Factors affecting delays in diagnosis and treatment of pulmonary tuberculosis in a tertiary care hospital in Istanbul, Turkey pptx

Results: Mean application interval was 31.4 days, mean referral interval was 22.1 days, mean diagnosis interval was 3.3 days, and mean initiation of treatment interval was 1.4 days.. Del

Clinical Research PMID: 14737045

Factors affecting delays in diagnosis and treatment

of pulmonary tuberculosis in a tertiary care hospital

in Istanbul, Turkey

Döndü Güneylioglu bdefg, Adnan Yilmaz abcdefg, Sevinc¸ Bilgin bdf, Ümmühan Bayram bf, Esen Akkaya ace

Department of Pulmonology, SSK Süreyyapas¸a Center for Chest Diseases and Thoracic Surgery, Istanbul-Turkey Source of support: none.

Summary

Background: To investigate delays in the diagnosis and treatment of inpatients with smear-positive

pul-monary tuberculosis and to identify factors affecting these delays

Materials/Methods: 204 hospitalized patients with smear-positive pulmonary tuberculosis were identified The

clinical files of the patients were analyzed and questionnaires were created

Results: Mean application interval was 31.4 days, mean referral interval was 22.1 days, mean diagnosis

interval was 3.3 days, and mean initiation of treatment interval was 1.4 days Patient delay was present in 34.8 percent of the patients The application interval was shorter for patients hav-ing an index case for tuberculosis (p=0.039) and for those with good economic status (p<0.005) 167 patients (81.9%) had institutional delay The referral interval was longer for female patients than for male patients (p=0.015) The most common causes of institutional delays were a low index of suspicion for tuberculosis, health care system delays, and underuti-lized chest X-ray examinations One hundred and three patients (50.5%) had delays in diag-nosis and 51 patients (25.0%) had delays in treatment The most frequent reason for diagnos-tic delay was health care system delays (35.9%)

Conclusions: There were several delays in the diagnosis of tuberculosis patients For an effective

tuberculo-sis control, efforts should be made to reduce these delays Physicians and the public should be educated about tuberculosis Health care system and laboratory delays should be improved

key words: delays • smear-positive • pulmonary tuberculosis • diagnosis, treatment

Full-text PDF: http://www.MedSciMonit.com/pub/vol_10/no_2/3261.pdf

Received: 2002.11.07

Accepted: 2003.07.03

Published: 2004.02.01

Author’s address: Dr Adnan Yilmaz, Maltepe Zümrütevler Atatürk Cad Abant Apt No:30 81530 Istanbul, Turkey,

e-mail: elifim@rt.net.tr

Authors’ Contribution:

A Study Design

B Data Collection

C Statistical Analysis

D Data Interpretation

E Manuscript Preparation

F Literature Search

G Funds Collection

BACKGROUND

Prior to the twentieth century, tuberculosis was one of

the major causes of death in both developed and

devel-oping countries [1] During the twentieth century it

con-tinued to be a major public health problem worldwide

In 1993, the World Health Organization (WHO)

declared a state of global emergency for tuberculosis due

to the steady increase of the disease worldwide [2] It is

estimated that by the year 2005 12 million cases of

tuber-culosis will be identified in the world annually, a 58%

increase from the 7.5 million estimated for 1990 [3] It

was reported that 19% to 43% of the world’s population

was infected with Mycobacterium tuberculosis [4] One of

the main objectives in any tuberculosis control program

is to reduce tuberculosis transmission in the community

through early detection of tuberculosis cases and prompt

implementation of a full course of therapy [5] This is

especially important in the case of untreated

smear-posi-tive patients, who are the main sources of infection in a

community [5,6] Delays in the diagnosis and start of

effective treatment of tuberculosis patients result in a

prolonged period of infectivity in the community and

health care workers [7–9] These delays have been noted

in both high- and low-prevalence countries [6,7,10–16]

