Saria, Vaibhav; Das, Veena; Daniels, Benjamin; Pai, Madhukar; Das, Jishnu The family doctor: health, kin testing and primary care in Patna, India (Journal Article) In: Anthropology & Medicine, 2023. @article{Saria2023,
title = {The family doctor: health, kin testing and primary care in Patna, India},
author = {Vaibhav Saria and Veena Das and Benjamin Daniels and Madhukar Pai and Jishnu Das},
url = {https://www.qutubproject.org/wp-content/uploads/2017/09/2023-10-Saria-AM.pdf},
year = {2023},
date = {2023-10-13},
journal = {Anthropology & Medicine},
abstract = {Private primary care providers are usually the first site where afflictions come under institutional view. In the context of poverty, the relationship between illness and care is more complex than a simple division of responsibilities between various actors—with care given by kin, and diagnosis and treatment being the purview of providers. Since patients would often visit the provider with family members, providers are attuned to the patients’ web of kinship. Providers would take patients’ kinship arrangements into account when prescribing diagnostic tests and treatments. This paper terms this aspect of the clinical encounter as ‘kin testing’ to refer to situations/clinical encounters when providers take into consideration that care provided by kin was conditional. ‘Kin testing’ allowed providers to manage the episode of illness that had brought the patient to the clinic by relying on clinical judgment rather than confirmed laboratory tests. Furthermore, since complaints of poor health also were an idiom to communicate kin neglect, providers had to also discern how to negotiate diagnoses and treatments. Kinship determined whether the afflicted bodies brought to the clinics were diagnosed, whether medicines reached the body, and adherence maintained. The providers’ actions make visible the difference that kinship made in how health is imagined in the clinic and in standardized protocols. Focusing on primary care clinics in Patna, India, we contribute to research that shows that kinship determines care and management of illnesses at home by showing that relatedness of patients gets folded in the clinic by providers as well.},
keywords = {},
pubstate = {published},
tppubtype = {article}
}
Private primary care providers are usually the first site where afflictions come under institutional view. In the context of poverty, the relationship between illness and care is more complex than a simple division of responsibilities between various actors—with care given by kin, and diagnosis and treatment being the purview of providers. Since patients would often visit the provider with family members, providers are attuned to the patients’ web of kinship. Providers would take patients’ kinship arrangements into account when prescribing diagnostic tests and treatments. This paper terms this aspect of the clinical encounter as ‘kin testing’ to refer to situations/clinical encounters when providers take into consideration that care provided by kin was conditional. ‘Kin testing’ allowed providers to manage the episode of illness that had brought the patient to the clinic by relying on clinical judgment rather than confirmed laboratory tests. Furthermore, since complaints of poor health also were an idiom to communicate kin neglect, providers had to also discern how to negotiate diagnoses and treatments. Kinship determined whether the afflicted bodies brought to the clinics were diagnosed, whether medicines reached the body, and adherence maintained. The providers’ actions make visible the difference that kinship made in how health is imagined in the clinic and in standardized protocols. Focusing on primary care clinics in Patna, India, we contribute to research that shows that kinship determines care and management of illnesses at home by showing that relatedness of patients gets folded in the clinic by providers as well. |
Svadzian, Anita; Daniels, Benjamin; Sulis, Giorgia; Das, Jishnu; Daftary, Amrita; Kwan, Ada; Das, Veena; Das, Ranendra; Pai, Madhukar Use of standardised patients to assess tuberculosis case management by private pharmacies in Patna, India: A repeat cross-sectional study (Journal Article) In: PLoS Global Public Health, vol. 3, no. 5, pp. e0001898, 2023. @article{svadzian2023use,
title = {Use of standardised patients to assess tuberculosis case management by private pharmacies in Patna, India: A repeat cross-sectional study},
author = {Anita Svadzian and Benjamin Daniels and Giorgia Sulis and Jishnu Das and Amrita Daftary and Ada Kwan and Veena Das and Ranendra Das and Madhukar Pai},
url = {https://journals.plos.org/globalpublichealth/article/file?id=10.1371/journal.pgph.0001898&type=printable},
year = {2023},
date = {2023-05-26},
urldate = {2023-01-01},
journal = {PLoS Global Public Health},
volume = {3},
number = {5},
pages = {e0001898},
publisher = {Public Library of Science San Francisco, CA USA},
abstract = {As the first point of care for many healthcare seekers, private pharmacies play an important role in tuberculosis (TB) care. However, previous studies in India have showed that private pharmacies commonly dispense symptomatic treatments and broad-spectrum antibiotics over-the-counter (OTC), rather than referring patients for TB testing. Such inappropriate management by pharmacies can delaye TB diagnosis. We assessed medical advice and OTC drug dispensing practices of pharmacists for standardized patients presenting with classic symptoms of pulmonary TB (case 1) and for those with sputum smear positive pulmonary TB (case 2), and examined how practices have changed over time in an urban Indian site. We examined how and whether private pharmacies improved practices for TB in 2019 compared to a baseline study conducted in 2015 in the city of Patna, using the same survey sampling techniques and study staff. The proportion of patient-pharmacist interactions that resulted in correct or ideal management, as well as the proportion of interactions resulting in antibiotic, quinolone, and corticosteroid are presented, with standard errors clustered at the provider level. To assess the difference in case management and the use of drugs across the two cases by round, a difference in difference (DiD) model was employed. A total of 936 SP interactions were completed over both rounds of survey. Our results indicate that across both rounds of data collection, 331 of 936 (35%; 95% CI: 32–38%) of interactions were correctly managed. At baseline, 215 of 500 (43%; 95% CI: 39–47%) of interactions were correctly managed whereas 116 of 436 (27%; 95% CI: 23–31%) were correctly managed in the second round of data collection. Ideal management, where in addition to a referral, patients were not prescribed any potentially harmful medications, was seen in 275 of 936 (29%; 95% CI: 27–32%) of interactions overall, with 194 of 500 (39%; 95% CI: 35–43%) of interactions at baseline and 81 of 436 (19%; 95% CI: 15–22%) in round 2. No private pharmacy dispensed anti-TB medications without a prescription. On average, the difference in correct case management between case 1 vs. case 2 dropped by 20 percent points from baseline to the second round of data collection. Similarly, ideal case management decreased by 26 percentage points between rounds. This is in contrast with the dispensation of medicines, which had the opposite effect between rounds; the difference in dispensation of quinolones between case 1 and case 2 increased by 14 percentage points, as did corticosteroids by 9 percentage points, antibiotics by 25 percentage points and medicines generally by 30 percentage points. Our standardised patient study provides valuable insights into how private pharmacies in an Indian city changed their management of patients with TB symptoms or with confirmed TB over a 5-year period. We saw that overall, private pharmacy performance has weakened over time. However, no OTC dispensation of anti-TB medications occurred in either survey round. As the first point of contact for many care seekers, continued and sustained efforts to engage with Indian private pharmacies should be prioritized.},
keywords = {},
pubstate = {published},
tppubtype = {article}
}
