Treatment of tuberculosis by private general practitioners in India

doi:10.1016/0041-3879(91)90055-W

Tubercle

Volume 72, Issue 4, December 1991, Pages 284-290

Tubercle

https://doi.org/10.1016/0041-3879(91)90055-W Get rights and content

Abstract

Early detection and optimal treatment constitute the most important measures in the control of tuberculosis. This study of prescriptions for tuberculosis recommended by 102 private doctors, practising in the slums of Bombay, shows a lack of awareness among doctors who treat tuberculosis patients in their own clinics about the standard drug regimens for treatment of tuberculosis recommended by national and international agencies. While there are a few standard, efficient, recommended regimens, 100 private doctors prescribed 80 different regimens, most of which were both inappropriate and expensive. The study highlights the need for effective communication between those implementing national tuberculosis programmes and the practising private doctors, continuing education of these doctors for updating their knowledge and their active participation in at least those national disease programme for which their curative functions could contribute significantly to control of a disease.

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Tuberculosis (TB), caused by mycobacterium tuberculosis, is one of the most severe respiratory diseases that kill thousands of people annually around the world. Late diagnosis and drug resistance adversely affect the treatment plan. This paper introduces several deep learning models for TB diagnosis from CT scans. Specifically, for the detection of multi-drug resistance and for the detection of the TB types. These models are multi-channel models as they take, as input, the image frame, the mask frame and the gender/age data to make the final classification. Transfer learning based on VGG19 and ResNet neural networks were used for feature extraction from CT scans. The best performing model, for the classification of multi-drug resistance, was a three-channel model which used VGG19 for feature extraction and a cascade of convolutional and dense layers for classification with accuracy equals to 74.13% and AUC equals to 64.2%. By comparison, the best performing model for the TB type classification, employed the ResNet for feature extraction and a cascade of convolutional and dense layers for classification with accuracy equals to 53% and Kappa index equals to 34.3%. These results outperform the reported results in the literature for the same type of tasks. The dataset was obtained from the Image CLEFF 2018 data on TB.
Review of advances in diagnosis and treatment of pulmonary tuberculosis
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There has been a substantial leap in our understanding and the management of tuberculosis over the past couple of decades. New diagnostic tests, regimens and drugs have emerged. With a background of milestones in the management of tuberculosis, we review the advances made in the diagnosis and treatment of pulmonary tuberculosis. Since India accounts for 27% of word's burden of tuberculosis, the changes in RNTCP have been highlighted.
Tapping private health sector for public health program? Findings of a novel intervention to tackle TB in Mumbai, India
2020, Indian Journal of Tuberculosis
Citation Excerpt :
India's mixed healthcare market, with a dominant private health-sector (both qualified and non-qualified practitioners) further complicated TB control efforts.3–6 Reportedly, most TB patients in India prefer private-provider for seeking care.3,7,8 At least one million estimated TB cases a year are ‘missing’ or not reported as ‘accountably treated’.
India carries one-fourth of the global tuberculosis (TB) burden. Hence the country has drafted the ambitious National Strategic Plan to eliminate tuberculosis by 2025. To realise this goal, India's Revised National Tuberculosis Control Programme (RNTCP) and partners piloted a novel strategy to engage private-providers for tuberculosis care via a “Private-provider Interface Agency” (PPIA) in Mumbai and other locations.
The program mapped and engaged private-providers, chemists, and laboratories; facilitated TB notification via call centers and field staff; provided free tuberculosis diagnostic tests and anti-TB drugs using novel electronic vouchers; monitored quality of care; and supported patients to ensure anti-TB treatment adherence and completion. This report summarises the descriptive analysis of PPIA implementation data piloted in Mumbai from 2014 to 2017.
The program mapped 8789 private doctors, 3438 chemists, and 985 laboratories. Of these, 3836 (44%) doctors, 285 (29%) laboratories, and 353 (10%) chemists were prioritized and engaged in the program. Over three and a half years, the program recorded 60,366 privately-notified tuberculosis patients, of which, 24,146 (40%) were microbiologically-confirmed, 5203 (9%) were rifampicin-resistant, and 4401 (7%) were paediatric TB patients. Mumbai's annual total TB case notification rate increased from a pre-program baseline of 272 per 100,000/year in 2013 to 416 per 100,000/year in 2017. Overall, 42,300 (78%) patients completed the TB treatment, and 4979 (9%) could not be evaluated.
The PPIA program in Mumbai demonstrated that private-providers can be effectively engaged for TB control in urban India. This program has influenced national policy and has been adapted and funded for a country-wide scale up. The model may also be considered in conditions where private-provider engagement is needed to improve access and quality of care for any area of public health.
Map, know dynamics and act; a better way to engage private health sector in TB management. A report from Mumbai, India
2020, Indian Journal of Tuberculosis
India, world's leading Tuberculosis burden country envisions to End-TB by optimally engaging private-sector, in-spite of several unsuccessful attempts of optimal private sector engagement. Private Provider Interface Agency (PPIA), a new initiative for private-sector engagement, studied the private-sector networking and dynamics to understand the spread, typology of providers and facilities and their relations in TB case management, which was critical to design an intervention to engage private-sector. We report the observations of this exercise for a larger readership.
ology: It is a descriptive analysis of mapping data (quantitative) and perceived factors influencing their engagement in the PPIA network (qualitative).
Of 7396 doctors, 2773 chemists and 747 laboratories mapped, 3776 (51%) doctors, 353 (13%) chemists and 255 (34%) laboratories were prioritized and engaged. While allopathic doctors highly varied between wards (mean ratio 48/100,000 population; range 13–131), non-allopathic doctors were more evenly distributed (mean ratio 58/100,000 population; range 36–83). The mean ratio between non-allopathic to allopathic doctors was 1.75. Return benefit, apprehension on continuity of funding and issues of working with the Government were top three concerns of private providers during engagement. Similarly, irrational business expectations, expectation of advance financing for surety and fear of getting branded as TB clinic were three top reasons for non-engagement.