Turkey has an estimated incidence of tuberculosis of 30

per 100,000 of the population The SSK Süreyyapalba

Center, located in Istanbul, is a tertiary care hospital for

chest diseases and tuberculosis This center is one of

Turkey’s main health facilities and provides treatment

to tuberculosis patients who have been referred by

dis-trict health care facilities throughout the country In

this study, we aimed to investigate delays in the

diagno-sis and treatment of hospitalized patients with

smear-positive pulmonary tuberculosis and to identify the

fac-tors affecting these delays

MATERIAL ANDMETHODS

The present study was conducted at the SSK

Sürey-yapalba Center for Chest Disease and Thoracic Surgery,

consisting of 1600 beds We reviewed the clinic records

of all patients hospitalized between June and August

2001 and identified 204 newly diagnosed inpatients

with smear-positive pulmonary tuberculosis Cases with

previous histories of tuberculosis treatment were

excluded

Study design

The clinical files of the cases were analyzed and a

ques-tionnaire was created to obtain data by interview For

each patient, the following information was gathered:

(1) sex, (2) age, (3) education level, (4) area of residence,

(5) index case, (6) economic status, (7) first symptom, (8)

first visiting physician, (9) symptom duration, (10) date

of first doctor visit, (11) date of admission to hospital,

(12) date of diagnosis, and (13) date of treatment

initia-tion The presence of cough, fever, night sweats,

hemoptysis, weight loss, anorexia, fatigue, and dyspnea

were the criteria for the onset date of symptoms

Patients were classified as ‘urban’ if they lived in a city

or metropolis and ‘rural’ if they lived in the towns and villages surrounding these The patients were catego-rized into three groups with respect to their economic status When monthly income was below $200 (US), the patient’s economic status was regarded as poor

Monthly income was between $200 and $550 for patients with moderate economic status Patients with good economic status had monthly incomes over $550

The following time intervals and delays were

deter-mined for each patient: The patient’s application interval

was defined as the time interval between the onset of symptoms and the first doctor visit Intervals that

exceeded 30 days were considered indicative of a patient delay [12] The referral interval was defined as the time

from the first doctor visit to admission [17] With regard

to our health care system, intervals that exceeded two

days were considered indicative of an institutional delay [14] The diagnosis interval was regarded as the time from

admission to a positive acid-fast smear Intervals that exceeded one day were considered indicative of a

delayed diagnosis [14,18] The treatment interval was the

time from diagnosis to initiation of treatment Intervals that exceeded one day were considered indicative of a

delayed treatment [14,18] Clinic delay was defined as the

time from admission to initiation of treatment Regar-ding the diagnosis and treatment intervals, those that exceeded two days were considered indicative of a

delay Doctor delay was defined as the time from the first

doctor visit to initiation of treatment Intervals that exceeded four days were considered indicative of a delay [14,19] Figure 1 presents the time intervals and delays The reasons for the delays were also evaluated

Statistical analysis

The chi-square test, ANOVA test or Student-t test were used to assess differences between groups

RESULTS During the study period, 204 new smear-positive adult patients were evaluated There were 122 male and 82 female The mean age of the patients was 38.6 years (range 14–90 years) One hundred and eighteen patients (57.9%) had primary school education, 56 (27.4%) had secondary school education, 7 (3.4%) were university graduates and 23 (11.3%) had no formal edu-cation One hundred and fifty-one patients (74%) lived

in urban areas and 53 patients (26%) in rural areas

While 139 patients (68.1%) had no history of an index case for tuberculosis, there was a positive history in 65 cases (31.9%)

Table 1 presents the values of the intervals The mean values of the time intervals (SD) were 31.4 (38.9) days for the application interval, 22.1 (29.7) days for the referral interval, 3.3 (5.2) days for the diagnosis interval, and 1.4 (1.8) days for the initiation of treatment inter-val The application interval was shorter than 30 days in

133 patients (65.2%) and longer than 30 days in 71 patients (34.8%) According to these results, 34.8% of the patients had patient delays

Table 2 gives a sub-analysis of application interval and

patient delays with respect to several factors Age, sex,

area of residence, and education level had no effect on

the application interval Significantly shorter mean

appli-cation intervals were noted in patients having an index

case for tuberculosis (p=0.04) and patients who had good

economic status (p=0.03) The rate of cases having

patient delay was lower among patients with hemoptysis

than patients with other first symptoms (p=0.04)