As the first point of care for many healthcare seekers, private pharmacies play an important role in tuberculosis (TB) care. However, previous studies in India have showed that private pharmacies commonly dispense symptomatic treatments and broad-spectrum antibiotics over-the-counter (OTC), rather than referring patients for TB testing. Such inappropriate management by pharmacies can delaye TB diagnosis. We assessed medical advice and OTC drug dispensing practices of pharmacists for standardized patients presenting with classic symptoms of pulmonary TB (case 1) and for those with sputum smear positive pulmonary TB (case 2), and examined how practices have changed over time in an urban Indian site. We examined how and whether private pharmacies improved practices for TB in 2019 compared to a baseline study conducted in 2015 in the city of Patna, using the same survey sampling techniques and study staff. The proportion of patient-pharmacist interactions that resulted in correct or ideal management, as well as the proportion of interactions resulting in antibiotic, quinolone, and corticosteroid are presented, with standard errors clustered at the provider level. To assess the difference in case management and the use of drugs across the two cases by round, a difference in difference (DiD) model was employed. A total of 936 SP interactions were completed over both rounds of survey. Our results indicate that across both rounds of data collection, 331 of 936 (35%; 95% CI: 32–38%) of interactions were correctly managed. At baseline, 215 of 500 (43%; 95% CI: 39–47%) of interactions were correctly managed whereas 116 of 436 (27%; 95% CI: 23–31%) were correctly managed in the second round of data collection. Ideal management, where in addition to a referral, patients were not prescribed any potentially harmful medications, was seen in 275 of 936 (29%; 95% CI: 27–32%) of interactions overall, with 194 of 500 (39%; 95% CI: 35–43%) of interactions at baseline and 81 of 436 (19%; 95% CI: 15–22%) in round 2. No private pharmacy dispensed anti-TB medications without a prescription. On average, the difference in correct case management between case 1 vs. case 2 dropped by 20 percent points from baseline to the second round of data collection. Similarly, ideal case management decreased by 26 percentage points between rounds. This is in contrast with the dispensation of medicines, which had the opposite effect between rounds; the difference in dispensation of quinolones between case 1 and case 2 increased by 14 percentage points, as did corticosteroids by 9 percentage points, antibiotics by 25 percentage points and medicines generally by 30 percentage points. Our standardised patient study provides valuable insights into how private pharmacies in an Indian city changed their management of patients with TB symptoms or with confirmed TB over a 5-year period. We saw that overall, private pharmacy performance has weakened over time. However, no OTC dispensation of anti-TB medications occurred in either survey round. As the first point of contact for many care seekers, continued and sustained efforts to engage with Indian private pharmacies should be prioritized. |
Svadzian, Anita; Daniels, Benjamin; Sulis, Giorgia; Das, Jishnu; Daftary, Amrita; Kwan, Ada; Das, Veena; Das, Ranendra; Pai, Madhukar Do Private Providers Initiate Anti-Tuberculosis Therapy on the Basis of Chest Radiographs? A Standardised Patient Study in Urban India (Journal Article) In: The Lancet Regional Health - Southeast Asia, 2023. @article{Svadzian2023,
title = {Do Private Providers Initiate Anti-Tuberculosis Therapy on the Basis of Chest Radiographs? A Standardised Patient Study in Urban India},
author = {Anita Svadzian and Benjamin Daniels and Giorgia Sulis and Jishnu Das and Amrita Daftary and Ada Kwan and Veena Das and Ranendra Das and Madhukar Pai},
url = {https://www.sciencedirect.com/science/article/pii/S2772368223000124/pdfft?md5=5d54dfb026b5a8122933861e9ae3dadf&pid=1-s2.0-S2772368223000124-main.pdf},
year = {2023},
date = {2023-02-02},
journal = {The Lancet Regional Health - Southeast Asia},
abstract = {BACKGROUND
The initiation of anti-tuberculosis treatment (ATT) based on results of WHO-approved microbiological diagnostics is an important marker of quality tuberculosis (TB) care. Evidence suggests that other diagnostic processes leading to treatment initiation may be preferred in high TB incidence settings. This study examines whether private providers start anti-TB therapy on the basis of chest radiography (CXR) and clinical examinations.
METHODS
This study uses the standardized patient (SP) methodology to generate accurate and unbiased estimates of private sector, primary care provider practice when a patient presents a standardized TB case scenario with an abnormal CXR. Using multivariate log-binomial and linear regressions with standard errors clustered at the provider level, we analyzed 795 SP visits conducted over three data collection waves from 2014 to 2020 in two Indian cities. Data were inverse-probability-weighted based on the study sampling strategy, resulting in city-wave-representative results.
FINDINGS
Amongst SPs who presented to a provider with an abnormal CXR, 25% (95% CI: 21–28%) visits resulted in ideal management, defined as the provider prescribing a microbiological test and not offering a concurrent prescription for a corticosteroid or antibiotic (including anti-TB medications). In contrast, 23% (95% CI: 19–26%) of 795 visits were prescribed anti-TB medications. Of 795 visits, 13% (95% CI: 10–16%) resulted in anti-TB treatment prescriptions/dispensation and an order for confirmatory microbiological testing.
INTERPRETATION
One in five SPs presenting with abnormal CXR were prescribed ATT by private providers. This study contributes novel insights to empiric treatment prevalence based on CXR abnormality. Further work is needed to understand how providers make trade-offs between existing diagnostic practices, new technologies, profits, clinical outcomes, and the market dynamics with laboratories.},
keywords = {},
pubstate = {published},
tppubtype = {article}
}
BACKGROUND
The initiation of anti-tuberculosis treatment (ATT) based on results of WHO-approved microbiological diagnostics is an important marker of quality tuberculosis (TB) care. Evidence suggests that other diagnostic processes leading to treatment initiation may be preferred in high TB incidence settings. This study examines whether private providers start anti-TB therapy on the basis of chest radiography (CXR) and clinical examinations.
METHODS
This study uses the standardized patient (SP) methodology to generate accurate and unbiased estimates of private sector, primary care provider practice when a patient presents a standardized TB case scenario with an abnormal CXR. Using multivariate log-binomial and linear regressions with standard errors clustered at the provider level, we analyzed 795 SP visits conducted over three data collection waves from 2014 to 2020 in two Indian cities. Data were inverse-probability-weighted based on the study sampling strategy, resulting in city-wave-representative results.
FINDINGS
Amongst SPs who presented to a provider with an abnormal CXR, 25% (95% CI: 21–28%) visits resulted in ideal management, defined as the provider prescribing a microbiological test and not offering a concurrent prescription for a corticosteroid or antibiotic (including anti-TB medications). In contrast, 23% (95% CI: 19–26%) of 795 visits were prescribed anti-TB medications. Of 795 visits, 13% (95% CI: 10–16%) resulted in anti-TB treatment prescriptions/dispensation and an order for confirmatory microbiological testing.
INTERPRETATION
One in five SPs presenting with abnormal CXR were prescribed ATT by private providers. This study contributes novel insights to empiric treatment prevalence based on CXR abnormality. Further work is needed to understand how providers make trade-offs between existing diagnostic practices, new technologies, profits, clinical outcomes, and the market dynamics with laboratories. |
Daniels, Benjamin; Shah, Daksha; Kwan, Ada T; Das, Ranendra; Das, Veena; Puri, Varsha; Tipre, Pranita; Waghmare, Upalimitra; Gomare, Mangala; Keskar, Padmaja; Das, Jishnu; Pai, Madhukar Tuberculosis diagnosis and management in the public versus private sector: a standardised patients study in Mumbai, India (Journal Article) In: BMJ Global Health, vol. 7, no. 10, pp. e009657, 2022. @article{Daniels2022,
title = {Tuberculosis diagnosis and management in the public versus private sector: a standardised patients study in Mumbai, India},
author = {Benjamin Daniels and Daksha Shah and Ada T Kwan and Ranendra Das and Veena Das and Varsha Puri and Pranita Tipre and Upalimitra Waghmare and Mangala Gomare and Padmaja Keskar and Jishnu Das and Madhukar Pai},
url = {https://gh.bmj.com/content/bmjgh/7/10/e009657.full.pdf?with-ds=yes},
year = {2022},
date = {2022-10-19},
urldate = {2022-01-01},
journal = {BMJ Global Health},
volume = {7},
number = {10},
pages = {e009657},
publisher = {BMJ Specialist Journals},
abstract = {BACKGROUND
There are few rigorous studies comparing quality of tuberculosis (TB) care in public versus private sectors.
METHODS
We used standardised patients (SPs) to measure technical quality and patient experience in a sample of private and public facilities in Mumbai.
