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Determinants of patient and health system delay among Italian and foreign-born patients with pulmonary tuberculosis: a multicentre cross-sectional study
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    Commentary on the recruitment of clinic patients

    Quattrocchi et al’s recent publication explored the association between tuberculosis (TB) stigma and delays in care among Italians.1 As the authors note, this investigation distinguishes itself from other research on the topic of tuberculosis stigma and its impact on delays in care by assessing this association in a European population in contrast to prior work, which has primarily focused on Asian and African populations. Thus, while the results add to a growing body of literature, several limitations and biases, many of which the authors acknowledge, narrow the generalizability of the results. Specifically, selection bias may have underestimated the findings with regard to patient delay (PD).

    In this investigation, healthcare providers at participating clinics collected data during an in-person visit in which tuberculosis patients were diagnosed or initiating treatment. If the underlying question of interest is Does increased TB stigma lead to longer delays in care? and the answer is Yes, then the current study is not constructed to accurately capture that association since those with the highest levels of perceived TB stigma may never present at the clinic and would therefore be excluded from the study. This is of particular concern given the estimated 10.4 million cases of TB worldwide, 4 million of which are presumed missing.2

    For illustrative purposes, we can use data provided in the paper to roughly construct a contingency table that would yield the r...

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    Conflict of Interest:
    None declared.