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Svadzian A, Daniels B, Sulis G, Das J, Daftary A, Kwan A, Das V, Das R, Pai M. Do private providers initiate anti-tuberculosis therapy on the basis of chest radiographs? A standardised patient study in urban India. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2023; 13:100152. [PMID: 37383564 PMCID: PMC10306035 DOI: 10.1016/j.lansea.2023.100152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 01/08/2023] [Accepted: 01/11/2023] [Indexed: 06/30/2023]
Abstract
Background The initiation of anti-tuberculosis treatment (ATT) based on results of WHO-approved microbiological diagnostics is an important marker of quality tuberculosis (TB) care. Evidence suggests that other diagnostic processes leading to treatment initiation may be preferred in high TB incidence settings. This study examines whether private providers start anti-TB therapy on the basis of chest radiography (CXR) and clinical examinations. Methods This study uses the standardized patient (SP) methodology to generate accurate and unbiased estimates of private sector, primary care provider practice when a patient presents a standardized TB case scenario with an abnormal CXR. Using multivariate log-binomial and linear regressions with standard errors clustered at the provider level, we analyzed 795 SP visits conducted over three data collection waves from 2014 to 2020 in two Indian cities. Data were inverse-probability-weighted based on the study sampling strategy, resulting in city-wave-representative results. Findings Amongst SPs who presented to a provider with an abnormal CXR, 25% (95% CI: 21-28%) visits resulted in ideal management, defined as the provider prescribing a microbiological test and not offering a concurrent prescription for a corticosteroid or antibiotic (including anti-TB medications). In contrast, 23% (95% CI: 19-26%) of 795 visits were prescribed anti-TB medications. Of 795 visits, 13% (95% CI: 10-16%) resulted in anti-TB treatment prescriptions/dispensation and an order for confirmatory microbiological testing. Interpretation One in five SPs presenting with abnormal CXR were prescribed ATT by private providers. This study contributes novel insights to empiric treatment prevalence based on CXR abnormality. Further work is needed to understand how providers make trade-offs between existing diagnostic practices, new technologies, profits, clinical outcomes, and the market dynamics with laboratories. Funding This study was funded by the Bill & Melinda Gates Foundation (grant OPP1091843), and the Knowledge for Change Program at The World Bank.
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Affiliation(s)
- Anita Svadzian
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
- McGill International TB Centre, McGill University, Montreal, QC, Canada
| | - Benjamin Daniels
- McCourt School of Public Policy, Georgetown University, Washington, DC, USA
| | - Giorgia Sulis
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jishnu Das
- McCourt School of Public Policy, Georgetown University, Washington, DC, USA
- Centre for Policy Research, New Delhi, India
| | - Amrita Daftary
- Dahdaleh Institute of Global Health Research, School of Global Health, York University, Toronto, ON, Canada
- Centre for the Aids Programme of Research in South Africa MRC-HIV-TB Pathogenesis and Treatment, Research Unit, Durban, South Africa
| | - Ada Kwan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, CA, USA
| | - Veena Das
- Department of Anthropology, Johns Hopkins University, Baltimore, USA
| | - Ranendra Das
- Institute for Socio-Economic Research on Development and Democracy, Delhi, India
| | - Madhukar Pai
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
- McGill International TB Centre, McGill University, Montreal, QC, Canada
- Manipal McGill Program for Infectious Diseases, Manipal Centre for Infectious Diseases, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Grandjean Lapierre S, Nouvet E, Boutin CA, Rabodoarivelo MS, Mahboob O, Smith MJ, Rakotosamimanana N. Complexities and benefits of adopting next-generation sequencing-based tuberculosis diagnostics: a qualitative study among stakeholders in low and high-income countries. BMJ Open 2023; 13:e066651. [PMID: 37037623 PMCID: PMC10111191 DOI: 10.1136/bmjopen-2022-066651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2023] Open
Abstract
OBJECTIVES To clarify perceived benefits, barriers and facilitators of Mycobacterium tuberculosis next-generation sequencing implementation in Madagascar and Canada, towards informing implementation of this diagnostic technology in public health agencies and clinical settings in and beyond these settings. DESIGN This qualitative study involved conducting semistructured interviews with key stakeholders engaged with next-generation sequencing implementation in Madagascar and Canada. Team-based descriptive analysis supported by Nvivo V.12.0 was used to identify key themes. SETTING The study was conducted with participants involved at the clinical, diagnostic and surveillance levels of tuberculosis (TB) management from Madagascar and Canada. PARTICIPANTS Eighteen participants were interviewed (nine Madagascar and nine Canada) and included individuals purposively sampled based on involvement with TB surveillance, laboratory diagnosis and clinical management. RESULTS The following five themes emerged in the analysis of Malagasy and Canadian interviews: (1) heterogeneity in experience with established TB diagnostics, (2) variable understanding of new sequencing-based diagnostics potential; (3) further evidence as being key to expand adoption; (4) ethical arguments and concerns; (5) operational and system-level considerations. CONCLUSION There persists important lack of familiarity with TB next-generation sequencing (TB NGS) applications among stakeholders in Canada and Madagascar. This translates into skepticism on the evidence underlying its use and its true potential value added within global public health systems. If deployed, TB NGS testing should be integrated with clinical and surveillance programmes. Although this is perceived as a priority, leadership and funding responsibilities for this integration to happen remains unclear to clinical, laboratory and public health stakeholders.
