Ahmad et al. BMC Public Health 2012, 12:132 http://www.biomedcentral.com/1471-2458/12/132 Table 1 Determinants of patient loss among 554 TB suspects in health centres in Jogjakarta municipality Variable All First step work-up Sputum smear microscopy Other Ť Nothing ± Sex Male Female Age group (years) 18-25 26-35 36-45 46-55 56-65 > 65 Type of health facility MHC SHC n/N 241/554 215/497 22/53 4/4 115/262 126/292 28/81 40/88 47/89 45/92 34/95 47/109 53/168 188/386 % 43.3 43.3 OR 1 41.5 0.93 100.0 43.9 1.03 43.2 1 34.6 0.70 45.5 1.10 52.8 1.48 48.9 1.26 35.8 0.74 43.1 1 31.5 1 48.7 2.06 Univariate 95% CI P-value 0.52-1.65 0.74-1.44 0.39-126 0.62-1.94 0.84-2.59 0.72-2.21 0.42-1.29 0.81 0.86 0.10 0.23 0.74 0.18 0.41 0.29 1.41-3.02 < 0.001* Ť Chest X-ray, antibiotics, or combination of X-ray and antibiotics with/without sputum smears ±Suspects who were directly lost before any examination was performed. Not included in the statistical analysis *Only this variable remained in multivariate analysis first examination was associated with TB-positive smears (OR 2.93, 95% CI 1.10-7.77, P < 0.03). The median duration of diagnostic delay for smear- positive cases, excluding the patients who dropped out, was 1 day in lung clinics, 4 days in MHC, and 7.5 days in SHC. The median delay until diagnosis for smear- negative TB and non-TB cases was also longer in the SHC compared to MHC and lung clinics. The median tests showed significantly longer diagnostic delays in SHC and MHC compared to lung clinics among smear- positive, smear-negative, and non-TB patients (Table 2). Discussion This study is one of a few that focus on the process of diagnostic work-ups in DOTS facilities. Our study found that all of the diagnostic work-ups in lung clinics and Page 4 of 6 the majority of diagnostic work-ups in health centres did not comply with the standardised national algo- rithm. No patients were lost in lung clinics, and 43.5% of patients were lost in health centres. The duration of diagnostic delay was longer in health centres compared to lung clinics. Some limitations of our study need to be taken into account. First, we limited ourselves to the lung clinics and health centres; TB work-ups at DOTS-affiliated hos- pitals were not documented. However, the hospitals’ diagnostic infrastructure and technical capacity are simi- lar to that of the lung clinics, and we expect the varia- tion in diagnostic pathways in these hospitals to be comparable to that of the lung clinics. Second, patients who were lost were not traced back, which reflects the actual performance of the health services. Third, culture examination was not performed because we did not aim to evaluate the effectiveness of the diagnostic algorithm. Non-adherence to the standardised diagnostic algo- rithm was high. One important reason for non-adher- ence to the diagnostic algorithm was a non-TB diagnosis among patients with an initial negative sputum smear who showed clinical improvement. This decision is reasonable clinically, but the existing algorithm does not accommodate this option. If the decision is consid- ered acceptable, non-adherence in the health centres drops to 18.2% (n = 57). Studies in Ethiopia and India have also shown a high rate of non-adherence [17-19]. Though different types of non-adherence exist (e.g., sequence of examination, inadequate examination, or absence of recommended examination [17-19]), we found that the sequence of examination was the main reason for non-adherence. Most patients in lung clinics, in particular, received multiple examinations at the first consultation due to the availability of chest radiography. Also, specialised chest doctors are more likely to rely on their clinical judgment than on the diagnostic algorithm. The proportion of patients lost in health centres was surprisingly high. A study in Pakistan reported a lower proportion of lost patients (13%), but 5.2% of these patients were smear-positive cases and, therefore, at high risk of spreading infection [20]. We found that gender did not correlate with the default rate, whereas another study found that males defaulted more Table 2 Duration of diagnostic delay (in days) according to the diagnostic outcome for TB suspects who completed the diagnostic work-up TB smear-positive TB smear-negative Non-TB IQR = inter-quartile range n 27 12 131 Lung clinics Median (IQR) 1 (1 - 1) 2 (1 - 4) 2 (1 - 4) n 16 4 95 MHC Median (IQR) 4 (2 - 7) 10 (5 - 88) 8 (5 - 15) n 26 8 164 SHC Median (IQR) 7.5 (5 - 12) 13.5 (5 - 14) 11 (8 - 11) P-value < 0.001 0.006 < 0.001