Factors associated with the referral interval are

summa-rized in Table 3 The referral interval was shorter than

three days in 37 patients (18.1%) This interval was

between 3 and 10 days in 64 patients (31.4%) and was

longer than 10 days in 103 patients (50.5%) One

hun-dred and sixty-seven (81.9%) patients had institutional

delay Sub-analysis identified 200 reasons for

institu-tional delay in these patients While age, education

level, residence area, and economic status had no effect

on the referral interval, this interval was significantly

shorter in male patients (p=0.015) Similarly, the rate of

cases having institutional delay was significantly lower

among male patients (p=0.003) Patients referred by a

chest specialist had a significantly shorter referral

inter-val than those referred by the other physicians

(p=0.043), with a subsequent lower rate of institutional

delay (p=0.038) Of the 167 patients with an

institution-al delay, tuberculosis was not suspected in 82 patients

(41%) at the time of their first visit Fifty-one patients

(25.5%) had delays in chest-X ray examinations There

were delays in the health care system in 47 (23.5%)

patients Economic status resulted in institutional delays

in twelve patients (6%) The reason of institutional delay

was not identified in eight patients (4%)

Table 4 shows the distribution of the diagnosis intervals and initiation of treatment intervals with respect to days One hundred and three patients (50.5%) had delays in diagnosis and 51 patients (25%) had delays in initiation of treatment The mean (95%, CI) diagnosis interval was 3.7 days (2.5 to 4.0 days) in male patients and 2.4 days (1.9 to 2.9 days) in female patients (p=0.015) Age and education level had no effect on the diagnosis interval Our health care system resulted in delayed diagnosis in 37 patients (35.9%) Reasons for delayed diagnosis included underutilized or delayed sputum examinations for acid-fast smears in 30 patients (29.1%) A low index of suspicion for tuberculosis by a chest physician was a reason of delayed diagnosis in 22 patients (21.4%) While laboratory delays were identi-fied in 9 patients (8.7%), no reason was determined for delayed diagnosis in 5 patients (4.9%) The mean initia-tion of treatment interval (95%, CI) was 1.5 days (1.2 to 1.8 days) in male patients and 1.3 days (0.9 to 1.7 days)

in female patients (p>0.05) Age and education level had no effect on this interval

The distribution of time from the first doctor visit to ini-tiation of treatment with respect to days is shown in Table 5 The mean (95%, CI) interval was 26.7 days (22.5 to 30.8 days) and median interval was 15 days There were doctor delays in 178 of 204 patients (87.2%) The mean interval (95%, CI) from onset of symptoms to initiation of treatment was 64.1 days (55.2

to 73.1 days) This interval suggested total delay

DISCUSSION

We analyzed delays in the diagnosis and treatment of inpatients with smear-positive pulmonary tuberculosis and factors affecting these delays The present study indicated that there were several delays between the onset of symptoms and initiation of treatment in our patients These delays included patient delay, institu-tional delay, diagnostic delay, and delay in the treat-ment Both patient and institutional delays result in increased infection risk for the population Diagnostic and treatment delays result in increased infection risk for medical personnel [14] An untreated smear-positive patient may infect on average more than 10 contacts

onset of first visit to admission to diagnosis initiation of symptoms physician hospital treatment

patient’s delay institutional diagnostic delay delayed treatment

delay

application interval referral interval diagnosis interval treatment interval

doctor’s delay

Clinic delay

Figure 1 Components of the

time from onset of

symptoms to initiation

of treatment and the

delays

Application

Referral

Diagnosis

Treatment

31.4

22.1

3.3

1.4

38.9 29.7 5.2 1.8

17.5 11.0 1.5 1.0

26.1–36.7 18.1–26.2 2.5–4.0 1.2–1.7

Table 1 The values associated with several intervals (days).

annually [20] A previous report indicated that at least

24% of the employees exposed to infectious tuberculosis

in their office for 4 months were infected [13] Delays

for patients with pulmonary tuberculosis are more

com-mon in developing countries [10,12,14] A has previous

report suggested that delays associated with pulmonary

tuberculosis were common in Turkey [14] Delays have

also been reported in developed countries [7,11,13]

