Related Articles

Background

In Tashkent (Uzbekistan), TB treatment is provided in accordance with the DOTS strategy. Of 1087 pulmonary TB patients started on treatment in 2005, 228 (21%) defaulted. This study investigates who the defaulters in Tashkent are, when they default and why they default.

Methods

We reviewed the records of 126 defaulters (cases) and 132 controls and collected information on time of default, demographic factors, social factors, potential risk factors for default, characteristics of treatment and recorded reasons for default.

Results

Unemployment, being a pensioner, alcoholism and homelessness were associated with default. Patients defaulted mostly during the intensive phase, while they were hospitalized (61%), or just before they were to start the continuation phase (26%). Reasons for default listed in the records were various, 'Refusal of further treatment' (27%) and 'Violation of hospital rules' (18%) were most frequently recorded. One third of the recorded defaulters did not really default but continued treatment under 'non-DOTS' conditions.

Conclusion

Whereas patient factors such as unemployment, being a pensioner, alcoholism and homelessness play a role, there are also system factors that need to be addressed to reduce default. Such system factors include the obligatory admission in TB hospitals and the inadequately organized transition from hospitalized to ambulatory treatment.

Background:

Default remains an important challenge for the Revised National Tuberculosis Control Programme, which has achieved improved cure rates.

Objectives:

This study describes the pattern of time of default in patients on DOTS.

Settings and Design:

Tuberculosis Unit in District Tuberculosis Centre, Yavatmal, India; Retrospective cohort study.

Materials and Methods:

This analysis was done among the cohort of patients of registered at the Tuberculosis Unit during the year 2004. The time of default was assessed from the tuberculosis register. The sputum smear conversion and treatment outcome were also assessed.

Statistical Analysis:

Kaplan-Meier plots and log rank tests.

Results:

Overall, the default rate amongst the 716 patients registered at the Tuberculosis Unit was 10.33%. There was a significant difference in the default rate over time between the three DOTS categories (log rank statistic= 15.49, P=0.0004). Amongst the 331 smear-positive patients, the cumulative default rates at the end of intensive phase were 4% and 16%; while by end of treatment period, the default rates were 6% and 31% in category I and category II, respectively. A majority of the smear-positive patients in category II belonged to the group ‘treatment after default’ (56/95), and 30% of them defaulted during re-treatment. The sputum smear conversion rate at the end of intensive phase was 84%. Amongst 36 patients without smear conversion at the end of intensive phase, 55% had treatment failure.

Conclusions:

Patients defaulting in intensive phase of treatment and without smear conversion at the end of intensive phase should be retrieved on a priority basis. Default constitutes not only a major reason for patients needing re-treatment but also a risk for repeated default.

Background

Completing treatment for multidrug-resistant (MDR) tuberculosis (TB) may be more challenging than completing first-line TB therapy, especially in resource poor settings. The objectives of this study were to (1) identify risk factors for default from MDR TB therapy; (2) quantify mortality among patients who default; and (3) identify risk factors for death following default.

Methods

We performed a retrospective chart review to identify risk factors for default and conducted home visits to assess mortality among patients who defaulted.

Results

67 of 671 patients (10.0%) defaulted. The median time to default was 438 days (interquartile range [IQR]: 152−710), and 40.3% of patients had culture-positive sputum at the time of default. Substance use (hazard ratio [HR]: 2.96, 95% confidence interval [CI]: [1.56, 5.62], p-value [p]=0.001), substandard housing conditions (HR: 1.83, CI: [1.07, 3.11], p=0.03), later year of enrollment (HR: 1.62, CI: [1.09, 2.41], p=0.02) and health district (p=0.02) predicted default in a multivariable analysis. Severe adverse events did not predict default. Of 47 (70.1%) patients who defaulted and were successfully traced, 25 (53.2%) had died. Poor bacteriologic response, less than a year of treatment at default, low education level, and diagnosis with a psychiatric disorder significantly predicted death after default in a multivariable analysis.

Conclusions

The proportion of patients who defaulted from MDR TB treatment was relatively low. The large proportion of patients who defaulted while culture-positive underscores the public health importance of minimizing default. Prognosis for patients who defaulted was poor. Interventions aimed at preventing default may reduce TB-related mortality.

Setting

Under India's Revised National Tuberculosis Control Programme (RNTCP), >15% of previously-treated patients in the reported 2006 patient cohort defaulted from anti-tuberculosis treatment.

Objective

To assess the timing, characteristics, and risk factors for default amongst re-treatment TB patients.

Methodology

For this case-control study, in 90 randomly-selected programme units treatment records were abstracted from all 2006 defaulters from the RNTCP re-treatment regimen (cases), with one consecutively-selected non-defaulter per case. Patients who interrupted anti-tuberculosis treatment for >2 months were classified as defaulters.

