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Only 41% of TB cases in rural China correctly managed
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Only 41% of tuberculosis cases in rural China — an area with a significant burden caused by the disease — are correctly managed in village clinics, township health centers or county hospitals, according to research published in PLoS Medicine.
The researchers note that this percentage will fall to 16% if village clinics are required to be “gatekeepers” to higher levels of care.
“Although TB prevalence has more than halved since 1990 in China, early diagnosis remains a challenge,” Sean Sylvia, PhD, from the department of health policy and management in the Gillings School of Global Public Health at the University of North Carolina, told Infectious Diseases in Children. “Part of the problem is that there has been little data on the availability of primary care providers in rural areas to diagnose and properly manage presumptive cases. We’ve also had no data comparing differences between the different levels of the rural health system.”
“This kind of information is critical to an ongoing debate around health reforms which, in part, seek to relieve stress at upper tiers of the health system by encouraging patients to seek care at lower tiers,” Sylvia added.
To assess the capability of health care providers to manage plausible TB cases in rural China, to examine barriers between provider knowledge and practice and to evaluate how changes in China’s health care system affect patients with TB, the researchers conducted a study that used unannounced standardized patients with classic pulmonary TB symptoms.
Sylvia and colleagues assessed 274 interactions with random physicians within three village clinics, 2017 township health centers and 21 county hospitals. All interactions were compared with the current international and national standards of care for patients with TB. Correct management was defined by the researchers as at least a referral, sputum test or chest X-ray study.
When considering all 274 interactions, 41% of the standardized patients were correctly managed. Antibiotics for other conditions were prescribed in 61.3% of TB cases (95% CI, 55%-67%), and no empirical anti-TB treatment was administered. County hospitals were more likely to provide correct management when compared with township health centers (OR 0.06; 95% CI, 0.01-0.25; P < .001). Hospitals were also more likely to provide correct management than village clinics (OR 0.02; 95% CI, 0.0-0.17; P < .001).
Knowledge tests administered to the same 274 physicians demonstrated 45% higher scores related to correct management (95% CI, 37%-53%). Physicians also prescribed antibiotics 24% less than when treating standardized patients (95% CI, –33% to –15%). If patients were required to visit a village clinic for a referral to higher levels of care, the percent of correct management of TB would drop from 41% to 16%. If this “gatekeeping” policy was held at the township hospital level, percentages would remain similar at 37%.
“Improving the quality of primary care available in rural areas — particularly at lower level village clinics and township health centers — should be policy priority,” Sylvia said. “Improving quality, though, will require more than training or other interventions to improve provider knowledge since knowledge is already high relative to practice. Quality deficits may be more effectively improved by addressing the reasons that the practice of providers often diverges from what they know to do.” – by Katherine Bortz
Disclosure: Pai serves as a consultant to the Bill & Melinda Gates Foundation, which had no involvement in the study or manuscript. Pai also serves on the editorial board of PLoS Medicine and PLoS ONE.
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