RESULTS
SPs presented a ‘classic, suspected TB’ scenario and a ‘recurrence or drug-resistance’ scenario. In the private sector, SPs completed 643 interactions. In the public sector, 164 interactions. Outcomes included indicators of correct management, medication use and client experience. Public providers used microbiological testing (typically, microscopy) more frequently, in 123 of 164 (75%; 95% CI 68% to 81%) vs 223 of 644 interactions (35%; 95% CI 31% to 38%) in the private sector. Private providers were more likely to order chest X-rays, in 556 of 639 interactions (86%; 95% CI 84% to 89%). According to national TB guidelines, we found higher proportions of correct management in the public sector (75% vs 35%; (adjusted) difference 35 percentage points (pp); 95% CI 25 to 46). If X-rays were considered acceptable for the first case but drug-susceptibility testing was required for the second case, the private sector correctly managed a slightly higher proportion of interactions (67% vs 51%; adjusted difference 16 pp; 95% CI 7 to 25). Broad-spectrum antibiotics were used in 76% (95% CI 66% to 84%) of the interactions in public hospitals, and 61% (95% CI 58% to 65%) in private facilities. Costs in the private clinics averaged rupees INR 512 (95% CI 485 to 539); public facilities charged INR 10. Private providers spent more time with patients (4.4 min vs 2.4 min; adjusted difference 2.0 min; 95% CI 1.2 to 2.9) and asked a greater share of relevant questions (29% vs 43%; adjusted difference 13.7 pp; 95% CI 8.2 to 19.3).
CONCLUSION
While the public providers did a better job of adhering to national TB guidelines (especially microbiological testing) and offered less expensive care, private sector providers did better on client experience.},
keywords = {},
pubstate = {published},
tppubtype = {article}
}
BACKGROUND
There are few rigorous studies comparing quality of tuberculosis (TB) care in public versus private sectors.
METHODS
We used standardised patients (SPs) to measure technical quality and patient experience in a sample of private and public facilities in Mumbai.
RESULTS
SPs presented a ‘classic, suspected TB’ scenario and a ‘recurrence or drug-resistance’ scenario. In the private sector, SPs completed 643 interactions. In the public sector, 164 interactions. Outcomes included indicators of correct management, medication use and client experience. Public providers used microbiological testing (typically, microscopy) more frequently, in 123 of 164 (75%; 95% CI 68% to 81%) vs 223 of 644 interactions (35%; 95% CI 31% to 38%) in the private sector. Private providers were more likely to order chest X-rays, in 556 of 639 interactions (86%; 95% CI 84% to 89%). According to national TB guidelines, we found higher proportions of correct management in the public sector (75% vs 35%; (adjusted) difference 35 percentage points (pp); 95% CI 25 to 46). If X-rays were considered acceptable for the first case but drug-susceptibility testing was required for the second case, the private sector correctly managed a slightly higher proportion of interactions (67% vs 51%; adjusted difference 16 pp; 95% CI 7 to 25). Broad-spectrum antibiotics were used in 76% (95% CI 66% to 84%) of the interactions in public hospitals, and 61% (95% CI 58% to 65%) in private facilities. Costs in the private clinics averaged rupees INR 512 (95% CI 485 to 539); public facilities charged INR 10. Private providers spent more time with patients (4.4 min vs 2.4 min; adjusted difference 2.0 min; 95% CI 1.2 to 2.9) and asked a greater share of relevant questions (29% vs 43%; adjusted difference 13.7 pp; 95% CI 8.2 to 19.3).
CONCLUSION
While the public providers did a better job of adhering to national TB guidelines (especially microbiological testing) and offered less expensive care, private sector providers did better on client experience. |
Sulis, Giorgia; Adam, Pierrick; Nafade, Vaidehi; Gore, Genevieve; Daniels, Benjamin; Daftary, Amrita; Das, Jishnu; Gandra, Sumanth; Pai, Madhukar Antibiotic prescription practices in primary care in low- and middle-income countries: A systematic review and meta-analysis (Journal Article) In: PLoS Medicine, vol. 17, no. 6, pp. 1-20, 2020. @article{Sulis2020,
title = {Antibiotic prescription practices in primary care in low- and middle-income countries: A systematic review and meta-analysis},
author = {Giorgia Sulis and Pierrick Adam and Vaidehi Nafade and Genevieve Gore and Benjamin Daniels and Amrita Daftary and Jishnu Das and Sumanth Gandra and Madhukar Pai},
url = {https://journals.plos.org/plosmedicine/article/file?id=10.1371/journal.pmed.1003139&type=printable},
year = {2020},
date = {2020-06-16},
journal = {PLoS Medicine},
volume = {17},
number = {6},
pages = {1-20},
abstract = {Background
The widespread use of antibiotics plays a major role in the development and spread of antimicrobial resistance. However, important knowledge gaps still exist regarding the extent of their use in low- and middle-income countries (LMICs), particularly at the primary care level. We performed a systematic review and meta-analysis of studies conducted in primary care in LMICs to estimate the prevalence of antibiotic prescriptions as well as the proportion of such prescriptions that are inappropriate.
Methods and findings
We searched PubMed, Embase, Global Health, and CENTRAL for articles published between 1 January 2010 and 4 April 2019 without language restrictions. We subsequently updated our search on PubMed only to capture publications up to 11 March 2020. Studies conducted in LMICs (defined as per the World Bank criteria) reporting data on medicine use in primary care were included. Three reviewers independently screened citations by title and abstract, whereas the full-text evaluation of all selected records was performed by 2 reviewers, who also conducted data extraction and quality assessment. A modified version of a tool developed by Hoy and colleagues was utilized to evaluate the risk of bias of each included study. Meta-analyses using random-effects models were performed to identify the proportion of patients receiving antibiotics. The WHO Access, Watch, and Reserve (AWaRe) framework was used to classify prescribed antibiotics. We identified 48 studies from 27 LMICs, mostly conducted in the public sector and in urban areas, and predominantly based on medical records abstraction and/or drug prescription audits. The pooled prevalence proportion of antibiotic prescribing was 52% (95% CI: 51%–53%), with a prediction interval of 44%–60%. Individual studies’ estimates were consistent across settings. Only 9 studies assessed rationality, and the proportion of inappropriate prescription among patients with various conditions ranged from 8% to 100%. Among 16 studies in 15 countries that reported details on prescribed antibiotics, Access-group antibiotics accounted for more than 60% of the total in 12 countries. The interpretation of pooled estimates is limited by the considerable between-study heterogeneity. Also, most of the available studies suffer from methodological issues and report insufficient details to assess appropriateness of prescription.
Conclusions
Antibiotics are highly prescribed in primary care across LMICs. Although a subset of studies reported a high proportion of inappropriate use, the true extent could not be assessed due to methodological limitations. Yet, our findings highlight the need for urgent action to improve prescription practices, starting from the integration of WHO treatment recommendations and the AWaRe classification into national guidelines.},
keywords = {},
pubstate = {published},
tppubtype = {article}
}
Background
The widespread use of antibiotics plays a major role in the development and spread of antimicrobial resistance. However, important knowledge gaps still exist regarding the extent of their use in low- and middle-income countries (LMICs), particularly at the primary care level. We performed a systematic review and meta-analysis of studies conducted in primary care in LMICs to estimate the prevalence of antibiotic prescriptions as well as the proportion of such prescriptions that are inappropriate.
