The dismal state of tuberculosis (TB) care in the private sector in India has been exposed by a November 2015 study published in The Lancet that employed a novel strategy of using standardised TB patients — healthy individuals trained to pose as patients and interact with health-care providers — for assessing the actual clinical practice and quality of TB care in India.
“Relative to other methods, data from standardised patients yield an assessment of provider practice free from observation bias, less vulnerable to recall bias, and more complete than medical records… the methodology allows for quality comparisons across different care providers (public and private practitioners),” Dr. Madhukar Pai, the senior author of the paper from McGill University, Montreal, Canada, says in an email.
Tests and resultsSeventeen individuals who posed as TB patients made 250 interactions with 100 doctors as either patient 1 or patient 2 (presumed TB — suspected but not already diagnosed to have TB), patient 3 (confirmed TB) or patient 4 (suspected multidrug (MDR)-resistant TB). The doctors practising in low- and middle-income settings in Delhi had an MBBS degree (29), a degree in alternative medicine (40) or were informal health-care providers with no qualification. All the interactions took place between April 1 and April 23, 2014. The standardised patients were correctly managed for their respective TB conditions only in 21 per cent (52 of 250) interactions overall. Those with confirmed TB were the most correctly managed ones — 14 per cent for treatment and 26 per cent for referral to DOTS centre or qualified providers; only 12-13 per cent of those with presumed TB were correctly managed.
In the case of suspected MDR-TB, referral to a DOTS centre or a qualified provider was only 20 per cent, indicating a “low use of drug-susceptibility testing”. MBBS doctors were less likely to correctly treat those with suspected MDR-TB as they started treatment without seeking drug-susceptibility testing.
Like earlier studies that revealed private practitioners’ tendency to initially treat TB patients with antibiotics, the current study found this practice to be widely prevalent. While fluoroquinolones were given to all the four standardised patients in 10-16 per cent of the cases, broad-spectrum antibiotics were widely given to those who presented with presumed TB. In spite of having microbiological confirmation — the gold standard for TB diagnosis — standardised patients with confirmed TB and suspected MDR-TB were asked to take a chest X-ray by a large proportion of the doctors.
The study revealed that MBBS doctors were more likely to correctly manage “patients” and more likely to ask for sputum tests and chest X-rays than others. Yet, they were “equally likely” to prescribe antibiotics and “more likely” to prescribe fluoroquinolones than others.
Deviations and delayIncidentally, the study found a major gap in provider knowledge and practice. While doctors showed low adherence to established standards of TB care in clinical practice, they had “markedly high levels of knowledge”.
The private sector is the first point of contact for nearly 80 per cent of TB patients in India, and it offers TB care to nearly 50 per cent. Yet, the deviation from the established standards of TB care in clinical practice as seen in this study is the reason why TB patients most often encounter a delay of nearly two months before a correct diagnosis is made.
The doctors were able to detect the standardised patients only in 11 of 232 (five per cent) instances though they were informed beforehand that they might come across “patients” who were not real. “We were told that standardised patient method will not work for TB because patients have to have fever and appear sick. So, we were happy that the detection rate was [only] about 5 per cent,” says Dr. Pai. “Now that we know it works, we are doing much larger studies.”
prasad.ravindranath@thehindu.co.in