In our study, the median application interval was found

to be 17.5 days Seventy-one patients (34.8%) had

patient delay While many reports present a shorter

median application interval than ours [21,22], longer

median application intervals were noted in two previous

studies [10,12] This interval was between 0.3 weeks and

120 days in these reports [12,22] A previous report

indicated that 28.4 percent of the patients had patient

delay and that the median application interval was 17.5

days [14] The rate of patient delay was slightly higher

in the present study than in our previous report

Similar median application intervals were determined

in these series

This study showed that the rates of doctor delay were

higher than those of patient delay We noted that one

hundred and seventy-eight patients (87.2%) had doctor

delay and that the median doctor delay was 15 days A

previous report indicated that the rate of doctor delay

was 88.2% and that the median doctor delay was 9 days

[14] Liam et al reported that median doctor delay was

7 weeks [21] Doctor delay included institutional delay,

diagnostic delay and delayed treatment [14] The rates

of delay were 81.9% for institutional delay, 50.5% for diagnostic delay, and 25% for delayed treatment in the present study These results indicate that the rate of institutional delay was more significant than those of delays in diagnosis and treatment In a previous study, the rates of institutional, diagnostic and treatment delays were presented as 61.1%, 69.4% and 25.4%, respectively [14] Pirkis et al reported lower rates of delayed treatment than our study [11] The median interval for diagnosis was 6.5 days in a previous report [7] Taylor et al [17] noted that the median referral interval was 18 days When our results were compared with these reports, it was suggested that our patients had shorter median referral and diagnosis intervals, but longer treatment intervals

It is known that the length of the interval may be associ-ated with several factors [12,16,21,23–25] Long et al

reported that the application interval was longer among women than among men [22] A previous report noted longer patient delay in patients aged 45 years and over and in rural patients [12] However, Liam et al showed that sex [21], age, education level, and initial symptom had no significant association with patient delay We ascertained lower application intervals for patients hav-ing an index case for tuberculosis and for those with good economic status The rate of cases having patient delay was lower among patients with hemoptysis than patients with cough and other symptoms We also found that sex, age, residence area, and education level had no significant effect on the application interval The referral interval was shorter in males than in females This

inter-CR

Application interval (days) Patient delay n (%)

Sex

Male

Female

Age

<45

≥45

Residence

Urban

Rural

Index case

Yes

No

Education

No education

Primary

Secondary

University

Economic status

Poor

Moderate

Good

First symptom

Cough

Hemoptysis

Other

35.2 (42.9)*

25.7 (31.4)*

29.5 (38.3)*

34.5 (39.8)*

33.2 (43.2)*

25.8 (22.2)*

25.0 (37.5)**

33.6 (39.1)**

34.1 (44.8)***

33.8 (39.5)***

27.4 (31.3)***

19.3 (18.1)***

66.2 (52.5) 21.9 (24.9) 9.8 (9.1) 32.1 (38.0) 26.6 (43.1) 33.1 (36.6)

45 (36.9)**

26 (31.7)**

41 (32.5)**

30 (38.5)**

51 (33.8)**

20 (37.7)**

16 (24.6)

55 (39.5)

7 (30.4)*

47 (39.8)*

15 (26.8)*

2 (28.6)*

8 (20.0)###,&&

14 (43.8)&,&&

18.0 15.0 17.0 19.0 16.0 20.0 13.0 20.0 15.0 16.0 16.0 15.0 52.0 15.0 8.0 20.0 10.0 20.0

27.4–42.6 18.7–32.5 22.8–36.2 25.5–43.4 26.4–40.2 19.6–31.9 15.7–34.3 27.1–40.1 14.7–53.4 8.4–48.9 19.0–35.8 2.5–36.1 51.7–80.7 17.3–26.5 6.7–12.9 25.6–38.6 12.8–40.4 19.8–46.2

**p=0.039

*p=0.026

&p>0.05

&&p=0.04

Table 2 A sub-analysis of patient delay.

