Fifty-four patients were assessed for TB during the reference period. Most patients (69% (37/54)) referred had a diagnosis of TB made. Over half (51% (19/37)) of patients with TB had PTB (Table 1). Males comprised 57% (21/37) of patients. The median age of TB patients was 41.7 years (Interquartile range 35.1-46.3). Sixty per cent of patients (22/37) were from a country with a high incidence of TB (≥40 cases annually per 100,000 of population). Most patients (87% (32/37)) reviewed had a risk factor for TB. While screening for HIV in the TB clinic was imperfect, only 8% (3/37) of TB patients had a diagnosis of HIV. No TB patient had a history of treatment for LTBI.
Table 1
| Tuberculosis (n=37) | Pulmonary tuberculosis (n=19) | Extrapulmonary tuberculosis (n=18) |
Median age (IQR) | 41.7 (35.1-46.3) | 41.4 (33.3-54) | 42.1 (37.7-50) |
Male sex (percentage) | 21(57%) | 12 (63%) | 9 (50%) |
Any TB risk factor (percentage) | 32 (87%) | 15 (79%) | 16 (89%) |
Born in a country of high TB incidence (percentage) | 22 (60%) | 8 (42%) | 14 (78%) |
HIV Positive (percentage) HIV Negative (percentage) Not tested for HIV (percentage) | 3 (8%) 29 (78%) 5 (14%) | 2 (11%) 14 (74%) 3 (16%) | 1 (6%) 15 (83%) 2 (11%) |
Immunosuppression (percentage) | 4 (11%) | 1 (5%) | 3 (17%) |
Homeless (percentage) | 2 (5%) | 2 (11%) | 0 |
Asylum seeker (percentage) | 1 (3%) | 0 | 1 (6%) |
Person who uses drugs (percentage) | 2 (5%) | 2 (11%) | 0 |
History of incarceration | 0 | 0 | 0 |
Healthcare worker (percentage) | 5 (14%) | 2 (11%) | 3 (17%) |
Recent TB contact (percentage) | 4 (11%) | 4 (21%) | 0 |
History of active TB History of negative LTBI screen (percentage) | 0 3 (8%) | 0 3 (16%) | 0 0 |
Diabetes mellitus (percentage) | 3 (8%) | 3 (16%) | 0 |
Alcohol misuse (percentage) | 4 (11%) | 4 (21%) | 0 |
Bacteriological confirmation of TB infection occurred in 95% (35/37) of patients and the majority (78% (29/37)) were culture positive. Nearly two-thirds of patients (63% (12/19)) with PTB were smear positive at diagnosis. Drug-resistant TB was found in 16% (6/37) of patients, five of whom had isoniazid resistance and one of whom and pyrazinamide resistance. None had rifampicin resistant or multi-drug resistant TB. Treatment success was achieved in 95% (35/37) of patients, 92% (34/37) and 3% (1/37) of whom had treatment completion and cure, respectively. Two patients (5%) were not evaluated, because they transferred their care elsewhere.
Among patients who remained under the care of the TB service, hospitalization occurred in 91% (32/35) of patients and amounted to 1484.5 bed-days. Over half (51% (18/35)) of all TB patients had an emergency hospitalization. Illness due to undiagnosed TB requiring management or investigation was the reason for 86% (44/51) of hospitalizations and the remainder of admissions related to rehabilitation in patients treated for TB (6% (3/51)) or management of disease or treatment-related complications (8% (4/51)).
Patient-related delays
Forty-six percent (17/37) of patients presented first to their primary care physician with their symptoms prior to diagnosis, 41% (15/37) presented with their symptoms directly to an emergency department and 13% (5/37) patients presented their symptoms to a physician while attending another hospital outpatient clinic. Overall, 59% (22/37) of patients had their diagnosis established by attending the emergency department.
In patients with PTB, the median patient-related delay was 60 days (IQR 30-180). In a multivariable regression model (Table 2), neither age, sex, nationality, or HIV status predicted patient-related delay among those with PTB. In patients with EPTB the median patient-related delay was 30 days (IQR 21-60) and in a multivariable progression model that included age, sex, nationality, and HIV status, only HIV infection predicted patient-related.
