Assessment of system barriers in MDR-TB management: a case study in a provincial hospital in Lopburi, Thailand - การประเมินอุปสรรคเชิงระบบในการบริหารจัดการ วัณโรคดือยาหลายขนาน: กรณีศึกษาโรงพยาบาลแห่งหนึงในจังหวัดลพบุรี

Thailand is confronting with a serious level of under-reporting of multidrug-resistant tuberculosis (MDR-TB), and the detection rate was relatively low. This study aimed to assess the systems of MDR-TB case finding, laboratory testing, reporting and treatment in a selected hospital in central Thailand, Lopburi province. The study results would contribute to policy and system strengthening for MDR-TB prevention and control in Thailand. Qualitative method was applied, including retrospective review of medical records of all pulmonary TB patients treated at the provincial hospital between fiscal year 2012 and 2014. The problems of each step were identified, such as identifying high risk of MDR TB for proper diagnosis and laboratory test, enrolling the confirmed patients for treatment and following up their outcomes. The causes of bottleneck were discussed with clinicians and other related staffs. Of the total 282 pulmonary TB medical record reviewed by the researchers, 96 cases were high risk of MDR-TB, but only 54 cases (56.3% of high risk of MDR-TB) were identified and reported in the system. Of the total 96 high risk MDR-TB, 66 cases (68.8%) were sent for sputum culture. Finally, only 8 patients were confirmed as MDR-TB (8.3% of 96 high risk of MDR TB patients or 2.8% of the total 282 pulmonary TB patients in three-year pool); and six enrolled for treatment. Problems and causes were analyzed. There were no drug susceptibility test results in one-third of high risk cases because health care providers did not send sputum for TB culture or patients did not meet indications for sending sputum for culture. In conclusion, there were gaps and obstacles in hospital MDR-TB management systems. The Bureau of Tuberculosis and the re-gional office of disease prevention and control should support the provincial health office and the hospital team to improve the system management for MDR-TB detection and treatment. Key words: MDR-TB, detection, enrolment, reporting, treatment, management system, Thailand