Use of standardised patients to assess quality of healthcare in Nairobi, Kenya: a pilot, cross-sectional study with international comparisons

Abstract

IntroductionThe quality of clinical care can be reliably measured in multiple settings using standardised patients (SPs), but this methodology has not been extensively used in Sub-Saharan Africa. This study validates the use of SPs for a variety of tracer conditions in Nairobi, Kenya, and provides new results on the quality of care in sampled primary care clinics.MethodsWe deployed 14 SPs in private and public clinics presenting either asthma, child diarrhoea, tuberculosis or unstable angina. Case management guidelines and checklists were jointly developed with the Ministry of Health. We validated the SP method based on the ability of SPs to avoid detection or dangerous situations, without imposing a substantial time burden on providers. We also evaluated the sensitivity of quality measures to SP characteristics. We assessed quality of practice through adherence to guidelines and checklists for the entire sample, stratified by case and stratified by sector, and in comparison with previously published results from urban India, rural India and rural China.ResultsAcross 166 interactions in 42 facilities, detection rates and exposure to unsafe conditions were both zero. There were no detected outcome correlations with SP characteristics that would bias the results. Across all four conditions, 53% of SPs were correctly managed with wide variation across tracer conditions. SPs paid 76% less in public clinics, but proportions of correct management were similar to private clinics for three conditions and higher for the fourth. Kenyan outcomes compared favourably with India and China in all but the angina case.ConclusionsThe SP method is safe and effective in the urban Kenyan setting for the assessment of clinical practice. The pilot results suggest that public providers in this setting provide similar rates of correct management to private providers at significantly lower out-of-pocket costs for patients. However, comparisons across countries are sensitive to the tracer condition considered.

Building a tuberculosis-free world: The Lancet Commission on tuberculosis

“…Moreover, referral links to the National Tuberculosis Programme are weak, with data from standardised patient studies in these three countries showing that only 28% to 45% of patients were correctly managed by primary care providers. 34,35,46 Simply put, the global capacity to diagnose, link to care, treat, and cure patients with tuberculosis is woefully inadequate for the massive burden of disease that exists. The public health implications, as well as the poor clinical and financial implications for patients, 41 are self-evident.…”

“…Unfortunately, cascade of care analyses shows large gaps in the quality of care for both adults and children, and for both drug-susceptible and drug-resistant tuberculosis in many high-burden countries. [36][37][38]112,133 Standardised patient studies in India, Kenya, South Africa, and China [33][34][35]46 have shown that the quality of care for tuberculosis is poor. In a study in China, for example, health-care providers did not correctly manage patients presenting with archetypal symptoms or results suggesting active tuberculosis 59% of the time.…”

“…216 New research continues to add to our understanding of the functioning of private health-care markets regarding tuberculosis. 34,217,218 Since 2013, sustained scale-up of private provider engagement has taken place in several key countries (figure 6). Bangladesh has sustained moderate private provider engagement since 2013, with private notifications reaching 18% of incident cases in 2017, whereas notifications in Myanmar have declined in the same time period from a similar percentage of notifications between both countries in 2012.…”

Missed opportunities for diagnosis and treatment in patients with tuberculosis symptoms: a systematic review

“…We excluded 12 articles: two because the data applicable to the review was already included in the authors' other included publication, [15,16] two because data were not original to research manuscripts (one commentary and one systematic review), [7,17] seven studies because they did not report data that could be mapped to our pre-defined patient categories, and one because it was a community-based study. [18][19][20][21][22][23][24] Description Of Studies The 14 eligible studies were published between 2000 and 2018 and reported data from India, [25][26][27][28][29] South Africa, [9,[30][31][32] Kenya, [33] Thailand, [34] China, [35] Vietnam [36] and Ghana [37] (Table 1).…”

Crucial role of primary healthcare professionals in the assessment and diagnosis of dementia

“…They have shown that the quality of primary care in low-and-middle-income countries was poor. [11][12][13][14][15][16] Most cases were incorrectly diagnosed based on a very lenient definition, and simple medical conditions were improperly managed in the majority of cases. Antibiotics were usually inappropriately overprescribed, and it was less likely for primary care providers to refer patients to higher-level hospitals for specialist care when needed.…”