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Affiliation(s)
- Simon Grandjean Lapierre
- Mycobacteria Unit, Institut Pasteur Madagascar, Antananarivo, Madagascar
- Microbiology, Infectious Diseases and Immunology Department, Université de Montréal, Montreal, Québec, Canada
| | - Elysée Nouvet
- School of Health Studies, Western University, London, Ontario, Canada
| | - Catherine-Audrey Boutin
- Microbiology, Infectious Diseases and Immunology Department, Université de Montréal, Montreal, Québec, Canada
| | - Marie-Sylvianne Rabodoarivelo
- Mycobacteria Unit, Institut Pasteur Madagascar, Antananarivo, Madagascar
- Departamento de Microbiología, Pediatría, Radiología y Salud Pública, Universidad de Zaragoza, Zaragoza, Spain
| | - Omar Mahboob
- Florida State University College of Medicine, Florida State University, Tallahassee, Florida, USA
| | - Maxwell J Smith
- School of Health Studies, Western University, London, Ontario, Canada
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Engel N, Ochodo EA, Karanja PW, Schmidt BM, Janssen R, Steingart KR, Oliver S. Rapid molecular tests for tuberculosis and tuberculosis drug resistance: a qualitative evidence synthesis of recipient and provider views. Cochrane Database Syst Rev 2022; 4:CD014877. [PMID: 35470432 PMCID: PMC9038447 DOI: 10.1002/14651858.cd014877.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Programmes that introduce rapid molecular tests for tuberculosis and tuberculosis drug resistance aim to bring tests closer to the community, and thereby cut delay in diagnosis, ensure early treatment, and improve health outcomes, as well as overcome problems with poor laboratory infrastructure and inadequately trained personnel. Yet, diagnostic technologies only have an impact if they are put to use in a correct and timely manner. Views of the intended beneficiaries are important in uptake of diagnostics, and their effective use also depends on those implementing testing programmes, including providers, laboratory professionals, and staff in health ministries. Otherwise, there is a risk these technologies will not fit their intended use and setting, cannot be made to work and scale up, and are not used by, or not accessible to, those in need. OBJECTIVES To synthesize end-user and professional user perspectives and experiences with low-complexity nucleic acid amplification tests (NAATs) for detection of tuberculosis and tuberculosis drug resistance; and to identify implications for effective implementation and health equity. SEARCH METHODS We searched MEDLINE, Embase, CINAHL, PsycInfo and Science Citation Index Expanded databases for eligible studies from 1 January 2007 up to 20 October 2021. We limited all searches to 2007 onward because the development of Xpert MTB/RIF, the first rapid molecular test in this review, was completed in 2009. SELECTION CRITERIA We included studies that used qualitative methods for data collection and analysis, and were focused on perspectives and experiences of users and potential users of low-complexity NAATs to diagnose tuberculosis and drug-resistant tuberculosis. NAATs included Xpert MTB/RIF, Xpert MTB/RIF Ultra, Xpert MTB/XDR, and the Truenat assays. Users were people with presumptive or confirmed tuberculosis and drug-resistant tuberculosis (including multidrug-resistant (MDR-TB)) and their caregivers, healthcare providers, laboratory technicians and managers, and programme officers and staff; and were from any type of health facility and setting globally. MDR-TB is tuberculosis caused by resistance to at least rifampicin and isoniazid, the two most effective first-line drugs used to treat tuberculosis. DATA COLLECTION AND ANALYSIS We used a thematic analysis approach for data extraction and synthesis, and assessed confidence in the findings using GRADE CERQual approach. We developed a conceptual framework to illustrate how the findings relate. MAIN RESULTS We found 32 studies. All studies were conducted in low- and middle-income countries. Twenty-seven studies were conducted in high-tuberculosis burden countries and 21 studies in high-MDR-TB burden countries. Only one study was from an Eastern European country. While the studies covered a diverse use of low-complexity NAATs, in only a minority of studies was it used as the initial diagnostic test for all people with presumptive tuberculosis. We identified 18 review findings and grouped them into three overarching categories. Critical aspects users value People with tuberculosis valued reaching diagnostic closure with an accurate diagnosis, avoiding diagnostic delays, and keeping diagnostic-associated cost low. Similarly, healthcare providers valued aspects of accuracy and the resulting confidence in low-complexity NAAT results, rapid turnaround times, and keeping cost to people seeking a diagnosis low. In addition, providers valued diversity of sample types (for example, gastric aspirate specimens and stool in children) and drug resistance information. Laboratory professionals appreciated the improved ease of use, ergonomics, and biosafety of low-complexity NAATs compared to sputum microscopy, and increased staff satisfaction. Challenges reported to realizing those values People with tuberculosis and