Use of standardised patients to assess quality of tuberculosis care: a pilot, cross-sectional study
Summary
Background
Existing studies of the
quality of tuberculosis care have relied on recall-based patient
surveys, questionnaire surveys of knowledge, and prescription or
medical record analysis, and the results mostly show the
health-care provider's knowledge rather than actual practice. No
study has used standardised patients to assess clinical
practice. Therefore we aimed to assess quality of care for
tuberculosis using such patients.
Methods
We did a pilot,
cross-sectional validation study of a convenience sample of
consenting private health-care providers in low-income and
middle-income areas of Delhi, India. We recruited standardised
patients in apparently good health from the local community to
present four cases (two of presumed tuberculosis and one each of
confirmed tuberculosis and suspected multidrug-resistant
tuberculosis) to a randomly allocated health-care provider. The
key objective was to validate the standardised-patient method
using three criteria: negligible risk and ability to avoid
adverse events for providers and standardised patients, low
detection rates of standardised patients by providers, and data
accuracy across standardised patients and audio verification of
standardised-patient recall. We also used medical vignettes to
assess providers' knowledge of presumed tuberculosis. Correct
case management was benchmarked using Standards for Tuberculosis
Care in India (STCI).
Findings
Between Feb 2, and March
28, 2014, we recruited and trained 17 standardised patients who
had 250 interactions with 100 health-care providers, 29 of whom
were qualified in allopathic medicine (ie, they had a Bachelor
of Medicine & Surgery [MBBS] degree), 40 of whom practised
alternative medicine, and 31 of whom were informal health-care
providers with few or no qualifications. The interactions took
place between April 1, and April 23, 2014. The proportion of
detected standardised patients was low (11 [5%] detected out of
232 interactions among providers who completed the follow-up
survey), and standardised patients' recall correlated highly
with audio recordings (r=0·63 [95% CI
0·53–0·79]), with no safety concerns
reported. The mean consultation length was 6 min (95% CI
5·5–6·6) with a mean of 6·18
(5·72–6·64) questions or examinations
completed, representing 35% (33–38) of essential checklist
items. Across all cases, only 52 (21% [16–26]) of 250 were
correctly managed. Correct management was higher among
MBBS-qualified doctors than other types of health-care provider
(adjusted odds ratio 2·41 [95% CI
1·17–4·93]; p=0·0166). Of the 69
providers who completed the vignette, knowledge in the vignettes
was more consistent with STCI than their actual clinical
practice—eg, 50 (73%) ordered a chest radiograph or sputum
test during the vignette compared with seven (10%) during the
standardised-patient interaction; OR 0·04 (95% CI
0·02–0·11); p<0·0001.
Interpretation
Standardised patients
can be successfully implemented to assess tuberculosis care. Our
data suggest a big gap between private provider knowledge and
practice. Additional work is needed to substantiate our pilot
data, understand the know-do gap in provider behaviour, and to
identify the best approach to measure and improve the quality of
tuberculosis care in India.
Funding
Grand Challenges Canada, the
Bill & Melinda Gates Foundation, Knowledge for Change
Program, and the World Bank Development Research Group.
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Source:
The Lancet Infectious Diseases
