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Factors associated with delay in treatment initiation for pulmonary tuberculosis

David J. Roberts, Trish Mannes, Neville Q. Verlander, Charlotte Anderson
ERJ Open Research 2020 6: 00161-2019; DOI: 10.1183/23120541.00161-2019
David J. Roberts
1Field Epidemiology Training Programme, Public Health England Colindale, London, UK
2European Programme for Interventional Epidemiology Training (EPIET), European Centers for Disease Control, Stockholm, Sweden
3Thames Valley Health Protection Team, Public Health England South East, Chilton, UK
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  • For correspondence: david.j.roberts@phe.gov.uk
Trish Mannes
3Thames Valley Health Protection Team, Public Health England South East, Chilton, UK
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Neville Q. Verlander
4Statistics, Modelling and Economics Dept, Public Health England Colindale, London, UK
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Charlotte Anderson
5Public Health England, Field Service South East and London, London, UK
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  • FIGURE 1
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    FIGURE 1

    Case data flow. ETS: Enhanced Tuberculosis Surveillance system. #: identified as tuberculosis contacts/by port health/by occupational health; ¶: delay of <1 day; +: these cases are included in descriptive analysis of “decision” and “referral” delays, but not other descriptive analyses, nor regression analyses of healthcare delay.

Tables

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  • TABLE 1

    Presentation delay and healthcare delay by descriptive characteristics of people with pulmonary tuberculosis (TB), South East England, 2011–2015

    Presentation delayHealthcare delay
    Cases with delay dataDelay daysCases with delay dataDelay days
    All81330 (11–72)88540 (13–89)
    Year
     20113851 (10–111)4434 (8–99)
     201210230 (12–70)11850 (14–99)
     201322428 (9–60)23232 (14–72)
     201423229 (12–62)25744 (14–94)
     201521731 (12–91)23443 (12–98)
     Unknown00
    Health protection team
     Hampshire Isle of Wight13233 (15–67)13239 (15–83)
     Kent23631 (13–86)26537 (9–87)
     Surrey Sussex13445 (17–111)15328 (9–70)
     Thames Valley31121 (8–53)33552 (18–102)
     Unknown00
    Cases by area TB incidence
     <20/100 00055431 (13–83)61543 (14–95)
     ≥20/100 00025924 (9–61)27032 (10–85)
     Unknown00
    Rurality
     Rural7039 (13–82)7838 (16–96)
     Urban74329 (11–70)80741 (12–89)
     Unknown00
    Sex
     Male48530 (12–81)52835 (10–78)
     Female32730 (11–62)35648 (19–111)
     Unknown11 (1–1)1327 (327–327)
    Age group years
     0–1496 (4–20)1045 (33–51)
     15–4444429 (12–67)48934 (10–79)
     45–6420031 (193–80)21143 (14–96)
     ≥6516027 (9–84)17450 (17–129)
     Unknown00
    Time resident in UK years
     <2 years9633 (15–68)10531 (10–62)
     2–10 years24828 (10–61)27434 (10–83)
     ≥11 years16723 (9–61)17455 (19–116)
     UK-born28331 (10–92)30944 (16–99)
     Unknown1964 (23–121)2326 (5–56)
    Social risk factor
     None70428 (10–66)76843 (14–98)
     16650 (26–121)7423 (7–71)
     ≥24334 (17–88)4318 (5–65)
     Unknown00
    QIMD
     1 (least)14031 (10–73)15846 (18–96)
     213929 (13–61)15647 (16–114)
     319126 (8–67)20842 (12–99)
     423131 (13–72)24740 (12–85)
     5 (most)11234 (12–100)14620 (7–59)
     Unknown00
    Ethnicity
     Not white50127 (10–61)54138 (11–83)
     White31235 (13–92)34242 (15–100)
     Unknown00
    Language barriers#
     Present8832 (15–96)NC
     Absent72530 (11–68)NC
     Unknown0NC
    Mental health comorbidity#
     Present3143 (19–135)NC
     Absent78230 (11–68)NC
     Unknown0NC
    Physical health comorbidity#
     Present7530 (11–76)79941 (13–89)
     Absent73831 (12–56)8633 (15–95)
     Unknown00
    Post mortem diagnosis
     Yes88 (5–91)NC
     No80530 (11–72)NC
     Unknown0NC
    Previous TB diagnosis
     Yes5131 (10–92)5738 (16–70)
     No74430 (11–67)81042 (13–94)
     Unknown1848 (7–105)1413 (5–19)
    Sputum smear
     Positive37931 (12–84)40625 (8–66)
     Negative30027 (11–65)33051 (20–107)
     Unknown13430 (11–64)14959 (27–132)
    Chest radiography
     Abnormal: TBNC64238 (12–83)
     Not TB or NADNC6156 (19–129)
     UnknownNC18243 (15–88)
    Culture status
     PositiveNC72038 (12–79)
     NegativeNC16559 (19–132)
     UnknownNC0
    Referred by
     Primary careNC34051 (21–102)
     Secondary careNC42027 (8–78)
     PrisonNC440 (10–67)
     PrivateNC5162 (29–179)
     UnknownNC11654 (20–99)

