Patient and Health System Delays in the Diagnosis of Tuberculosis in Southern Thailand After Health Care Reform

INT J TUBERC LUNG DIS 10(4):422–428 © 2006 The Union Patient and health system delays in the diagnosis of tuberculosis in Southern Thailand after health care reform M. Rojpibulstit,* J. Kanjanakiritamrong,† V. Chongsuvivatwong* * Epidemiology Unit, Faculty of Medicine, Prince of Songkla University (PSU), Hat-Yai, Songkhla, † Department of Pharmacy, Songkhla Hospital, Muang, Songkhla, Thailand SUMMARY SETTING: Seven public hospitals in a southern province was significant longer for patients with health insurance of Thailand. and first presenting to low-level public health facility OBJECTIVES: To measure delays in tuberculosis (TB) (i.e., community hospital, health centre, primary care diagnosis and to examine the factors associated with unit or private clinic/hospital). these delays, with special focus on the effect of drug CONCLUSIONS: The public should be informed how to store utilisation and health insurance coverage on pa- recognise TB symptoms to shorten patient delay. The tient delay. Thai National Tuberculosis Control Programme needs DESIGN: A total of 202 newly diagnosed smear-positive to supervise the private health sector, including drug and smear-negative pulmonary TB patients were inter- stores, for better TB control. Drug store personnel need viewed using a structured questionnaire. to be trained to recognise and refer TB suspects. The ca- RESULTS: The median patient, health system and total pacity of low-level public health facilities and private delay were 4.4, 2.8 and 9.4 weeks, respectively. Risk fac- doctors in TB diagnosis needs improvement. A proper tors for patient delay were age 31–60 years, having mild referral system should be developed. illness, previous similar symptoms and first presenting to KEY WORDS: tuberculosis; delay; drug store; health insur- non-qualified providers. Health insurance was not asso- ance coverage; Thailand ciated with a shorter patient delay. Health system delay DELAYS IN TREATMENT of tuberculosis (TB) can METHODS result in a higher risk of mortality among patients and The protocol was approved by the Ethics Committees transmission of the disease in the community.1,2 Early of Prince of Songkla University and of the Ministry of detection and effective treatment, the two key factors Public Health, Thailand. in successful TB control, can be achieved by shorten- ing the time from the first symptom to arriving in standard health care (patient delay) and time between Study setting and health service systems first visit and diagnosis (health system delay). A first Songkhla province, the study population, was ap- visit to a drug store is common in developing coun- proximately 1.2 million. It is served by three tertiary tries,3–6 and has been reported to be a source of delay.3 hospitals, 15 community hospitals, 228 public health At the end of 2001, health system reform toward centres/primary care units (PCUs), 201 private clinics universal health care coverage (UC) was started in and six private hospitals. Of 270 drug stores in the Thailand.7 An understanding of whether reform has community, 94 operate without a pharmacist. shortened these delays would be an important lesson A TB clinic in each public hospital is supervised by for other developing countries where reform is also the National TB Control Programme (NTP). Accord- underway. ing to the referral system, UC patients must first at- The present study investigates factors associated tend a PCU or health centre to obtain free care at all with patient delay, with emphasis on the effect of levels of the service. Others, including those bypass- drug store utilisation and health insurance coverage. ing referral, receive free anti-tuberculosis drugs subsi- It also investigates health system delay, which might dised by the NTP, but must pay for medical investiga- be affected by the reform. tions and non-anti-tuberculosis drugs. Correspondence to: Malee Rojpibulstit, Epidemilogy Unit, Faculty of Medicine, Prince of Songkla University, Hat-Yai, Songkhla, Thailand 90110. Tel: (ϩ66) 74-451165. Fax: (ϩ66) 74-212900. e-mail: [email protected] Article submitted 21 September 2005. Final version accepted 11 November 2005. Delays in diagnosis of TB, Southern Thailand 423 Study design and subjects ard ratio Ͻ1 suggests that the factor increases the risk Five community hospitals and two tertiary hospitals for delay. were selected; each had at least 10 new cases per 4- month cohort. All newly diagnosed pulmonary TB (PTB) patients RESULTS aged at least 15 years who were either sputum smear- Patient characteristics and site of first visit positive or smear-negative were included in the study. Of 212 initially recruited patients, 10 were excluded Those who were smear-negative and finally diag- due to uncertainty about the