Pulmonary Tuberculosis Diagnosed at a Fourth Presentation in a Patient with Limited Language Access: A Narrative Review of Where Diagnostic Delay Accrues
DOI:
https://doi.org/10.5281/zenodo.22237564Keywords:
Pulmonary Tuberculosis, Diagnostic Delay, Migrant Health, Language Access, Health System DelayAbstract
A patient who attends four times before tuberculosis is diagnosed invites an obvious explanation: the system failed to listen. The
published data support a more uncomfortable and more useful account, in which the two halves of the delay behave in opposite
directions depending on who the patient is.Objectives: To review the published evidence on diagnostic delay in pulmonary tuberculosis in low-incidence settings: how the delay divides between patient and health system, how that division differs between migrant and native-born populations, and what role language and access play. Material and Methods: Narrative review of multicentre cross-sectional studies, regional cohorts, qualitative systematic reviews and society correspondence indexed in PubMed and the major infectious disease, respiratory and public health journals. No new patient data were generated; every estimate quoted is one published by the original investigators. Results: In a retrospective multicentre study of 669 patients across 10 Italian hospitals, migrants had a substantially longer patient-related delay than native-born patients (median 90 against 10 days) but a substantially shorter health-system delay (5 against 40 days), producing a longer total delay overall (96 against 65 days), all p < 0.0001. A separate Italian multicentre study of 137 patients reported a median total delay of 66 days, of which 31 was health-system and 14.5 patient-related, with first contact through a general practitioner independently associated with health-system delay exceeding ten weeks.
Conclusion: Total delay is the wrong single number to work with, because its components have different causes and different
remedies. Language and access barriers act principally before the patient reaches care, while diagnostic suspicion acts after,
and interventions aimed at one will not touch the other. Abbreviations: HDD – Health system-related Diagnostic Delay, IQR – Interquartile Range, OR – Odds Ratio, PDD – Patient-related Diagnostic Delay, TB – Tuberculosis, TDD – Total Diagnostic Delay.
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