Tuberculosis care: variation and deficits uncovered in urban India

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A study, published this week in PLoS Medicine, has reported that private practitioners are delivering a wide range of often inadequate care to tuberculosis patients in India.

Ahead of the United Nations General Assembly’s first-ever high-level meeting on tuberculosis this week (26 September), India announced its plans to eliminate TB by 2025. This is an ambitious goal, with India having the world’s largest TB burden and also facing growing multi-drug resistance.

Private health care providers serve as the first point of contact for approximately 50–70% of patients with TB symptoms in India, however, as author Mahukar Pai (McGill University, Montreal, Canada) explained: “The Indian government is working hard to engage the private health sector, but little is known about the quality of care they provide.”

The team hoped to assess this care using 24 standardized patients (SPs) – seemingly healthy actors trained to portray four different tuberculosis case scenarios during unannounced visits. Both management and quality outcomes of private practitioners, who were stratified by qualification in Patna and Mumbai, India, were assessed.

Overall, a total of 2652 SP–provider interactions were analyzed across 730 Mumbai and 473 Patna providers and weighted for city-representative interpretation. The researchers reported that only a third of providers correctly managed SP cases according to national and international standards (949 interactions, 35% after weighting; 95% CI 32%–37%).

The team uncovered some other trends; providers often stuck to the same erroneous protocols, repeating their own observed actions 75% of the time in a second visit by a different SP. In addition, there was not a single widely-adopted practice among providers, a wide range of quality and treatment protocols were observed by SPs within each qualification stratum.

However, there were also some positive findings; providers with Bachelor of Medicine, Bachelor of Surgery (MBBS) degrees or higher were more likely to correctly manage cases when compared with non-MBBS providers. Moreover, there was a near-zero use of anti-TB drugs among non-MBBS providers, with drugs generally being used judiciously with the correct dosage and regimen in all but five of 118 cases. Finally, providers presented with more diagnostic information from the SP offered better care, even it meant referring the patient on to the public sector’s TB program.

Although this research using SPs can’t account for a broader mix of patients, how a provider might manage subsequent visits, or management in the public sector program, the team note that improving TB management in India’s private health sector will be critical for the 2025 TB elimination strategy.

Pai, and first author Ada Kwan, a PhD student at the University of California at Berkeley (CA, USA), believe that there may be challenges in the quest for TB elimination but there are also opportunities, concluding: “Rather than a simple message of “good” or “bad” care in the private sector, our study shows that a number of qualified physicians provide excellent care, while we also found providers who consistently mismanaged patients.

“Engaging quality providers, ensuring a referral chain that leads patients to these providers, and linking their patients to free TB drugs and other subsidies in the public sector could be a useful strategy for India.”

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Source: Kwan A, Daniels B, Saira V et al. Variations in the quality of tuberculosis care in urban India: A cross-sectional, standardized patient study in two cities. PLoS Med. 15(9) e1002653 (2018).

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