Results

1,141 defaulters and 1,189 non-defaulters were included. The median duration of treatment prior to default was 81 days (25%–75% interquartile range 44–117 days) and documented retrieval efforts after treatment interruption were inadequate. Defaulters were more likely to have been male (adjusted odds ratio [aOR] 1.4, 95% confidence interval [CI] 1.2–1.7), have previously defaulted anti-tuberculosis treatment (aOR 1.3 95%CI 1.1–1.6], have previous treatment from non-RNTCP providers (AOR 1.3, 95%CI 1.0–1.6], or have public health facility-based treatment observation (aOR 1.3, 95%CI 1.1–1.6).

Conclusions

Amongst the large number of re-treatment patients in India, default occurs early and often. Improved pre-treatment counseling and community-based treatment provision may reduce default rates. Efforts to retrieve treatment interrupters prior to default require strengthening.

Objectives:

The study was undertaken to assess the adherence to World Health Organization (WHO)-multidrug therapy (MDT) and its successful completion by the leprosy patients and the extent of such defaulting, its correlates and reasons.

Design:

Retrograde cohort analysis was conducted during the first quarter of 2007 from the cases registered for WHO-MDT treatment during 2002 to 2005 in Kamrup district of Assam, India.

Results:

A total of 254 leprosy cases reflected the treatment seeking behavior of registered cases during the study period. Majority of the cases were from urban areas and defaulter rate higher in urban areas. The study group consisted of 60.63% males and 39.37% females.. Both the compliance and default was higher in the age group of 16 to 30 years. Majority of defaulters (32.28%) had passed the high school leaving certificate examination had per capita monthly income between Rs 500 - 749 (30.71%) and belonged to social class IV (33.86%) and V (30.71%). Significant statistical association was found between gender, literacy status, per capita income per month and socioeconomic status with treatment outcome. On analysis for the reasons of defaulting treatment; majority (33.07%) defaulted treatment due to loss of occupational hours when they come for receiving drugs at health center, 25.98% defaulted due to adverse reactions of drugs and 18.11% feared social stigma among major causes.

Conclusions:

The causes of defaulting treatment were related to gender, educational status, income as well as social class, or some combination of these. Recommendations, on strategic interventions to obviate the cause for noncompliance, were presented.

Background

Poor treatment adherence leading to risk of drug resistance, treatment failure, relapse, death and persistent infectiousness remains an impediment to the tuberculosis control programmes. The objective of the study was to identify predictors of default among new smear positive TB patients registered for treatment to suggest possible interventions to set right the problems to sustain and enhance the programme performance.

Methodology & Principal Findings

Twenty districts selected from six states were assigned to six strata formed, considering the geographic, socio-cultural and demographic setup of the area. New smear positive patients registered for treatment in two consecutive quarters during III quarter 2004 to III quarter 2005 formed the retrospective study cohort. Case control analysis was done including defaulted patients as “cases” and equal number of age and sex matched patients completing treatment as “controls”. The presence and degree of association between default and determinant factors was computed through univariate and multivariate logistic regression analysis. Data collection was through patient interviews using pre-tested semi structured questionnaire and review of treatment related records. Information on a wide range of socio demographic and patient related factors was obtained. Among the 687 defaulted and equal numbers of patients in completed group, 389 and 540 patients respectively were satisfactorily interviewed. In the logistic regression analysis, factors independently associated with default were alcoholism [AOR-1.72 (1.23–2.44)], illiteracy [AOR-1.40 (1.03–1.92)], having other commitments during treatment [AOR-3.22 (1.1–9.09)], inadequate knowledge of TB [AOR-1.88(1.35–2.63)], poor patient provider interaction [AOR-1.72(1.23–2.44)], lack of support from health staff [AOR-1.93(1.41–2.64)], having instances of missed doses [AOR-2.56(1.82–3.57)], side effects to anti TB drugs [AOR-2.55 (1.87–3.47)] and dissatisfaction with services provided [AOR-1.73 (1.14–2.6)].

Conclusion

Majority of risk factors for default were treatment and provider oriented and rectifiable with appropriate interventions, which would help in sustaining the good programme performance.

Objectives

To better understand the reasons why patients default from antiretroviral treatment (ART) programmes to help design interventions that improve treatment retention and ultimately, patient outcomes.

Methods

Prospective cohort study at two treatment sites in South Africa followed by qualitative interviews with patients that had defaulted.

Results

Respondents overwhelmingly reported that ART improved their health status and quality of life. Nevertheless, despite improved health from taking ART and worse health when treatment is stopped, serious barriers to treatment remained: transport costs, time needed for treatment, and logistical challenges were barriers to treatment, whereas stigma around HIV/AIDS, and side effects associated with ART were less influential.

