title: Missed opportunities in TB diagnosis: a TB process-based performance review tool to evaluate and improve clinical care.
abstract: BACKGROUND
  Traditional tuberculosis (TB) treatment outcome measures, such as cure rate, do not provide insight into the underlying reasons for missing clinical targets. We evaluated a TB Process-Based Performance Review (TB-PBPR) tool, developed to identify "missed opportunities" for timely and accurate diagnosis of TB. The tool enables performance assessment at the level of process and quality of care.
  
  
  METHODS
  The TB-PBPR tool is a single-page structured flow-sheet that identifies 14 clinical actions (grouped into elicited symptoms, clinical examination and investigations). Medical records from selected deceased patients were reviewed at two South African mine hospitals (A = 56 cases; B = 26 cases), a South African teaching hospital (C = 20 cases) and a UK teaching hospital (D = 13 cases).
  
  
  RESULTS
  In hospital A, where autopsy was routine, TB was missed in life in 52% (23/44) of cases and was wrongly attributed as the cause of death in 16% (18/110). Clinical omissions were identified at each hospital and at every stage of clinical management. For example, recording of chest symptoms was omitted in up to 39% of cases, sputum smear examination in up to 85% and chest radiograph in up to 38% of cases respectively.
  
  
  CONCLUSIONS
  This study introduces the TB-PBPR tool as a novel method to review and evaluate clinical performance in TB management. We found that simple clinical actions were omitted in many cases. The tool, in conjunction with a manual describing best practice, is adaptable to a range of settings, is educational and enables detailed feedback within a TB programme. The TB-PBPR tool and manual are both freely available for general use.
authors.affiliation: Centre for Sexual Health & HIV Research, Research Department of Infection & population Health, University College London, UK. fienige@gmail.com
authors.forename: Nigel
authors.initials: N
authors.lastname: Field
authors.forename: Jill
authors.initials: J
authors.lastname: Murray
authors.forename: Michelle L
authors.initials: ML
authors.lastname: Wong
authors.forename: Rob
authors.initials: R
authors.lastname: Dowdeswell
authors.forename: Ntomboxolo
authors.initials: N
authors.lastname: Dudumayo
authors.forename: Lesego
authors.initials: L
authors.lastname: Rametsi
authors.forename: Neil
authors.initials: N
authors.lastname: Martinson
authors.forename: Marc
authors.initials: M
authors.lastname: Lipman
authors.forename: Judith R
authors.initials: JR
authors.lastname: Glynn
authors.forename: Pam
authors.initials: P
authors.lastname: Sonnenberg
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D006784:Hospitals, Teaching; D006801:Humans; D008297:Male; D008485:Medical Audit; D008875:Middle Aged; D013019:South Africa / Q000453:epidemiology; D014374:Tuberculin Test / Q000592:standards*; D014376:Tuberculosis / Q000175:diagnosis* / Q000453:epidemiology; D006113:United Kingdom / Q000453:epidemiology; D055815:Young Adult