Variations in the Quality of Tuberculosis Care in Urban India: A Cross-Sectional, Standardized Patient Study in Two Cities

Kwan, Ada; Daniels, Benjamin; Saria, Vaibhav; Satyanarayana, Srinath; Subbaraman, Ramnath; McDowell, Andrew; Bergkvist, Sofi; Das, Ranendra; Das, Veena; Das, Jishnu; Pai, Madhukar

doi:10.1596/31368

Cited by 6 publications

(11 citation statements)

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“…The key programmatic implication of our findings is that frontline health workers in the TB diagnostic pathway are either unaware of expectations of national programmes or are unable to adhere to current TB case-finding guidelines. Results from two included studies carried out in India 27,28 suggest that TB diagnosis can be improved in that setting by having better qualified personnel at the entry point of the diagnostic pathway. On the other hand, Silvia et al found that management at a higher level facility (hospital) was more likely to include TB diagnosis than health centre or village clinic management.…”

Section: Discussionmentioning

confidence: 99%

“…The 16 eligible studies were published between 2000 and 2021 and reported data from India, [27][28][29][30][31] South Africa, 11,[32][33][34] Ghana, 35 Kenya, 37 Malawi, 38 Thailand, 39 China, 18 Vietnam 11,32,34 and Ghana 40 (Table 1). Nine studies employed the standardised patient design, five were exit interview studies, and the remaining two were cross-sectional studies.…”

Section: Description Of Studiesmentioning

confidence: 99%

“…35 The two cross-sectional studies were a rural hospital study from Ghana; 40 and a hospital-based study from India. 33 Four of the seven standardised patient studies were conducted in pharmacies in India, 36 Thailand, 27,28 and Vietnam; 39 1 was in a South African primary health care setting; 33 1 involved facilities at various levels of care in Kenya; 36 and another 2 involved various levels of the Indian healthcare system. 27,28…”

Section: Description Of Studiesmentioning

confidence: 99%

“…The proportion of symptomatic attendees offered a diagnostic investigation (data available for 16 studies), was highly variable, ranging from 0.04 to 0.84 (median 0.38, IQR 0.14-0.44; Figure 3B). To note, 9/16 studies were standardised patient studies [27][28][29][30]33,36,37,39,41 in which, despite reporting classical TB symptoms to attending care givers, up to 96% of the participants were not offered a TB diagnostic investigation (Table 1). The five studies that assessed receipt of TB investigation reported the following proportions: 50% (2/4), 11 46% (61/134), 34 24% (230/932), 40 100% (31/31) 35 and 58% (21/36).…”

Section: Tb Diagnostic and Care Pathwaymentioning

confidence: 99%

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

Divala

Lewis

Bulterys

et al. 2022

public health action

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BACKGROUND: The identification of patients with symptoms is the foundation of facility-based TB screening and diagnosis, but underdiagnosis is common. We conducted this systematic review with the hypothesis that underdiagnosis is largely secondary to patient drop out along the diagnostic and care pathway.METHODS: We searched (up to 22 January 2019) MEDLINE, Embase, and Cinahl for studies investigating patient pathway to TB diagnosis and care at health facilities. We used Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) to assess risk of bias. We reported proportions of patients with symptoms at each stage of the pathway from symptom screening to treatment initiation.RESULTS: After screening 3,558 abstracts, we identified 16 eligible studies. None provided data addressing the full cascade of care from clinical presentation to treatment initiation in the same patient population. Symptom screening, the critical entry point for diagnosis of TB, was not done for 33–96% of participants with symptoms in the three studies that reported this outcome. The proportion of attendees with symptoms offered a diagnostic investigation (data available for 15 studies) was very low with a study level median of 38% (IQR 14–44, range 4–84)CONCLUSIONS: Inefficiencies of the TB symptom screen-based patient pathway are a major contributor to underdiagnosis of TB, reflecting inconsistent implementation of guidelines to ask all patients attending health facilities about respiratory symptoms and to offer diagnostic tests to all patients promptly once TB symptoms are identified. Better screening tools and interventions to improve the efficiency of TB screening and diagnosis pathways in health facilities are urgently needed.