Table 2
Multiple regression models for predictors of delays among patients with tuberculosis
Patient-related delay | Coef. | Std. Err. | T | P>t | 95% Confidence Interval (Lower Limit) | 95% Confidence Interval (Upper Limit) |
Multiple regression model for predictors of patient-related delay among patients with pulmonary TB |
Age at first presentation | 2.78 | 1.96 | 1.42 | 0.18 | -1.46 | 7.02 |
Male sex | 19.24 | 57.90 | 0.33 | 0.75 | -105.84 | 144.32 |
Irish nationality | -20.20 | 62.17 | -0.32 | 0.75 | -154.50 | 114.11 |
HIV infected | 48.69 | 80.32 | 0.61 | 0.56 | -124.83 | 222.20 |
_cons | -30.56 | 89.26 | -0.34 | 0.74 | -223.40 | 162.27 |
Multiple regression model for predictors of patient-related delay among patients with extrapulmonary TB |
Age at first presentation | 1.71 | 1.48 | 1.15 | 0.27 | -1.55 | 4.97 |
Male sex | 64.65 | 33.98 | 1.90 | 0.08 | -10.13 | 139.43 |
Irish nationality | 70.18 | 60.90 | 1.15 | 0.27 | -63.86 | 204.22 |
HIV infected | 285.79 | 68.38 | 4.18 | 0.00 | 135.28 | 436.30 |
_cons | -61.42 | 61.92 | -0.99 | 0.34 | -197.70 | 74.85 |
Multiple regression model for predictors of health care provider-related delay among patients with pulmonary TB |
Age at first presentation | 1.35 | 1.24 | 1.09 | 0.31 | -1.46 | 4.16 |
Male sex | -40.56 | 36.47 | -1.11 | 0.30 | -123.06 | 41.93 |
Irish nationality | -39.88 | 39.63 | -1.01 | 0.34 | -129.52 | 49.76 |
HIV infected | -46.31 | 47.60 | -0.97 | 0.36 | -153.99 | 61.37 |
Culture-positive TB | -240.37 | 68.57 | -3.51 | 0.01 | -395.48 | -85.27 |
Drug-resistant TB | -16.57 | 50.25 | -0.33 | 0.75 | -130.25 | 97.11 |
Acutely hospitalized | -32.35 | 33.71 | -0.96 | 0.36 | -108.62 | 43.91 |
_cons | 291.16 | 86.85 | 3.35 | 0.01 | 94.70 | 487.62 |
Multiple regression model for predictors of health care provider-related delay among patients with extrapulmonary TB |
Age at first presentation | 5.79 | 13.02 | 0.44 | 0.67 | -23.67 | 35.26 |
Male sex | 111.70 | 175.54 | 0.64 | 0.54 | -285.39 | 508.80 |
Irish nationality | -319.50 | 563.40 | -0.57 | 0.59 | -1594.00 | 954.99 |
HIV infected | -94.37 | 497.42 | -0.19 | 0.85 | -1219.62 | 1030.87 |
Culture-positive TB | -130.02 | 191.05 | -0.68 | 0.51 | -562.21 | 302.17 |
Drug-resistant TB | -109.82 | 270.67 | -0.41 | 0.69 | -722.11 | 502.47 |
Acutely hospitalized | -32.39 | 297.81 | -0.11 | 0.92 | -706.09 | 641.30 |
_cons | 40.84 | 559.54 | 0.07 | 0.94 | -1224.92 | 1306.60 |
Health care provider-related delays
The median health care provider-related delay among patients with PTB was 16 days (IQR 2-54). In a multivariable regression model including age, sex, nationality, HIV status, culture status, drug resistance status and being acutely hospitalized, culture-positivity was associated with a shorter health care provider-related delay (coefficient -240.37, standard error 68.57, 95% -395.48- -85.27, P<0.05) among patients with PTB (Table 2). The median health care provider-related delay among patients with EPTB was 66 days (IQR 24-176) and in a multivariable regression model including age, sex, nationality, HIV status, culture status, drug-resistance status and being acutely hospitalized, no variable was found to predict health care provider-related delay among patients with EPTB.
Direct cost of care
The total direct cost of TB care was €1,216,712. Hospitalizations consisted of 92.1% (€1,120,576) of costs, the majority of which (60.2%) related to emergency hospitalizations. Outpatient care comprised the remaining 7.9% of costs. The median cost of care among all patients with TB treated successfully who remained under the care of the TB service (n= 30) was €8298 (IQR 4,344-19,641). The median cost of care among patients with PTB with a successful treatment outcome (n=16) was €10,162 (IQR 4,898-19,549). The median cost of care among patients with EPTB with a successful treatment outcome (n=14) was €7,534 (IQR 3,730-18,057). In a multivariable model that included age, sex, nationality, HIV status, culture status, patient-related delays, and health care provider-related delays only patient-related delays predicted a higher cost of care among patients with PTB who completed treatment (Table 3). In a multivariable model that included age, sex, nationality, HIV status, culture status, patient-related delay, and health care provider-related delay, no variable predicted the cost of TB care among patients with EPTB.