val was also shorter in patients who visited a chest

spe-cialist Age, education level, residence area, and

econom-ic status had no signifeconom-icant effect on the referral interval

While Nakagawa et al found that the referral interval

was longer in female than in male patients [24], Taylor

et al determined that the median referral interval was

similar between males and females [17] It is known that

health care providers and physicians first visited by

patients affect the rates of doctor delay [12,21,25] In our

opinion, the degree of suspicion of tuberculosis differs

among physicians, and this difference may be an

impor-tant reason for difference among doctor delays There

are several differences among the studies with respect to

delays We conclude that the patient’s characteristics

may result in these differences among studies

Many reasons for delays have been identified in

previ-ous reports Underutilized chest X-ray examinations

and sputum smear examinations, a low degree of

suspi-cion of tuberculosis, health care system and laboratory

delays, as well as patient characteristics, such as age, sex,

education level and socioeconomic status, are the most

common reasons for doctor delays [7,12,14,16,18,26]

We determined similar reasons for delays A low degree

of suspicion of tuberculosis was one of the most com-mon causes for delay acom-mong our patients Chest X-ray and sputum smear examinations were underutilized by physicians in our patients with pulmonary tuberculosis The present data suggest that the health care system and laboratory delays result in high rates of institutional and diagnostic delays Poor economic status was an important reason of patient delay in our series

CONCLUSIONS

In conclusion, the present study suggests that our patients with smear-positive pulmonary tuberculosis had several delays from the onset of symptoms to initiation of treatment Because untreated smear-positive patients are the main sources of infection, delays in the diagnosis and treatment of these patients increase the risk of disease transmission in the community These delays are also associated with a prolonged period of infectivity for medical personnel According to our data, doctor delay was more significant than patient delay, and institutional delay was the most important component of doctor delay The low index of tuberculosis, underutilized chest

Days

Diagnosis interval Diagnosis interval

0–1

2–10

>10

101

93

10

153 50 1

49.5 45.6 4.9

75.0 24.5 0.5

Table 4 The distribution of diagnosis and treatment intervals with

respect to days

0–4 5–10 11–20

>20

26 53 36 89

12.8 26.0 17.6 43.6

Table 5 The distribution of the time interval between the time

of the first doctor visit and initiation of treatment with respect to days

Referral interval (days) Institutional delay n (%)

Sex

Male

Female

Age

<45

≥45

Residence

Urban

Rural

Education

No education

Primary

Secondary

University

Economic status

Poor

Moderate

Good

First visit

Chest specialist

Practitioner

Other

19.1 (28.7)*

26.6 (30.8)*

20.5 (26.9)*

24.8 (33.1)*

21.2 (27.8)*

22.6 (30.5)*

29.6 (37.2)**

21.3 (30.5)**

19.8 (21.9**

14.1 (21.3)**

25.1 (34.6)*

21.5 (27.8)*

20.3 (28.3)*

11.4 (20.6)**

23.1 (26.8)**

25.3 (33.0)**

91 (74.6)***

76 (92.7)***

104 (82.5)***

63 (80.8)***

123 (81.5)***

44 (83.0)***

21 (91.3)*

95 (80.5)*

45 (80.4)*

6 (85.7)*

41 (77.4)***

95 (82.6)***

31 (86.1)***

26 (68.4)*

47 (83.9)*

94 (85.5)*

7.5 14.5 11.0 11.0 11.0 11.0 19.0 8.0 11.0 4.0 15.0 10.0 11.0 6.0 14.0 14.0

14.0–24.2 19.8–33.4 15.8–25.1 17.4–32.3 13.4–29.0 17.7–27.1 13.5–45.7 15.5–27.1 13.9–25.6 5.5–33.8 15.5–34.6 16.3–26.6 10.7–29.9 4.7–18.2 15.9–30.3 19.1–31.6

*p=0.015

***p=0.003

**p=0.043

*p=0.48

Table 3 Factors associated with the referral interval.

X-ray and sputum smear examinations among

physi-cians, and health care system and laboratory delays were

the most common causes of doctor delay Several efforts

should be made to reduce these delays for the sake of

tuberculosis control Physicians and the public should be

educated about tuberculosis Health care system and

lab-oratory delays should be minimized These efforts can

reduce delays in pulmonary tuberculosis treatment We

conclude that delays are important reasons for the

increased period of infectivity, and that decreasing these

delays will help tuberculosis control

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CR