length of delay. The sub- nosed as non-TB, those diagnosed without sputum jects had a wide age range (15–83 years), and a mean examination and prisoners were excluded. age of 43.3 years (standard deviation ϭ 16.2). Over three quarters were male; 80% were Thai Buddhists. Data collection Two-thirds had finished only primary school or below, After obtaining written informed consent, a structured and the average monthly income (baht 5880, approx- questionnaire, pre-tested with 30 new TB patients imately US$150) was close to the national average and thoroughly revised, was used by a well-trained monthly per capita income (baht 5001, approximately researcher to interview each subject at the hospital US$125). Labourers with temporary employment shortly after diagnosis (up to 1 month). Five patients were most common (44%). Despite the declaration of declined to participate. Data were collected from June UC, more than a fifth of subjects were not covered by 2003 to April 2004. any insurance at the current visit, mainly due to their The questionnaire consisted of two parts. The first being a mobile population. part included socio-economic characteristics, health One-fifth of the patients were negative for AFB. At insurance status, clinical information on the current the time of the study, universal human immunodefi- illness and health service utilisation for the index symp- ciency virus (HIV) voluntary counselling and testing tom (cough). The second part, exclusively for drug for TB patients was not part of the national policy, store users, included details of drug store visits and and only 24% of subjects had benefited from this ser- drug store personnel practices. vice. Of 49 tested, 42.8% were positive. With such in- To minimise error in recalling patient delay, in ad- complete information, HIV status was not included in dition to structured sequencing of the time line, quali- the main analysis. tative probing questions were used. The interview data The drug store was the most common first site of were also checked against the data in medical records visit after the start of symptoms (43%); up to 12% for those patients who had previously visited a hospi- self-medicated from a grocery; only 31.5% sought tal with suspected TB symptoms. health care from public health facilities, and the private health sector occupied a minor share (13%). Definitions Adapted from previous studies,8,9 patient delay was de- Patient delay and determinants fined as the time from commencing cough to the first The median patient delay was 4.4 weeks (range 0.3– contact with a qualified provider (a doctor, health 33.1), with 61% reaching a qualified provider after centre or PCU). Health system delay was the time 3 weeks of cough. from first contact with the qualified provider to time The 86 initial drug store users had a median delay of diagnosis. Insured persons were patients receiving from first symptoms to drug store visit of 1 week. The free medical services, including government staff, pri- subsequent part of their patient delay had a median of vate employees under a social security scheme, people 6.4 weeks. After 3 weeks of cough, 52 made a repeat under the gold-card scheme (providing free care for visit to a drug store. Ͻ elderly and children 12 years of age or co-payment From univariate analysis (Table 1), patients with of 30 baht [US$0.76] per visit for others) and those the following characteristics had a significantly longer holding government health cards and private health patient delay: male, age 31–60 years compared with insurance. younger age, AFB-positive, mild illness, being a smoker, The main independent variables were socio-demo- previous symptoms similar to the current illness, no graphic characteristics, health insurance status, acid-fast past experience of using the current visited hospital bacilli (AFB) status, severity of illness and place of and first presenting to non-qualified providers (drug first visit. store, grocery and traditional healer). Multivariate Cox regression analysis for patient Data analysis delay reduced significant predictors for prolonged The Mann-Whitney U and Kruskal-Wallis tests were delay to age 31–60 years compared with younger age, initially used to explore the association between delay mild illness, previous similar symptoms and first pre- and independent variables. Cox regression was then senting to non-qualified providers. Having health used to investigate factors associated with delay. A haz- insurance did not affect the time to seek help from 424 The International Journal of Tuberculosis and Lung Disease Table 1 Univariate and multivariate analysis of factors associated with patient delay Patient delay Median duration HR* Adjusted HR* Study variables n (IQR in weeks) (95%CI) (95%CI) Sex Male 156 4.5 (2.0–13.1) 1 1 Female 46 2.8 (1.1–7.0)

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