    Data are presented as n or median (interquartile range). QIMD: Quintile of Index of Multiple Deprivation; NAD: no abnormality detected; NC: not calculated as not considered as a risk factor for this outcome. #: all unknown=“no”: the reporting form used by the TB nurses for cohort review had a simple tick box (tick means “yes”) for these variables. We have assumed if unticked that this meant “no”.

    • TABLE 2

      Median delay for different classifications of healthcare delay, South East of England, 2011–2015, and stratified by smear status

      All healthcare delay#Decision delayReferral delayDiagnostic delay#Treatment initiation delay#
      CasesDelay daysCasesDelay daysCasesDelay daysCasesDelay daysCasesDelay days
      Any88540 (13–89)78426 (4–73)7882 (0–8)6052 (0–14)8891 (0–3)
      Negative33051 (20–107)28627 (5–79)2823 (0–13)2418 (1–31)3301 (0–4)
      Positive40625 (8–66)36517 (3–63)3691 (0–6)2661 (0–4)4101 (0–2)

      Data are presented as n or median (interquartile range). All categories exclude cases known to have been referred by public health contact tracing or screening. #: excludes cases diagnosed post mortem.

      • TABLE 3

        Crude and adjusted time ratio# of presentation delay by risk factor, for people with pulmonary tuberculosis (TB) in the South East of England, 2011–2015 (n=779)

        Crude time ratio (95% CI)p-valueAdjusted time ratio (95% CI)p-value
        Ethnicity
         Not whiteRef.Ref.
         White1.22 (0.99–1.50)0.0631.08 (0.82–1.42)0.601
        Mental health barriers
         NoRef.Ref.
         Yes2.26 (1.37–3.75)0.0012.06 (1.22–3.50)0.007
        Rurality
         RuralRef.Ref.
         Urban0.92 (0.65–1.32)0.6560.88 (0.61–1.27)0.500
        Physical health comorbidity
         NoRef.Ref.
         Yes0.86 (0.62–1.20)0.3660.75 (0.54–1.05)0.091
        Language barriers
         NoRef.Ref.
         Yes1.25 (0.92–1.71)0.1601.40 (1.01–1.94)0.042
        Sex
         FemaleRef.Ref.
         Male1.10 (0.90–1.34)0.3351.04 (0.85–1.27)0.698
        Prior TB diagnosis
         NoRef.Ref.
         Yes1.36 (0.92–2.02)0.1251.01(0.68–1.51)0.953
        Age group years¶
         ≥65Ref.Ref.
         45–641.30 (0.97–1.74)0.0781.27 (0.95–1.72)0.103
         15–440.94 (0.72–1.21)0.6151.05 (0.79–1.41)0.718
         0–140.22 (0.08–0.56)0.0020.23 (0.09–0.59)0.002
        Social risk factors present+
         NoneRef.Ref.
         11.44 (1.01–2.05)0.0431.18 (0.82–1.71)0.362
         ≥21.02 (0.65–1.59)0.9360.76 (0.47–1.21)0.248
        Time resident in UK§
         UK-bornRef.Ref.
         ≥11 years1.01 (0.77–1.18)0.9470.99 (0.71–1.39)0.959
         2–10 years0.74 (0.59–0.95)0.0160.77 (0.56–1.04)0.090
         <2 years0.86 (0.62–1.18)0.3500.84 (0.58–1.22)0.366
        QIMDƒ
         1 (least deprived)Ref.Ref.
         20.83 (0.59–1.16)0.2760.86 (0.64–1.24)0.358
         30.93 (0.58–1.28)0.6680.98 (0.73–1.36)0.878
         41.08 (0.79–1.49)0.6191.04 (0.75–1.43)0.818
         5 (most deprived)1.19 (0.81–1.75)0.3811.20 (0.86–1.85)0.341

