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PLoS Med. 2019 Feb 27;16(2):e1002754. doi: 10.1371/journal.pmed.1002754. eCollection 2019 Feb.

Constructing care cascades for active tuberculosis: A strategy for program monitoring and identifying gaps in quality of care.

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Department of Public Health and Community Medicine and Center for Global Public Health, Tufts University School of Medicine, Boston, Massachusetts, United States of America.
Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts, United States of America.
Division of Infectious Diseases, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America.
The Fenway Institute, Boston, Massachusetts, United States of America.
Centre for Operational Research, International Union Against Tuberculosis and Lung Disease, Paris, France.
Central Leprosy Teaching and Research Institute, Chengalpattu, India.
MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom.
Department of Epidemiology, Biostatistics and Occupational Health and McGill International TB Centre, McGill University, Montreal, Canada.


The cascade of care is a model for evaluating patient retention across sequential stages of care required to achieve a successful treatment outcome. This approach was first used to evaluate HIV care and has since been applied to other diseases. The tuberculosis (TB) community has only recently started using care cascade analyses to quantify gaps in quality of care. In this article, we describe methods for estimating gaps (patient losses) and steps (patients retained) in the care cascade for active TB disease. We highlight approaches for overcoming challenges in constructing the TB care cascade, which include difficulties in estimating the population-level burden of disease and the diagnostic gap due to the limited sensitivity of TB diagnostic tests. We also describe potential uses of this model for evaluating the impact of interventions to improve case finding, diagnosis, linkage to care, retention in care, and post-treatment monitoring of TB patients.

Conflict of interest statement

I have read the journal's policy and the authors of this manuscript have the following competing interests: MP is a member of the Editorial Board of PLOS Medicine. All other authors declare that no competing interests exist.

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