Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada.
McGill International TB Centre, Montreal, Canada.
PLoS One. 2021 Mar 26;16(3):e0249225. doi: 10.1371/journal.pone.0249225. eCollection 2021.
A key component of the WHO End TB Strategy is quality of care, for which case fatality is a critical marker. Half of India's nearly 3 million TB patients are treated in the highly unregulated private sector, yet little is known about the outcomes of these patients. Using a retrospective cohort design, we estimated the case fatality ratio (CFR) and rate of recurrent TB among patients managed in the private healthcare sector in Patna, India.
World Health Partners' Private Provider Interface Agencies (PPIA) pilot project in Patna has treated 89,906 private sector TB patients since 2013. A random sample of 4,000 patients treated from 2014 to 2016 were surveyed in 2018 for case fatality and recurrent TB. CFR is defined as the proportion of patients who die during the period of interest. Treatment CFRs, post-treatment CFRs and rates of recurrent TB were estimated. Predictors for fatality and recurrence were identified using Cox proportional hazards modelling. Survey non-response was adjusted for using inverse probability selection weighting.
The survey response rate was 56.0%. The weighted average follow-up times were 8.7 months in the treatment phase and 26.4 months in the post-treatment phase. Unobserved patients were more likely to have less than one month of treatment adherence (32.0% vs. 13.5%) and were more likely to live in rural Patna (21.9% vs. 15.0%). The adjusted treatment phase CFR was 7.27% (5.97%, 8.49%) and at 24 months post-treatment was 3.32% (2.36%, 4.42%). The adjusted 24 month post-treatment phase recurrent TB rate was 3.56% (2.54%, 4.79%).
Our cohort study provides critical estimates of TB patient outcomes in the Indian private sector, and accounts for selection bias. Patients in the private sector in Patna experienced a moderate treatment CFR but rates of recurrent TB and post-treatment fatality were low.
世界卫生组织终止结核病战略的一个关键组成部分是医疗质量，而病死率是一个关键指标。印度近 300 万结核病患者中有一半在高度不受监管的私营部门接受治疗，但对这些患者的结局知之甚少。本研究采用回顾性队列设计，估计了在印度巴特那私营医疗部门接受治疗的患者的病死率（CFR）和结核病复发率。
自 2013 年以来，世界卫生组织私营医疗服务提供者接口机构（PPIA）试点项目已在巴特那治疗了 89906 例私营部门结核病患者。2018 年对 2014 年至 2016 年期间治疗的 4000 名随机抽样患者进行了病死率和结核病复发调查。CFR 定义为在研究期间死亡的患者比例。估计了治疗期间 CFR、治疗后 CFR 和结核病复发率。采用 Cox 比例风险模型确定病死率和复发的预测因素。使用逆概率选择加权法对调查无应答进行了调整。
调查应答率为 56.0%。加权平均随访时间分别为治疗阶段 8.7 个月和治疗后阶段 26.4 个月。未观察到的患者更有可能治疗依从性不足一个月（32.0% vs. 13.5%），且更有可能居住在巴特那农村（21.9% vs. 15.0%）。调整后的治疗阶段 CFR 为 7.27%（5.97%，8.49%），治疗后 24 个月时为 3.32%（2.36%，4.42%）。调整后的 24 个月治疗后阶段结核病复发率为 3.56%（2.54%，4.79%）。
本队列研究提供了印度私营部门结核病患者结局的关键估计值，并考虑了选择偏倚。巴特那私营部门的患者治疗期间 CFR 适中，但结核病复发率和治疗后病死率较低。
