Do private providers give patients what they demand, even if it is inappropriate? A randomised study using unannounced standardised patients in Kenya

Abstract

IntroductionLow 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.MethodsWe 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.ResultsCompared 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.ConclusionPrivate 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.Trial registration numbersAmerican Economic Association Registry (#AEARCTR-0000217) and Pan African Clinical Trial Registry (#PACTR201502000770329).

What drives poor quality of care for child diarrhea? Experimental evidence from India

“…NA, not applicable. role in inappropriate antibiotic prescribing in those countries (30,31). Our work extends this literature, showing that inappropriate prescribing could also be driven by providers' perceptions of patient preferences (e.g., that they do not want ORS) rather than patients' expressed preferences.…”

“…However, Lagarde and Blaauw, who also used variation in SP profiles, showed that financial incentives are not important for inappropriate antibiotic prescribing in South Africa and that providers overprescribe antibiotics even when they bear the cost of the drugs ( 29 ). Moreover, studies from Kenya and Tanzania have shown that patient preferences for antibiotics play a limited role in inappropriate antibiotic prescribing in those countries ( 30 , 31 ). Our work extends this literature, showing that inappropriate prescribing could also be driven by providers’ perceptions of patient preferences (e.g., that they do not want ORS) rather than patients’ expressed preferences.…”

Levels and determinants of overprescribing of antibiotics in the public and private primary care sectors in South Africa

“…To address these methodological issues, researchers have recently used standardised 'mystery' patients-healthy individuals sent to providers to portray specific symptoms-and shown high levels of overprovision of antibiotics. [24][25][26][27][28][29] In this paper, we build on this recent literature to answer three questions. First, we overcome empirical challenges to obtain objective and reliable measures of antibiotic overprescription for viral respiratory illnesses in South Africa, a country that has some of the world's highest rates of antibiotic resistance from both Gram-positive and Gram-negative bacteria.…”

“…This is a particularly relevant concern in comparative studies of the public and private sectors. To address these methodological issues, researchers have recently used standardised ‘mystery’ patients—healthy individuals sent to providers to portray specific symptoms—and shown high levels of overprovision of antibiotics 24–29…”

Can a private sector engagement intervention that prioritizes pro-poor strategies improve healthcare access and quality? A randomized field experiment in Kenya

“…The impact of AHME on management and care delivery is forthcoming (Contreras-Loya et al, 2022). AHME has also been evaluated using qualitative methods (Montagu et al, 2020;Suchman et al, 2019), and the SP data from the impact evaluation has been used to understand the impact of clients demanding different medications (Kwan et al, 2022). Here, we focus on the effects of AHME on healthcare equity.…”