WHY DO SYMPTOMATIC PATIENTS DELAY OBTAINING CARE FOR TUBERCULOSIS

The resurgence of tuberculosis (TB) has coincided with deteriorating a ccess to care for high-risk populations. We sought to determine what p erceived access barriers delayed symptomatic TB patients from obtainin g care. In order to do this, we conducted a survey in Los Angeles Coun ty, California, using a consecutive sample of patients with active TB as confirmed by the county TB control authority. The measures used in the study were a self-reported delay in seeking care of more than 60 d from symptom onset, a period sufficient to cause skin-test conversion in exposed contacts, and self-reported access barriers. The county TB registry provided supplementary clinical data. We found that one in f ive of the 248 symptomatic respondents (response rate: 60%) delayed ob taining care for > 60 d (mean = 74 d, SD = 216 d). During the delay, p atients exposed an average of eight contacts. As compared with the res t of the sample, delay was more common in those who were unemployed (2 5% versus 14%), concerned about cost (27% versus 14%), anticipated pro longed waiting-room time (26% versus 14%), believed they could treat t hemselves (31% versus 14%), anticipated difficulty in getting an appoi ntment (28% versus 16%), were uncertain about where to get care (33% v ersus 16%), and feared immigration authorities (47% versus 18%) (p < 0 .05). Logistic regression revealed that uncertainty about where to get care, unemployment, and belief in the efficacy of self-treatment inde pendently predicted delay > 60 d. Illness severity as measured by ches t radiography, sputum smears, and symptoms had little impact on delay. We conclude that because access variables such as lack of employment and knowledge about where to obtain care were more closely associated with clinically significant delay than was severity of illness, these results raise concerns about the equity of access to care among TB pat ients. The results suggest that improving the availability of services for high-risk groups may substantially reduce TB patients' delay in o btaining care, and thus may limit the spread of the disease.