Patient and health care system delays in pulmonary tuberculosis diagnosis in a low-incidence state

SETTING: Tuberculosis (TB) patients reported to the Maryland Department of Health and Mental Hygiene from 1 June 2000 to 30 November 2001. OBJECTIVE: To determine the extent of delayed diagnosis of TB and to assess patient and provider factors associated with delays. DESIGN: A prospective cohort study. RESULTS: Median patient, health care and total delays were 32, 26 and 89 days, respectively, for 158 patients. Non-white (relative hazard [RH] 0.62; 95%CI 0.39-0.98) and less educated (RH 0.43; 95%CI 0.26-0.72) patients had longer patient delays. English-speaking patients (RH 0.40; 95%CI 0.24-0.68) had increased health care delays, as did patients who received a diagnosis of a respiratory illness and non-TB antibiotics (RH 0.69; 95%CI 0.49-0.96) prior to a TB diagnosis. Patients first presenting to a private physician (51 days) rather than a hospital emergency room (18 days; RH 1.87; 95%CI 1.05-3.33) or public health clinic (10 days; RH 1.79; 95%CI 1.21-2.63) had longer health care delays. When a TB diagnostic tool (chest radiograph or AFB culture) was utilized, a more rapid diagnosis of TB was made. CONCLUSION: Education of the patient population about TB symptoms might reduce delays. Increased physician awareness of the current epidemiology of TB and better use of available diagnostic tools will reduce delays and may reduce TB transmission.