. Results: Limited occupational opportunities, fear of disclosure and stigmatization all contributed to treatment LTFU. Patients felt that the TB messaging received was inadequate. Many of the clinicians interviewed felt that improving patient’s TB knowledge would reinforce adherence to treatment and thus focused on sharing information on treatment completion, side effects and infection control. However, the inability of clinicians to establish rapport with patients or to identify social support challenged TB treatment adherence by patients. Clinicians perceived this as patients did not follow their instructions despite what they considered lengthy TB education. Having said this, clinicians concurred that their medical management of TB lacked the psycho-social dimension to treat a social disease of this magnitude. Conclusions: Limited occupational opportunities, fear of disclosure and stigmatization all contributed to treatment LTFU. Clinicians concurred that poor patient understanding of TB and that biomedical management lacking a psycho-social dimension further exacerbated the poor treatment outcome. TB remains a social disease, the successful management of which hinges on patient-centred care. Keywords: tuberculosis TB, adherence, messaging, loss to follow up, knowledge, health literacy, patient-centered care

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