Tuberculosis detection and the cost of integrated care in rural China: a cross-sectional standardised patient study

Abstract

BackgroundFuture progress against tuberculosis in China will likely rely on improved detection, particularly in rural areas where prevalence remains high. The ability of rural providers to correctly diagnose Tuberculosis is largely unknown, as are the potential effects on tuberculosis patients of health-system reforms promoting initial contact with grassroots providers. MethodsWe employed unannounced standardised patients presenting with classic pulmonary tuberculosis symptoms in a representative survey of village, township, and county level providers in three provinces and assessed provider management of standardised patients against international and national standards of care. We then measured the gap between knowledge and practice by comparing doctor care of standardised patients to their performance in clinical vignettes of an identical presumptive tuberculosis case. Finally, we simulated the management of patients at the health-system level under alternative managed care policies accounting for provider referrals. FindingsIn July, 2015, we successfully completed 274 standardised patient interactions. Of 46 interactions in village clinics, 13 (28%) were correctly managed (95% CI 17–43%), compared with 79 (38%) of 207 in township health centers (32–45%) and 19 (90%) of 21 in county hospitals (71–97%). The same providers were 45 percentage points (95% CI 37–53%) more likely to correctly manage the same case in vignettes. Under existing policy, which allows patients to freely choose initial providers, simulations suggest that 40% (95% CI 34–47%) of patients encountering the health system are correctly managed. This would reduce to 16% with gatekeeping from village clinics and to 37% from township centers. InterpretationWe uncovered important quality deficits among grassroots providers in the management of a case of presumptive tuberculosis and a large gap between provider knowledge and practice. In view of the current quality of care, reforms encouraging first contact in village clinics could reduce the rate of detection of patients with tuberculosis. FundingFundamental Research Funds for the Central Universities and the Research Funds of Renmin University of China (2015030245), the 111 Project (B16031), the National Science Foundation of China (71473152), and the Department of Science and Technology of Shandong Province (BS2012SF010).