Department of Medicine, University of California San Francisco, San Francisco, California, USA
Division of Health Policy and Management, University of California Berkeley School of Public Health, Berkeley, California, USA.
BMJ Open. 2022 Mar 18;12(3):e058746. doi: 10.1136/bmjopen-2021-058746.
Low and varied quality of care has been demonstrated for childhood illnesses in low-income and middle-income countries. Some quality improvement strategies focus on increasing patient engagement; however, evidence suggests that patients demanding medicines can favour the selection of resistant microbial strains in the individual and the community if drugs are inappropriately used. This study examines the effects on quality of care when patients demand different types of inappropriate medicines.
We conducted an experiment where unannounced standardised patients (SPs), locally recruited individuals trained to simulate a standardised case, present at private clinics. Between 8 March and 28 May 2019, 10 SPs portraying caretakers of a watery diarrhoea childhood case scenario (in absentia) conducted N=200 visits at 200 private, primary care clinics in Kenya. Half of the clinics were randomly assigned to receive an SP demanding amoxicillin (an antibiotic); the other half, an SP demanding albendazole (an antiparasitic drug often used for deworming), with other presenting characteristics the same. We used logistic and linear regression models to assess the effects of demanding these inappropriate medicines on correct and unnecessary case management outcomes.
Compared with 3% among those who did not demand albendazole, the dispensing rate increased significantly to 34% for those who did (adjusted OR 0.06, 95% CI 0.02 to 0.22, p<0.0001). Providers did not give different levels of amoxicillin between those demanding it and those not demanding it (adjusted OR 1.73, 95% CI 0.51 to 5.82). Neither significantly changed any correct management outcomes, such as treatment or referral elsewhere.
Private providers appear to account for both business-driven benefits and individual health impacts when making prescribing decisions. Additional research is needed on provider knowledge and perceptions of profit and individual and community health trade-offs when making prescription decisions after patients demand different types of inappropriate medicines.
American Economic Association Registry (#AEARCTR-0000217) and Pan African Clinical Trial Registry (#PACTR201502000770329).
在低收入和中等收入国家，儿童疾病的医疗质量普遍较低且参差不齐。一些质量改进策略侧重于提高患者参与度；然而，有证据表明，如果药物使用不当，患者要求使用药品可能会导致个体和社区中耐药微生物菌株的选择。本研究考察了当患者要求使用不同类型的不适当药物时，对医疗质量的影响。
我们进行了一项实验，在实验中，当地招募的经过培训以模拟标准病例的未公开标准化患者（SP）出现在私人诊所。在 2019 年 3 月 8 日至 5 月 28 日期间，10 名扮演水样腹泻儿童病例（不在场）看护人的 SP 在肯尼亚的 200 家私人初级保健诊所进行了 N=200 次就诊。诊所的一半被随机分配给接受要求阿莫西林（一种抗生素）的 SP；另一半诊所则分配给要求阿苯达唑（一种常用于驱虫的抗寄生虫药物）的 SP，其他呈现特征相同。我们使用逻辑和线性回归模型评估了要求使用这些不适当药物对正确和不必要的病例管理结果的影响。
与未要求使用阿苯达唑的患者中 3%的比例相比，要求使用阿苯达唑的患者中药物的配给率显著增加至 34%（调整后的比值比 0.06，95%置信区间 0.02 至 0.22，p<0.0001）。要求使用阿莫西林的患者和不要求使用阿莫西林的患者之间，提供者的阿莫西林配给水平没有差异（调整后的比值比 1.73，95%置信区间 0.51 至 5.82）。这两种药物都没有显著改变任何正确的管理结果，如治疗或转至其他地方。
私人提供者在做出处方决策时，似乎考虑到了商业利益和个人健康影响。当患者要求使用不同类型的不适当药物时，需要进一步研究提供者对利润以及个人和社区健康权衡的知识和看法，以了解他们在做出处方决策时的情况。
美国经济协会注册处（#AEARCTR-0000217）和泛非临床试验注册处（#PACTR201502000770329）。