Methods and findings
We searched PubMed, Embase, Global Health, and CENTRAL for articles published between 1 January 2010 and 4 April 2019 without language restrictions. We subsequently updated our search on PubMed only to capture publications up to 11 March 2020. Studies conducted in LMICs (defined as per the World Bank criteria) reporting data on medicine use in primary care were included. Three reviewers independently screened citations by title and abstract, whereas the full-text evaluation of all selected records was performed by 2 reviewers, who also conducted data extraction and quality assessment. A modified version of a tool developed by Hoy and colleagues was utilized to evaluate the risk of bias of each included study. Meta-analyses using random-effects models were performed to identify the proportion of patients receiving antibiotics. The WHO Access, Watch, and Reserve (AWaRe) framework was used to classify prescribed antibiotics. We identified 48 studies from 27 LMICs, mostly conducted in the public sector and in urban areas, and predominantly based on medical records abstraction and/or drug prescription audits. The pooled prevalence proportion of antibiotic prescribing was 52% (95% CI: 51%–53%), with a prediction interval of 44%–60%. Individual studies’ estimates were consistent across settings. Only 9 studies assessed rationality, and the proportion of inappropriate prescription among patients with various conditions ranged from 8% to 100%. Among 16 studies in 15 countries that reported details on prescribed antibiotics, Access-group antibiotics accounted for more than 60% of the total in 12 countries. The interpretation of pooled estimates is limited by the considerable between-study heterogeneity. Also, most of the available studies suffer from methodological issues and report insufficient details to assess appropriateness of prescription.
Conclusions
Antibiotics are highly prescribed in primary care across LMICs. Although a subset of studies reported a high proportion of inappropriate use, the true extent could not be assessed due to methodological limitations. Yet, our findings highlight the need for urgent action to improve prescription practices, starting from the integration of WHO treatment recommendations and the AWaRe classification into national guidelines. |
Nafade, Vaidehi; Huddart, Sophie; Sulis, Giorgia; Daftary, Amrita; Miraj, Sonal Sekhar; Saravu, Kavitha; Pai, Madhukar Over-the-counter antibiotic dispensing by pharmacies: a standardised patient study in Udupi district, India (Journal Article) In: BMJ Global Health, vol. 4, no. 6, pp. e001869, 2019. @article{nafade2019over,
title = {Over-the-counter antibiotic dispensing by pharmacies: a standardised patient study in Udupi district, India},
author = {Vaidehi Nafade and Sophie Huddart and Giorgia Sulis and Amrita Daftary and Sonal Sekhar Miraj and Kavitha Saravu and Madhukar Pai},
url = {https://gh.bmj.com/content/bmjgh/4/6/e001869.full.pdf},
year = {2019},
date = {2019-11-01},
urldate = {2019-11-01},
journal = {BMJ Global Health},
volume = {4},
number = {6},
pages = {e001869},
publisher = {BMJ Publishing Group Ltd},
keywords = {},
pubstate = {published},
tppubtype = {article}
}
|
Kwan, Ada; Daniels, Benjamin; Bergkvist, Sofi; Das, Veena; Pai, Madhukar; Das, Jishnu Use of standardised patients for healthcare quality research in low-and middle-income countries (Journal Article) In: BMJ Global Health, vol. 4, no. 5, pp. e001669, 2019. @article{kwan2019use,
title = {Use of standardised patients for healthcare quality research in low-and middle-income countries},
author = {Ada Kwan and Benjamin Daniels and Sofi Bergkvist and Veena Das and Madhukar Pai and Jishnu Das},
url = {https://gh.bmj.com/content/bmjgh/4/5/e001669.full.pdf, Paper
https://gh.bmj.com/content/bmjgh/4/5/e001908.full.pdf, Accompanying editorial},
year = {2019},
date = {2019-09-12},
journal = {BMJ Global Health},
volume = {4},
number = {5},
pages = {e001669},
publisher = {BMJ Specialist Journals},
abstract = {The use of standardised patients (SPs)—people recruited from the local community to present the same case to multiple providers in a blinded fashion—is increasingly used to measure the quality of care in low-income and middle-income countries. Encouraged by the growing interest in the SP method, and based on our experience of conducting SP studies, we present a conceptual framework for research designs and surveys that use this methodology. We accompany the conceptual framework with specific examples, drawn from our experience with SP studies in low-income and middle-income contexts, including China, India, Kenya and South Africa, to highlight the versatility of the method and illustrate the ongoing challenges. A toolkit and manual for implementing SP studies is included as a companion piece in the online supplement.},
keywords = {},
pubstate = {published},
tppubtype = {article}
}
The use of standardised patients (SPs)—people recruited from the local community to present the same case to multiple providers in a blinded fashion—is increasingly used to measure the quality of care in low-income and middle-income countries. Encouraged by the growing interest in the SP method, and based on our experience of conducting SP studies, we present a conceptual framework for research designs and surveys that use this methodology. We accompany the conceptual framework with specific examples, drawn from our experience with SP studies in low-income and middle-income contexts, including China, India, Kenya and South Africa, to highlight the versatility of the method and illustrate the ongoing challenges. A toolkit and manual for implementing SP studies is included as a companion piece in the online supplement. |
Daniels, Benjamin; Kwan, Ada; Pai, Madhukar; Das, Jishnu Lessons on the quality of tuberculosis diagnosis from standardized patients in China, India, Kenya, and South Africa (Journal Article) In: Journal of Clinical Tuberculosis and Other Mycobacterial Diseases, vol. 16, pp. 100109, 2019. @article{Daniels2019c,
title = {Lessons on the quality of tuberculosis diagnosis from standardized patients in China, India, Kenya, and South Africa},
author = {Benjamin Daniels and Ada Kwan and Madhukar Pai and Jishnu Das},
url = {https://www.sciencedirect.com/science/article/pii/S2405579419300270/pdfft?md5=99968392015916fe0825bd04ab91ea91&pid=1-s2.0-S2405579419300270-main.pdf},
year = {2019},
date = {2019-06-07},
journal = {Journal of Clinical Tuberculosis and Other Mycobacterial Diseases},
volume = {16},
pages = {100109},
publisher = {Elsevier},
abstract = {Standardized patients (SPs) are people who are recruited locally, trained to make identical scripted clinical presentations, deployed incognito to multiple different health care providers, and debriefed using a structured reporting instrument. The use of SPs has increased dramatically as a method for assessing quality of TB care since it was first validated and used for tuberculosis in 2015. This paper summarizes common findings using 3,086 SP-provider interactions involving tuberculosis across various sampling strata in published studies from India, China, South Africa and Kenya. It then discusses the lessons learned from implementing standardized patients in these diverse settings. First, quality is low: relatively few SPs presenting to a health care provider for the first time were given an appropriate diagnostic test, and most were given unnecessary or inappropriate medication. Second, care takes a wide variety of forms – SPs did not generally receive “wait and see” or “symptomatic” care from providers, but they received a medley of care patterns that included broad-spectrum antibiotics as well as contraindicated quinolone antibiotics and steroids. Third, there is a wide range of estimated quality in each observed sampling stratum: more-qualified providers and higher-level facilities performed better than others in all settings, but in every stratum there were both high- and low-quality providers. Evidence from SP studies paired with medical vignettes has shown that providers of all knowledge levels significantly underperform their demonstrated ability with real patients. Finally, providers showed little response to differences in patient identity, but showed strong responses to differences in case presentation that give some clues as to the reasons for these behaviors.},
keywords = {},
pubstate = {published},
tppubtype = {article}
}
Standardized patients (SPs) are people who are recruited locally, trained to make identical scripted clinical presentations, deployed incognito to multiple different health care providers, and debriefed using a structured reporting instrument. The use of SPs has increased dramatically as a method for assessing quality of TB care since it was first validated and used for tuberculosis in 2015. This paper summarizes common findings using 3,086 SP-provider interactions involving tuberculosis across various sampling strata in published studies from India, China, South Africa and Kenya. It then discusses the lessons learned from implementing standardized patients in these diverse settings. First, quality is low: relatively few SPs presenting to a health care provider for the first time were given an appropriate diagnostic test, and most were given unnecessary or inappropriate medication. Second, care takes a wide variety of forms – SPs did not generally receive “wait and see” or “symptomatic” care from providers, but they received a medley of care patterns that included broad-spectrum antibiotics as well as contraindicated quinolone antibiotics and steroids. Third, there is a wide range of estimated quality in each observed sampling stratum: more-qualified providers and higher-level facilities performed better than others in all settings, but in every stratum there were both high- and low-quality providers. Evidence from SP studies paired with medical vignettes has shown that providers of all knowledge levels significantly underperform their demonstrated ability with real patients. Finally, providers showed little response to differences in patient identity, but showed strong responses to differences in case presentation that give some clues as to the reasons for these behaviors. |
Daniels, Benjamin; Kwan, Ada; Satyanarayana, Srinath; Subbaraman, Ramnath; Das, Ranendra K; Das, Veena; Das, Jishnu; Pai, Madhukar Use of standardised patients to assess gender differences in quality of tuberculosis care in urban India: a two-city, cross-sectional study (Journal Article) In: The Lancet Global Health, pp. 1-11, 2019. @article{Daniels2019,
title = {Use of standardised patients to assess gender differences in quality of tuberculosis care in urban India: a two-city, cross-sectional study},
author = {Benjamin Daniels and Ada Kwan and Srinath Satyanarayana and Ramnath Subbaraman and Ranendra K Das and Veena Das and Jishnu Das and Madhukar Pai},
url = {https://www.thelancet.com/action/showPdf?pii=S2214-109X%2819%2930031-2},
doi = {10.1016/S2214-109X(19)30031-2},
year = {2019},
date = {2019-03-27},
journal = {The Lancet Global Health},
pages = {1-11},
abstract = {Background
In India, men are more likely than women to have active tuberculosis but are less likely to be diagnosed and notified to national tuberculosis programmes. We used data from standardised patient visits to assess whether these gender differences occur because of provider practice.