        QIMD: Quintile of Index of Multiple Deprivation. Bold type represents statistical significance at a p-value ≤0.05. #: all models include a random effect on 62 local authority districts; ¶: Wald p-value for overall effect of age group categorical variable crude <0.001, adjusted 0.003; +: Wald p-value for overall effect of social risk factor categorical variable crude 0.128, adjusted 0.275; §: Wald p-value for overall effect of time in UK categorical variable crude 0.058, adjusted 0.247; ƒ: Wald p-value for overall effect of QIMD categorical variable crude 0.306, adjusted 0.474.

        • TABLE 4

          Crude and adjusted time ratio# of healthcare delay by risk factor, for people with pulmonary tuberculosis (TB) in the South East of England, 2011–2015 (n=621)

          Crude time ratio (95% CI)p-valueAdjusted time ratio (95% CI)p-value
          Ethnicity
           Not whiteRef.Ref.
           White1.15 (0.92–1.43)0.2131.15 (0.87–1.51)0.325
          Physical health comorbidity
           NoRef.Ref.
           Yes1.05 (0.74–1.50)0.7861.10 (0.78–1.56)0.583
          Sex
           FemaleRef.Ref.
           Male0.69 (0.56–0.85)<0.0010.74 (0.60–0.91)0.005
          Prior TB diagnosis
           NoRef.Ref.
           Yes0.92 (0.62–1.37)0.6900.95 (0.65–1.41)0.815
          Age group years¶
           ≥65Ref.Ref.
           45–640.81 (0.59–1.12)0.2070.78 (0.57–1.09)0.144
           15–440.68 (0.51–0.90)0.0080.79 (0.57–1.09)0.151
           0–140.45 (0.13–1.58)0.2120.55 (0.17–1.85)0.337
          Time resident in UK+
           UK-bornRef.Ref.
           ≥11 years1.08 (0.81–1.44)0.6001.06 (0.76–1.47)0.741
           2–10 years0.81(0.64–1.04)0.1050.81 (0.60–1.09)0.161
           <2 years0.56 (0.39–0.79)0.0010.47 (0.32–0.67)<0.001
          Area-level incidence
           Low/mediumRef.Ref.
           High0.83 (0.59–1.17)0.3231.04 (0.73–1.47)0.838
          Referred by§
           Primary careRef.Ref.
           Secondary0.65 (0.53–0.81)<0.0010.63 (0.51–0.78)<0.001
           Prison0.53 (0.15–1.87)0.3230.61 (0.18–2.10)0.432
          Sputum smear
           NegativeRef.Ref.
           Positive0.60 (0.49–0.74)<0.0010.58 (0.47–0.70)<0.001
          Social risk factors presentƒ
           NoneRef.Ref.
           10.71 (0.50–1.00)0.050.91 (0.64–1.28)0.578
           ≥20.54 (0.34–0.86)0.0090.59 (0.38–0.94)0.025

          Bold type represents statistical significance at a p-value ≤0.05. #: all models include a random effect on 62 local authority districts; ¶: Wald p-value for overall effect of age group categorical variable crude 0.039, adjusted 0.40; +: Wald p-value for overall effect of time in UK categorical variable crude 0.002, adjusted <0.001; §: Wald p-value for overall effect of referred by categorical variable crude <0.001, adjusted <0.001; ƒ: Wald p-value for overall effect of social risk factor categorical variable crude 0.007, adjusted 0.08.

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            Figures S1-S5 00161-2019.figures

            Data sample cohort review form 00161-2019.form

            Table S1-S5 00161-2019.tables

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          Factors associated with delay in treatment initiation for pulmonary tuberculosis
          David J. Roberts, Trish Mannes, Neville Q. Verlander, Charlotte Anderson
          ERJ Open Research Jan 2020, 6 (1) 00161-2019; DOI: 10.1183/23120541.00161-2019

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          Factors associated with delay in treatment initiation for pulmonary tuberculosis
          David J. Roberts, Trish Mannes, Neville Q. Verlander, Charlotte Anderson
          ERJ Open Research Jan 2020, 6 (1) 00161-2019; DOI: 10.1183/23120541.00161-2019
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