Abstract
BackgroundIn low-incidence countries, clinical experience of tuberculosis is becoming more limited, with potential consequences for patient outcomes. In 2007, the Department of Health released a guidance ‘toolkit’ recommending that tuberculosis patients in England should not be solely managed by clinicians who see fewer than 10 cases per year. This caseload threshold was established to try to improve treatment outcomes and reduce transmission, but was not evidence based. We aimed to assess the association between clinician or hospital caseload and treatment outcomes, as well as the relative suitability of making recommendations using each caseload parameter.MethodsDemographic and clinical data for tuberculosis cases in England notified to Public Health England’s Enhanced Tuberculosis Surveillance system between 2003 and 2012 were extracted. Mean clinician and hospital caseload over the past 3 years were calculated and treatment outcomes grouped into good/neutral and unfavourable. Caseloads over time and their relationship with outcomes were described and analysed using random effects logistic regression, adjusted for clustering.ResultsIn a fully adjusted multivariable model (34,707 cases)there was very strong evidence that management of tuberculosis by clinicians with fewer than 10 cases per year was associated with greater odds of an unfavourable outcome compared to clinicians who managed greater numbers of cases (cluster-specific odds ratio, 1.14; 95 % confidence interval, 1.05–1.25; P = 0.002). The relationship between hospital caseload and treatment outcomes was more complex and modified by a patient’s place of birth and ethnicity. The clinician caseload association held after adjustment for hospital caseload and when the clinician caseload threshold was reduced down to one.ConclusionsDespite the relative ease of making recommendations at the hospital level and the greater reliability of recorded hospital versus named clinician, our results suggest that clinician caseload thresholds are more suitable for clinical guidance. The current recommended clinician caseload threshold is functional. Sensitivity analyses reducing the threshold indicated that clinical experience is pertinent even at very low average caseloads, which is encouraging for low burden settings.Electronic supplementary materialThe online version of this article (doi:10.1186/s12916-016-0592-8) contains supplementary material, which is available to authorized users.
Highlights
In low-incidence countries, clinical experience of tuberculosis is becoming more limited, with potential consequences for patient outcomes
As documented in previous reports, England has a high proportion of extrapulmonary TB cases compared to some other low-incidence settings [1, 16]
In our study of the relationship between caseloads and treatment outcomes, we observed very strong evidence for higher cluster-specific odds of an unfavourable outcome if TB cases were managed by clinicians who saw less than 10 cases, on average, over the preceding 3 years
Summary
In low-incidence countries, clinical experience of tuberculosis is becoming more limited, with potential consequences for patient outcomes. In 2007, the Department of Health released a guidance ‘toolkit’ recommending that tuberculosis patients in England should not be solely managed by clinicians who see fewer than 10 cases per year This caseload threshold was established to try to improve treatment outcomes and reduce transmission, but was not evidence based. In 2007, the Department of Health’s TB guidance toolkit (hereafter referred to as the ‘toolkit’) for England advised that: “[if TB] is confirmed, the patient is best managed by, or in conjunction with, a clinician (a respiratory physician or appropriately trained infectious disease physician) who sees at least 10 confirmed cases per year” [4] This caseload threshold was established to improve treatment outcomes and reduce transmission, but was not evidence based
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