Conclusion

With a better understanding of the reasons for defaulting, interventions can be designed that improve treatment retention and ultimately, patient outcomes. This study argues for realistic interventions and policy changes designed to reduce the financial and time burden of ART and to reduce logistical barriers, such as simplifying the referral and transfer process, employing patient advocates, and adopting extended and weekend clinic hours.

Background

Tuberculosis treatment failure and death rates are low in the Western Pacific Region, including Vietnam. However, failure or death may also occur among patients who did not complete treatment, i.e. reported as default or transfer-out. We aimed to assess the proportion failures and deaths among new smear-positive pulmonary tuberculosis patients with reported default or transfer-out.

Treatment outcomes rates were 1.4% default, 3.0% transfer-out, 0.4% failure and 2.6% death in northern Vietnam in 2003.

Methods

Tuberculosis patients in 32 randomly selected district tuberculosis units in northern Vietnam were followed up 1 to 3 years after treatment initiation for survival, recent treatment history and bacteriologically confirmed tuberculosis.

Results

Included were 85 transferred patients and 42 who defaulted. No information was available of 41 (32%), 28 (22%) had died. Fifty-eight were available for follow-up (46%); all had sputum smear results. Tuberculosis was recorded in 11 (13%), including 6 (7%) with positive sputum smears, 3 (3%) with negative smears but positive culture and 2 (2%) who had started re-treatment for bacteriologically confirmed tuberculosis. Fifteen (17%, 95%CI 10–27%) had died within 8 months after treatment initiation. Of 86 patients with known study outcomes, 39 (45%, 95%CI 35–56%) had died or had bacteriologically confirmed tuberculosis. This was recorded for 29/53 (55%, 95%CI 40–68%) transferred patients and 10/33 (30%, 95%CI 16–49%) patients who defaulted.

Conclusion

The total failure and death rates are 0.6% and 0.8% higher than based on routine reporting in northern Vietnam. Although this was a large proportion of treatment failures and deaths, failure and death rates were low. Defaulting and transfer carry a high risk of failure and in particular death.

Background

Defaulting from treatment remains a challenge for most tuberculosis control programmes. It may increase the risk of drug resistance, relapse, death, and prolonged infectiousness. The aim of this study was to determine factors predicting treatment adherence among smear-positive pulmonary tuberculosis patients.

Methods and Findings

A cohort of smear-positive tuberculosis patients diagnosed and registered in Hossana Hospital in southern Ethiopia from 1 September 2002 to 30 April 2004 were prospectively included. Using a structured questionnaire, potential predictor factors for defaulting from treatment were recorded at the beginning of treatment, and patients were followed up until the end of treatment. Default incidence rate was calculated and compared among preregistered risk factors. Of the 404 patients registered for treatment, 81 (20%) defaulted from treatment. A total of 91% (74 of 81) of treatment interruptions occurred during the continuation phase of treatment. On a Cox regression model, distance from home to treatment centre (hazard ratio [HR] = 2.97; p < 0.001), age > 25 y (HR = 1.71; p = 0.02), and necessity to use public transport to get to a treatment centre (HR = 1.59; p = 0.06) were found to be independently associated with defaulting from treatment.

Conclusions

Defaulting due to treatment noncompletion in this study setting is high, and the main determinants appear to be factors related to physical access to a treatment centre. The continuation phase of treatment is the most crucial time for treatment interruption, and future interventions should take this factor into consideration.

A prospective cohort study of smear-positive tuberculosis patients at an Ethiopian hospital found treatment default rates to be high; the main factors relate to physical access to the treatment centre.

Editors' Summary

Background.

Tuberculosis (TB) is one of the leading causes of death from infectious disease worldwide, and it kills around 1.7 million people each year. TB can be successfully treated but the treatment course is long (at least six months). In 1995 the World Health Organization set up “DOTS”, an international strategy for TB control. One of the links below explains what DOTS is in more detail. One of the main elements of DOTS involves the use of standard courses of drug treatment, with the recommendation that trained observers watch people take their treatment. These steps should prevent people from failing to complete their course of treatment, and the World Health Organization has set a target level of 85% for treatment success. However, people do often have problems sticking to treatment and the reasons for this are not clearly understood. Factors such as access to care and a person's social and financial situation might affect whether an individual sticks to their prescribed treatment.

Why Was This Study Done?

This study was carried out in Ethiopia, which has been recognized as being in the top 22 countries with the highest burden of tuberculosis. In the region of southern Ethiopia studied, the proportion of patients not completing their treatment has declined from 38% to 18% between 1994 and 2000. However, the World Health Organization's targets have not been met, with 20% of patients currently failing to complete treatment. These researchers wanted, therefore, to identify the factors that play a part in determining whether a patient completes their course of treatment. They hope that once such factors are identified, they could ultimately be overcome with appropriate interventions and the level of treatment success improved.

What Did the Researchers Do and Find?

