Physician compliance with national tuberculosis treatment guidelines: A university hospital study

SETTING: The Aga Khan University Hospital, in Karachi, Pakistan, is a 650-bed university teaching hospital. OBJECTIVES: There is little data from Pakistan on the awareness and application of the World Health Organisation (WHO)'s tuberculosis treatment guidelines among physicians. This study evaluates physician compliance with these guidelines. DESIGN: A questionnaire to measure physician compliance was developed, pilot tested and standardised. Case records of all patients hospitalized with tuberculosis were reviewed (January-December 1995, n = 229), and were classified into WHO Category 1 (n = 191), Category 2 (n = 9) and Category 3 (n = 29). RESULTS: A total of 53 (23%) patients had a diagnostic bacteriological sputum smear examination, of which 38% were smear positive and 47% culture positive. Of 25 cerebrospinal fluid cultures 12% were positive. No sputum smear tests were conducted during treatment. Of 58 patients in Category 1 who completed therapy 74% received a 2-month intensive phase consisting of HRZE (isoniazid, rifampicin, pyrazinamide, ethambutol) (n = 43), while 41% received a 6 month continuation phase with HE (n = 24). Over 70% patients were lost to follow up, more than half of these during the intensive phase. CONCLUSION: Our study reflects poor awareness of the WHO guidelines and low compliance among physicians, and a high loss to follow-up. Efforts are needed to create physician awareness about the WHO guidelines and their use. This study can be used to assess the effectiveness of any future physician education and to identify areas of weakness in health care.