Early implementation challenges in electronic referral and feedback mechanism for patients with tuberculosis using Nikshay - A mixed-methods study from a medical college TB referral unit of Delhi, India

Reema Arora; Ashwini Khanna; Nandini Sharma; Vishal Khanna; Kalpita Shringarpure; Soundappan Kathirvel

doi:10.4103/jfmpc.jfmpc_1360_20

Early implementation challenges in electronic referral and feedback mechanism for patients with tuberculosis using Nikshay - A mixed-methods study from a medical college TB referral unit of Delhi, India

J Family Med Prim Care. 2021 Apr;10(4):1678-1686. doi: 10.4103/jfmpc.jfmpc_1360_20. Epub 2021 Apr 29.

Authors

Reema Arora¹, Ashwini Khanna², Nandini Sharma³, Vishal Khanna⁴, Kalpita Shringarpure⁵, Soundappan Kathirvel⁶

Affiliations

¹ RNTCP, Referral Unit, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India.
² State Programme Office (RNTCP), New Delhi, India.
³ Department of Community Medicine, Maulana Azad Medical College, New Delhi, India.
⁴ District Programme Office (RNTCP), New Delhi, India.
⁵ Department of Preventive and Social Medicine, Medical College, Baroda, Gujarat, India.
⁶ Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.

Abstract

Background: Diagnosis, notification and timely initiation of treatment is an important cornerstone for the elimination of tuberculosis (TB). The referral and feedback mechanism under National Tuberculosis Programme of India has been changed from paper-based to web-based electronic system (Nikshay) since 2018. The current study was carried out to assess the effect of Nikshay in referral and receipt of feedback on treatment initiation and to understand the early implementation challenges.

Methods: A mixed-methods study was conducted in a medical college referral unit (MCRU) of Delhi, India. The electronic TB notification data for July 2018-March 2019 were abstracted from Nikshay portal and analysed. Unadjusted and adjusted relative risk (aRR) was calculated to assess the factors associated with the receipt of feedback. Themes and subthemes were generated from qualitative data obtained through key-informant interviews of healthcare providers.

Results: Of the total 4395 patients handled by MCRU during the study period, 3315 (75.4%) were referred out within and outside Delhi for treatment. Feedback was received among 797 (24.0%) of the patients who were referred out. Patients with extrapulmonary TB (aRR: 1.3, confidence interval (CI): 1.1-1.8), previously treated (aRR: 1.2, CI: 1.2-1.3) and registered for drug-resistant TB care (aRR: 1.4, CI: 1.1-1.8), had high chance of receiving feedback. Four broad themes emerged, namely, (a) awareness of programme and Nikshay; (b) tracking of patients; (c) user-friendly portal and (d) workload.

Conclusion: The low feedback on treatment initiation of patients with TB needs further research after health system-level quality improvement interventions. Real-time tracking of patients is the need of the hour towards the path for TB elimination.

Keywords: Disease notification; Nikshay; feedback; referral; tuberculosis.