Patient Pathways of Tuberculosis Care-Seeking and Treatment: An Individual-Level Analysis of National Health Insurance Data

Abstract

Background: Tuberculosis patients often experience difficulties in accessing diagnosis and treatment. Patient Pathway Analysis provides a tool to identify mismatches between provision of, and patient demand for, tuberculosis care, but was developed using cross-sectional, aggregate data. Methods: We developed an algorithmic approach to analyse and interpret patient-level routine data on healthcare utilisation and construct patients' pathways from initial care-seeking to treatment outcome. We applied this to tuberculosis patients in a simple random sample of one million patients' records in the Taiwan National Health Insurance database. We analysed heterogeneity in pathway patterns, delays, service coverage, and patient flows between different health system levels. Findings: We constructed 7,255 pathways for 6,258 patients. Patients most commonly initially sought care at the primary clinic level, where the capacity for diagnosing tuberculosis was 12%, before eventually initiating treatment at higher levels. Patient pathways are extremely heterogeneous prior to diagnosis, with the 10% most complex pathways accounting for 48% of all clinical encounters, and 55% of those pathways yet to initiate treatment after a year. Extended consideration of alternative diagnoses was more common for patients aged 65 or older and for patients with chronic lung disease. Interpretation: Patient-level routine healthcare data can be analysed to generate individual patient tuberculosis care-seeking pathways. Improving tuberculosis awareness and specimen-handling capacity at primary care level may improve patient experience of accessing tuberculosis care in Taiwan. Funding Statement: PJD was supported by a fellowship from the UK MRC (MR/P022081/1). HHL was supported by the Taiwan MoST, (101-2314-B-002-124) and the Taiwan NHRI (NHRI-EX105- 10228PC). Declaration of Interests: The authors declare that they have no competing interests. Ethics Approval Statement: The study was approved by the ethics committee of the University of Sheffield (Reference Number 017693).