How Do Urban Indian Private Practitioners Diagnose and Treat Tuberculosis? A Cross-Sectional Study in Chennai

Liza Bronner Murrison; Ramya Ananthakrishnan; Sumanya Sukumar; Sheela Augustine; Nalini Krishnan; Madhukar Pai; David W Dowdy

doi:10.1371/journal.pone.0149862

How Do Urban Indian Private Practitioners Diagnose and Treat Tuberculosis? A Cross-Sectional Study in Chennai

PLoS One. 2016 Feb 22;11(2):e0149862. doi: 10.1371/journal.pone.0149862. eCollection 2016.

Authors

Liza Bronner Murrison^{1

2}, Ramya Ananthakrishnan³, Sumanya Sukumar³, Sheela Augustine³, Nalini Krishnan³, Madhukar Pai⁴, David W Dowdy^{1

2}

Affiliations

¹ Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.
² Center for Tuberculosis Research, Johns Hopkins University, Baltimore, Maryland, United States of America.
³ REACH, Chennai, India.
⁴ McGill International TB Centre & Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada.

Abstract

Setting: Private practitioners are frequently the first point of healthcare contact for patients with tuberculosis (TB) in India. Inappropriate TB management practices among private practitioners may contribute to delayed TB diagnosis and generate drug resistance. However, these practices are not well understood. We evaluated diagnostic and treatment practices for active TB and benchmarked practices against International Standards for TB Care (ISTC) among private medical practitioners in Chennai.

Design: A cross-sectional survey of 228 practitioners practicing in the private sector from January 2014 to February 2015 in Chennai city who saw at least one TB patient in the previous year. Practitioners were randomly selected from both the general community and a list of practitioners who referred patients to a public-private mix program for TB treatment in Chennai. Practitioners were interviewed using standardized questionnaires.

Results: Among 228 private practitioners, a median of 12 (IQR 4-28) patients with TB were seen per year. Of 10 ISTC standards evaluated, the median of standards adhered to was 4.0 (IQR 3.0-6.0). Chest physicians reported greater median ISTC adherence than other MD and MS practitioners (score 7.0 vs. 4.0, P<0.001), or MBBS practitioners (score 7.0 vs. 4.0, P<0.001). Only 52% of all practitioners sent >5% of patients with cough for TB testing, 83% used smear microscopy for diagnosis, 33% monitored treatment response, and 22% notified TB cases to authorities. Of 228 practitioners, 68 reported referring all patients with new pulmonary TB for treatment, while 160 listed 27 different regimens; 78% (125/160) prescribed a regimen classified as consistent with ISTC. Appropriate treatment practices differed significantly between chest physicians and other MD and MS practitioners (54% vs. 87%, P<0.001).

Conclusion: TB management practices in India's urban private sector are heterogeneous and often suboptimal. Private providers must be better engaged to improve diagnostic capacity and decrease TB transmission in the community.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Adult
Aged
Cross-Sectional Studies
Disease Management*
Female
Humans
India
Male
Middle Aged
Physicians / statistics & numerical data
Practice Patterns, Physicians'*
Private Practice / statistics & numerical data
Surveys and Questionnaires
Tuberculosis / diagnosis*
Tuberculosis / drug therapy*

Grants and funding

This study was supported by a grant by the Bill & Melinda Gates Foundation (grant OPP1061487) and by a Global Health Field Research Award grant by the Johns Hopkins Center for Global Health. Madhukar Pai was a recipient of a Tier 1 Canada Research Chair from the Canadian Institutes of Health Research. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The other authors received no specific funding for this work.