Quality of comprehensive assessment among severely ill TB patients referred after triaging in southern India

To reduce TB deaths, Tamil Nadu, a southern Indian state, implemented the first state-wide differentiated TB care strategy starting April 2022. Triage-positive severely ill patients are prioritised for comprehensive assessment and inpatient care. Routine program data during October–December 2022 revealed that documentation of total score after comprehensive assessment was available in only 39%, possibly indicating poor quality of comprehensive assessment. We confirmed this using operational research. The case record form to record comprehensive assessment was used only in 26% and among these, the completeness and correctness in filling out the form were sub-optimal. There is a clear need to enhance the quality of comprehensive assessments.

http://dx.doi.org/10.5588/pha.23.0051 To reduce TB deaths, Tamil Nadu, a southern Indian state, implemented the first state-wide differentiated TB care strategy starting April 2022.Triage-positive severely ill patients are prioritised for comprehensive assessment and inpatient care.Routine program data during October-December 2022 revealed that documentation of total score after comprehensive assessment was available in only 39%, possibly indicating poor quality of comprehensive assessment.We confirmed this using operational research.The case record form to record comprehensive assessment was used only in 26% and among these, the completeness and correctness in filling out the form were sub-optimal.There is a clear need to enhance the quality of comprehensive assessments.
I n 2020-2021 during the COVID-19 pandemic, there was an increase in estimated TB deaths and the reported TB death rate in India, including Tamil Nadu. 1,2amil Nadu is a southern Indian state with 70 million population and approximately 0.1 million TB notifications per year. 1 With the aim to reduce the TB death rate, Tamil Nadu implemented the first state-wide (excluding Chennai, the capital city) differentiated TB care strategy among all adult (≥15 years) TB patients notified from public health facilities (not known to be drug-resistant at diagnosis) in April 2022.[3][4][5] The strategy is called Tamil Nadu Kasanoi Erappila Thittam, (TNKET) meaning Tamil Nadu TB death-free project in Tamil.3,4 Using a paper-based triage tool, all adults with TB are triaged for severe illness at diagnosis.[3][4][5] Those detected with very severe undernutrition (body mass index ≤14 kg/m 2 or 14.1-16 kg/m 2 with pedal oedema) or respiratory insufficiency (respiratory rate more than 24 per min or oxygen saturation ,94%) or poor performance status (unable to stand without support), defined as 'triage-positive', are identified and prioritised for referral to a nodal inpatient care facility for comprehensive assessment (using paperbased case record form [CRF]) and inpatient care using an inpatient care guide for people with TB with severe illness (for details on this, the 2-page TNKET standard operating procedure containing links to the paper-based triage tool, the CRF, inpatient care guide, and details about the monitoring and evaluation framework, see Supplementary Data, at https://doi.org/10.6084/m9.figshare.24564403;][4][5] The key variables required for monitoring the TNKET care cascade were transcribed from paper-based tools to Severe TB Web Application (TB SeWA) by the Senior Treatment Supervisor (STS; sub-district-level staff in charge of TB patients in a population of approximately 50-100,000; for details see Supplementary Figure S1 at https://doi.org/10.6084/m9.figshare.24625026.v2).[3][4][5] The CRF is a single paper tool with front and back print.The initial section contains information about the facility where the patient was diagnosed and the contact details of STS, has to be filled out by the referring STS.Details regarding clinical, laboratory and radiological assessment are subsequently filled out by the nodal physician at the designated inpatient care facility.Triagepositive patients are scored based on a set of 16 indicators. 3 T Unless there is an error in triaging at diagnosis, triage-positives get confirmed as 'severely ill'.Those with a total score of more than three or with very severe undernutrition are recommended admission to a facility with high dependency and/or an intensive care unit of the teaching hospital.3,4 This is followed by documentation of issues that need to be addressed during inpatient care.The patient is discharged after fulfilling the discharge criteria; date of admission, discharge and admission outcome are documented.
The paper-based CRF was introduced in August 2022.In addition to the ongoing transcription of comprehensive assessment (yes/no) in TB SeWA, we added the transcription of total scores after comprehensive assessment from August 2022.