The researchers carried out a cohort study, in which all patients diagnosed with clinical tuberculosis during a particular period of time at a major regional hospital in southern Ethiopia were included. Patients were followed up throughout their treatment course and then counted as either having defaulted from treatment (if they had been on treatment for at least 4 weeks and then interrupted for at least 8 weeks), or having completed. The researchers carried out interviews with each participant at the start of the study, to collect information on factors which might affect how each participant might stick to their treatment plan. These factors included basic information such as whether the patient was male or female, their age, marital status, educational level and occupation, as well as others including family income, whether their home was rural or urban, and the distance to the treatment centre. Finally, patients who stopped their treatment were asked an open-ended question: “Why did you stop taking TB medication?”

404 patients were included in the study and 20% defaulted, most of these within the first few months of treatment. The researchers found that a number of factors seemed to be linked to an increased chance that the person would default from treatment. These included age (patients over 25 were less likely to complete); living in a rural setting; having a lower level of education; greater distances from home to the treatment centre; the need for transport to get to treatment; and whether the patient was admitted to hospital in a serious condition. When defaulters were questioned about the reasons they did not complete treatment, the main reasons were related to physical access to the treatment clinic—for example that it was too far, they could not afford to get there, or were not able to walk to get treatment.

What Do These Findings Mean?

The proportion of patients failing to complete their tuberculosis treatment here supports the view that the default rate in Ethiopia has been falling over the past two decades; but that it is still higher than that recommended by the World Health Organization. The researchers also found that physical access to treatment poses a significant barrier to completing treatment. In this study 72% of patients were within two hours' walk of the health facility, a much greater proportion than is the case for the general population in that region. These findings suggest that government initiatives will be needed in order to address the problem of access to treatment and therefore improve adherence. New initiatives are underway in Ethiopia to train health service workers who can provide community-based care.

Additional Information

World Health Organization (WHO) fact sheet on tuberculosis. More detailed information from WHO is available on DOTS, including the five key elements of DOTS

The US Centers for Disease Control and Prevention has a minisite dedicated to tuberculosis, including a questions-and-answers page

The Stop TB Partnership was established in 2000 to realize the goal of eliminating TB as a public health problem and, ultimately, to obtain a world free of TB. It comprises a network of international organizations, countries, donors from the public and private sectors, governmental and nongovernmental organizations, and individuals that have expressed an interest in working together to achieve this goal

Médecins Sans Frontières, an international medical humanitarian organization, has information on its website about its activities in Ethiopia

A prospective cohort study of LTBI treatment conducted within the Haitian population of South Florida investigated the predictive association between illness-related stigma among patients near the beginning of treatment and completion of preventive therapy. Factors associated with perceived stigma were also investigated. Ninety patients from Broward and Palm Beach counties were administered a questionnaire that included items related to illness history, perceptions and understanding of latent tuberculosis, and a 25-item stigma scale adapted from previously developed measures of tuberculosis-related stigma. Therapy completion was determined through a follow-up chart review. Data analyses compared patients who completed therapy with those who defaulted on a number of variables including perceived stigma. No association was found between perceived stigma or demographic characteristics and adherence to preventive therapy. Perceived stigma was associated with patient report of illness-related distress and was higher among patients who were lost to follow up. Some evidence suggested that stigma was higher among contacts of cases, patients with limited understanding of the condition, and patients who were more closely monitored during treatment. Case management should focus on patient-centered approaches to education and counseling about LTBI that address patient understanding of the condition and concerns about its physical and psychosocial effects.

A series of 40 patients in general practice who failed to attend for their appointments were studied to look at their patterns of attendance over the previous five years, together with their reasons for default. The group not only defaulted more often than a group of age and sex matched controls but made significantly more visits to the surgery. Seventeen of the patients increased their default rate as their attendance rate increased over the five year period. The main reasons patients gave for defaulting on the occasion studied were: feeling too ill to attend (eight patients), resolution of symptoms (six) or forgotten/confused appointment time (seven). Four patients were thought by the general practitioner to need a home visit, two of whom were suffering from depression. Further research is needed to define those who would be expected to need a visit.

OBJECTIVE--Firstly to compare the proportion of patients defaulting from follow up at a genitourinary medicine clinic with those attending other hospital based clinics. Secondly to determine which factors are associated with non attendance at a city centre genitourinary medicine clinic. METHODOLOGY--The proportion of patients who defaulted at a genitourinary medicine clinic, a general medical clinic, a general surgical clinic and a dermatology clinic during March 1995 were compared. A multivariate logistic regression analysis was performed comparing attenders and non attenders at the genitourinary medicine clinic with respect to time of appointment, diagnosis, previous contacts with clinic staff, potential domestic commitments and patient demographics in a prospective case control study. RESULTS--The default rate at the genitourinary medicine clinic was 15% compared with 13%, 15% and 14% for medical, surgical and dermatology clinics respectively. Patients who defaulted from the genitourinary medicine clinic (167) were compared with 172 attenders and significant differences found for timing of appointments, area of residence, frequency of counselling by the health advisor and age of the patient. Other factors such as the diagnosis, whether a woman had children, sexual orientation, whether negative results had been given over the phone, source of referral, sex of patient, employment status and the weather were not found to be significantly associated with defaulting from an appointment. CONCLUSIONS--The time of the appointment and being seen by a health advisor were the only variables identified over which the clinic has control and therefore could potentially reduce non attendance rates.

