Population Services International, Yangon, Myanmar.
PLoS One. 2019 Jun 17;14(6):e0218450. doi: 10.1371/journal.pone.0218450. eCollection 2019.
Population Services International (PSI) Myanmar's social franchise network of general practitioners, known as Sun Quality Health Clinics (SQHC), provided tuberculosis (TB) diagnosis and treatment with Direct Observed Treatment Short course (DOTs) across Myanmar since 2004, with a total of 898 clinics across the country. People who sought TB treatment from these SQHC by themselves were regarded as walk-in patients. To augment TB case notification, PSI Myanmar developed two treatment seeking channels: Community Health Services Providers (CHSP) and Interpersonal Communicators (IPC). They actively sought people who were suspected to have TB and referred them to SQH clinics. In this study, we compared the loss to follow-up rates of TB patients across three treatment seeking channels; and investigated risk-factors for loss to follow-up.
A retrospective cohort design was applied using TB client records between 2012 and 2016. Outcome was defined as loss to follow-up in comparison to successful TB treatment (completed or cured). Multivariate Poisson regression was conducted to estimate incidence rate ratio of loss to follow-up. Of the 62,664 TB patients registered at the SQHC, around 10% each were actively screened by the CHSP and the IPC, and 78.9% were walk-in patients. Overall cumulative incidence for loss to follow-up rate was significantly higher in the IPC channel (14.2%, 95% CI 13.4-15.1%) than walk-in patients (8.9%, 95% CI 8.6-9.1%) and the CHSP channel (5.5%, 95% CI 5.0-6.1%) (p<0.001). The median time after which patients were lost to follow-up from treatment was 4.04 months. We found that patients with older age, male sex, patients residing in hilly region, unknown smear status, retreated cases, HIV co-infection, and unknown HIV status were risk-factors for loss to follow-up in the continuation phase of treatment; whereas patients with higher initial body weight, patients who received travel support and patients taking treatment in older providers were less likely to be lost to follow-up.
Based on these findings, we recommend that implementation strategies for improving case notification and treatment seeking should carefully consider retention strategies in parallel, and the identified influencing factors for loss to follow-up should be taken account for such consideration.
国际人口服务组织（PSI）缅甸的全科医生社会特许经营网络，称为阳光质量健康诊所（SQHC），自 2004 年以来在缅甸各地提供结核病（TB）诊断和治疗，采用直接观察治疗短期疗程（DOTs），全国共有 898 家诊所。自行到这些 SQHC 就诊的 TB 患者被视为门诊患者。为了增加结核病病例报告，PSI 缅甸开发了两种治疗途径：社区卫生服务提供者（CHSP）和人际传播者（IPC）。他们积极寻找疑似结核病患者，并将其转介到 SQH 诊所。在这项研究中，我们比较了三种治疗途径的 TB 患者的失访率，并调查了失访的风险因素。
采用 2012 年至 2016 年 TB 患者病历的回顾性队列设计。结果定义为与成功治疗 TB（完成或治愈）相比的失访。采用多变量泊松回归估计失访的发生率比。在 SQHC 登记的 62664 名 TB 患者中，约有 10%是由 CHSP 和 IPC 主动筛查的，78.9%是门诊患者。IPC 途径的失访率（14.2%，95%CI 13.4-15.1%）明显高于门诊患者（8.9%，95%CI 8.6-9.1%）和 CHSP 途径（5.5%，95%CI 5.0-6.1%）（p<0.001）。从治疗开始后患者失访的中位数时间为 4.04 个月。我们发现，年龄较大、男性、居住在丘陵地区、未知涂片状态、复治病例、HIV 合并感染和未知 HIV 状态的患者是治疗延续阶段失访的风险因素；而初始体重较高、接受旅行支持和在较年长提供者处接受治疗的患者不太可能失访。
基于这些发现，我们建议，提高病例报告和治疗途径的实施策略应认真考虑并行的保留策略，应考虑失访的影响因素。
