Establishing the cascade of care for patients with tuberculous meningitis.

Darma Imran,Jacob Mcknight,Reinout Van Crevel,Philip C Hill

doi:10.12688/wellcomeopenres.15515.2

Abstract

Meningitis is a relatively rare form of tuberculosis, but it carries a high mortality rate, reaching 50% in some settings, with higher rates among patients with HIV co-infection and those with drug-resistant disease. Most studies of tuberculosis meningitis (TBM) tend to focus on better diagnosis, drug treatment and supportive care for patients in hospital. However, there is significant variability in mortality between settings, which may be due to specific variation in the availability and quality of health care services, both prior to, during, and after hospitalization. Such variations have not been studied thoroughly, and we therefore present a theoretical framework that may help to identify where efforts should be focused in providing optimal services for TBM patients. As a first step, we propose an adjusted cascade of care for TBM and patient pathway studies that might help identify factors that account for losses and delays across the cascade. Many of the possible gaps in the TBM cascade are related to health systems factors; we have selected nine domains and provide relevant examples of systems factors for TBM for each of these domains that could be the basis for a health needs assessment to address such gaps. Finally, we suggest some immediate action that could be taken to help make improvements in services. Our theoretical framework will hopefully lead to more health system research and improved care for patients suffering from this most dangerous form of tuberculosis.

Highlights

Meningitis is a relatively rare form of tuberculosis, but it carries a high mortality rate, reaching 50% in some settings, with higher rates among patients with HIV co-infection and those with drug-resistant disease
In the absence of empirical data, we aim to provide a theoretical framework that may help identify barriers and challenges in providing optimal care for tuberculosis meningitis (TBM) patients, by combining cascade of care, patient pathway and health needs analyses
We propose that a theoretical cascade might comprise of the numbers in sequence: TBM patients in a particular community; those accessing a health facility able to diagnose TBM; those diagnosed as TBM; those started on treatment; those discharged alive; those retained to care after discharge; and those completing treatment without significant disability (Figure 1)

Summary

13 Nov 2019

Any reports and responses or comments on the article can be found at the end of the article. Patient pathway studies might help identify factors that account for losses and delays across the cascade of care for TBM, the first being access to appropriate health services. Health systems factors Many of the possible gaps in diagnosis and treatment of TBM are related to health systems factors Health systems factors, such as the availability of the right facilities or workforce, health information, guidelines, drugs, financing, and organization of the healthy system can explain the wide variability in patient pathways, losses across the ‘cascade of care’ and delays across different settings and countries, and thereby the variable mortality of TBM. Possible actions Establishing the cascade of care for TBM, conducting a patient pathway analysis, and further study of health systems factors could help identify priority areas for further action to improve care and outcomes for TBM patients.

Conclusion

World Health Organization

Findings

22. World Health Organization