Svadzian Anita, Daniels Benjamin, Sulis Giorgia, Das Jishnu, Daftary Amrita, Kwan Ada, Das Veena, Das Ranendra, Pai Madhukar
Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada.
McGill International TB Centre, McGill University, Montreal, QC, Canada.
Lancet Reg Health Southeast Asia. 2023 Feb 2;13:100152. doi: 10.1016/j.lansea.2023.100152. eCollection 2023 Jun.
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.
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.
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.
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.
This study was funded by the Bill & Melinda Gates Foundation (grant OPP1091843), and the Knowledge for Change Program at The World Bank.
基于世界卫生组织批准的微生物诊断结果启动抗结核治疗（ATT）是优质结核病（TB）护理的一个重要标志。有证据表明，在结核病高发地区，其他导致治疗启动的诊断流程可能更受青睐。本研究调查了私立医疗机构是否根据胸部X光检查（CXR）和临床检查来启动抗结核治疗。
本研究采用标准化患者（SP）方法，当患者呈现出具有异常CXR的标准化结核病病例场景时，对私立基层医疗服务提供者的实践进行准确且无偏差的评估。使用多变量对数二项式回归和线性回归，并将标准误聚类到提供者层面，我们分析了2014年至2020年在印度两个城市的三个数据收集阶段进行的795次SP就诊。数据根据研究抽样策略进行逆概率加权，从而得出具有城市阶段代表性的结果。
在向医疗机构呈现异常CXR的SP中，25%（95%置信区间：21 - 28%）的就诊获得了理想管理，理想管理定义为医疗机构开具微生物检测处方且不同时开具皮质类固醇或抗生素（包括抗结核药物）的处方。相比之下，在795次就诊中，有23%（95%置信区间：19 - 26%）被开具了抗结核药物。在795次就诊中，13%（95%置信区间：10 - 16%）的结果是开具了抗结核治疗处方/配药并下达了确认性微生物检测医嘱。
每五名呈现异常CXR的SP中就有一名被私立医疗机构开具了ATT。本研究为基于CXR异常的经验性治疗患病率提供了新的见解。需要进一步开展工作，以了解医疗机构如何在现有诊断实践、新技术、利润、临床结果以及与实验室的市场动态之间进行权衡。
本研究由比尔及梅琳达·盖茨基金会（资助编号OPP1091843）和世界银行的知识促进变革项目资助。
