An Evaluation of Private Sector Pathways to Diagnosis of Tuberculosis in Chennai, India

Setting Private practitioners are frequently the first point of healthcare contact for patients with tuberculosis (TB) in India. However, inappropriate TB management practices among private practitioners may contribute to delayed TB diagnosis. As new TB diagnostic tests are developed and the national TB control program seeks to better engage the private sector, it is important to understand pathways to TB diagnosis in urban India. Design A cross-sectional study was conducted among patients and practitioners in Chennai city from January 2014 to February 2015. Patient participants were diagnosed with TB in the private sector and referred for TB treatment through a public-private mix program in Chennai. Practitioners practicing in the private sector, who saw at least one TB patient per year, were randomly selected from both the general community and a list of practitioners who referred patients to the public-private mix program. Cross-section interviews were conducted with 289 patients and 228 practitioners using standardized questionnaires. Results Among 212 patients with pulmonary TB, 90% first contacted a formal private provider, and 78% were diagnosed by the first or second provider seen after a median of three visits per provider. Median total delay was 52 days (Mean 69). Consulting an informal (rather than formally trained) provider first, was associated with an increase in risk of prolonged total delay >90 days (aRR 2.5, 95%CI: 1.3-4.5). Among 228 private practitioners, only 52% of practitioners sent >5% of patients with cough for TB testing, 83% used smear microscopy for diagnosis, and 22% notified TB cases to authorities. For new patients with pulmonary TB, 30% of practitioners reported referring all patients for treatment, while 70% (160/228) listed 27 different regimens; 78% (125/160) of these prescribed a regimen classified as consistent with ISTC. Under half (48%, 110/228) of all practitioners utilized any point-of-care (POC) tests in their clinics. Providers using POC tests were more likely to work in hospitals (56% vs. 43%, P=0.05) and less likely to be chest specialists (21% vs. 54%, P