healthcare workers were reluctant to test for tuberculosis (including MDR-TB) due to fears, stigma, or cost concerns. Thus, low-complexity NAAT testing is not implemented with sufficient support or discretion to overcome barriers that are common to other approaches to testing for tuberculosis. Delays were reported at many steps of the diagnostic pathway owing to poor sample quality; difficulties with transporting specimens; lack of sufficient resources; maintenance of low-complexity NAATs; increased workload; inefficient work and patient flows; over-reliance on low-complexity NAAT results in lieu of clinical judgement; and lack of data-driven and inclusive implementation processes. These challenges were reported to lead to underutilization. Concerns for access and equity The reported concerns included sustainable funding and maintenance and equitable use of resources to access low-complexity NAATs, as well as conflicts of interest between donors and people implementing the tests. Also, lengthy diagnostic delays, underutilization of low-complexity NAATs, lack of tuberculosis diagnostic facilities in the community, and too many eligibility restrictions hampered access to prompt and accurate testing and treatment. This was particularly the case for vulnerable groups, such as children, people with MDR-TB, or people with limited ability to pay. We had high confidence in most of our findings. AUTHORS' CONCLUSIONS Low-complexity diagnostics have been presented as a solution to overcome deficiencies in laboratory infrastructure and lack of skilled professionals. This review indicates this is misleading. The lack of infrastructure and human resources undermine the added value new diagnostics of low complexity have for recipients and providers. We had high confidence in the evidence contributing to these review findings. Implementation of new diagnostic technologies, like those considered in this review, will need to tackle the challenges identified in this review including weak infrastructure and systems, and insufficient data on ground level realities prior and during implementation, as well as problems of conflicts of interest in order to ensure equitable use of resources.
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Affiliation(s)
- Nora Engel
- Department of Health, Ethics & Society, School of Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, Netherlands
| | - Eleanor A Ochodo
- Centre for Evidence-based Health Care, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | | | - Bey-Marrié Schmidt
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Ricky Janssen
- Department of Health, Ethics & Society, School of Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, Netherlands
| | - Karen R Steingart
- Honorary Research Fellow, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Sandy Oliver
- EPPI-Centre, Social Science Research Unit, UCL Institute of Education, University College London, London, UK
- Africa Centre for Evidence, Faculty of Humanities, University of Johannesburg, Johannesburg, South Africa
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Mwaura M, Engel N. Constructing confidence: User perspectives on AlereLAM testing for tuberculosis. Int J Infect Dis 2021; 112:237-242. [PMID: 34525399 DOI: 10.1016/j.ijid.2021.09.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 09/01/2021] [Accepted: 09/03/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Diagnosing tuberculosis (TB) in people living with HIV (PLHIV) is challenging due to atypical clinical and radiological presentation and higher rates of sputum-negative or extrapulmonary disease. Urine LAM is a promising diagnostic biomarker to address these challenges. Yet, AlereLAM, a World Health Organization-recommended point-of-care (POC) test of this kind, remains underutilized. This study aimed to understand perspectives and experiences of those using AlereLAM. METHODS Fifteen semi-structured interviews were conducted with clinicians, nurses, program officers, laboratory staff, and patient advocates in Uganda, Kenya, and South Africa. Discussed topics included the approach to diagnosing TB, and experiences, perspectives, and country policy of AlereLAM testing. RESULTS The POC-friendly characteristics of AlereLAM require more work to be realized. Although limited by relatively low sensitivity and specificity, AlereLAM has important value for identifying TB in people with advanced HIV disease, especially when the environment enables constructing confidence in the test. The initial communication about the low performance by global agencies, restrictive eligibility criteria, reliance on CD4+ testing, and lack of advocacy and awareness were noted as reasons for its slow uptake. CONCLUSION The work of operationalizing diagnostics, including constructing confidence, is important to consider for policymakers, implementers, and funders when assessing acceptability, feasibility, and scale-up of a diagnostic.
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Affiliation(s)
- Muthoni Mwaura
- Department of Health, Ethics & Society; Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Nora Engel
- Department of Health, Ethics & Society; Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands.
