RT Journal Article
SR Electronic
T1 The First Differentiated TB Care Model From India: Delays and Predictors of Losses in the Care Cascade
JF Global Health: Science and Practice
JO GLOB HEALTH SCI PRACT
FD Johns Hopkins University- Global Health. Bloomberg School of Public Health, Center for Communication Programs
SP e2200505
DO 10.9745/GHSP-D-22-00505
VO 11
IS 2
A1 Hemant Deepak Shewade
A1 Asha Frederick
A1 G. Kiruthika
A1 Madhanraj Kalyanasundaram
A1 Joshua Chadwick
A1 T. Daniel Rajasekar
A1 K. Gayathri
A1 R. Vijayaprabha
A1 R. Sabarinathan
A1 Jeyashree Kathiresan
A1 P.K. Bhavani
A1 S. Aarthi
A1 K.V. Suma
A1 Delphina Peter Pathinathan
A1 Raghavan Parthasarathy
A1 M. Bhavani Nivetha
A1 Jerome G. Thampi
A1 Deiveegan Chidambaram
A1 Tarun Bhatnagar
A1 S. Lokesh
A1 Shanmugasundaram Devika
A1 Timothy S. Laux
A1 Stalin Viswanathan
A1 R. Sridhar
A1 K. Krishnamoorthy
A1 M. Sakthivel
A1 S. Karunakaran
A1 S. Rajkumar
A1 M. Ramachandran
A1 K.D. Kanagaraj
A1 M. Kaleeswari
A1 V.P. Durai
A1 R. Saravanan
A1 A. Sugantha
A1 S. Zufire Hassan Mohamed Khan
A1 P. Sangeetha
A1 R. Vasudevan
A1 R. Nedunchezhian
A1 M. Sankari
A1 N. Jeevanandam
A1 S. Ganapathy
A1 V. Rajasekaran
A1 T. Mathavi
A1 A.R. Rajaprakash
A1 Lakshmi Murali
A1 U. Pugal
A1 K. Sundaralingam
A1 S. Savithri
A1 S. Vellasamy
A1 D. Dheenadayal
A1 P. Ashok
A1 K. Jayasree
A1 R. Sudhakar
A1 K.P. Rajan
A1 N. Tharageshwari
A1 D. Chokkalingam
A1 S.M. Anandrajkumar
A1 T.S. Selvavinayagam
A1 C. Padmapriyadarshini
A1 Ranjani Ramachandran
A1 Manoj V. Murhekar
YR 2023
UL http://www.ghspjournal.org/content/11/2/e2200505.abstract
AB Key FindingsTo reduce TB deaths in resource-limited settings, triaging at diagnosis can identify those with immediate need for comprehensive assessment and inpatient care.This type of differentiated TB care model was successfully implemented in Tamil Nadu, India, without additional stress on the health system.Half of the patients referred as a result of triaging were very severely undernourished, which implies a need for capacity-building of inpatient care facilities in clinical management of very severe undernutrition in adults.The identification of predictors of not being triaged and comprehensively assessed will inform ongoing and future improvements to the care model.Key ImplicationsThe state should immediately focus on increasing the duration and quality of inpatient care, particularly for very severe undernutrition.Specific strategies should be developed to address the predictors of not being triaged and not being comprehensively assessed.To reduce TB deaths in resource-limited settings, a differentiated care strategy can be used to triage patients with high risk of severe illness (i.e., those with very severe undernutrition, respiratory insufficiency, or inability to stand without support) at diagnosis and refer them for comprehensive assessment and inpatient care. Globally, there are few examples of implementing this type of strategy in routine program settings. Beginning in April 2022, the Indian state of Tamil Nadu implemented a differentiated care strategy called Tamil Nadu-Kasanoi Erappila Thittam (TN-KET) for all adults aged 15 years and older with drug-susceptible TB notified by public facilities. Before evaluating the impact on TB deaths, we sought to understand the retention and delays in the care cascade as well as predictors of losses. During April–June 2022, 14,961 TB patients were notified and 11,599 (78%) were triaged. Of those triaged, 1,509 (13%) were at high risk of severe illness; of these, 1,128 (75%) were comprehensively assessed at a nodal inpatient care facility. Of 993 confirmed as severely ill, 909 (92%) were admitted, with 8% unfavorable admission outcomes (4% deaths). Median admission duration was 4 days. From diagnosis, the median delay in triaging and admission of severely ill patients was 1 day each. Likelihood of triaging decreased for people with extrapulmonary TB, those diagnosed in high-notification districts or teaching hospitals, and those transferred out of district. Predictors of not being comprehensively assessed included: aged 25–34 years, able to stand without support, and diagnosis at a primary or secondary-level facility. Inability to stand without support was a predictor of unfavorable admission outcomes. To conclude, the first quarter of implementation suggests that TN-KET was feasible to implement but could be improved by addressing predictors of losses in the care cascade and increasing admission duration.