International Standards of Tuberculosis Care Implementation by Pulmonologists in Private Practice in

JakartaE. Burhan1, M. A. Nawas1, D. Kusumo Sutoyo2, F. Yunus1, L. Chen3, B. M.

Djojonegoro3,

P. C. Hopewell3, F. Mulyani4, D. E. Mustikawati5

1The Indonesian Society of Respirology, Jakarta, Indonesia; 2Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia; 3American Thoracic Society, New York, New York, and Curry International Tuberculosis Center, UCSF, Oakland, USA; 4DKI Jakarta Provincial Health Office,

Jakarta, Indonesia; 5Subdirectorate of Tuberculosis Control, Ministry of Health, Jakarta, IndonesiaBackground: Most pulmonologists in Jakarta practice in private hospitals and treat

tuberculosis (TB) patients. With the introduction of the International Standards of Care (ISTC) and DOTS, pulmonologists are expected to implement the standards in their practice regardless of limitations in their private practice settings. To improve case notification and monitoring of treatment outcomes, the Indonesian Society of Respirology (PDPI) implemented a project in which selected private pulmonologists agreed to manage patients in accordance with the ISTC and National TB Program (NTP) guidelines.

Methods:  To validate information from TB case reporting through the PDPI project, we reviewed medical records from the practices of 21 pulmonologists from 16 private hospitals in East, South, and Central Jakarta. Abstractors with TB clinical background collected data from 258 TB patients, diagnosed between October-December 2010, with expected treatment completion by June 2011. We developed a questionnaire and scoring system related to diagnosis, therapy, monitoring, and outcomes of TB treatment to assess ISTC implementation.

Discussion: Most of the pulmonologists performed appropriate ISTC implementation in their private practice. The high number of patients who defaulted from treatment may indicate the lack of patient education given by pulmonologists or the need of a better linkage system among private providers and the local Health Office to ensure continued TB treatment of patients.

Result: We evaluated 11 of 21 standards: 4 diagnostic, 5 treatment, 1 co-morbidity, and 1 public health standards. Four pulmonologists (19%) adhered to all standards, 8 (38%) adhered to 10 of 11 standards, 1 met only 8 of 12 standards, while the rest met varied numbers of standards. Standard 21 is implemented by all pulmonologists and Standards 4 and 8 are implemented well by >80% of pulmonologists. Standard 11 was least implemented, with no or partial implementation by 90% of pulmonologists. Of 258 TB cases, 65% were successfully treated, 1% failed, 1% died, 28% defaulted from treatment, and 5% transferred out to another facility.

Standard

Description Implementation on Patients

Implement-ationScore*

2 Two sputum specimens

104 of 219 (47%). 70%

3 Appropriate specimen submitted (extrapulmonary TB)

21 of 39 (54%). 78%

4 All with suspect chest X-ray submit sputum

154 of 211 (73%). 95%

5 Diagnosis of sputum smear negative pulmonary TB

50 of 94 (53%) 52%

7 Appropriate regimen and adherence assessment

230 of 231 (100%) with no history of prior TB and 14 of 25 with TB history (56%) given appropriate regimen.

56%

8 Appropriate first line regimen

230 of 231 (100%) with no history of prior TB.

84%

10 Monitoring of response to therapy

33 of 64 with positive smear at diagnosis (52%) converted, 6 (9%) did not convert, and 25 (39%) unknown.

72%

11 Assessment of drug resistance

2 of 25 with TB history (15%) had culture and susceptibility test.

8%

13 Written record 160 of 219 pulmonary TB patients (73%) had diagnostic smear. Of those smear +, 61% had monitoring smear. All but 1 patient had record of drug regimen. 11 were noted with side effects.

39%

17 Co-morbid conditions

24 patients with co-morbidities; diabetes mellitus was most common at 18 (75%)

24%

21 Reporting of all TB patients

All were reported to local health office and according to NTP policy

100%

*Percent of pulmonologists who implemented the standard for >=50% of their patients

Excerpt of Abstraction Tool

Standards and Their Implementation

Outcome N (%)Cured 70 (27)

Completed 97 (38)

Failed 2 (1)

Deceased 3 (1)

Transferred out

14 (5)

Defaulted 72 (28)

Patient Outcome