Methods
We sent standardised patients (people recruited from local populations and trained to portray a scripted medical condition to health-care providers) to present four tuberculosis case scenarios to private health-care providers in the cities of Mumbai and Patna. Sampling and weighting allowed for city representative interpretation. Because standardised patients were assigned to providers by a field team blinded to this study, we did balance and placebo regression tests to confirm standardised patients were assigned by gender as good as randomly. Then, by use of linear and logistic regression, we assessed correct case management, our primary outcome, and other dimensions of care by standardised patient gender.
Findings
Between Nov 21, 2014, and Aug 21, 2015, 2602 clinical interactions at 1203 private facilities were completed by 24 standardised patients (16 men, eight women). We found standardised patients were assigned to providers as good as randomly. We found no differences in correct management by patient gender (odds ratio 1·05; 95% CI 0·76–1·45; p=0·77) and no differences across gender within any case scenario, setting, provider gender, or provider qualification.
Interpretation
Systematic differences in quality of care are unlikely to be a cause of the observed under-representation of men in tuberculosis notifications in the private sector in urban India.},
keywords = {},
pubstate = {published},
tppubtype = {article}
}
Background
In India, men are more likely than women to have active tuberculosis but are less likely to be diagnosed and notified to national tuberculosis programmes. We used data from standardised patient visits to assess whether these gender differences occur because of provider practice.
Methods
We sent standardised patients (people recruited from local populations and trained to portray a scripted medical condition to health-care providers) to present four tuberculosis case scenarios to private health-care providers in the cities of Mumbai and Patna. Sampling and weighting allowed for city representative interpretation. Because standardised patients were assigned to providers by a field team blinded to this study, we did balance and placebo regression tests to confirm standardised patients were assigned by gender as good as randomly. Then, by use of linear and logistic regression, we assessed correct case management, our primary outcome, and other dimensions of care by standardised patient gender.
Findings
Between Nov 21, 2014, and Aug 21, 2015, 2602 clinical interactions at 1203 private facilities were completed by 24 standardised patients (16 men, eight women). We found standardised patients were assigned to providers as good as randomly. We found no differences in correct management by patient gender (odds ratio 1·05; 95% CI 0·76–1·45; p=0·77) and no differences across gender within any case scenario, setting, provider gender, or provider qualification.
Interpretation
Systematic differences in quality of care are unlikely to be a cause of the observed under-representation of men in tuberculosis notifications in the private sector in urban India. |
Subbaraman, Ramnath; Nathavitharana, Ruvandhi R; Mayer, Kenneth H; Satyanarayana, Srinath; Chadha, Vineet K; Arinaminpathy, Nimalan; Pai, Madhukar Constructing care cascades for active tuberculosis: A strategy for program monitoring and identifying gaps in quality of care (Journal Article) In: PLoS Medicine, vol. 16, no. 2, pp. 1-18, 2019. @article{Subbaraman2019,
title = {Constructing care cascades for active tuberculosis: A strategy for program monitoring and identifying gaps in quality of care},
author = {Ramnath Subbaraman and Ruvandhi R Nathavitharana and Kenneth H Mayer and Srinath Satyanarayana and Vineet K Chadha and Nimalan Arinaminpathy and Madhukar Pai},
url = {https://journals.plos.org/plosmedicine/article/file?id=10.1371/journal.pmed.1002754&type=printable},
doi = {10.1371/journal.pmed.1002754},
year = {2019},
date = {2019-02-27},
journal = {PLoS Medicine},
volume = {16},
number = {2},
pages = {1-18},
publisher = {Public Library of Science},
abstract = {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.},
keywords = {},
pubstate = {published},
tppubtype = {article}
}
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. |
Pai, Madhukar; Temesgen, Zelalem Quality: the missing ingredient in TB care and control (Journal Article) In: Journal of Clinical Tuberculosis and Other Mycobacterial Diseases, vol. 14, pp. 12-13, 2019. @article{Pai2018b,
title = {Quality: the missing ingredient in TB care and control},
author = {Madhukar Pai and Zelalem Temesgen},
url = {https://www.sciencedirect.com/science/article/pii/S2405579418300846/pdfft?md5=522e3d85373483192cb3dae1e72f29bb&pid=1-s2.0-S2405579418300846-main.pdf},
year = {2019},
date = {2019-01-04},
journal = {Journal of Clinical Tuberculosis and Other Mycobacterial Diseases},
volume = {14},
pages = {12-13},
publisher = {Elsevier},
abstract = {Good health is a function of the utilization of healthcare services and the quality of healthcare. In the field of global health, there is growing awareness of the need to go beyond coverage of services and improve the quality of care.},
keywords = {},
pubstate = {published},
tppubtype = {article}
}
Good health is a function of the utilization of healthcare services and the quality of healthcare. In the field of global health, there is growing awareness of the need to go beyond coverage of services and improve the quality of care. |
Kwan, Ada; Daniels, Benjamin; Saria, Vaibhav; Satyanarayana, Srinath; Subbaraman, Ramnath; McDowell, Andrew; Bergkvist, Sofi; Das, Ranendra K.; Das, Veena; Das, Jishnu; Pai, Madhukar Variations in the quality of tuberculosis care in urban India: A cross-sectional, standardized patient study in two cities (Journal Article) In: PLoS Medicine, vol. 15, no. 9, pp. e1002653, 2018. @article{Kwan2018,
title = {Variations in the quality of tuberculosis care in urban India: A cross-sectional, standardized patient study in two cities},
author = {Ada Kwan and Benjamin Daniels and Vaibhav Saria and Srinath Satyanarayana and Ramnath Subbaraman and Andrew McDowell and Sofi Bergkvist and Ranendra K. Das and Veena Das and Jishnu Das and Madhukar Pai},
url = {https://journals.plos.org/plosmedicine/article/file?id=10.1371/journal.pmed.1002653&type=printable},
year = {2018},
date = {2018-09-25},
journal = {PLoS Medicine},
volume = {15},
number = {9},
pages = {e1002653},
abstract = {India has the highest burden of tuberculosis (TB). Although most patients with TB in India seek care from the private sector, there is limited evidence on quality of TB care or its correlates. Following our validation study on the standardized patient (SP) method for TB, we utilized SPs to examine quality of adult TB care among health providers with different qualifications in 2 Indian cities.},
keywords = {},
pubstate = {published},
tppubtype = {article}
}
India has the highest burden of tuberculosis (TB). Although most patients with TB in India seek care from the private sector, there is limited evidence on quality of TB care or its correlates. Following our validation study on the standardized patient (SP) method for TB, we utilized SPs to examine quality of adult TB care among health providers with different qualifications in 2 Indian cities. |
Miller, Rosalind; Das, Jishnu; Pai, Madhukar Quality of tuberculosis care by Indian pharmacies: mystery clients offer new insights (Journal Article) In: Journal of Clinical Tuberculosis and Other Mycobacterial Diseases, vol. 10, pp. 6-8, 2018. @article{miller2017quality,
title = {Quality of tuberculosis care by Indian pharmacies: mystery clients offer new insights},
author = {Rosalind Miller and Jishnu Das and Madhukar Pai},
url = {https://www.sciencedirect.com/science/article/pii/S2405579417300669},
year = {2018},
date = {2018-01-01},
journal = {Journal of Clinical Tuberculosis and Other Mycobacterial Diseases},
volume = {10},
pages = {6-8},
