Research Article: Constructing care cascades for active tuberculosis: A strategy for program monitoring and identifying gaps in quality of care

Date Published: February 27, 2019

Publisher: Public Library of Science

Author(s): Ramnath Subbaraman, Ruvandhi R. Nathavitharana, Kenneth H. Mayer, Srinath Satyanarayana, Vineet K. Chadha, Nimalan Arinaminpathy, Madhukar Pai

Abstract: The cascade of care is a model for evaluating patient retention across sequential stages of care required to achieve a successful treatment outcome. This approach was first used to evaluate HIV care and has since been applied to other diseases. The tuberculosis (TB) community has only recently started using care cascade analyses to quantify gaps in quality of care. In this article, we describe methods for estimating gaps (patient losses) and steps (patients retained) in the care cascade for active TB disease. We highlight approaches for overcoming challenges in constructing the TB care cascade, which include difficulties in estimating the population-level burden of disease and the diagnostic gap due to the limited sensitivity of TB diagnostic tests. We also describe potential uses of this model for evaluating the impact of interventions to improve case finding, diagnosis, linkage to care, retention in care, and post-treatment monitoring of TB patients.

Partial Text: Tuberculosis (TB) is the leading infectious cause of death globally [1]. The World Health Organization (WHO) has highlighted “patient-centered care for all people with TB” as a central pillar of its post-2015 End TB strategy [2]. The cascade of care (also called the continuum of care) is a useful model for evaluating patient retention across sequential stages of care required to achieve a successful outcome. The cascade helps to quantify gaps in care delivery, pointing to areas in which quality of care could be improved. Over the last decade, the HIV community has pioneered use of the cascade to evaluate care delivery in diverse populations [3–5]. This model has subsequently been applied to other diseases [6,7]. The care cascade is instrumental in tracking progress in the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 global strategy for HIV [8,9].

The care cascade represents a valuable and feasible approach for monitoring TB programs [10]. Unique challenges involved in constructing a TB care cascade include difficulties in estimating the number of individuals with active TB in the population, challenges in estimating the diagnostic gap (Gap 2) due to the suboptimal sensitivity of common diagnostic tests, and heterogeneity in approaches for estimating cascade stages for different forms of TB. In addition, the case-finding gap (Gap 1) includes individuals with TB who do not access TB tests for various reasons, including not having access to health facilities, not seeking care, and not being referred for TB testing after reaching a healthcare provider. Understanding which barrier contributes most to Gap 1 is an important undertaking that we have not covered in this manuscript. Some challenges involved in estimating the care cascade are not unique to TB—for example, use of written records and lack of unique identification numbers, which makes tracking patients across stages more difficult. Additionally, it is not easy to account for patients managed in the private sector in some countries, without conducting primary data collection.

The care cascade has the potential to improve program monitoring and to inform targeting of interventions to improve case finding, diagnosis, linkage to treatment, retention in care, and recurrence-free survival for TB patients. Combined with other approaches, such as patient pathways analyses, the care cascade can provide critical information on quality of care to national TB programs [12]. The model may refine estimates for the STOP TB Partnership’s 90-(90)-90 global targets, which include getting 90% of people with active TB on appropriate therapy, reaching at least 90% of key high-risk or underserved populations as part of this approach, and ensuring that 90% of those patients achieve treatment success by 2025 at the latest. By providing a systematic approach to evaluating care delivery, followed by corrective interventions, the care cascade may serve as an important tool for achieving the ambitious goal of reducing TB incidence by 90% by 2035, as envisioned by the End TB strategy [92].



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