Uncertainty in tuberculosis clinical decision-making

An umbrella review with systematic methods and thematic analysis

Bibliographic Data

ID19590903
AuthorsFrancesca Wanda Basile (0009-0009-8872-732X, University of Oxford, corresponding author), Stuart Sweeney (0000-0003-4233-9080, London School of Hygiene & Tropical Medicine, corresponding author), Sedona Sweeney, Maninder Pal Singh (0000-0001-7396-1273, London School of Hygiene & Tropical Medicine, corresponding author), Else M Bijker (0000-0002-2367-5874, Maastricht University Medical Centre, corresponding author), Ted Cohen (0000-0002-8091-7198, Yale University, corresponding author), Nicolas A Menzies (0000-0002-2571-016X, Harvard Global Health Institute, corresponding author), Anna Vassall (0000-0002-2911-1375, London School of Hygiene & Tropical Medicine, corresponding author), Pitchaya Indravudh (0000-0003-4013-7645, London School of Hygiene & Tropical Medicine, corresponding author)
EditorsSok King Ong (0000-0001-8176-8561)
Year2024
Volume4
Issue7
Pagese0003429
Publication date2024-07-23
Peer ReviewedYes
Open AccessYes
TypeARTICLE
VenuePLOS Global Public Health (JOURNAL)
Journal identifiersISSN: 2767-3375 • E-ISSN: 2767-3375
PublisherPublic Library of Science (PLoS) (PUBLISHER)
DOI10.1371/journal.pgph.0003429
PMID39042611
OpenAlexW4400908421
LanguageEN
Citations received1
References cited57

Tuberculosis is a major infectious disease worldwide, but currently available diagnostics have suboptimal accuracy, particularly in patients unable to expectorate, and are often unavailable at the point-of-care in resource-limited settings. Test/treatment decision are, therefore, often made on clinical grounds. We hypothesized that contextual factors beyond disease probability may influence clinical decisions about when to test and when to treat for tuberculosis. This umbrella review aimed to identify such factors, and to develop a framework for uncertainty in tuberculosis clinical decision-making. Systematic reviews were searched in seven databases (MEDLINE, CINAHL Complete, Embase, Scopus, Cochrane, PROSPERO, Epistemonikos) using predetermined search criteria. Findings were classified as barriers and facilitators for testing or treatment decisions, and thematically analysed based on a multi-level model of uncertainty in health care. We included 27 reviews. Study designs and primary aims were heterogeneous, with seven meta-analyses and three qualitative evidence syntheses. Facilitators for decisions to test included providers’ advanced professional qualification and confidence in tests results, availability of automated diagnostics with quick turnaround times. Common barriers for requesting a diagnostic test included: poor provider tuberculosis knowledge, fear of acquiring tuberculosis through respiratory sampling, scarcity of healthcare resources, and complexity of specimen collection. Facilitators for empiric treatment included patients’ young age, severe sickness, and test inaccessibility. Main barriers to treatment included communication obstacles, providers’ high confidence in negative test results (irrespective of negative predictive value). Multiple sources of uncertainty were identified at the patient, provider, diagnostic test, and healthcare system levels. Complex determinants of uncertainty influenced decision-making. This could result in delayed or missed diagnosis and treatment opportunities. It is important to understand the variability associated with patient-provider clinical encounters and healthcare settings, clinicians’ attitudes, and experiences, as well as diagnostic test characteristics, to improve clinical practices, and allow an impactful introduction of novel diagnostics

CINAHL · Cochrane Library · Family medicine · Health care · Intensive care medicine · MEDLINE · Meta-analysis · Pathology · Psychological intervention · Tuberculosis · Clinical Reasoning and Diagnostic Skills · Healthcare cost, quality, practices · Medicine · Nursing · Tuberculosis Research and Epidemiology