Resource implications of the latent tuberculosis cascade of care: a time and motion study in five countries

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Abstract

Background

The End TB Strategy calls for global scale-up of preventive treatment for latent tuberculosis infection (LTBI), but little information is available about the associated human resource requirements. Our study aimed to quantify the healthcare worker (HCW) time needed to perform the tasks associated with each step along the LTBI cascade of care for household contacts of TB patients.

Methods

We conducted a time and motion (TAM) study between January 2018 and March 2019, in which consenting HCWs were observed throughout a typical workday. The precise time spent was recorded in pre-specified categories of work activities for each step along the cascade. A linear mixed model was fit to estimate the time at each step.

Results

A total of 173 HCWs in Benin, Canada, Ghana, Indonesia, and Vietnam participated. The greatest amount of time was spent for the medical evaluation (median: 11 min; IQR: 6–16), while the least time was spent on reading a tuberculin skin test (TST) (median: 4 min; IQR: 2–9). The greatest variability was seen in the time spent for each medical evaluation, while TST placement and reading showed the least variability. The total time required to complete all steps along the LTBI cascade, from identification of household contacts (HHC) through to treatment initiation ranged from 1.8 h per index TB patient in Vietnam to 5.2 h in Ghana.

Conclusions

Our findings suggest that the time requirements are very modest to perform each step in the latent TB cascade of care, but to achieve full identification and management of all household contacts will require additional human resources in many settings.

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Most cited references 15

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The cascade of care in diagnosis and treatment of latent tuberculosis infection: a systematic review and meta-analysis.

Hannah Alsdurf, Philip C Hill, Alberto Matteelli … (2016)

WHO estimates that a third of the world's population has latent tuberculosis infection and that less than 5% of those infected are diagnosed and treated to prevent tuberculosis. We aimed to systematically review studies that report the steps from initial tuberculosis screening through to treatment for latent tuberculosis infection, which we call the latent tuberculosis cascade of care. We specifically aimed to assess the number of people lost at each stage of the cascade.

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Cost-effectiveness of tuberculosis control strategies among immigrants and refugees.

Swapan K. Dasgupta, D. Menzies (2005)

Today, in Western Europe, Canada and the USA, more than half of all new active tuberculosis (TB) cases occur among foreign-born migrants. This article examines the impact of migration from high TB-incidence to low TB-incidence countries, and compares the cost-effectiveness of different TB control strategies. A Medline search was conducted to identify relevant English language publications prior to December 2003. Additional articles were identified from the reference lists from these publications. Despite the high proportion of active cases in low-incidence countries attributable to foreign-born residents, the public health impact is relatively low. Current chest radiograph screening programmes have little impact and are not cost-effective. Screening with sputum culture would improve cost-effectiveness marginally. Treatment of latent infection detected through screening with tuberculin skin testing or chest radiographs may require coercive measures to maximise impact and cost-effectiveness. In contrast, contact tracing, particularly within ethnic communities, appears to be more cost-efficient and less intrusive. In low-incidence countries, screening of migrants at entry has little overall impact and is not a very cost-effective tuberculosis control strategy. More effective alternatives include contact tracing delivered through primary care and increased investment in global tuberculosis control.

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Cost of tuberculosis diagnosis and treatment from the patient perspective in Lusaka, Zambia.

Henry Godfrey, A Aspler, L Mwenge … (2008)

Urban primary health centres in Lusaka, Zambia. 1) To estimate patient costs for tuberculosis (TB) diagnosis and treatment and 2) to identify determinants of patient costs. A cross-sectional survey of 103 adult TB patients who had been on treatment for 1-3 months was conducted using a standardised questionnaire. Direct and indirect costs were estimated, converted into US$ and categorised into two time periods: 'pre-diagnosis/care-seeking' and 'post-diagnosis/treatment'. Determinants of patient costs were analysed using multiple linear regression. The median total patient costs for diagnosis and 2 months of treatment was $24.78 (interquartile range 13.56-40.30) per patient--equivalent to 47.8% of patients' median monthly income. Sex, patient delays in seeking care and method of treatment supervision were significant predictors of total patient costs. The total direct costs as a proportion of income were higher for women than men (P < 0.001). Treatment costs incurred by patients on the clinic-based directly observed treatment strategy were more than three times greater than those incurred by patients on the self-administered treatment strategy (P < 0.001). Clinic-based treatment supervision posed a significant economic burden on patients. The creation or strengthening of community-based treatment supervision programmes would have the greatest potential impact on reducing patients' TB-related costs.