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Section: Discussionmentioning

confidence: 99%

Section: Description Of Studiesmentioning

confidence: 99%

Section: Description Of Studiesmentioning

confidence: 99%

Section: Tb Diagnostic and Care Pathwaymentioning

confidence: 99%

See 2 more Smart Citations

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

Divala

Lewis

Bulterys

et al. 2022

public health action

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“…The method of medical vignettes that they developed has since been used in samples from other Indian states, including Chhattisgarh, Madhya Pradesh, Andhra Pradesh, Uttar Pradesh and Bihar ( Das and Hammer, 2005 ; Gautham et al, 2014 ; Mohanan et al, 2015 ; Rao et al, 2013 ). In 2016 Das et al used the technique of standardized patients to address several shortcomings of quality measurement from direct clinical observations, and since then this technique has also been used – again in select samples from Madhya Pradesh, Bihar, Maharashtra, West Bengal and Delhi ( Das et al, 2016a ; Das et al, 2016b ; Das et al, 2015 ; Kwan et al, 2018 ; Mohanan et al, 2015 ). These measurements have helped inform discussions around quality of care in India, but there has been no attempt to compare quality across states (these studies were not sufficiently coordinated to permit such comparisons), with the absence of quality measurement from states in South India a particularly important omission from these studies.…”

Section: Introductionmentioning

confidence: 99%

Two Indias: The structure of primary health care markets in rural Indian villages with implications for policy

Das

Daniels

Ashok

et al. 2022

Social Science & Medicine

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Barriers to engagement by people with active tuberculosis in the care cascade in India: a systematic review of two decades of quantitative research

Jhaveri,

Galivanche

et al. 2023

Preprint

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Background. India has the highest burden of tuberculosis (TB), accounting for more than one-quarter of people with active TB and nearly one-third of TB deaths globally. Most people contracting active TB in India do not successfully navigate all stages of the care cascade to receive treatment and achieve TB recurrence-free survival. Understanding reasons for losses across the care cascade is critical to improve outcomes. In this paper, guided by a PECO (population/exposure/comparison/outcome) framework, we describe quantitative findings of a systematic review aimed at identifying factors contributing to unfavorable outcomes experienced by people with TB at each care cascade gap in India. Methods and findings. We defined care cascade gaps as comprising people with confirmed or presumptive TB who did not: start the TB diagnostic workup (Gap 1), complete the diagnostic workup (Gap 2), start treatment (Gap 3), achieve treatment success (Gap 4), or achieve TB recurrence-free survival (Gap 5). Three systematic searches were conducted to identify 147 unique articles published from 2000 to 2021 that evaluated factors associated with unfavorable outcomes for each gap (reported as odds, relative risk, or hazard ratios) and, among people experiencing unfavorable outcomes, reasons reported for these outcomes (reported as proportions). Findings were organized into patient-, family-, society-, or health system-related factors, using a social-ecological framework. Some factors were common and associated with unfavorable outcomes across multiple care cascade stages. These included male sex, older age (variably defined across studies), a broad array of poverty-related factors, lower symptom severity or duration, undernutrition, alcohol use, smoking, and distrust of (or dissatisfaction with) local government health services. People who had been previously treated for TB were more likely to seek care and engage in the TB diagnostic workup (Gaps 1 and 2) but were also more likely to suffer pretreatment loss to follow-up (Gap 3) and unfavorable outcomes during TB treatment (Gap 4), especially those who had been lost to follow-up during their prior treatment episode. For individual care cascade gaps, multiple studies highlighted the importance of lack of TB knowledge and structural barriers to care (e.g., transport or financial challenges in reaching clinics) in contributing to lack of care-seeking for TB symptoms (Gap 1, 15 studies or analyses); lack of access to diagnostics (e.g., chest X-ray), non-identification of eligible patients for testing, and failure of providers to communicate concern for TB to patients in contributing to non-completion of the diagnostic workup (Gap 2, 20 studies or analyses); TB stigma, poor recording of patient contact information by providers, and early death due to diagnostic delays in contributing to pretreatment loss to follow-up (Gap 3, 25 studies); and medication adverse effects, TB stigma, and lack of TB knowledge in contributing to unfavorable treatment outcomes (Gap 4, 104 studies). Medication nonadherence contributed to unfavorable treatment outcomes (Gap 4) and post-treatment TB recurrence (Gap 5, 15 studies). Conclusions. This extensive systematic review illuminates common patterns of risk that shape outcomes for people with TB in India, while also highlighting gaps in knowledge, particularly with regard to TB care for children or in the private sector, that can help to guide future research. These findings may help inform targeting of additional support services to people with TB who are at higher risk of poor outcomes and inform development of multi-component interventions to close gaps in India′s TB care cascade.

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Variations in the Quality of Tuberculosis Care in Urban India: A Cross-Sectional, Standardized Patient Study in Two Cities

Cited by 6 publications

References 0 publications

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

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

Two Indias: The structure of primary health care markets in rural Indian villages with implications for policy

Barriers to engagement by people with active tuberculosis in the care cascade in India: a systematic review of two decades of quantitative research

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