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Prediction and Implications of TB Treatment Default in Urban Morocco

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Total Posts: 16

Joined 2014-04-02

PM

Are patients who default at high risk of transmitting TB?  Is drug resistance common among patients who return to care after TB treatment default?

     
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Total Posts: 10

Joined 2014-05-06

PM

very good work done.

     
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Total Posts: 14

Joined 2014-05-07

PM

This is a very good study which has used mixed methodology tapping the perspectives of both the health care providers and the patients as well as using quantitative data to bring out the risk factors for default.
The study goes a step further and wonderfully comes up with a scoring system which can be used to identify the patients who could be at high risk of default.
The study interestingly does not stop at identifying risk factors but goes on to give scores based on the beta coefficients, uses the total scores for drawing the ROC curves and comes up with a cutoff point for identifying patients at risk of default. The methodology in very interesting and innovative.
A ‘wholesome’ study if I may call it so!
A few comments:
1. Default is associated with increased risk of mortality. Patients who have defaulted and subsequently died could not be included in the sample. Could this introduce a bias?
2. In this study all patients were HIV seronegative. Does this area in urban Morrocco have a very low prevalence of HIV? The risk factors and reasons for default in HIV seropositive patients with TB could be different.
3. Some factors show significant association with default in the first few tables , yet have not been considered in the final multivariate regression model viz. Male gender, Pulmonary TB, number of people living with patient, current alcohol use and cannabis use, can be reached by phone.
4. The question ‘how long does TB treatment take to complete?’ was asked to controls who were patients who had completed their treatment successfully. They would be expected to report the duration correctly (Yet 14% did not know the duration of treatment!)
5. The survey tool can, not only help in identifying those at risk of default but also be helpful as a tool for the kind of action to be taken to prevent default. E.g. Those who do not know the duration of treatment can be given the information, smokers can be counseled to give up smoking,patients can be encouraged to share their diagnosis with friends, the timings of TB treatment can be adjusted to avoid interference with work.What would happen if these measures reduce the score on the survey tool? Will the probability of default for the individual patient reduce?
6. When should the tool be used to screen patients? Some questions ( side effects,regression of symptoms) will not be reported at the time of treatment initiation.

     
Rank

Total Posts: 24

Joined 2014-05-05

PM

what is the role of Diagnosis in controlling the duration of Treatment ?

     
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Total Posts: 8

Joined 2014-05-05

PM

I feel it’s a very good study, very well planned, as used both the qualitative and quantitative research methodology is used to address the various factors associated with Tb treatment defaulters. Both qualitative and quantitative research methodologies have their limitations, but when you use it combined a mixed study methodology, you come up with strengths of each – a synergistic effect.
What was interesting is your invention of an innovative survey tool based on strength of association for various risk and protective factors from Odds ratios based on the results of logistic regression model.
A few comments:
1) Why is it that all of your defaulters were sero negative for HIV infection, whereas literature quotes in fact many studies have identified HIV/AIDS as a potential risk factor for default or does the country has very low incidence of HIV?
2) Then some things are really unclear as I am not well versed with the National TB programme at Morocco, like under RNTCP in India, in the national programme itself there is an inbuilt provision for taking corrective action if the patient doesn’t turn out to take his treatment or misses few of his doses, they do phone him, his relatives and if still doesn’t come back for treatment the health care workers visit at their home, try to find out the reasons, counsel them and take corrective action. Are such kind of provisions not available at Morocco?
3) There is one more comment in your presentation which is really worrisome, you said the hospitals do not have a TB treatment register from which the health care authorities would know who is taking treatment regularly and who is a potential defaulter, is it so and if true whether corrective actions were taken?
4)  Most of the factors identified by you in qualitative research methodology like doctors spending less time with patients, ill motivated health care staff , the health care workers not wearing masks etc. did you share your research findings with the Health care workers and the authorities and did they made any attempt to improve those conditions.
5) I do agree and various research papers do mention about relief from symptoms, unmotivated patients tends to default and we should come out with health education materials, videos, counselling sessions before the start of anti-tuberculosis treatment . All health care workers need to be a good educationist as well as a good counselor too.
6) I think your this innovative survey tool of finding which patient would default can be rather used as a tool to take corrective action so that you do not have defaulters itself, may be the tool needs to be tested and further studies need to be carried out to authenticate this.

     
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Total Posts: 21

Joined 2014-05-04

PM

We’ll planned study. A few comments
1. Defaulters should have been included in the analysis.
2. Scoring systems work well during research settings but have not been found to be effective in routine practise.
3. TB health visitors and counsellors together could reduce defaulters to some extent, more important is health education again and again to the TB diagnosed patient and also the families.