Open Access Research article

Missed opportunities in TB diagnosis: a TB Process-Based Performance Review tool to evaluate and improve clinical care

Nigel Field1*, Jill Murray2, Michelle L Wong3, Rob Dowdeswell4, Ntomboxolo Dudumayo5, Lesego Rametsi4, Neil Martinson67, Marc Lipman8, Judith R Glynn9 and Pam Sonnenberg1

Author Affiliations

1 Centre for Sexual Health & HIV Research, Research Department of Infection & population Health, University College London, London, UK

2 National Institute for Occupational Health, National Health Laboratory Service, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa

3 Division of Pulmonology, Department of Medicine, Chris Hani Baragwanath Hospital, Johannesburg, South Africa

4 Rustenburg Platinum Mines, Anglo Platinum, Rustenburg, South Africa

5 Lonmin PLC, Rustenburg, South Africa

6 Perinatal HIV Research Unit, University of the Witwatersrand, South Africa

7 Johns Hopkins University Center for TB Research, Baltimore, USA

8 Respiratory Medicine, Royal Free Hospital, London, UK

9 Infectious Disease Epidemiology Unit, Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK

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BMC Public Health 2011, 11:127  doi:10.1186/1471-2458-11-127

Published: 22 February 2011



Traditional tuberculosis (TB) treatment outcome measures, such as cure rate, do not provide insight into the underlying reasons for missing clinical targets. We evaluated a TB Process-Based Performance Review (TB-PBPR) tool, developed to identify "missed opportunities" for timely and accurate diagnosis of TB. The tool enables performance assessment at the level of process and quality of care.


The TB-PBPR tool is a single-page structured flow-sheet that identifies 14 clinical actions (grouped into elicited symptoms, clinical examination and investigations). Medical records from selected deceased patients were reviewed at two South African mine hospitals (A = 56 cases; B = 26 cases), a South African teaching hospital (C = 20 cases) and a UK teaching hospital (D = 13 cases).


In hospital A, where autopsy was routine, TB was missed in life in 52% (23/44) of cases and was wrongly attributed as the cause of death in 16% (18/110). Clinical omissions were identified at each hospital and at every stage of clinical management. For example, recording of chest symptoms was omitted in up to 39% of cases, sputum smear examination in up to 85% and chest radiograph in up to 38% of cases respectively.


This study introduces the TB-PBPR tool as a novel method to review and evaluate clinical performance in TB management. We found that simple clinical actions were omitted in many cases. The tool, in conjunction with a manual describing best practice, is adaptable to a range of settings, is educational and enables detailed feedback within a TB programme. The TB-PBPR tool and manual are both freely available for general use.