Research Article: Tuberculosis detection and the challenges of integrated care in rural China: A cross-sectional standardized patient study

Date Published: October 17, 2017

Publisher: Public Library of Science

Author(s): Sean Sylvia, Hao Xue, Chengchao Zhou, Yaojiang Shi, Hongmei Yi, Huan Zhou, Scott Rozelle, Madhukar Pai, Jishnu Das, Carlton Evans

Abstract: BackgroundDespite recent reductions in prevalence, China still faces a substantial tuberculosis (TB) burden, with future progress dependent on the ability of rural providers to appropriately detect and refer TB patients for further care. This study (a) provides a baseline assessment of the ability of rural providers to correctly manage presumptive TB cases; (b) measures the gap between provider knowledge and practice and; (c) evaluates how ongoing reforms of China’s health system—characterized by a movement toward “integrated care” and promotion of initial contact with grassroots providers—will affect the care of TB patients.Methods/FindingsUnannounced standardized patients (SPs) presenting with classic pulmonary TB symptoms were deployed in 3 provinces of China in July 2015. The SPs successfully completed 274 interactions across all 3 tiers of China’s rural health system, interacting with providers in 46 village clinics, 207 township health centers, and 21 county hospitals. Interactions between providers and standardized patients were assessed against international and national standards of TB care. Using a lenient definition of correct management as at least a referral, chest X-ray or sputum test, 41% (111 of 274) SPs were correctly managed. Although there were no cases of empirical anti-TB treatment, antibiotics unrelated to the treatment of TB were prescribed in 168 of 274 interactions or 61.3% (95% CI: 55%–67%). Correct management proportions significantly higher at county hospitals compared to township health centers (OR 0.06, 95% CI: 0.01–0.25, p < 0.001) and village clinics (OR 0.02, 95% CI: 0.0–0.17, p < 0.001). Correct management in tests of knowledge administered to the same 274 physicians for the same case was 45 percentage points (95% CI: 37%–53%) higher with 24 percentage points (95% CI: −33% to −15%) fewer antibiotic prescriptions. Relative to the current system, where patients can choose to bypass any level of care, simulations suggest that a system of managed referral with gatekeeping at the level of village clinics would reduce proportions of correct management from 41% to 16%, while gatekeeping at the level of the township hospital would retain correct management close to current levels at 37%. The main limitations of the study are 2-fold. First, we evaluate the management of a one-time new patient presenting with presumptive TB, which may not reflect how providers manage repeat patients or more complicated TB presentations. Second, simulations under alternate policies require behavioral and statistical assumptions that should be addressed in future applications of this method.ConclusionsThere were significant quality deficits among village clinics and township health centers in the management of a classic case of presumptive TB, with higher proportions of correct case management in county hospitals. Poor clinical performance does not arise only from a lack of knowledge, a phenomenon known as the “know-do” gap. Given significant deficits in quality of care, reforms encouraging first contact with lower tiers of the health system can improve efficiency only with concomitant improvements in appropriate management of presumptive TB patients in village clinics and township health centers.

Partial Text: National prevalence surveys conducted by the Chinese Center for Disease Control and Prevention (CCDC) show that between 1990 and 2010 smear-positive prevalence of tuberculosis (TB) decreased by 65%, from 170 to 59 per 100,000 [1]. Though improved socioeconomic conditions almost certainly helped, better treatment of those diagnosed with TB is also thought to have played an important role, as evidenced by large reductions in the number of smear-positive cases among previously diagnosed individuals. In part due to this success, by 2010 the large majority (approximately 90%) of smear-positive cases were individuals who had not received a previous diagnosis of TB. This suggests that further progress in China—which remains a high-burden country second only to India—will rely on improving case detection, most importantly in rural areas where the prevalence of TB is 3 times the national average at 163 per 100,000 and patients report longer diagnostic and treatment delays compared to urban patients [2–3].

Our study uses SPs to evaluate the management of TB among healthcare providers in China. We find that rates of correct management are low among village and township level providers in rural areas. Given that most rural patients with TB symptoms initially see providers at these levels, our results suggest that deficits in performance can contribute significantly to delayed detection of TB in China. The poor quality of care that we found for TB is consistent with previous findings for other conditions in studies using SPs [6]. Like in other studies, even in those cases that are correctly managed, there is a preference for radiography over microbiological testing. This contrasts with WHO recommendations for TB diagnosis, as CXRs often yield significant false positives.



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