Use of standardised patients to assess gender differences in quality of tuberculosis care in urban India: a two-city, cross-sectional study

Benjamin Daniels,Ada Kwan,Srinath Satyanarayana,Ramnath Subbaraman,Ranendra K Das,Veena Das,Jishnu Das,Madhukar Pai

doi:10.1016/s2214-109x(19)30031-2

Abstract

SummaryBackgroundIn India, men are more likely than women to have active tuberculosis but are less likely to be diagnosed and notified to national tuberculosis programmes. We used data from standardised patient visits to assess whether these gender differences occur because of provider practice.MethodsWe sent standardised patients (people recruited from local populations and trained to portray a scripted medical condition to health-care providers) to present four tuberculosis case scenarios to private health-care providers in the cities of Mumbai and Patna. Sampling and weighting allowed for city representative interpretation. Because standardised patients were assigned to providers by a field team blinded to this study, we did balance and placebo regression tests to confirm standardised patients were assigned by gender as good as randomly. Then, by use of linear and logistic regression, we assessed correct case management, our primary outcome, and other dimensions of care by standardised patient gender.FindingsBetween Nov 21, 2014, and Aug 21, 2015, 2602 clinical interactions at 1203 private facilities were completed by 24 standardised patients (16 men, eight women). We found standardised patients were assigned to providers as good as randomly. We found no differences in correct management by patient gender (odds ratio 1·05; 95% CI 0·76–1·45; p=0·77) and no differences across gender within any case scenario, setting, provider gender, or provider qualification.InterpretationSystematic differences in quality of care are unlikely to be a cause of the observed under-representation of men in tuberculosis notifications in the private sector in urban India.FundingGrand Challenges Canada, Bill & Melinda Gates Foundation, World Bank Knowledge for Change Program.

Highlights

Multiple systematic reviews,[1,2,3] including a review of 56 prevalence surveys from 24 countries, have found that men are more than twice as likely to have active tuberculosis but are considerably less likely than women to be diagnosed and notified to national tuberculosis programmes
2602 interactions were done by 24 unannounced stan dardised patients at 1203 different health-care facilities across two cities. 1900 (73%) interactions were done by men, who made up 16 of our 24 individual standardised patients
We describe the findings in three parts: (1) whether assignment of standardised patients in the field produced as good as random allocations of women and men for valid inference; (2) how the objective and subjective patient experience varied between women and men; and (3) how provider case management decisions and quality of care varied between women and men

Summary

Introduction

Multiple systematic reviews,[1,2,3] including a review of 56 prevalence surveys from 24 countries, have found that men are more than twice as likely to have active tuberculosis but are considerably less likely than women to be diagnosed and notified to national tuberculosis programmes. After an individual develops active tuberculosis, they must traverse a process of care-seeking, diagnosis, linkage to treatment, treatment initiation, and notification to national tuberculosis programmes.[11,12] Men might face a disadvantage at any or all of these stages, and identifying the stage of the care cascade that contributes most to the relative undernotification of men could help to focus interventions on the most important gaps in care In India, this represents a reversal of the usual pattern of disadvantage for women in use of health care.[4,5,6,7] India’s national tuberculosis programme receives 1∙9 notifications regarding men for every noti fication regarding women,[8] tuberculosis population prevalence is even higher among men, suggesting that men access tuberculosis care at substantially lower rates than women.[1,9] Understanding the sources of this gender imbalance is crucial to identifying and treating the missing millions of patients with tuberculosis globally.[10]

Methods

Results

Conclusion