ASPECTS OF INTEREST
By the end of 2022, nearly 80% of triage-positive were identified, comprehensively assessed and admitted within a median of 1 day of diagnosis. 5The average admission duration was 6 days. 5This, along with quality comprehensive assessment and inpatient care, will increase the likelihood of TNKET achieving its goal of reducing TB death rate. 3,4lthough comprehensive assessment among triagepositive was documented as 'yes' in TB SeWA for 90% patients, the total score was documented in only 39% in

Public Health Action
TNKET: quality of comprehensive assessment the quarter following the introduction of the CRF (October-December 2022), possibly indicating poor quality of comprehensive assessment.To investigate this, we conducted operational research in 10 (out of 30) randomly selected TB programme districts to evaluate the quality of the comprehensive assessment conducted in terms of completeness and accuracy in filling out the CRF.Of the 4,058 TB patients notified, 446 were triagepositive and of these, 402 underwent comprehensive assessment ('yes' in TB SeWA as on 10 March 2023; see Supplementary Figure S2 at https://doi.org/10.6084/m9.figshare.24625026.v2).During March-May 2023, we visited the 10 study districts to obtain a copy of the filled CRF.Of the 10 districts, only four utilised the CRF.Of these 402 patients, the CRF was filled out for 104 (25.9%) patients.We assessed the completeness and correctness of these 104 CRFs.
The seven fields meant for the STS before referral were complete in 29 forms (27.9%).Complete documentation of clinical, radiological and laboratory assessment was documented in 19 forms (18.3%).Among the six questions related to undernutrition assessment, 32 forms (30.8%) had all six responses.
Of the 104 forms that had been filled out, 54 (51.9%) contained scores for each of the 16 indicators, along with a documented total score.Only four forms (3.8%) had documented confirmation of severe illness, whether or not high-dependency unit care was required, as well as an 'issue to be addressed during inpatient care'.A total of 84 forms (80.8%) had all fields related to admission and discharge-related details filled out.A comprehensive breakdown of the completeness of documentation in the CRF is provided in Tables 1 and 2.
Of the 104 CRFs, we were able to objectively verify correctness of two variables: 'severe' and 'very severe' undernutrition status was correctly documented in 32 (30.8%); and in 12 forms (12.4%), the total score was correctly calculated.

DISCUSSION
During October-December 2022, the failure to utilise the CRF seemed to be the cause behind the nontranscription of the total score (after comprehensive assessment) in TB SeWA.Even among those using the CRF, quality (completeness and accuracy) was suboptimal.This has major implications in that it can potentially affect patient management adversely, resulting in missed opportunities for optimal care.
A possible reason might be the lack of awareness of the utility of the TNKET CRF among the nodal physicians.There is a clear need to intensify efforts to enhance the quality of the comprehensive assessment through reorientation of the district TB officers and nodal physicians.This is being done during the quarterly supportive supervisory visit to a district and online reorientation session.The transcription of the total scores in TB SeWA has increased to 79% in April-June 2023 from 39% in October-December 2022.Districts that initially did not

Public Health Action
TNKET: quality of comprehensive assessment use these forms have started implementing them.We are hopeful of a corresponding improvement in the quality of comprehensive assessment, which needs to be confirmed through a repeat assessment of completeness and correctness.This is essential if we are to move closer to the UN Sustainable Development Goal target of reducing TB deaths by 90% in 2030 compared to 2015. 7

7 )*
104 of 402 triage-positive adults with TB who were documented as comprehensively assessed in severe TB web application; 104 had the CRF filled at the nodal inpatient care facility.TNKET = Tamil Nadu Kasanoi Erappila Thittam (meaning Tamil Nadu TB death-free project in Tamil language); CRF = case record form; BMI = body mass index; MUAC = mid-upper arm circumference; WBC = white blood cell; ART = antiretroviral treatment; HDU = high-dependency unit; ICU = intensive care unit.

TABLE 1 .
Completeness of paper-based TNKET CRF among triage-positive adults with TB who were documented to be comprehensively assessed, Tamil Nadu, India, October-December 2022 (n = 104).*104 of 402 triage-positive adults with TB who were documented as comprehensively assessed in severe TB web application; 104 had the CRF filled at the nodal inpatient care facility.TNKET = Tamil Nadu Kasanoi Erappila Thittam (meaning Tamil Nadu TB death-free project in Tamil); CRF = case record form; STS = senior treatment supervisor. *

TABLE 2 .
Completeness of paper-based TNKET CRF among triage-positive adults with TB that were documented to be comprehensively assessed, Tamil Nadu, India, October-December 2022 (n = 104).*