publisher = {Elsevier},
abstract = {For many patients in India, pharmacies are their first point of contact, where most drugs, including antibiotics, can be purchased over-the-counter (OTC). Recent standardised (simulated) patient studies, covering four Indian cities, provide new insights on how Indian pharmacies manage patients with suspected or known tuberculosis. Correct management of the simulated patients ranged from 13% to 62%, increasing with the certainty of the TB diagnosis. Antibiotics were frequently dispensed OTC to patients, with 16% to 37% receiving such drugs across the cases. On a positive note, these studies showed that no pharmacy dispensed first-line anti-TB drugs. Engagement of pharmacies is important to not only improve TB detection and care, but also limit the abuse of antibiotics.},
keywords = {},
pubstate = {published},
tppubtype = {article}
}
For many patients in India, pharmacies are their first point of contact, where most drugs, including antibiotics, can be purchased over-the-counter (OTC). Recent standardised (simulated) patient studies, covering four Indian cities, provide new insights on how Indian pharmacies manage patients with suspected or known tuberculosis. Correct management of the simulated patients ranged from 13% to 62%, increasing with the certainty of the TB diagnosis. Antibiotics were frequently dispensed OTC to patients, with 16% to 37% receiving such drugs across the cases. On a positive note, these studies showed that no pharmacy dispensed first-line anti-TB drugs. Engagement of pharmacies is important to not only improve TB detection and care, but also limit the abuse of antibiotics. |
Cazabon, Danielle; Alsdurf, Hannah; Satyanarayana, Srinath; Nathavitharana, Ruvandhi; Subbaraman, Ramnath; Daftary, Amrita; Pai, Madhukar Quality of tuberculosis care in high burden countries: the urgent need to address gaps in the care cascade (Journal Article) In: International Journal of Infectious Diseases, vol. 56, pp. 111–116, 2017. @article{cazabon2017quality,
title = {Quality of tuberculosis care in high burden countries: the urgent need to address gaps in the care cascade},
author = {Danielle Cazabon and Hannah Alsdurf and Srinath Satyanarayana and Ruvandhi Nathavitharana and Ramnath Subbaraman and Amrita Daftary and Madhukar Pai},
url = {http://www.paitbgroup.org/wp-content/uploads/Papers/2017/2017-03-CazabonD-IJID.pdf, Full article},
year = {2017},
date = {2017-03-01},
journal = {International Journal of Infectious Diseases},
volume = {56},
pages = {111--116},
publisher = {Elsevier},
abstract = {Summary
Despite the high coverage of directly observed treatment short-course (DOTS), tuberculosis (TB) continues to affect 10.4 million people each year, and kills 1.8 million. High TB mortality, the large number of missing TB cases, the emergence of severe forms of drug resistance, and the slow decline in TB incidence indicate that merely expanding the coverage of TB services is insufficient to end the epidemic. In the era of the End TB Strategy, we need to think beyond coverage and start focusing on the quality of TB care that is routinely offered to patients in high burden countries, in both public and private sectors. In this review, current evidence on the quality of TB care in high burden countries, major gaps in the quality of care, and some novel efforts to measure and improve the quality of care are described. Based on systematic reviews on the quality of TB care or surrogates of quality (e.g., TB diagnostic delays), analyses of TB care cascades, and newer studies that directly measure quality of care, it is shown that the quality of care in both the public and private sector falls short of international standards and urgently needs improvement. National TB programs will therefore need to systematically measure and improve quality of TB care and invest in quality improvement programs.},
keywords = {},
pubstate = {published},
tppubtype = {article}
}
Summary
Despite the high coverage of directly observed treatment short-course (DOTS), tuberculosis (TB) continues to affect 10.4 million people each year, and kills 1.8 million. High TB mortality, the large number of missing TB cases, the emergence of severe forms of drug resistance, and the slow decline in TB incidence indicate that merely expanding the coverage of TB services is insufficient to end the epidemic. In the era of the End TB Strategy, we need to think beyond coverage and start focusing on the quality of TB care that is routinely offered to patients in high burden countries, in both public and private sectors. In this review, current evidence on the quality of TB care in high burden countries, major gaps in the quality of care, and some novel efforts to measure and improve the quality of care are described. Based on systematic reviews on the quality of TB care or surrogates of quality (e.g., TB diagnostic delays), analyses of TB care cascades, and newer studies that directly measure quality of care, it is shown that the quality of care in both the public and private sector falls short of international standards and urgently needs improvement. National TB programs will therefore need to systematically measure and improve quality of TB care and invest in quality improvement programs. |
Satyanarayana, Srinath; Kwan, Ada; Daniels, Benjamin; Subbaraman, Ramnath; McDowell, Andrew; Bergkvist, Sofi; Das, Ranendra K; Das, Veena; Das, Jishnu; Pai, Madhukar Use of standardised patients to assess antibiotic dispensing for tuberculosis by pharmacies in urban India: a cross-sectional study (Journal Article) In: The Lancet Infectious Diseases, vol. 16, no. 11, pp. 1261–1268, 2016. @article{Satyanarayana2016,
title = {Use of standardised patients to assess antibiotic dispensing for tuberculosis by pharmacies in urban India: a cross-sectional study},
author = {Srinath Satyanarayana and Ada Kwan and Benjamin Daniels and Ramnath Subbaraman and Andrew McDowell and Sofi Bergkvist and Ranendra K Das and Veena Das and Jishnu Das and Madhukar Pai},
url = {http://www.paitbgroup.org/wp-content/uploads/Papers/2016/2016-11-SatyanarayanaS-LID.pdf, Full article
https://qutubproject.github.io/lancetid2016, Source data},
year = {2016},
date = {2016-08-24},
journal = {The Lancet Infectious Diseases},
volume = {16},
number = {11},
pages = {1261--1268},
publisher = {Elsevier},
abstract = {Background
India's total antibiotic use is the highest of any country. Patients often receive prescription-only drugs directly from pharmacies. Here we aimed to assess the medical advice and drug dispensing practices of pharmacies for standardised patients with presumed and confirmed tuberculosis in India.
Methods
In this cross-sectional study in the three Indian cities Delhi, Mumbai, and Patna, we developed two standardised patient cases: first, a patient presenting with 2–3 weeks of pulmonary tuberculosis symptoms (Case 1); and second, a patient with microbiologically confirmed pulmonary tuberculosis (Case 2). Standardised patients were scheduled to present each case once to sampled pharmacies. We defined ideal management for both cases a priori as referral to a health-care provider without dispensing antibiotics or steroids or both.
Findings
Between April 1, 2014, and Nov 29, 2015, we sampled 622 pharmacies in Delhi, Mumbai, and Patna. Standardised patients completed 1200 (96%) of 1244 interactions. We recorded ideal management (defined as referrals without the use of antibiotics or steroids) in 80 (13%) of 599 Case 1 interactions (95% CI 11–16) and 372 (62%) of 601 Case 2 interactions (95% CI 58–66). Antibiotic use was significantly lower in Case 2 interactions (98 [16%] of 601, 95% CI 13–19) than in Case 1 (221 [37%] of 599, 95% CI 33–41). First-line anti-tuberculosis drugs were not dispensed in any city. The differences in antibiotic or steroid use and number of medicines dispensed between Case 1 and Case 2 were almost entirely attributable to the difference in referral behaviour.
