The First Differentiated TB Care Model From India: Delays and Predictors of Losses in the Care Cascade

To reduce TB deaths in resource-limited settings, a differentiated care strategy can be used to triage patients with high risk of severe illness (i.e., those with very severe undernutrition, respiratory insufficiency, or inability to stand without support) at diagnosis and refer them for com-prehensive assessment and inpatient care. Globally, there are few examples of implementing this type of strategy in routine program set-tings. Beginning in April 2022, the Indian state of Tamil Nadu imple-mented a differentiated care strategy called Tamil Nadu-Kasanoi Erappila Thittam (TN-KET) for all adults aged 15 years and older with drug-susceptible TB notified by public facilities. Before evaluat-ing the impact on TB deaths, we sought to understand the retention and delays in the care cascade as well as predictors of losses. During April-June 2022, 14,961 TB patients were notified and 11,599 (78%) were triaged. Of those triaged, 1,509 (13%) were at high risk of severe illness; of these, 1,128 (75%) were comprehen-sively assessed at a nodal inpatient care facility. Of 993 confirmed as severely ill, 909 (92%) were admitted, with 8% unfavorable admis-sion outcomes (4% deaths). Median admission duration was 4 days. From diagnosis, the median delay in triaging and admission of se-verely ill patients was 1 day each. Likelihood of triaging decreased for people with extrapulmonary TB, those diagnosed in high -notification districts or teaching hospitals, and those transferred out of district. Predictors of not being comprehensively assessed includ-ed: aged 25-34 years, able to stand without support, and diagnosis at a primary or secondary-level facility. Inability to stand without support was a predictor of unfavorable admission outcomes. To conclude, the first quarter of implementation suggests that TN-KET was feasible to implement but could be improved by addressing predictors of losses in the care cascade and increasing admission duration.

Automated summary

In order to reduce TB deaths in areas with limited resources, a differentiated care strategy called TN-KET was implemented in Tamil Nadu, India starting from April 2022. This strategy aims to triage high-risk patients at diagnosis and refer them for comprehensive assessment and inpatient care. During the first quarter of implementation, it was found that most severely ill patients were successfully assessed and admitted, but there were some delays and predictors of losses in the care cascade that need to be addressed for improvement.