A survey of tuberculosis clinic provision in England and Wales

Optimising spatial accessibility to inform rationalisation of specialist health services

Background

In an era of budget constraints for healthcare services, strategies for provision of services that improve quality whilst saving costs are highly valued. A proposed means to achieve this is consolidation of services into fewer specialist centres, but this may lead to reduced spatial accessibility. We describe a methodology which includes implementing a combinatorial optimisation algorithm to derive combinations of services which optimise spatial accessibility in the context of service rationalisation, and demonstrate its use through the exemplar of tuberculosis clinics in London.

Methods

Our methodology involves (1) identifying the spatial distribution of the patient population using the service; (2) calculating patient travel times to each service location, and (3) using a combinatorial optimisation algorithm to identify subsets of locations that minimise overall travel time. We estimated travel times for tuberculosis patients notified in London between 2010 and 2013 to each of 29 clinics in the city. Travel time estimates were derived from the Transport for London Journey Planner service. We identified the subset of clinics that would provide the shortest overall travel time for each possible number of clinic subsets (1–28).

Results

Based on the 29 existing clinic locations, mean estimated travel time to clinics used by 12,061 tuberculosis patients in London was 33 min; and mean time to their nearest clinics was 28 min. Using optimum combinations of clinic locations, and assuming that patients attended their nearest clinics, a mean travel time of less than 45 min could be achieved with three clinics; of 34 min with ten clinics, and of less than 30 min with 18 clinics.

Conclusions

We have developed a methodological approach to optimise spatial accessibility which can be used to inform rationalisation of health services. In urban conurbations, this may enable service reorganisation which increases quality and efficiency without substantially affecting spatial accessibility. This approach could be used to inform planning of service reorganisations, but may not be generalisable to rural areas or smaller urban centres.

Tuberculosis control in big cities and urban risk groups in the European Union: a consensus statement

In low-incidence countries in the European Union (EU), tuberculosis (TB) is concentrated in big cities, especially among certain urban high-risk groups including immigrants from TB high-incidence countries, homeless people, and those with a history of drug and alcohol misuse. Elimination of TB in European big cities requires control measures focused on multiple layers of the urban population. The particular complexities of major EU metropolises, for example high population density and social structure, create specific opportunities for transmission, but also enable targeted TB control interventions, not efficient in the general population, to be effective or cost effective. Lessons can be learnt from across the EU and this consensus statement on TB control in big cities and urban risk groups was prepared by a working group representing various EU big cities, brought together on the initiative of the European Centre for Disease Prevention and Control. The consensus statement describes general and specific social, educational, operational, organisational, legal and monitoring TB control interventions in EU big cities, as well as providing recommendations for big city TB control, based upon a conceptual TB transmission and control model.

An exploration of NHS staff views on tuberculosis service delivery in Scottish NHS boards

Tuberculosis (TB) is a bacterial disease and major worldwide killer with an increased UK incidence rate. This study aimed to explore the views of National Health Service (NHS) staff on TB service delivery models of care in NHS boards across Scotland. Eighteen semi-structured interviews were conducted with 13 nurse specialists and five consultants in public health medicine (CPHM) across five Scottish NHS boards. Five main themes emerged and findings showed that: directly observed treatment (DOT) was provided only to patients assessed to be at high risk of poor treatment adherence; contact tracing was conducted by participating NHS boards but screening at ports was thought to be weak; all NHS boards implemented TB awareness campaigns for TB health professionals; three NHS boards conducted team meetings that monitored TB patient progress; participants believed that TB funding should be increased; contact tracing was routinely conducted by TB nurses. Improved TB screening at airports was recommended and a need for TB health education for high risk groups was identified.

Knowledge of tuberculosis-treatment prescription of health workers: a systematic review

Treating tuberculosis (TB) patients with inappropriate treatment regimens can lead to treatment failure and, thus, patients who have not been cured and/or to the development of (multi)-drug resistance. A systematic review was performed to assess the knowledge of appropriate TB drug regimens among all categories of healthcare workers (HCWs).

In January 2011, MEDLINE, EMBASE and other databases were searched for relevant articles. Observational studies published as of the year 2000 that assessed HCW knowledge of TB treatment were selected. A treatment regimen, drug dosage or treatment duration was considered inappropriate if it was not recommended by national guidelines or by the World Health Organization (WHO).

Of 1,896 studies, 31 were included from 14 different countries. No study was performed in Europe. In all studies, HCWs with inappropriate knowledge of treatment regimens (8–100%) or treatment duration (5–99%) were observed. The few studies providing detailed data showed that HCWs mainly reported giving treatment regimens with too many drugs and for too long. Knowledge of appropriate doses was also insufficient in most studies.

The available studies show that there is a lack of knowledge of national or international TB treatment guidelines and recommendations. Generalisation of the findings to other settings and countries should be done with caution.