Preprint / Version 1

Do private providers initiate anti-tuberculosis therapy on the basis of chest radiographs? A standardised patient study in urban India

Authors

  • Anita Svadzian aDepartment of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
  • Benjamin Daniels cMcCourt School of Public Policy, Georgetown University, Washington, DC, USA
  • Giorgia Sulis dSchool of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
  • Jishnu Das cMcCourt School of Public Policy, Georgetown University, Washington, DC, USA
  • Amrita Daftary fDahdaleh Institute of Global Health Research, School of Global Health, York University, Toronto, ON, Canada
  • Ada Kwan hDivision of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, CA, USA
  • Veena Das iDepartment of Anthropology, Johns Hopkins University, Baltimore, USA
  • Ranendra Das jInstitute for Socio-Economic Research on Development and Democracy, Delhi, India
  • Madhukar Pai aDepartment of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada

Keywords:

Tuberculosis, Quality of care, India, Private health providers, Standardized patients, Mystery clients

Abstract

Summary 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. Funding This study was funded by the Bill & Melinda Gates Foundation (grant OPP1091843), and the Knowledge for Change Program at The World Bank. Keywords: Tuberculosis, Quality of care, India, Private health providers, Standardized patients, Mystery clients

Author Biographies

Anita Svadzian, aDepartment of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada

bMcGill International TB Centre, McGill University, Montreal, QC, Canada

Jishnu Das, cMcCourt School of Public Policy, Georgetown University, Washington, DC, USA

eCentre for Policy Research, New Delhi, India

Amrita Daftary, fDahdaleh Institute of Global Health Research, School of Global Health, York University, Toronto, ON, Canada

gCentre for the Aids Programme of Research in South Africa MRC-HIV-TB Pathogenesis and Treatment, Research Unit, Durban, South Africa

Madhukar Pai, aDepartment of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada

kManipal McGill Program for Infectious Diseases, Manipal Centre for Infectious Diseases, Manipal Academy of Higher Education, Manipal, Karnataka, India

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