Interpretation
Only some urban Indian pharmacies correctly managed patients with presumed tuberculosis, but most correctly managed a case of confirmed tuberculosis. No pharmacy dispensed anti-tuberculosis drugs for either case. Absence of a confirmed diagnosis is a key driver of antibiotic misuse and could inform antimicrobial stewardship interventions.},
keywords = {},
pubstate = {published},
tppubtype = {article}
}
Background
India's total antibiotic use is the highest of any country. Patients often receive prescription-only drugs directly from pharmacies. Here we aimed to assess the medical advice and drug dispensing practices of pharmacies for standardised patients with presumed and confirmed tuberculosis in India.
Methods
In this cross-sectional study in the three Indian cities Delhi, Mumbai, and Patna, we developed two standardised patient cases: first, a patient presenting with 2–3 weeks of pulmonary tuberculosis symptoms (Case 1); and second, a patient with microbiologically confirmed pulmonary tuberculosis (Case 2). Standardised patients were scheduled to present each case once to sampled pharmacies. We defined ideal management for both cases a priori as referral to a health-care provider without dispensing antibiotics or steroids or both.
Findings
Between April 1, 2014, and Nov 29, 2015, we sampled 622 pharmacies in Delhi, Mumbai, and Patna. Standardised patients completed 1200 (96%) of 1244 interactions. We recorded ideal management (defined as referrals without the use of antibiotics or steroids) in 80 (13%) of 599 Case 1 interactions (95% CI 11–16) and 372 (62%) of 601 Case 2 interactions (95% CI 58–66). Antibiotic use was significantly lower in Case 2 interactions (98 [16%] of 601, 95% CI 13–19) than in Case 1 (221 [37%] of 599, 95% CI 33–41). First-line anti-tuberculosis drugs were not dispensed in any city. The differences in antibiotic or steroid use and number of medicines dispensed between Case 1 and Case 2 were almost entirely attributable to the difference in referral behaviour.
Interpretation
Only some urban Indian pharmacies correctly managed patients with presumed tuberculosis, but most correctly managed a case of confirmed tuberculosis. No pharmacy dispensed anti-tuberculosis drugs for either case. Absence of a confirmed diagnosis is a key driver of antibiotic misuse and could inform antimicrobial stewardship interventions. |
McDowell, A; Pai, M Treatment as diagnosis and diagnosis as treatment: empirical management of presumptive tuberculosis in India (Journal Article) In: The International Journal of Tuberculosis and Lung Disease, vol. 20, no. 4, pp. 536–543, 2016. @article{McDowell2016,
title = {Treatment as diagnosis and diagnosis as treatment: empirical management of presumptive tuberculosis in India},
author = {A McDowell and M Pai},
url = {http://www.paitbgroup.org/wp-content/uploads/Papers/2016/2016-04-McDowellA-IJTLD.pdf, Full article},
year = {2016},
date = {2016-04-01},
journal = {The International Journal of Tuberculosis and Lung Disease},
volume = {20},
number = {4},
pages = {536--543},
publisher = {International Union Against Tuberculosis and Lung Disease},
abstract = {BACKGROUND: Mismanagement of TB is a concern in the Indian private sector, and empirical management might be a key contributor.
OBJECTIVE: To understand factors associated with empirical diagnosis and treatment of presumed TB in India's private sector and examine their effects on TB care.
DESIGN: In this ethnographic study, 110 private practitioners of varying qualification who interacted with TB patients (90 in Mumbai and 20 in Patna) were interviewed, and a subset was observed while providing clinical care. Interviews and observations were analysed for indicators of empirical diagnosis and treatment.
RESULTS: All non-specialist practitioners began antibiotic treatment, especially quinolones, for persistent cough before prescribing a test. Several factors contribute to empirical management. These include a common practice use of medications as diagnostic tools, a desire to provide rapid symptom relief to patients, a desire to manage illness costs effectively, uncertainty about the presentation of TB, the effects of broad spectrum antibiotics on TB symptomology, and uncertainty about the accuracy of available TB tests.
CONCLUSION: Empiricism in general and in TB care is widespread in the urban private sector in India. Ethnography might offer useful insights for addressing this in public-private mix models. },
keywords = {},
pubstate = {published},
tppubtype = {article}
}
BACKGROUND: Mismanagement of TB is a concern in the Indian private sector, and empirical management might be a key contributor.
OBJECTIVE: To understand factors associated with empirical diagnosis and treatment of presumed TB in India's private sector and examine their effects on TB care.
DESIGN: In this ethnographic study, 110 private practitioners of varying qualification who interacted with TB patients (90 in Mumbai and 20 in Patna) were interviewed, and a subset was observed while providing clinical care. Interviews and observations were analysed for indicators of empirical diagnosis and treatment.
RESULTS: All non-specialist practitioners began antibiotic treatment, especially quinolones, for persistent cough before prescribing a test. Several factors contribute to empirical management. These include a common practice use of medications as diagnostic tools, a desire to provide rapid symptom relief to patients, a desire to manage illness costs effectively, uncertainty about the presentation of TB, the effects of broad spectrum antibiotics on TB symptomology, and uncertainty about the accuracy of available TB tests.
CONCLUSION: Empiricism in general and in TB care is widespread in the urban private sector in India. Ethnography might offer useful insights for addressing this in public-private mix models. |
McDowell, Andrew; Pai, Madhukar Alternative medicine: an ethnographic study of how practitioners of Indian medical systems manage TB in Mumbai (Journal Article) In: Transactions of The Royal Society of Tropical Medicine and Hygiene, vol. 110, no. 3, pp. 192–198, 2016. @article{McDowell2016,
title = {Alternative medicine: an ethnographic study of how practitioners of Indian medical systems manage TB in Mumbai},
author = {Andrew McDowell and Madhukar Pai},
url = {http://www.paitbgroup.org/wp-content/uploads/Papers/2016/2016-03-McDowellA-TRSTMH.pdf, Full article},
year = {2016},
date = {2016-01-01},
journal = {Transactions of The Royal Society of Tropical Medicine and Hygiene},
volume = {110},
number = {3},
pages = {192--198},
publisher = {Oxford University Press},
abstract = {Background
Mumbai is a hot spot for drug-resistant TB, and private practitioners trained in AYUSH systems (Ayurveda, yoga, Unani, Siddha and homeopathy) are major healthcare providers. It is important to understand how AYUSH practitioners manage patients with TB or presumptive TB.
Methods
We conducted semi-structured interviews of 175 Mumbai slum-based practitioners holding degrees in Ayurveda, homeopathy and Unani. Most providers gave multiple interviews. We observed 10 providers in clinical interactions, documenting: clinical examinations, symptoms, history taking, prescriptions and diagnostic tests.
Results
No practitioners exclusively used his or her system of training. The practice of biomedicine is frequent, with practitioners often using biomedical disease categories and diagnostics. The use of homeopathy was rare (only 4% of consultations with homeopaths resulted in homeopathic remedies) and Ayurveda rarer (3% of consultations). For TB, all mentioned chest x-ray while 31 (17.7%) mentioned sputum smear as a TB test. One hundred and sixty-four practitioners (93.7%) reported referring TB patients to a public hospital or chest physician. Eleven practitioners (6.3%) reported treating patients with TB. Nine (5.1%) reported treating patients with drug-susceptible TB with at least one second-line drug.
Conclusions
Important sources of health care in Mumbai's slums, AYUSH physicians frequently use biomedical therapies and most refer patients with TB to chest physicians or the public sector. They are integral to TB care and control.},
keywords = {},
pubstate = {published},
tppubtype = {article}
}
Background
Mumbai is a hot spot for drug-resistant TB, and private practitioners trained in AYUSH systems (Ayurveda, yoga, Unani, Siddha and homeopathy) are major healthcare providers. It is important to understand how AYUSH practitioners manage patients with TB or presumptive TB.