Background

Successful treatment of tuberculosis (TB) involves taking anti-tuberculosis drugs for at least six months. Poor adherence to treatment means patients remain infectious for longer, are more likely to relapse or succumb to tuberculosis and could result in treatment failure as well as foster emergence of drug resistant tuberculosis. Kenya is among countries with high tuberculosis burden globally. The purpose of this study was to determine the duration tuberculosis patients stay in treatment before defaulting and factors associated with default in Nairobi.

Methods

A Case-Control study; Cases were those who defaulted from treatment and Controls those who completed treatment course between January 2006 and March 2008. All (945) defaulters and 1033 randomly selected controls from among 5659 patients who completed treatment course in 30 high volume sites were enrolled. Secondary data was collected using a facility questionnaire. From among the enrolled, 120 cases and 154 controls were randomly selected and interviewed to obtain primary data not routinely collected. Data was analyzed using SPSS and Epi Info statistical software. Univariate and multivariate logistic regression analysis to determine association and Kaplan-Meier method to determine probability of staying in treatment over time were applied.

Results

Of 945 defaulters, 22.7% (215) and 20.4% (193) abandoned treatment within first and second months (intensive phase) of treatment respectively. Among 120 defaulters interviewed, 16.7% (20) attributed their default to ignorance, 12.5% (15) to traveling away from treatment site, 11.7% (14) to feeling better and 10.8% (13) to side-effects. On multivariate analysis, inadequate knowledge on tuberculosis (OR 8.67; 95% CI 1.47-51.3), herbal medication use (OR 5.7; 95% CI 1.37-23.7), low income (OR 5.57, CI 1.07-30.0), alcohol abuse (OR 4.97; 95% CI 1.56-15.9), previous default (OR 2.33; 95% CI 1.16-4.68), co-infection with Human immune-deficient Virus (HIV) (OR 1.56; 95% CI 1.25-1.94) and male gender (OR 1.43; 95% CI 1.15-1.78) were independently associated with default.

Conclusion

The rate of defaulting was highest during initial two months, the intensive phase of treatment. Multiple factors were attributed by defaulting patients as cause for abandoning treatment whereas several were independently associated with default. Enhanced patient pre-treatment counseling and education about TB is recommended.

Background

High levels of defaulting from treatment challenge tuberculosis control in many African cities. We assessed defaulting from tuberculosis treatment in an African urban setting.

Methods

An observational study among adult patients with smear-positive pulmonary tuberculosis receiving treatment at urban primary care clinics in Kampala, Uganda. Defaulting was defined as having missed two consecutive monthly clinic visits while not being reported to have died or continued treatment elsewhere. Defaulting patients were actively followed-up and interviewed. We assessed proportions of patients abandoning treatment with and without the information obtained through active follow-up and we examined associated factors through multivariable logistic regression.

Results

Between April 2007 and April 2008, 270 adults aged ≥15 years were included; 54 patients (20%) were recorded as treatment defaulters. On active follow-up vital status was established of 28/54 (52%) patients. Of these, 19 (68%) had completely stopped treatment, one (4%) had died and eight (29%) had continued treatment elsewhere. Extrapolating this to all defaulters meant that 14% rather than 20% of all patients had truly abandoned treatment. Daily consumption of alcohol, recorded at the start of treatment, predicted defaulting (adjusted odds ratio [ORadj] 4.4, 95%CI 1.8–13.5), as did change of residence during treatment (ORadj 8.7, 95%CI 1.8–41.5); 32% of patients abandoning treatment had changed residence.

Conclusions

A high proportion of tuberculosis patients in primary care clinics in Kampala abandon treatment. Assessing change of residence during scheduled clinic appointments may serve as an early warning signal that the patient may default and needs adherence counseling.

Background

Epidemiological investigations of recent outbreaks of vaccine preventable diseases have indicated that incomplete immunization was the major reason for the outbreaks. In Ethiopia, full immunization rate is low and reasons for defaulting from immunization are not studied well. The objective of the study was to identify the predictors of defaulting from completion of child immunization among children between ages 9–23 months in Wonago district, South Ethiopia.

