Public Release: 

'Mystery clients' reveal weaknesses of tuberculosis care in rural China

PLOS

Many health care providers in China--especially those at village clinics and township health centers--fail to correctly manage tuberculosis (TB) cases, according to a study involving standardized patients published this week in PLOS Medicine by Sean Sylvia of the University of North Carolina at Chapel Hill, USA, Chengchao Zhou of Shangdong University, China, and colleagues at the World Bank, McGill University, Stanford University and other institutions in China.

Despite recent reductions in prevalence, China still faces a significant TB burden, especially in poor rural areas of the country. In the new study, researchers sent unannounced standardized patients (SPs) presenting with classic pulmonary TB symptoms to providers in 46 village clinics, 207 township health centers and 21 county hospitals. In all, 247 interactions with providers were assessed against international and national standards of TB care.

Overall, 41% (111 of 274 SPs) were correctly managed, with a referral, chest X-ray or sputum test ordered based on the symptoms. Antibiotics unrelated to the treatment of TB were prescribed in 168 interactions (61.3%; 95% confidence interval [CI] 55-67%). Correct management proportions were higher at county hospitals compared to township health centers (odds ratio [OR] 0.06, CI 0.01-0.25, p<0.001) and compared to village clinics (OR 0.02, CI 0.0-0.17, p<0.001). When the researchers tested the same physicians on their knowledge about TB, they were aware of correct management 45% more often than they had carried out these correct practices.

"Given significant deficits in quality of care, reforms encouraging first contact with village providers in rural areas would undermine further progress against tuberculosis in China unless substantial efforts are also made to improve the management of patients with suspected TB in village clinics and township health centers," the authors say.

The current study builds on earlier work by Jishnu Das and Madhukar Pai, co-authors on the current study, which found similar deficits among providers in India.

In an accompanying Perspective, Carlton Evans of Imperial College London and colleagues discuss the need to close the "know-do gap," the disconnect between provider's knowledge of TB recommendations and what they actually do in the clinic. The new research, they point out, highlights the fact that new TB interventions aren't the only challenge to addressing the disease. "To be effective, better tests, pills and TB policies should be integrated with interventions addressing the factors limiting access to TB care and urgently require a greater emphasis on assessing and improving TB care as an integrated component of the basic universal healthcare that people receive in the real world," they write.

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Research Article

Funding:

The authors are supported by the Fundamental Research Funds for the Central Universities and the Research Funds of Renmin University of China (Grant Number: 2015030245), the 111 Project (Grant Number: B16031), the National Science Foundation of China (Grant Number: 71473152), and the Department of Science and Technology of Shandong Province (Grant Number: BS2012SF010). JD additionally acknowledges funding from the Knowledge for Change program at The World Bank (Grant Number: 7172469). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing Interests:

MP serves as a consultant to the Bill & Melinda Gates Foundation (BMGF), which had no involvement in this study or manuscript. MP also serves on the editorial boards of PLoS Medicine & PLoS ONE.

Citation:

Sylvia S, Xue H, Zhou C, Shi Y, Yi H, Zhou H, et al. (2017) Tuberculosis detection and the challenges of integrated care in rural China: A cross-sectional standardized patient study. PLoS Med 14(10): e1002405. https://doi.org/10.1371/journal.pmed.1002405

Author Affiliations:

Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
Center for Experimental Economics in Education, Shaanxi Normal University, Xi'an, China
Institute of Social Medicine and Health Administration, School of Public Health, Shandong University, Jinan, China
School of Advanced Agricultural Sciences, Peking University, Beijing, China
Department of Health and Social Behavior, West China School of Public Health, Sichuan University, Chengdu, China
Freeman Spogli Institute for International Studies, Stanford University, Stanford, California, United States of America
McGill International TB Centre & Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
Development Research Group, The World Bank, Washington, D.C., United States of America

IN YOUR COVERAGE PLEASE USE THIS URL TO PROVIDE ACCESS TO THE FREELY AVAILABLE PAPER: http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002405

Perspective Article

Funding:

The authors acknowledge grant support from the Wellcome Trust (awards 105788/Z/14/Z and 201251/Z/16/Z), the Joint Global Health Trials consortium (award MR/K007467/1), the STOP TB partnership's TB REACH initiative funded by the Government of Canada and the Bill and Melinda Gates Foundation (awards W5_PER_CDT1_PRISMA & OPP1118545), and the charity IFHAD: Innovation For Health And Development. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing Interests:

CAE is a member of the Editorial Board of PLOS Medicine. The other authors have no competing interests to declare.

Citation:

Datta S, Saunders MJ, Tovar MA, Evans CA (2017) Improving tuberculosis diagnosis: Better tests or better healthcare? PLoS Med 14(10): e1002406. https://doi.org/10.1371/journal.pmed.1002406

Author Affiliations:

Infectious Diseases & Immunity, Imperial College London, and Wellcome Trust Imperial College Centre for Global Health Research, London, United Kingdom
Innovacion Por la Salud Y Desarrollo (IPSYD), Asociacion Benefica PRISMA, Lima, Peru
Innovation For Health And Development (IFHAD), Laboratory of Research and Development, Universidad Peruana Cayetano Heredia, Lima, Peru

IN YOUR COVERAGE PLEASE USE THIS URL TO PROVIDE ACCESS TO THE FREELY AVAILABLE PAPER:

http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002406

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