A systematic study of dynamics of existing networking, typology and spread of private providers and using this information in establishing an ecosystem of referral network for TB control activities is crucial in an effort towards optimal engagement of private health providers. Understanding the factors influencing the network dynamics helped PPIA in effective engagement of private health providers in the project.
User-experience and patient satisfaction with quality of tuberculosis care in India: A mixed-methods literature review
2019, Journal of Clinical Tuberculosis and Other Mycobacterial Diseases
Citation Excerpt :
Within the public sector, a cascade of care analysis estimated that nearly one-fifth of prevalent TB patients (520,000 annually) interface with public TB services yet are either not successfully diagnosed or are lost to follow-up (LTFU) before starting treatment [11]. As such, whether it be the public sector [3,12] or private [6,13–17], TB patients must navigate between and within health systems that possess several gaps in quality. Exploration of the user's experiences may be a key step to finding out why TB care may be “missing millions” that go undiagnosed, untreated, or unreported, despite patients engaging with the health system [12,18].
Tuberculosis affected 2.7 million people in India in 2017. The Revised National TB Control Programme has achieved milestones in coverage, however quality of TB care remains highly variable and often poor, with significant gaps in provider knowledge, practices, and patients consistently lost to follow-up. These quality gaps are largely informed by studies on provider practices or objective chart abstractions and case data. Per the knowledge of the author, no review has been conducted on first-hand patient perspectives on the quality of TB care they receive. This mixed-methods literature review aims to synthesize evidence on user-experience and patient satisfaction with TB care in India and inform areas for service quality improvement.
Five medical databases, including PubMed, EMBASE, Global Health (Ovid), Web of Science, and CINAHL were searched for empirical studies on patient perspectives on TB health services published between January 1st, 2000 to December 31st, 2017. Studies in English with adult patients with any form of TB in the public or private health system were included. Studies prior to entering the health system, on distance to health facilities and cost were excluded. Seven Indian journals were hand searched and a grey literature search was conducted in GoogleScholar. Studies were assessed for methodological quality and thematic analysis was conducted by categorizing data using NVivo 12.
A total of 498 studies were screened, of which 23 met the inclusion criteria. 16 supplementary studies were identified from Indian journals and grey literature. Of the 39 total studies included most were quantitative (29; 74%), based in South India (17; 44%) and focused on drug-sensitive TB patients (19; 49%) within the public health system (25; 64%). Data collection methods were highly heterogenous which limited synthesis and comparisons across population demographics, health sectors, or regions. Overall quantitative patient satisfaction measured in seven studies was high. Two major themes identified were provider-related factors (n = 26 studies) and convenience (n = 25), and six minor themes were supplies and equipment availability (n = 12), confidence (n = 10), information and communication (n = 10), waiting time (n = 8), stigma (n = 4), and confidentiality (n = 4). Each reported positive and negative user-experiences. Most significantly, DOTS did not fit the daily needs and obligations of many patients, particularly due to conflicts with employment and frequency of visits; while positive provider support, information, and flexibility helped patients adhere to treatment.
Although quantitative patient satisfaction was found to be high, data were not collected using robust, validated tools. Qualitative and quantitative user-experiences in each theme were variable, making them both barriers and facilitators of good quality TB care. Poor user-experiences were often responsible for patients interrupting treatment or dropping out of TB care. Patient-centeredness, or user-friendliness of TB care can be improved by introducing individualized or flexible DOTS that is responsive to user circumstances and needs. User-experience data should be systematically collected using a standardized, national tool for identification of specific bottlenecks and successes in quality of TB care from the patients’ perspective.
In the eye of the multiple beholders: Qualitative research perspectives on studying and encouraging quality of TB care in India
2019, Journal of Clinical Tuberculosis and Other Mycobacterial Diseases
This paper outlines insights qualitative research brings to the study of quality of care. It advocates understanding care as sequential, interpersonal action aimed at improving health and documenting the networks in which care occurs. It assesses the strengths and weakness of contemporary quantitative and qualitative approaches to examining quality of care for tuberculosis (TB) before outlining three qualitative research programs aimed at understanding quality of TB in India. Three case studies focus on the diagnosis level in the cascade of TB care and use qualitative research to examine the clinical use of pharmaceuticals as diagnostics, the development of diagnostic tests, and the role of care providers in the utilization of diagnostic services. They show that 1) care must be understood as part of relationships over time, 2) the presence or absence of technologies does not always imply their expected use in care, 3) physicians’ provision of care is often inflected by their perceptions of patient desires, and 4) effective care is not always perfectly aligned with global health priorities. Qualitative methods with a networked perspective on care provide novel findings that can and have been used when developing quality of care improvement interventions for TB.

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^☆: This article is an outcome of a Research Fellowship awarded to Dr M.W. Uplekar under the Take ni Program in International Health at Harvard School of Public Health for the year 1988–1989.

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Original articleTreatment of tuberculosis by private general practitioners in India☆

Abstract

Tubercle

Tubercle

Tubercle

now and forever

Primary Health Care planning in big cities with particular reference to Greater Bombay

Integration of leprosy into general health services in an urban area — a feasibility study

Lepr Rev

WHO technical report series No. 671

WHO expert committee on tuberculosis. Ninth report

WHO technical report series No. 552

Compliance of patients and physicians: experience and lessons from tuberculosis-I

Br Med J

MIMS INDIA: Monthly Index of Medical Specialties

Original article
Treatment of tuberculosis by private general practitioners in India☆