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Tuberculosis Notification in a Private Tertiary Care Teaching Hospital in South India: a Mixed-Methods Study

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Tuberculosis Notification in a Private Tertiary Care Teaching Hospital in South India: a Mixed-Methods Study Open access Research BMJ Open: first published as 10.1136/bmjopen-2018-023910 on 5 February 2019. Downloaded from Tuberculosis notification in a private tertiary care teaching hospital in South India: a mixed-methods study Archana Siddaiah,1 Mohammad Naseer Ahmed,2 Ajay M V Kumar,3,4 George D'Souza,5 Ewan Wilkinson,6 Thae Maung Maung,7 Rashmi Rodrigues1,8,9 To cite: Siddaiah A, Ahmed MN, ABSTRACT Strengths and limitations of this study Kumar AMV, et al. Tuberculosis Objectives India contributes approximately 25% of notification in a private the ‘missing’ cases of tuberculosis (TB) globally. Even ► A mixed-methods design where the qualitative com- tertiary care teaching hospital though ~50% of patients with TB are diagnosed and in South India: a mixed- ponent explains and complements the findings from treated within India’s private sector, few are notified to methods study. BMJ Open the quantitative component. the public healthcare system. India’s TB notification policy 2019;9:e023910. doi:10.1136/ ► Retrospective nature of the quantitative component mandates that all patients with TB are notified through bmjopen-2018-023910 ensured that the study procedures did not influence Nikshay (TB notification portal). We undertook this study the notifications. ► Prepublication history for in a private hospital to assess the proportion notified and ► It is likely that both the proportions notified and the this paper is available online. factors affecting TB notifications. We explored barriers To view these files, please visit number of patients diagnosed or treated are margin- and probable solutions to TB notification qualitatively from the journal online (http:// dx. doi. al overestimates. health provider’s perspective. org/ 10. 1136/ bmjopen- 2018- ► The findings are limited by the quality of the records Study setting Private, tertiary care, teaching hospital in 023910). maintained. Bengaluru, South India. Received 8 May 2018 Methodology This was a mixed-methods study. Revised 31 October 2018 Quantitative component comprised a retrospective Accepted 5 November 2018 review of hospital records between 1 January 2015 and ‘missing’, that is, were undiagnosed or unre- 31 December 2017 to determine TB notifications. The ported.1 India contributes approximately 25% qualitative component comprised key informant interviews of the ‘missing’ cases globally.1 2 Finding these and focus groups to elicit the barriers and facilitators of TB ‘missing’ cases and treating them successfully notification. http://bmjopen.bmj.com/ is vital to ending TB by 2030, as envisaged by Results Of 3820 patients diagnosed and treated, 885 the United Nations Sustainable Development (23.2%) were notified. Notifications of sputum smear- 3 4 positive patients were significantly more likely, while Goals. notifications of children were less likely. Qualitative Healthcare delivery in India involves both analysis yielded themes reflecting the barriers to TB the public and private sectors. The Indian notification and their solutions. Themes related to barriers private healthcare sector is estimated to were: (1) basic diagnostic procedures and treatment cater to approximately two-thirds of the promote notification; (2) misconceptions regarding inpatients and three-fourths of the outpa- notification and its process are common among healthcare tients in the country.5 The private health- on September 27, 2021 by guest. Protected copyright. providers; (3) despite a national notification system other care sector also accounts for 54% of the factors have prevented notification of all patients; and (4) healthcare teaching facilities in India.5 It is establishing hospital systems for notification will go a long therefore not surprising that approximately way in improving notifications. Conclusions The proportion of patients with TB notified two-thirds of the 2.2 million patients with TB annually are diagnosed and treated within by the hospital was low. A comprehensive approach 6 both by the hospital management and the national TB the private healthcare sector. However, in programme is necessary for improving notification. This 2017 only 19% of these patients receive care includes improving awareness among healthcare providers from, or are notified, that is, reported, to about the requirement for TB notifications, establishing the Revised National Tuberculosis Control © Author(s) (or their 4 7 employer(s)) 2019. Re-use a single notification portal in hospital, digitally linking Programme (RNTCP), India’s national permitted under CC BY. hospital records to Nikshay and designating one person to health programme for the prevention and Published