Cost implications of delays to tuberculosis diagnosis among pulmonary tuberculosis patients in Ethiopia.

BACKGROUND: Delays seeking care worsen the burden of tuberculosis and cost of care for patients, families and the public health system. This study investigates costs of tuberculosis diagnosis incurred by patients, escorts and the public health system in 10 districts of Ethiopia. METHODS: New pulmonary tuberculosis patients > or = 15 years old were interviewed regarding their health care seeking behaviour at the time of diagnosis. Using a structured questionnaire patients were interviewed about the duration of delay at alternative care providers and the public health system prior to diagnosis. Costs incurred by patients, escorts and the public health system were quantified through patient interview and review of medical records. RESULTS: Interviews were held with 537 (58%) smear positive patients and 387 (42%) smear negative pulmonary patients. Of these, 413 (45%) were female; 451 (49%) were rural residents; and the median age was 34 years. The mean (median) days elapsed for consultation at alternative care providers and public health facilities prior to tuberculosis diagnosis was 5 days (0 days) and 3 (3 days) respectively. The total median cost incurred from first consultation to diagnosis was $27 per patient (mean = $59). The median costs per patient incurred by patient, escort and the public health system were $16 (mean = $29), $3 (mean = $23) and $3 (mean = $7) respectively. The total cost per patient diagnosed was higher for women, rural residents; those who received government food for work support, patients with smear negative pulmonary tuberculosis and patients who were not screened for TB in at least one district diagnostic centers. CONCLUSIONS: The costs of tuberculosis diagnosis incurred by patients and escorts represent a significant portion of their monthly income. The costs arising from time lost in seeking care comprised a major portion of the total cost of diagnosis, and may worsen the economic position of patients and their families. Getting treatment from alternative sources and low index of suspicion public health providers were key problems contributing to increased cost of tuberculosis diagnosis. Thus, the institution of effective systems of referral, ensuring screening of suspects across the district public health system and the involvement of alternative care providers in district tuberculosis control can reduce delays and the financial burden to patients and escorts.

Delayed consultation among pulmonary tuberculosis patients: a cross sectional study of 10 DOTS districts of Ethiopia.

BACKGROUND: Delays seeking care increase transmission of pulmonary tuberculosis and hence the burden of tuberculosis, which remains high in developing countries. This study investigates patterns of health seeking behavior and determines risk factors for delayed patient consultation at public health facilities in 10 districts of Ethiopia. METHODS: New pulmonary TB patients >or= 15 years old were recruited at 18 diagnostic centres. Patients were asked about their health care seeking behaviour and the time from onset of symptoms to first consultation at a public health facility. First consultation at a public health facility 30 days or longer after onset of symptoms was regarded as prolonged patient delay. RESULTS: Interviews were held with 924 pulmonary patients. Of these, 537 (58%) were smear positive and 387 (42%) were smear negative; 413 (45%) were female; 451 (49%) were rural residents; and the median age was 34 years. Prior to their first consultation at a public health facility, patients received treatment from a variety of informal sources: the Orthodox Church, where they were treated with holy water (24%); private practitioners (13%); rural drug vendors (7%); and traditional healers (3%). The overall median patient delay was 30 days (mean = 60 days). Fifty three percent [95% Confidence Intervals (CI) (50%, 56%)] of patients had delayed their first consultation for >or= 30 days. Patient delay for women was 54%; 95% CI (54%, 58%) and men 51%; 95% CI (47%, 55%). The delay was higher for patients who used informal treatment (median 31 days) than those who did not (15 days). Prolonged patient delay (>or= 30 days) was significantly associated with both patient-related and treatment-related factors. Significant patient-related factors were smear positive pulmonary disease [Adjusted Odds Ratio (AOR) 1.4; 95% CI (1.1 to 1.9)], rural residence [AOR 1.4; 95% CI (1.1 to 1.9)], illiteracy [AOR 1.7; 95% CI (1.2 to 2.4)], and lack of awareness/misperceptions of causes of pulmonary TB. Significant informal treatment-related factors were prior treatment with holy water [AOR 3.5; 95% CI (2.4 to 5)], treatment by private practitioners [AOR 1.7; 95% CI (1.1 to 2.6)] and treatment by drug vendors [AOR 1.9; 95% CI (1.1 to 3.5)]. CONCLUSION: Nearly half of pulmonary tuberculosis patients delayed seeking health care at a public health facility while getting treatment from informal sources. The involvement of religious institutions and private practitioners in early referral of patients with pulmonary symptoms and creating public awareness about tuberculosis could help reduce delays in starting modern treatment.

