Evaluating tuberculosis case detection via real-time monitoring of tuberculosis diagnostic services

Am J Respir Crit Care Med. 2011 Aug 1;184(3):362-7. doi: 10.1164/rccm.201012-1984OC. Epub 2011 Mar 11.


Rationale: Tuberculosis case-detection rates are below internationally established targets in high-burden countries. Real-time monitoring and evaluation of adherence to widely endorsed standards of tuberculosis care might facilitate improved case finding.

Objectives: To monitor and evaluate the quality of tuberculosis case-detection and management services in a low-income country with a high incidence of tuberculosis.

Methods: We prospectively evaluated tuberculosis diagnostic services at five primary health-care facilities in Uganda for 1 year, after introducing a real-time, electronic performance-monitoring system. We collected data on every clinical encounter, and measured quality using indicators derived from the International Standards of Tuberculosis Care.

Measurements and main results: In 2009, there were 62,909 adult primary-care visits. During the first quarter of 2009, clinicians referred only 21% of patients with cough greater than or equal to 2 weeks for sputum smear microscopy and only 71% of patients with a positive sputum examination for tuberculosis treatment. These proportions increased to 53% and 84%, respectively, in the fourth quarter of 2009. The cumulative probability that a smear-positive patient with cough greater than or equal to 2 weeks would be appropriately evaluated and referred for treatment rose from 11% to 34% (P = 0.005). The quarterly number of tuberculosis cases identified and prescribed treatment also increased four-fold, from 5 to 21.

Conclusions: Poor adherence to internationally accepted standards of tuberculosis care improved after introduction of real-time performance monitoring and was associated with increased tuberculosis case detection. Real-time monitoring and evaluation can strengthen health systems in low-income countries and facilitate operational research on the effectiveness and sustainability of interventions to improve tuberculosis case detection.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Adult
  • Diagnostic Services / standards
  • Diagnostic Services / statistics & numerical data*
  • Global Health
  • Guideline Adherence / statistics & numerical data
  • Humans
  • Incidence
  • Population Surveillance / methods
  • Practice Guidelines as Topic
  • Primary Health Care / methods
  • Primary Health Care / standards
  • Primary Health Care / statistics & numerical data*
  • Prospective Studies
  • Sputum / microbiology
  • Tuberculosis, Pulmonary / diagnosis*
  • Tuberculosis, Pulmonary / epidemiology
  • Uganda / epidemiology