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Author and article information

Contributors

D. Menzies: dick.menzies@mcgill.ca

Journal

Journal ID (nlm-ta): BMC Health Serv Res

Journal ID (iso-abbrev): BMC Health Serv Res

Title: BMC Health Services Research

Publisher: BioMed Central (London )

ISSN (Electronic): 1472-6963

Publication date (Electronic): 21 April 2020

Publication date PMC-release: 21 April 2020

Publication date Collection: 2020

Volume: 20

Electronic Location Identifier: 341

Affiliations

[1 ]GRID grid.14709.3b, ISNI 0000 0004 1936 8649, Department of Epidemiology, Biostatistics and Occupational Health, , McGill University, ; Montreal, QC Canada

[2 ]GRID grid.14709.3b, ISNI 0000 0004 1936 8649, McGill International TB Centre, , McGill University, ; 5252 Boulevard de Maisonneuve, Room 3D.58, Montreal, QC Canada

[3 ]GRID grid.14709.3b, ISNI 0000 0004 1936 8649, Respiratory Epidemiology and Clinical Research Unit (RECRU), , McGill University, ; Montreal, QC Canada

[4 ]GRID grid.420217.2, Programme National contre la Tuberculose-Bénin, , Centre National Hospitalier Universitaire de Pneumo-Phtisiologie-Cotonou, ; Cotonou, Benin

[5 ]GRID grid.412211.5, Social Medicine Institute, , State University of Rio de Janeiro, ; Rio de Janeiro, Brazil

[6 ]GRID grid.22072.35, ISNI 0000 0004 1936 7697, University of Calgary, ; Calgary, AB Canada

[7 ]GRID grid.415450.1, ISNI 0000 0004 0466 0719, Chest Clinic, , Komfo Anokye Teaching Hospital, ; Kumasi, Ghana

[8 ]Woolcock Institute of Medical Research, Hanoi, Vietnam

[9 ]GRID grid.418246.d, ISNI 0000 0001 0352 641X, Provincial Tuberculosis Services, British Columbia Centre for Disease Control, ; Vancouver, BC Canada

[10 ]GRID grid.17091.3e, ISNI 0000 0001 2288 9830, Department of Medicine, , University of British Columbia, ; Vancouver, BC Canada

[11 ]GRID grid.22072.35, ISNI 0000 0004 1936 7697, Division of Respiratory Medicine, , University of Calgary, ; Calgary, AB Canada

[12 ]GRID grid.1013.3, ISNI 0000 0004 1936 834X, The Faculty of Medicine and Health, , The University of Sydney Central Clinical School, The University of Sydney, ; Sydney, NSW Australia

[13 ]GRID grid.11553.33, ISNI 0000 0004 1796 1481, Department of Public Health, Faculty of Medicine, TB-HIV Research Center, , Universitas Padjadjaran, ; Bandung, Indonesia

[14 ]GRID grid.17089.37, Department of Medicine, Faculty of Medicine and Dentistry, , University of Alberta, ; Edmonton, AB Canada

[15 ]GRID grid.14848.31, ISNI 0000 0001 2292 3357, Department of Social and Preventive Medicine, , Université de Montréal, ; Montreal, QC Canada

[16 ]GRID grid.11553.33, ISNI 0000 0004 1796 1481, Department of Biomedical Sciences, Division of Pharmacology & Therapy, Faculty of Medicine, , Universitas Padjadjaran, ; Bandung, Indonesia

[17 ]GRID grid.21107.35, ISNI 0000 0001 2171 9311, Department of Epidemiology, , John Hopkins Bloomberg School of Public Health, ; Baltimore, MD USA

Article

Publisher ID: 5220

DOI: 10.1186/s12913-020-05220-7

PMC ID: 7175545

PubMed ID: 32316963

SO-VID: 77308aab-674e-4e16-8971-6251d23fab7c

License:

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

History

Date received : 27 January 2020

Date accepted : 13 April 2020

Funding

Funded by: FundRef http://dx.doi.org/10.13039/501100000024, Canadian Institutes of Health Research;

Award ID: FDN-143350

Custom metadata

ScienceOpen disciplines: Health & Social care

Keywords: latent tuberculosis infection,cascade-of-care,time and motion study

Data availability:

ScienceOpen disciplines: Health & Social care

Keywords: latent tuberculosis infection, cascade-of-care, time and motion study

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Resource implications of the latent tuberculosis cascade of care: a time and motion study in five countries

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Abstract

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Results

Conclusions

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Tobacco Prevention & Cessation

Most cited references 15

The cascade of care in diagnosis and treatment of latent tuberculosis infection: a systematic review and meta-analysis.

Cost-effectiveness of tuberculosis control strategies among immigrants and refugees.

Cost of tuberculosis diagnosis and treatment from the patient perspective in Lusaka, Zambia.

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