Data Completeness and Acceptability of Annual Feedback Reports and Tuberculosis Surveillance in Spain, 2018-2024: Mixed Methods Analysis

Abstract Background Surveillance of tuberculosis (TB) is challenging given the typically long course of the disease and treatment as well as the often complex socioeconomic factors that are associated with it. In Spain, surveillance is decentralized across autonomous communities (CCAAs), leading to additional challenges in heterogeneity and data quality. Objective We aimed to quantify changes in internal data completeness following introduction of annual regional surveillance quality reports and assess the acceptability and perceived usefulness among CCAAs. Methods This mixed methods assessment consisted of 2 stages. First, we quantitatively assessed the internal completeness of 40 key TB variables for all reported cases from 2018 to 2023, comparing 2 periods: before (2018‐2020) and after (2021‐2023) the implementation of feedback reports. Mean completeness for each variable was calculated for each period, and the differences were compared using either the paired t test or Wilcoxon signed rank test depending on whether differences were normally distributed. Analyses were conducted nationally and by CCAA as well as for different variable groups (patient-, illness-, and laboratory-related groups). For the second stage, we circulated the results to regional TB surveillance focal points, along with a survey to assess acceptability, perceived usefulness of reports, and barriers to data completeness. Results There were 25,229 reported cases across the study period: 13,328 in period 1 (2018‐2020) and 11,901 in period 2 (2021‐2023). Nationally, mean completeness increased from 66% in period 1 to 76.2% in period 2 (+10.2%, P <.001). Improvements were greatest for laboratory-related (+13.9%, P =.001) and illness-related variables (+12.8%, P <.001), while patient-related variables showed minimal change that was not statistically significant (+2.4%, P =.48). Most CCAAs (16/19, 84%) demonstrated improved completeness in period 2, though substantial regional variation persisted. Of the 19 CCAAs, 18 responded to the survey. Respondents reported high acceptability of the surveillance system and considered feedback reports useful. Challenges included resource constraints, system interoperability between laboratory and surveillance, and patient follow-up. Conclusions Following the introduction of annual feedback reports, which were well accepted by all regional stakeholders, Spain saw significant improvements in TB data completeness. Sustained feedback mechanisms, streamlined reporting requirements, and improved integration between epidemiological and laboratory systems are key to strengthening TB surveillance.