Methods

Unmatched case control study was conducted in eight Kebeles (lowest administrative unit) of Wonago district in south Ethiopia. Census was done to identify all cases and controls. A total of 266 samples (133 cases and 133 controls) were selected by simple random sampling technique. Cases were children in the age group of 9 to 23 months who did not complete the recommended immunization schedule. Pre-tested structured questionnaire were used for data collection. Data was analyzed using SPSS 15.0 statistical software.

Results

Four hundred eighteen (41.7%) of the children were fully vaccinated and four hundred twelve (41.2%) of the children were partially vaccinated. The BCG: measles defaulter rate was 76.2%. Knowledge of the mothers about child immunization, monthly family income, postponing child immunization and perceived health institution support were the best predictors of defaulting from completion of child immunization.

Conclusion

Mothers should be educated about the benefits of vaccination and the timely administration of vaccines.

Background:

Tuberculosis is a communicable disease requiring prolonged treatment.The therapeutic regimens as recommended by WHO have been shown to be highly effective for both preventing and treating tuberculosis but poor adherence to medication is a major barrier to its global control.

Aim:

The aim was to elicit reasons of treatment default from a cohort of tuberculosis patients treated under Directly Observed Treatment Short course chemotherapy.

Settings and design:

Thiscross-sectional study was conducted in Agra city using the multistage simple random sampling.

Materials and Methods:

A total of 900 patients attending DOTS centres of the selected designated microscopy centers (DMCs) were included in the study from January 2007 onward. The information was obtained from treatment cards of patients and those who defaulted were further interviewed in community.

Statistical analysis:

Chi-square test was applied to observe the significance of association using the Epi Info software (version 6).

Results:

More default was observed among the age group of >45 years (22.8%), male (18.7%), business men (30.6%), and retired and unemployed patients. Other factors associated with higher default were pulmonary disease (18.2%), retreatment cases (30.6%) and category II patients (26.4%). Important reasons of default were side effects following medication (43.2%), improvement in symptoms (14.4%), and lack of time (13.5%). No relief in symptoms and lack of awareness were other important reasons.

Conclusions:

Noncompliance was found to be mainly due to side effects of medicines, lack of time, and unawareness. So educating the patient about various aspects of tuberculosis and some measures to decrease side effects are of utmost importance.

Background

Patients with tuberculosis require retreatment if they fail or default from initial treatment or if they relapse following initial treatment success. Outcomes among patients receiving a standard World Health Organization Category II retreatment regimen are suboptimal, resulting in increased risk of morbidity, drug resistance, and transmission.. In this study, we evaluated the risk factors for initial treatment failure, default, or early relapse leading to the need for tuberculosis retreatment in Morocco. We also assessed retreatment outcomes and drug susceptibility testing use for retreatment patients in urban centers in Morocco, where tuberculosis incidence is stubbornly high.

Methods

Patients with smear- or culture-positive pulmonary tuberculosis presenting for retreatment were identified using clinic registries in nine urban public clinics in Morocco. Demographic and outcomes data were collected from clinical charts and reference laboratories. To identify factors that had put these individuals at risk for failure, default, or early relapse in the first place, initial treatment records were also abstracted (if retreatment began within two years of initial treatment), and patient characteristics were compared with controls who successfully completed initial treatment without early relapse.

Results

291 patients presenting for retreatment were included; 93% received a standard Category II regimen. Retreatment was successful in 74% of relapse patients, 48% of failure patients, and 41% of default patients. 25% of retreatment patients defaulted, higher than previous estimates. Retreatment failure was most common among patients who had failed initial treatment (24%), and default from retreatment was most frequent among patients with initial treatment default (57%). Drug susceptibility testing was performed in only 10% of retreatment patients. Independent risk factors for failure, default, or early relapse after initial treatment included male gender (aOR = 2.29, 95% CI 1.10-4.77), positive sputum smear after 3 months of treatment (OR 7.14, 95% CI 4.04-13.2), and hospitalization (OR 2.09, 95% CI 1.01-4.34). Higher weight at treatment initiation was protective. Male sex, substance use, missed doses, and hospitalization appeared to be risk factors for default, but subgroup analyses were limited by small numbers.

Conclusions

Outcomes of retreatment with a Category II regimen are suboptimal and vary by subgroup. Default among patients receiving tuberculosis retreatment is unacceptably high in urban areas in Morocco, and patients who fail initial tuberculosis treatment are at especially high risk of retreatment failure. Strategies to address risk factors for initial treatment default and to identify patients at risk for failure (including expanded use of drug susceptibility testing) are important given suboptimal retreatment outcomes in these groups.

Objective

To investigate antiretroviral treatment (ART) interruption in a long-term treatment cohort in South Africa.

Methods

All adults accessing ART between 2004 and 2009 were included in this analysis. Defaulting was defined as having stopped all ART drugs for more than 30 days. Treatment interrupters were patients who defaulted and returned to care during the study, whereas loss to follow-up was defined as defaulting and not returning to care. Kaplan-Meier estimates and Possion regression models were used to analyze rates and determinants of defaulting therapy and of treatment resumption.

