title: Patient and health care system delays in the diagnosis and treatment of tuberculosis.
abstract: METHODS
  All culture-positive tuberculosis patients without previous treatment for tuberculosis (n = 184), New York City, April 1994.
  
  
  OBJECTIVE
  To examine factors associated with delays in presenting to a health care provider (patient delay) and in starting antituberculosis treatment (health care system delay).
  
  
  METHODS
  Retrospective medical record review and patient interviews.
  
  
  RESULTS
  Median total delay was 57 days (range 4-764), 35 for acid-fast bacilli smear-positive patients and 79 for smear-negative patients (P < 0.001). Median patient delay was 25 (range 0-731). Median health care system delay was 15 days, 6 for smear-positive patients and 31 for smear-negative patients (P < 0.001). In logistic regression, age 55-64 years (adjusted odds ratio [OR(adj)] 10.6, 95% confidence interval [CI] 1.3-86.9), and primary language other than English (OR(adj) 2.5, 95%CI 1.0-5.8), were associated with longer patient delays. Homelessness (OR(adj) 7.1, 95%CI 1.05-33.5), not having a chest radiograph at the first medical visit (OR(adj) 2.4, 95%CI 1.0-5.4), negative smear (OR(adj) 10.2, 95%CI 4.4-23.3) and absence of cough (OR(adj) 2.9, 95%CI 1.2-6.8) were associated with longer health care system delays.
  
  
  CONCLUSIONS
  To reduce delays, patients should be educated to seek care more quickly, and should be provided with culturally appropriate health care and language services. Physicians should maintain a high index of suspicion for tuberculosis and perform appropriate diagnostic tests.
authors.affiliation: Bureau of Tuberculosis Control, New York City Department of Health, New York 10013, USA.
authors.forename: L F
authors.initials: LF
authors.lastname: Sherman
authors.forename: P I
authors.initials: PI
authors.lastname: Fujiwara
authors.forename: S V
authors.initials: SV
authors.lastname: Cook
authors.forename: L B
authors.initials: LB
authors.lastname: Bazerman
authors.forename: T R
authors.initials: TR
authors.lastname: Frieden
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D003695:Delivery of Health Care / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009519:New York City; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D010346:Patient Care Management / Q000592:standards; D010353:Patient Education as Topic; D012189:Retrospective Studies; D013997:Time Factors; D014397:Tuberculosis, Pulmonary / Q000175:diagnosis* / Q000628:therapy*