Variations in the quality of tuberculosis care in urban India: A cross-sectional, standardized patient study in two cities

Abstract

Background

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.

Methods and findings

During 2014–2017, pilot programs engaged the private health sector to improve TB management in Mumbai and Patna. Nested within these projects, to obtain representative, baseline measures of quality of TB care at the city level, we recruited 24 adults to be SPs. They were trained to portray 4 TB “case scenarios” representing various stages of disease and diagnostic progression. Between November 2014 and August 2015, the SPs visited representatively sampled private providers stratified by qualification: (1) allopathic providers with Bachelor of Medicine, Bachelor of Surgery (MBBS) degrees or higher and (2) non-MBBS providers with alternative medicine, minimal, or no qualifications.

Our main outcome was case-specific correct management benchmarked against the Standards for TB Care in India (STCI). Using ANOVA, we assessed variation in correct management and quality outcomes across (a) cities, (b) qualifications, and (c) case scenarios. Additionally, 2 micro-experiments identified sources of variation: first, quality in the presence of diagnostic test results certainty and second, provider consistency for different patients presenting the same case.

A total of 2,652 SP–provider interactions across 1,203 health facilities were analyzed. Based on our sampling strategy and after removing 50 micro-experiment interactions, 2,602 interactions were weighted for city-representative interpretation. After weighting, the 473 Patna providers receiving SPs represent 3,179 eligible providers in Patna; in Mumbai, the 730 providers represent 7,115 eligible providers. Correct management was observed in 959 out of 2,602 interactions (37%; 35% weighted; 95% CI 32%–37%), primarily from referrals and ordering chest X-rays (CXRs). Unnecessary medicines were given to nearly all SPs, and antibiotic use was common. Anti-TB drugs were prescribed in 118 interactions (4.5%; 5% weighted), of which 45 were given in the case in which such treatment is considered correct management.

MBBS and more qualified providers had higher odds of correctly managing cases than non-MBBS providers (odds ratio [OR] 2.80; 95% CI 2.05–3.82; p < 0.0001). Mumbai non-MBBS providers had higher odds of correct management than non-MBBS in Patna (OR 1.79; 95% CI 1.06–3.03), and MBBS providers’ quality of care did not vary between cities (OR 1.15; 95% CI 0.79–1.68; p = 0.4642). In the micro-experiments, improving diagnostic certainty had a positive effect on correct management but not across all quality dimensions. Also, providers delivered idiosyncratically consistent care, repeating all observed actions, including mistakes, approximately 75% of the time. The SP method has limitations: it cannot account for patient mix or care-management practices reflecting more than one patient–provider interaction.

Conclusions

Quality of TB care is suboptimal and variable in urban India’s private health sector. Addressing this is critical for India’s plans to end TB by 2025. For the first time, we have rich measures on representative levels of care quality from 2 cities, which can inform private-sector TB interventions and quality-improvement efforts.

Abstract

Madhukar Pai and colleagues use standardized patients trained to portray symptoms of tuberculosis to assess the quality of diagnosis and care across private sector health providers in Mumbai and Patna, India.

Author summary

Why was this study done?

• India accounts for a quarter of the world’s estimated 10.4 million new tuberculosis (TB) cases per year, nearly a third of the 1.7 million annual TB deaths, and a third of the estimated 4 million “missing patients” who are either not diagnosed or are not reported to national TB programs.

• The private health sector provides the bulk of primary care in India, serving as the first point of contact for 50% to 70% of patients with TB symptoms. The private sector comprises a wide range of qualification levels: allopathic providers with Bachelor of Medicine, Bachelor of Surgery (MBBS) or higher degrees; Ayurveda, Yoga, Unani, Siddha, or Homeopathy (AYUSH) practitioners (practitioners with degrees in alternative medicine or traditional systems of health); and providers with other or no formal qualifications, who are known to provide a large proportion of primary care.

• Little is known about quality of TB care in the private sector; however, the Government of India has prioritized the engagement of the private sector in the National Strategic Plan (NSP) for TB elimination (2017–2025).

What did the researchers do and find?

• In the 2 Indian cities of Mumbai and Patna, we used a list of all private-sector providers to construct a representative sample for a quality of care surveillance project using the standardized patient (SP) method.

• During 2014–2015, the SPs—seemingly healthy adults hired locally and trained to convincingly portray symptoms of illness or test results to providers—conducted a total of 2,652 incognito visits among 1,203 health facilities. SPs portrayed cases representing 4 different stages of TB progression and diagnosis and reported the providers’ actions and prescriptions for analysis.

• We report 4 novel findings in this publication. First, benchmarked against national and international standards of TB care, only 35% of interactions resulted in standards-compliant care during a one-time visit to a healthcare provider.

• Second, lack of adherence to TB standards does not represent a typical “alternative” care pattern that would be appropriate for polluted urban environments because providers followed multiple different protocols.

• Third, there is a wide range of estimated quality in each qualification stratum, and providers demonstrate consistency with their own previous behaviors.

• Finally, providers offer more TB-focused care in cases with higher diagnostic certainty provided by the patient.

What do these findings mean?

• Although the SP method deployed in this study cannot account for patient mix or care-management practices reflecting more than one patient–provider interaction, we find that quality of TB care is suboptimal and variable in urban India’s private health sector. Therefore, improving quality of TB management in the private sector must be a priority for India’s TB elimination strategy.

• With large-scale, city-level representative estimates, these findings can inform specific efforts for private-sector TB interventions and quality improvement.