Alarming rates of attrition among tuberculosis patients in public-private facilities in Lahore, Pakistan.

Aims and objectives: All public-private mix (PPM) facilities caring for tuberculosis (TB) patients in Lahore city, Pakistan, under four models: PPM1 (general practitioners), PPM2 (non-governmental organizations), PPM3 (private hospitals) and PPM4 (others). To assess the pre-treatment loss to follow-up (LTFU), defined as patients documented in the laboratory registers but not in the treatment registers of any PPM facility, among sputum smear-positive TB patients diagnosed during January–March 2015, and unfavorable treatment outcomes among patients registered for treatment and associated factors. Methods: This was a retrospective cohort study reviewing existing program records. Poisson regression was used to identify factors associated with outcomes. Data collection, variables and sources: The data were extracted from the TB laboratory registers and TB treatment registers maintained in the PPM facilities. The variables included type of PPM model, laboratory serial number, patient's name, age, sex, date of diagnosis and treatment start, smear grade, type of TB and treatment outcome. The data were collected using a structured proforma. Two electronic databases were created. Results: The two databases were then electronically matched for Results: Of 2473 patients diagnosed, 1590 (64%) were lost to follow-up before treatment. This was higher among males (68%) and the elderly (79%), and lower among 'high positives' (smear grading 2+ or 3+, 53%) and in the PPM1 model (34%). Of 883 patients started on treatment, 165 (19%) had unfavorable outcomes: 8% LTFU, 5% treatment failure, 3% died and 3% not evaluated. Previously treated patients (34%) and children (44%) had the worst outcomes. Conclusion: Pre-treatment LTFU was alarmingly high and requires urgent attention, including the development and institution of mechanisms for patient tracking using information and mobile phone technology, and making TB notification mandatory in the private sector.