Methods
We conducted semi-structured interviews of 175 Mumbai slum-based practitioners holding degrees in Ayurveda, homeopathy and Unani. Most providers gave multiple interviews. We observed 10 providers in clinical interactions, documenting: clinical examinations, symptoms, history taking, prescriptions and diagnostic tests.
Results
No practitioners exclusively used his or her system of training. The practice of biomedicine is frequent, with practitioners often using biomedical disease categories and diagnostics. The use of homeopathy was rare (only 4% of consultations with homeopaths resulted in homeopathic remedies) and Ayurveda rarer (3% of consultations). For TB, all mentioned chest x-ray while 31 (17.7%) mentioned sputum smear as a TB test. One hundred and sixty-four practitioners (93.7%) reported referring TB patients to a public hospital or chest physician. Eleven practitioners (6.3%) reported treating patients with TB. Nine (5.1%) reported treating patients with drug-susceptible TB with at least one second-line drug.
Conclusions
Important sources of health care in Mumbai's slums, AYUSH physicians frequently use biomedical therapies and most refer patients with TB to chest physicians or the public sector. They are integral to TB care and control. |
Das, Jishnu; Kwan, Ada; Daniels, Benjamin; Satyanarayana, Srinath; Subbaraman, Ramnath; Bergkvist, Sofi; Das, Ranendra K; Das, Veena; Pai, Madhukar Use of standardised patients to assess quality of tuberculosis care: a pilot, cross-sectional study (Journal Article) In: The Lancet Infectious Diseases, vol. 15, no. 11, pp. 1305–1313, 2015. @article{Das2015,
title = {Use of standardised patients to assess quality of tuberculosis care: a pilot, cross-sectional study},
author = {Jishnu Das and Ada Kwan and Benjamin Daniels and Srinath Satyanarayana and Ramnath Subbaraman and Sofi Bergkvist and Ranendra K Das and Veena Das and Madhukar Pai},
url = {http://www.paitbgroup.org/wp-content/uploads/Papers/2015/2015-08-DasJ-LID.pdf, Full article
https://qutubproject.github.io/lancetid2015, Source data},
year = {2015},
date = {2015-08-10},
journal = {The Lancet Infectious Diseases},
volume = {15},
number = {11},
pages = {1305--1313},
publisher = {Elsevier},
abstract = {Background
Existing studies of the quality of tuberculosis care have relied on recall-based patient surveys, questionnaire surveys of knowledge, and prescription or medical record analysis, and the results mostly show the health-care provider's knowledge rather than actual practice. No study has used standardised patients to assess clinical practice. Therefore we aimed to assess quality of care for tuberculosis using such patients.
Methods
We did a pilot, cross-sectional validation study of a convenience sample of consenting private health-care providers in low-income and middle-income areas of Delhi, India. We recruited standardised patients in apparently good health from the local community to present four cases (two of presumed tuberculosis and one each of confirmed tuberculosis and suspected multidrug-resistant tuberculosis) to a randomly allocated health-care provider. The key objective was to validate the standardised-patient method using three criteria: negligible risk and ability to avoid adverse events for providers and standardised patients, low detection rates of standardised patients by providers, and data accuracy across standardised patients and audio verification of standardised-patient recall. We also used medical vignettes to assess providers' knowledge of presumed tuberculosis. Correct case management was benchmarked using Standards for Tuberculosis Care in India (STCI).
Findings
Between Feb 2, and March 28, 2014, we recruited and trained 17 standardised patients who had 250 interactions with 100 health-care providers, 29 of whom were qualified in allopathic medicine (ie, they had a Bachelor of Medicine & Surgery [MBBS] degree), 40 of whom practised alternative medicine, and 31 of whom were informal health-care providers with few or no qualifications. The interactions took place between April 1, and April 23, 2014. The proportion of detected standardised patients was low (11 [5%] detected out of 232 interactions among providers who completed the follow-up survey), and standardised patients' recall correlated highly with audio recordings (r=0·63 [95% CI 0·53–0·79]), with no safety concerns reported. The mean consultation length was 6 min (95% CI 5·5–6·6) with a mean of 6·18 (5·72–6·64) questions or examinations completed, representing 35% (33–38) of essential checklist items. Across all cases, only 52 (21% [16–26]) of 250 were correctly managed. Correct management was higher among MBBS-qualified doctors than other types of health-care provider (adjusted odds ratio 2·41 [95% CI 1·17–4·93]; p=0·0166). Of the 69 providers who completed the vignette, knowledge in the vignettes was more consistent with STCI than their actual clinical practice—eg, 50 (73%) ordered a chest radiograph or sputum test during the vignette compared with seven (10%) during the standardised-patient interaction; OR 0·04 (95% CI 0·02–0·11); p<0·0001.
Interpretation
Standardised patients can be successfully implemented to assess tuberculosis care. Our data suggest a big gap between private provider knowledge and practice. Additional work is needed to substantiate our pilot data, understand the know-do gap in provider behaviour, and to identify the best approach to measure and improve the quality of tuberculosis care in India.},
keywords = {},
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Background
Existing studies of the quality of tuberculosis care have relied on recall-based patient surveys, questionnaire surveys of knowledge, and prescription or medical record analysis, and the results mostly show the health-care provider's knowledge rather than actual practice. No study has used standardised patients to assess clinical practice. Therefore we aimed to assess quality of care for tuberculosis using such patients.
Methods
We did a pilot, cross-sectional validation study of a convenience sample of consenting private health-care providers in low-income and middle-income areas of Delhi, India. We recruited standardised patients in apparently good health from the local community to present four cases (two of presumed tuberculosis and one each of confirmed tuberculosis and suspected multidrug-resistant tuberculosis) to a randomly allocated health-care provider. The key objective was to validate the standardised-patient method using three criteria: negligible risk and ability to avoid adverse events for providers and standardised patients, low detection rates of standardised patients by providers, and data accuracy across standardised patients and audio verification of standardised-patient recall. We also used medical vignettes to assess providers' knowledge of presumed tuberculosis. Correct case management was benchmarked using Standards for Tuberculosis Care in India (STCI).
Findings
Between Feb 2, and March 28, 2014, we recruited and trained 17 standardised patients who had 250 interactions with 100 health-care providers, 29 of whom were qualified in allopathic medicine (ie, they had a Bachelor of Medicine & Surgery [MBBS] degree), 40 of whom practised alternative medicine, and 31 of whom were informal health-care providers with few or no qualifications. The interactions took place between April 1, and April 23, 2014. The proportion of detected standardised patients was low (11 [5%] detected out of 232 interactions among providers who completed the follow-up survey), and standardised patients' recall correlated highly with audio recordings (r=0·63 [95% CI 0·53–0·79]), with no safety concerns reported. The mean consultation length was 6 min (95% CI 5·5–6·6) with a mean of 6·18 (5·72–6·64) questions or examinations completed, representing 35% (33–38) of essential checklist items. Across all cases, only 52 (21% [16–26]) of 250 were correctly managed. Correct management was higher among MBBS-qualified doctors than other types of health-care provider (adjusted odds ratio 2·41 [95% CI 1·17–4·93]; p=0·0166). Of the 69 providers who completed the vignette, knowledge in the vignettes was more consistent with STCI than their actual clinical practice—eg, 50 (73%) ordered a chest radiograph or sputum test during the vignette compared with seven (10%) during the standardised-patient interaction; OR 0·04 (95% CI 0·02–0·11); p<0·0001.
Interpretation
Standardised patients can be successfully implemented to assess tuberculosis care. Our data suggest a big gap between private provider knowledge and practice. Additional work is needed to substantiate our pilot data, understand the know-do gap in provider behaviour, and to identify the best approach to measure and improve the quality of tuberculosis care in India. |