A cluster randomised controlled trial of the effect of a treatment algorithm for hypertension in patients with type 2 diabetes.

BACKGROUND: Good blood pressure (BP) control reduces the risk of complications in people with type 2 diabetes, yet many do not achieve this. Guidelines for managing hypertension recommend increasing antihypertensive medications until control is achieved, but the effect of such recommendations in routine primary care is unknown. AIM: To evaluate the effectiveness of a BP treatment algorithm in primary care patients with type 2 diabetes. DESIGN OF STUDY: A cluster randomised controlled trial of 1534 patients with type 2 diabetes. SETTING: Forty-two practices in Nottingham, UK. METHOD: Practices were randomised to continue usual care or to use a treatment algorithm designed so that practice nurses and GPs would increase antihypertensive treatment in steps until the target of 140/80 mmHg was reached. Participants were assessed by a clinical interview and case note review at recruitment and at 1 year. The primary outcome measure was the proportion of participants achieving target BP at 1 year. RESULTS: At 1 year there was no difference between the proportions of participants with well controlled BP in the intervention and control arms (36.6% versus 34.3%; P = 0.27). Mean systolic and diastolic blood pressures were identical in the two arms (143/78 mmHg). There was some evidence that participants in the intervention arm were more likely to be receiving higher doses of their antihypertensive drugs, although there was no significant difference in the number of different antihypertensive drugs prescribed. Participants in the intervention arm had a higher rate of primary care BP-related consultations over 12 months than those receiving usual care (rate ratio = 1.55, 95% confidence interval [CI] = 1.26 to 1.88, P<0.001). CONCLUSION: Despite increased monitoring and possibly higher doses of medication there was no improvement in blood pressure control. Improvements achieved by specialist nurse-led clinics in secondary care may not translate to people with type 2 diabetes in primary care settings.

Indicators of mortality in African adults with malaria.

Malaria is a major cause of morbidity and mortality amongst adults in sub-Saharan Africa, but descriptions of symptoms and mortality in this group have received little attention in the past. A retrospective study was performed on adults admitted to a tertiary hospital in Tanzania with a primary diagnosis of malaria. Frequency and mortality for the criteria in the WHO definition of severe malaria were recorded. Logistic regression analysis was then used to identify symptoms with the greatest prognostic value. Two hundred and sixty-nine adults (median age 28 years) with a primary diagnosis of malaria were studied, with an overall mortality rate of 15.2%. Logistic regression identified three key prognostic indicators: unconsciousness (odds ratio (OR) 44.44; 95% CI 4.05-488.24), renal failure (OR 7.37; 95% CI 1.70-31.96) and pulmonary oedema (OR 13.83; 95% CI 3.52-54.32). Whilst the WHO criteria predicted all of the 41 adults who died, 37 (90.2%) had at least one of the following symptoms: unconsciousness (n=39, fatality rate 74.4%), renal failure (n=26, fatality rate 66.7%) and pulmonary oedema (n=28, fatality rate 64.3%). These symptoms can therefore identify those at a high risk of death in African adults with malaria.

Quality of tuberculosis care and its association with patient adherence to treatment in eight Ethiopian districts.

BACKGROUND: Little is known about the quality of tuberculosis (TB) service delivery in public health facilities in Ethiopia and its association with patients' non-adherence to TB treatment. This study assessed the organization, management and processes of TB care delivery, and their effects on patients' adherence to TB treatment. METHODS: The quality of TB care was investigated in 44 public health facilities from three perspectives: structure, processes of TB care delivery and patient treatment outcome. Quality of care was determined by adherence to national TB guidelines. On-site observations of TB service delivery and interviews with health providers were conducted to evaluate structural factors. Patients (n = 237) in the health facilities were interviewed prospectively at completion of their treatment to determine the quality of tuberculosis care delivered. Three measures of treatment adherence [treatment interruption (>or=2 weeks), availability of unused TB drugs and treatment default] were quantified from a review of patient treatment registers and an audit of unused TB drugs at patients' homes. Effects were identified of poor quality structures and processes of service delivery on these three measures of adherence. RESULTS: TB care providers were untrained in 18 (44%) of 44 facilities and daily outpatient TB care was not given in 13 of 44 (25%). Among the 237 patients, 43% interrupted treatment for >or=15 days and 30% had at least 1 day's dose of TB drugs unused. Patients tended to interrupt and default from treatment when their care provider had been inadequately supervised by district TB control experts and was incapable of dealing with patients' minor illnesses. Unavailability of daily TB care in health facilities was associated with missing daily doses. CONCLUSION: Better training of TB care providers and district supervisory support could be important interventions to improve the quality of care delivery and patient adherence to treatment.