Table 3
Multiple regression models for predictors of direct cost of care among patients with tuberculosis
Multiple Regression model for predictors of direct cost of pulmonary TB care |
Patient-related delay | Coef. | Std. Err. | T | P>t | 95% Confidence Interval (Lower Limit) | 95% Confidence Interval (Upper Limit) |
Age at first presentation | 2880.08 | 1319.81 | 2.18 | 0.06 | -105.55 | 5865.70 |
Male sex | 24231.74 | 39247.73 | 0.62 | 0.55 | -64552.80 | 113016.30 |
Irish nationality | -24453.15 | 41362.82 | -0.59 | 0.57 | -118022.30 | 69116.05 |
HIV infected | -31595.83 | 51704.20 | -0.61 | 0.56 | -148558.90 | 85367.19 |
Culture-positive TB | -80597.39 | 114364.10 | -0.70 | 0.50 | -339307.00 | 178112.20 |
Patient-related delay | 424.05 | 187.03 | 2.27 | 0.05 | 0.96 | 847.15 |
Health care provider-related delay | -305.31 | 365.80 | -0.83 | 0.43 | -1132.82 | 522.20 |
_cons | -43701.31 | 129315.30 | -0.34 | 0.74 | -336232.80 | 248830.20 |
Multiple Regression model for predictors of direct cost of extrapulmonary TB care |
Age at first presentation | -466.4403 | 446.8027 | -1.04 | 0.337 | -1559.727 | 626.8466 |
Male sex | -4199.576 | 9388.936 | -0.45 | 0.67 | -27173.48 | 18774.32 |
Irish nationality | 46504.35 | 32452.2 | 1.43 | 0.202 | -32903.33 | 125912 |
Culture positive TB | -4861.437 | 8622.483 | -0.56 | 0.593 | -25959.89 | 16237.02 |
Patient-related delay | -60.13667 | 85.82541 | -0.7 | 0.51 | -270.1439 | 149.8705 |
Health care provider-related delay | 0.790151 | 14.51181 | 0.05 | 0.958 | -34.71897 | 36.29927 |
_cons | 30585.9 | 17349.45 | 1.76 | 0.128 | -11866.67 | 73038.47 |
Comparison of evaluation outcomes with benchmarks
The results of the literature search are reported in Appendix 2. Studies reported the median patient-related delay among patients with PTB as being 7, 10, 18, 21, 30, 36 and 38 days [20][21][22][23][24][25]. Therefore, the median, minimum and maximum patient-related delay among patients with PTB reported in the literature are 21 days, 7 days, and 38 days, respectively. The median patient-related delay in this evaluation of 60 days among those with PTB suggests patient-related delays were prolonged. The health care-related delay among patients with PTB was reported in the included studies as 11, 14, 15, 22, 26, 27 and 36 days [23][24][26][22][27][20]. The median, minimum and maximum health care-related delays among patients with PTB are 22 days, 11 days, and 36 days, respectively. The median health care provider related delay among patients with PTB in this evaluation of 16 days is similar to that reported in the literature but suggests it could be improved.
With regard to patients with EPTB, there was significant variation in the patient-related delay reported in the literature among differing EPTB disease sites and symptom complexes. Therefore, a benchmark for EPTB patient-related delay could not be reliably defined for comparison with the outcomes reported in this evaluation. Among patients with EPTB, the health care-related delays reported in the included studies were 32, 39 and 42 days [22][28], all lesser than the health care-related delay among patients with EPTB in this evaluation of 66 days.
Regarding the direct cost of TB care, the median, minimum and maximum costs of non-rifampicin resistant non-multidrug resistant TB care reported in the included studies were €9,319, €6,486, and €14,750, respectively (Table 4). Therefore, the cost of care reported in this evaluation (€8298), while similar to that in other low incidence countries, suggests it could be improved.
Table 4
Direct cost of tuberculosis care reported in the literature
Study (year) | Country | Drug-susceptible TB cost (€) |
Diel et al. (2020) [29][30] | Germany | 9,455 |
De Vries et al. (2013) [31] | The Netherlands | 9,319 |
Deuffic-Burban et al. (2010) [32] | France | 6,486 |
Department of Health (2009) [33] | United Kingdom | 7,199 |
Chan et al. (2017) [34] | Australia | 6,952 |
Marks et al. (2014) [35] | USA | 14,750 |
Pina et al. (2013) [36] | Spain | 10,557 |
Median | 9,319 |
Minimum | 6,486 |
Maximum | 14,750 |