Results

Overall rate of defaulting treatment was 12.8/100 person years (95% CI 11.4-14.4). Risk factors for defaulting were male gender, high baseline CD4 count, recency of ART initiation and time on ART. The probability of resuming therapy within 3 years of defaulting therapy was 42% (event rate=21.4/100 person-years). Factors associated with restarting treatment were female gender, older age, and time since defaulting.

Conclusion

Defaulting treatment need not be an irreversible event. Interventions to increase retention in care should target men, less immunocompromised patients and patients during the first 6 months of treatment. Resumption of treatment is most likely within the first year of interrupting therapy.

In a two-month study in an urban general practice of eight partners, 11.7 per cent of patients failed to attend for their appointments. Defaulters were younger than a control group of attenders, but the male to female ratio was almost identical. Annual consultation rates for defaulters were slightly lower than controls. Return visits had a default rate of 18 per cent and there was a strong statistical correlation between how and when an appointment was made and the default rate, with a maximum default rate of 19 per cent if the appointment was made between one to two weeks in advance. There was a significant difference in default rate between the partners (range 7.2—14.6 per cent) and the default rate was lowest on Mondays (9.7 per cent) and highest on Fridays (14.9 per cent). The majority of the defaulters had only defaulted once in the previous 12 months. These findings have important implications when planning an appointment system and asking patients to return for follow-up.

SUMMARY

Setting

Multidrug-resistant tuberculosis (MDR TB) has emerged as a significant public health threat in South Africa.

Objective

To describe treatment outcomes and determine risk factors associated with unfavorable outcomes among MDR-TB patients admitted to the provincial TB referral hospital in KwaZulu-Natal province, South Africa.

Design

Retrospective observational study of MDR TB patients admitted from 2000–2003.

Results

Of 1209 MDR TB patients with documented treatment outcomes, 491 (41%) were cured, 35 (3%) completed treatment, 208 (17%) failed treatment, 223 (18%) died and 252 (21%) defaulted. 52% of patients with known HIV status were HIV-infected. Treatment failure, death and default each differed in their risk factors. Greater baseline resistance (AOR 2.3–3.0), prior TB (AOR 1.7), and diagnosis in years 2001, 2002 or 2003 (AOR 1.9–2.3) were independent risk factors for treatment failure. HIV co-infection was a risk factor for death (AOR 5.6) and both HIV (AOR 2.0) and male sex (AOR 1.9) were risk factors for treatment default.

Conclusion

MDR TB treatment outcomes in KwaZulu-Natal were substantially worse than those published from other MDR TB cohorts. Interventions, such as individualized treatment, concurrent antiretroviral therapy and decentralized MDR TB treatment must be considered to improve MDR TB outcomes in this high HIV-prevalence setting.

Multidisciplinary meeting recommendations are largely concordant with guidelines in the treatment of lung cancer.

Purpose:

Multidisciplinary meetings (MDMs) are increasingly being mandated as essential to oncology practice. However, there is a paucity of data on their effectiveness. The aim of this study was to assess whether MDM recommendations were concordant with guidelines in the treatment of lung cancer.

Patients and Methods:

The Lung Cancer Multidisciplinary Meeting in South West Sydney, Australia, prospectively collects data on all patients whose cases have been presented. New patients with lung cancer who presented between December 1, 2005, and December 31, 2007, were reviewed. Patients were assigned to treatment on the basis of evidence-based guidelines according to pathology, stage, and Eastern Cooperative Oncology Group (ECOG) performance status. MDM recommendations were compared with guideline treatment, and reasons for discrepancy were noted.

Results:

There were 335 patients with a median age of 69 years. Of these, 82% had non–small-cell lung cancer (NSCLC), 14% had small-cell lung cancer, and 4% had no pathologic diagnosis. Eighty-four percent had locally advanced or metastatic disease. Concordance of MDM recommendations with guideline treatment existed in 29 (58%) of 50 cases for surgery, 201 (88%) of 228 cases for radiotherapy, and 200 (77%) of 260 cases for chemotherapy. Overall concordance with guideline treatment was 71% (239 of 335 cases). On multivariate analysis, age greater than 70 years, ECOG performance status of 2 or higher, and stage III NSCLC were associated with the MDM not recommending guideline treatment. The primary reasons for this were physician decision (39%), comorbidity (25%), and technical factors (22%).

Conclusion:

MDM recommendations were largely concordant with guidelines. Physician discretion in not recommending guideline treatment was most often exercised in older patients and those with borderline performance status. Individual factors that may preclude guideline treatment cannot be accounted for by guidelines.