Practice and patient characteristics related to blood pressure in patients with type 2 diabetes in primary care: a cross-sectional study.

BACKGROUND: Good blood pressure control reduces the risk of long-term complications of diabetes; however, most people with diabetes do not achieve recommended blood pressure targets. OBJECTIVE: To quantify the relationships between patient and practice factors and blood pressure in patients with type 2 diabetes. METHODS: A cross-sectional study was carried out in 42 general practices in Nottingham. Participants were 1534 people with type 2 diabetes. Patient characteristics were assessed by a clinical interview and case note review and practice characteristics by questionnaire. The outcome measures were systolic and diastolic blood pressure. RESULTS: In all, 46% of participants had well-controlled blood pressure (or= 25 kg/m(2), and increased with alcohol consumption. Systolic blood pressure increased whereas diastolic blood pressure decreased with increasing age and duration of diabetes. Current smokers and ex-smokers had a significantly lower diastolic blood pressure than those who had never smoked. Patients from practices where blood pressure targets were negotiated with most patients had significantly lower mean systolic and diastolic blood pressure than those where targets were negotiated with few patients. CONCLUSIONS: A number of patient characteristics are associated with blood pressure. Negotiating individual goals for blood pressure may be important in achieving blood pressure control in patients with type 2 diabetes. Further research is required to confirm this finding and to explore the process of negotiating targets.

Designing smoking cessation services for school-age smokers: A survey and qualitative study.

To identify the preferred design characteristics of smoking cessation services for school-age smokers, we conducted focus groups with teenage smokers motivated to stop smoking. We surveyed all pupils in years 9-11 (aged 13-16) in a random sample of 10 schools in Nottinghamshire, United Kingdom, to elicit details of smoking behavior, and conducted 25 focus groups in 6 schools with current smokers who wanted to stop smoking. Of 4,065 pupils surveyed, 888 (22%) were current smokers, and 438 (50% of smokers) wanted to quit smoking. We sampled 226 of these individuals for focus group studies, and 135 (60%) participated. These participants were motivated to quit, and almost all had tried to do so but had found it too difficult. Many were aware of smoking cessation methods but had low perceptions of their effectiveness based on their own or others' poor experiences of these interventions, and few were aware of the possibility of professional cessation support. Given clear, nondirective information about interventions, participants reported a preference for confidential, nonjudgmental services delivered during school time by a trained counselor, allowed the option to attend with friends, and offered nicotine replacement therapy (NRT). School-age smokers in Nottinghamshire, United Kingdom, who are motivated to stop smoking have low knowledge and opinions of smoking cessation interventions. Our findings indicate that young smokers would favor school-based services offering confidential professional counseling and NRT.

Prospective study of the effect of exposure to other smokers in high school tutor groups on the risk of incident smoking in adolescence.

Adolescent smokers tend to have peers who smoke, but it is unclear whether this arises from self-selection of smoking peers or whether this is a causal effect on the uptake of smoking (incident smoking). The authors used school tutor group current smoking prevalence, an unbiased measure of peer smoking in high schools in the United Kingdom, to estimate the independent effect of peer smoking on incident smoking among high school students. In a prospective cohort study of children aged 13-15 years (grades 9 and 10) in 10 high schools in Nottinghamshire, United Kingdom, smoking behavior was surveyed in 2,881 students in 2000, and the survey was repeated in 2,109 students (73%) in 2001. There were 267 incident smokers (15%) among the 1,766 nonsmokers in 2000. The adjusted odds of incident smoking were significantly higher in girls, in students with parents or siblings who smoke, and in relation to school tutor group current smoking prevalence in 2000 (relative odds for highest relative to the lowest quartile of prevalence = 1.78, 95% confidence interval: 1.20, 2.64). This tutor group effect was independent of having a best friend who smoked in the 2001 study. Incident smoking is therefore increased among students exposed to other students who smoke, and preventing smoking at school may reduce adolescent smoking.