Patient and health care system delays in the diagnosis and treatment of tuberculosis

SETTING: All culture-positive tuberculosis patients without previous treatm ent for tuberculosis (n = 184), New York City, April 1994. OBJECTIVE: To examine factors associated with delays in presenting to a hea lth care provider (patient delay) and in starting antituberculosis treatmen t (health care system delay). DESIGN: Retrospective medical record review and patient interviews. RESULTS: Median total delay was 57 days (range 4-764), 35 for acid-fast bac illi smear-positive patients and 79 for smear-negative patients (P < 0.001) . Median patient delay was 25 (range 0-731). Median health care system dela y was 15 days, 6 for smear-positive patients and 31 for smear-negative pati ents (P < 0.001). In logistic regression, age 55-64 years (adjusted odds ra tio [ORadj] 10.6, 95% confidence interval [CI] 1.3-86.9), and primary langu age other than English (ORadj 2.5, 95%CI 1.0-5.8), were associated with lon ger patient delays. Homelessness (ORadj 7.1, 95%CI 1.05-33.5), not having a chest radiograph at the first medical visit (ORadj 2.4, 95%CI 1.0-5.4), ne gative smear (ORadj 10.2, 95%CI 4.4-23.3) and absence of cough (ORadj 2.9, 95%CI 1.2-6.8) were associated with longer health care system delays. CONCLUSION: TO reduce delays, patients should be educated to seek care more quickly, and should be provided with culturally appropriate health care an d language services. Physicians should maintain a high index of suspicion f or tuberculosis and perform appropriate diagnostic tests.