A prospective surveillance programme for patients with longstanding (> = 8 years), extensive (> = splenic flexure) ulcerative colitis was undertaken between 1978 and 1990. It comprised annual colonoscopy with pancolonic biopsy. One hundred and sixty patients were entered into the programme and had 739 colonoscopies (4.6 colonoscopies per patient; 709 patient years follow up). Eight eight per cent of examinations reached the right colon. There was no procedure related death. One Dukes's A cancer was detected. Forty one patients (25%) defaulted. Of these 25 remain well; 13 are unaccounted for, and one died from colonic cancer. One patient had colectomy for medical reasons, and another died of carcinoma of the pancreas. Retrospectively an additional 16 eligible patients were identified who had not been recruited. Of these, 14 remain well, two are unaccounted for. None developed colonic cancer. Four patients refused colonoscopy. All remain well. Over the same period seven other cases of colonic cancer were found in association with ulcerative colitis, two in patients who had erroneously been diagnosed as having only proctitis and were therefore not entered into the programme, but were found at operation to have total colitis, one in a patient with colitis of seven years duration, and four patients who had previously attended the clinic but had been lost to follow up before 1978 and then had represented with new symptoms during the surveillance period. Thus, of the nine colitis related cancers diagnosed in this centre during the study period only one was detected by the surveillance programme. The results of this large study, a a review of published works, cast doubts on the effectiveness of colonoscopic surveillance programmes in detecting colorectal cancer in patients with ulcerative colitis.

Background

Although tuberculosis (TB) care is provided free of charge in Morocco, a high number of patients voluntarily interrupt their treatment before the end. Treatment Default is a major obstacle in the fight against the disease. The purpose of this study was to describe the impact of knowledge and attitudes toward TB on treatment adherence.

Methods

Case-control study of 290 TB patients (85 defaulters and 205 controls). A defaulter was defined as a TB patient who interrupted treatment for two months or longer. Socio-demographic measurements, knowledge and attitude were collected by face to face anonymous questionnaire. Khi-square test was conducted to examine differences in TB attitudes and knowledge according to treatment adherence.

Results

The mean age of participants was 31.7 ± 12.0 years. Monthly income was under 2000 MAD (180 €) for 82% of them. Over sixty four percent were illiterate or had a basic educational level. Microbial cause was known by 17.2% respondents; 20.5% among adherent patients versus 9.4% (p=0.02). The fact that the disease is curable was more known by adherent patients: 99.0% versus 88.2% (p < 0.01). Eighty tree per cent of patients had been informed about treatment duration and consequences of not completing treatment: 89.0% among adherent patients versus 69.7% (p<0.001). The main reason evoked for defaulting was the sensation of being cured (72.9% of defaulters).

Conclusion

This study shows a poor knowledge on TB especially among non adherent patients. This finding justifies the need to incorporate patient's education into current TB case management.

It has been reported that many women referred to outpatient colposcopy clinics fail to attend for their appointments. The aim of this paper is to search the literature to assess the extent of default from colposcopy and to identify interventions, suitable for implementation within primary care, to reduce the proportion of women defaulting. Searches were performed on MEDLINE, PsychLIT, Bids and Cancerlit from 1986 to September 1997 using the terms colposcopy or cervical/Pap smear in association with default, non-attendance, adherence, patient compliance, treatment refusal, patient dropouts, attendance, barriers or intervention. The inclusion criteria for primary papers were that they contained data that enables the calculation of default rates for colposcopy or the results of interventions aimed at improving the default rates. Thirteen publications describing default rates and four describing interventions were included as primary papers. Combining the data from these studies suggests default rates of 3%, 11%, and 12% for assessment/treatment visits, first review, and second review respectively. The intervention studies suggested a need to tailor the intervention to the population and the type of information to suit the individual. Varying definitions make comparison of default rates difficult, and the use of a crude non-attendance rate may result in an overestimate of default rates. The vast majority of women invited to colposcopy eventually attend. It is questionable if there is a need for interventions to increase compliance. Where necessary, greater cooperation across the primary/secondary care interface and use of the extended primary care team may be a more cost-effective means of increasing compliance.

AIMS--The efficiency of preschool visual screening programmes to detect amblyopia is questionable. In this study such a programme in an inner city was assessed to determine its effectiveness. METHODS--The results of screening and hospital treatment of 712 patients who were considered to require referral were entered into a database for analysis. Default rates were assessed and the efficacy of treatment determined. RESULTS--The only effective screening test for the detection of amblyopia was visual acuity. A large proportion of referred patients had refractive problems only. High default rates, particularly in geographical areas of lower socioeconomic grading, severely handicapped any attempt to reduce the incidence of amblyopia. CONCLUSION--A fresh approach to the detection and care of amblyopia in the inner city community is required, perhaps by performing screening of children in their first year of attendance at school to reduce default rates. Cycloplegic refraction of children who are found to have reduced visual acuity before their referral to hospital is also recommended.