title: Health system delay in pulmonary tuberculosis treatment in a country with an intermediate burden of tuberculosis: a cross-sectional study.
abstract: BACKGROUND
  Delayed diagnosis and treatment of tuberculosis increase both the severity of the disease and the duration of infectivity. A number of studies have addressed the issue of health system delays in the treatment of tuberculosis, but mostly in countries with a high or low incidence of the disease. Our understanding of delay is quite limited in settings with an intermediate burden of tuberculosis. We explore the duration and factors associated with delays in the Croatian health system which has free health care and a sufficient network of health services providing tuberculosis diagnosis and care.
  
  
  METHODS
  A total of 241 consecutive adults with culture-confirmed pulmonary tuberculosis were interviewed in seven randomly selected Croatian counties and their medical records were evaluated. A health system delay was defined as the number of days from the first consultation with a physician to the initiation of anti-tuberculosis treatment. A long delay was defined as a period exceeding the median delay, while an extreme delay was considered to be above the 75th percentile delay.
  
  
  RESULTS
  The median health system delay was 15 days while the 75th percentile was 42 days (the 5th and 95th percentile being 1 and 105 days respectively). Almost 30% of tuberculosis patients remained undiagnosed for more than 30 days after the initial health care visit. Female patients (p = 0.005), patients with a negative sputum smear (p = 0.002) and patients having symptoms other than the usual ones (0.027) were found to be in significant correlation with a long delay. In a multivariate model, a long delay remained associated with the same variables (p = 0.008, p = 0.003, and p = 0.037, respectively).A significant association was demonstrated between both the female gender (p = 0.042) and a negative sputum smear (p < 0.001) and extreme delay, while only a negative sputum smear (p < 0.001) remained significant in the multivariate analysis.
  
  
  CONCLUSIONS
  Our findings suggest that some groups of tuberculosis patients experienced a health system delay. In such a setting where tuberculosis incidence is decreasing, which leads to a lack of physician experience and expertise, training in tuberculosis is required. Such measure may be useful in reducing the number of missed opportunities for tuberculosis diagnosis.
authors.affiliation: Teaching Public Health Institute of Split and Dalmatia County and School of Medicine, University of Split, Vukovarska 46, 21 000 Split, Croatia.
authors.forename: Anamarija
authors.initials: A
authors.lastname: Jurcev-Savicevic
authors.forename: Rosanda
authors.initials: R
authors.lastname: Mulic
authors.forename: Karlo
authors.initials: K
authors.lastname: Kozul
authors.forename: Bozica
authors.initials: B
authors.lastname: Ban
authors.forename: Jasna
authors.initials: J
authors.lastname: Valic
authors.forename: Ljiljana
authors.initials: L
authors.lastname: Bacun-Ivcek
authors.forename: Ivan
authors.initials: I
authors.lastname: Gudelj
authors.forename: Gordana
authors.initials: G
authors.lastname: Popijac-Cesar
authors.forename: Snjezana
authors.initials: S
authors.lastname: Marinovic-Dunatov
authors.forename: Aleksandar
authors.initials: A
authors.lastname: Simunovic
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D017281:Cost of Illness; D017523:Croatia / Q000453:epidemiology; D003430:Cross-Sectional Studies; D003695:Delivery of Health Care; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012307:Risk Factors; D012737:Sex Factors; D013183:Sputum / Q000382:microbiology; D013997:Time Factors; D061665:Time-to-Treatment / Q000706:statistics & numerical data*; D014397:Tuberculosis, Pulmonary / Q000453:epidemiology / Q000628:therapy*; D055815:Young Adult