by BMJ. be responsible for notification. control of TB, as compared with 81% from For numbered affiliations see public sector. Though mandatory TB notifica- end of article. tion introduced in 2012 saw a sharp increase Correspondence to BACKGROUND in TB notifications, notification from the 4 7–11 Dr Archana Siddaiah; In 2016, approximately 40% of the estimated private sector continues to be low. This archanapink@ yahoo. com 10.4 million tuberculosis (TB) cases were is despite launching Nikshay, the case-based Siddaiah A, et al. BMJ Open 2019;9:e023910. doi:10.1136/bmjopen-2018-023910 1 Open access BMJ Open: first published as 10.1136/bmjopen-2018-023910 on 5 February 2019. Downloaded from web-based national TB notification portal, accessible to observing treatment doses swallowed (DOT), patient all healthcare providers, laboratories and diagnostic facil- follow-up and patient retention in care. Until 2017, the ities, both public and private, nationwide. RNTCP followed an alternate day treatment regimen, Improving the estimates of disease prevalence though with DOT thrice a week in the intensive phase (2 months) is essential for planning, monitoring and evaluation of and weekly once in the continuation phase (4 months). RNTCP. Yet barriers such as lack of time, poor aware- All public PHIs function as DOT centres and have a TB ness regarding notification, concern about breaching health visitor (TBHV), responsible for DOT and patient patient confidentiality, operational complexities in noti- retention. DOT centres at academic institutions, however, fying, along with lack of trust in the public sector prevent have a medical officer in addition to the TBHV. A PHI complete notification.12–14 may also function as DMC. The information on the extent of notification from Even though the RNTCP sets guidelines it does not private tertiary care teaching facilities is limited. This dictate diagnostic or treatment protocols to the private study was designed to determine the proportion of TB sector. However, it attempts to deliver public services to cases notified and the factors that affect notification in a the private sector through public-private partnerships private tertiary care teaching healthcare facility in Karna- (PPP) and expects all private healthcare providers to taka State, South India. The study also explored qualita- notify patients with TB irrespective of a PPP through tively the gaps in the existing notification systems so as to Nikshay. enable the identification and development of strategies to improve notification. Management of TB at the hospital By virtue of being a private tertiary care teaching hospital the RNTCP has established a DMC and a DOT centre at METHODS the hospital through a PPP. The RNTCP staff at the study Study design hospital therefore comprised aLaboratory technician A mixed-methods study comprising a retrospective review (LT), a Medical Officer (MO) (position currently vacant) of records to quantitatively assess the proportions of and a TBHV. patients with TB notified, and a qualitative component to When diagnosed with TB at any of the clinical depart- identify barriers to TB notification was used. ments at the hospital, patients can choose to take anti- tubercular treatment (ATT) either through the DOT Study setting centre, at no cost, or through the hospital’s pharmacy for The study was conducted at a private tertiary-level a cost. The patient’s physician guides the patient’s choice teaching hospital in Bengaluru, Karnataka State, South of treatment on a case by case basis. India. The hospital has 1250 beds and caters to approxi- mately 2000 outpatients daily from diverse backgrounds. http://bmjopen.bmj.com/ Notification of patients with TB at the study hospital A network of laboratory, pathology and radiology services Irrespective of the source of treatment, all patients with support the clinical departments at the hospital. TB-spe- TB who are diagnosed or treated at the hospital are cific microbiological services available are microscopy, expected to be referred to the DOT centres for registra- GenXpert MTB/RIF, solid culture, and liquid TB culture tion with the RNTCP and subsequent notification via the and drug susceptibility testing (such as mycobacterial online notification portal Nikshay. In the study hospital growth indicator tube). notification of patients with TB was the responsibility of There is a computerised information system for these the TBHV. on September 27, 2021 by guest. Protected copyright. services and the pharmacy exists at the hospital. The Medical Records Department compiles and maintains inpatient and outpatient hospital records in paper Study population format. Inpatient records are available electronically and Quantitative component outpatient records are available in paper format. Study subjects comprised all patients diagnosed with TB and/or treated for TB from 1 January 2015 to 31 December
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