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Yuen CM, Puma D, Millones AK, Galea JT, Tzelios C, Calderon RI, Brooks MB, Jimenez J, Contreras C, Nichols TC, Nicholson T, Lecca L, Becerra MC, Keshavjee S. Identifying barriers and facilitators to implementation of community-based tuberculosis active case finding with mobile X-ray units in Lima, Peru: a RE-AIM evaluation. BMJ Open 2021; 11:e050314. [PMID: 34234000 PMCID: PMC8264873 DOI: 10.1136/bmjopen-2021-050314] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Identify barriers and facilitators to integrating community tuberculosis screening with mobile X-ray units into a health system. METHODS Reach, effectiveness, adoption, implementation and maintenance evaluation. SETTING 3-district region of Lima, Peru. PARTICIPANTS 63 899 people attended the mobile units from 7 February 2019 to 6 February 2020. INTERVENTIONS Participants were screened by chest radiography, which was scored for abnormality by computer-aided detection. People with abnormal X-rays were evaluated clinically and by GeneXpert MTB/RIF (Xpert) sputum testing. People diagnosed with tuberculosis at the mobile unit were accompanied to health facilities for treatment initiation. PRIMARY AND SECONDARY OUTCOME MEASURES Reach was defined as the percentage of the population of the three-district region that attended the mobile units. Effectiveness was defined as the change in tuberculosis case notifications over a historical baseline. Key implementation fidelity indicators were the percentages of people who had chest radiography performed, were evaluated clinically, had sputum samples collected, had valid Xpert results and initiated treatment. RESULTS The intervention reached 6% of the target population and was associated with an 11% (95% CI 6 to 16) increase in quarterly case notifications, adjusting for the increasing trend in notifications over the previous 3 years. Implementation indicators for screening, sputum collection and Xpert testing procedures all exceeded 85%. Only 82% of people diagnosed with tuberculosis at the mobile units received treatment; people with negative or trace Xpert results were less likely to receive treatment. Suboptimal treatment initiation was driven by health facility doctors' lack of familiarity with Xpert and lack of confidence in diagnoses made at the mobile unit. CONCLUSION Mobile X-ray units were a feasible and effective strategy to extend tuberculosis diagnostic services into communities and improve early case detection. Effective deployment however requires advance coordination among stakeholders and targeted provider training to ensure that people diagnosed with tuberculosis by new modalities receive prompt treatment.
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Affiliation(s)
- Courtney M Yuen
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Jerome T Galea
- School of Social Work, University of South Florida, Tampa, Florida, USA
- College of Public Health, University of South Florida, Tampa, Florida, USA
| | | | - Roger I Calderon
- Socios En Salud Sucursal Peru, Lima, Peru
- Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Meredith B Brooks
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Tim C Nichols
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Tom Nicholson
- Center for International Development, Duke University Sanford School of Public Policy, Durham, North Carolina, USA
- Advance Access & Delivery, Durham, North Carolina, USA
| | | | - Mercedes C Becerra
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Center for Global Health Delivery, Harvard Medical School, Boston, Massachusetts, USA
| | - Salmaan Keshavjee
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Center for Global Health Delivery, Harvard Medical School, Boston, Massachusetts, USA
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Raizada N, McDowell A, Parija D, Sachdeva KS, Khaparde SD, Rao R, Pavani TN, Sudha S, Tyagi H, Rebecca YM, Huddart S, Salhotra VS, Nair SA, Denkinger CM, Chadha SS, Sarin S, Kalra A. Pathways to diagnosis of pediatric TB patients: A mixed methods study from India. Indian J Tuberc 2021; 68:363-373. [PMID: 34099202 DOI: 10.1016/j.ijtb.2020.12.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 11/11/2020] [Accepted: 12/28/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND A significant proportion of pediatric tuberculosis (TB) patients go unnotified due to the challenges in diagnosis of TB among children. The experiences of this vulnerable group while going through the TB care cascade remain largely undocumented. The aim of this study was to explore the experiences of pediatric TB patients and families along the pathway to TB diagnosis and appropriate treatment in four cities of India. METHODS The study used a mixed methods, single phased, embedded design. The primary qualitative and secondary quantitative data were collected simultaneously by interviewing families of 100 randomly selected Xpert MTB/RIF positive pediatric TB patients, under the pediatric TB project, in 4 Indian cities using a semi-structured questionnaire. The qualitative component was analyzed to deduce patterns and themes on the patient and family experiences. Descriptive statistics were used to quantify various events along the TB care pathway including various delays (patient, diagnosis and total) and number of providers visited by patients during the diagnostic process. RESULTS The median patient, diagnostic and total delays were 3 (IQR: 2,5), 39 (IQR: 23, 91) and 43 days (IQR: 28.5, 98.5), respectively. Patients visited a median of 3 (IQR: 2,4) providers before accessing Xpert MTB/RIF testing. On an average, 68.4% of physicians ordered any test most of them being irrelevant for TB diagnosis. Qualitative data showed considerable suffering for children and their families before and after TB diagnosis including serious concerns of stigma, disruption in education and social life and recurrence of the disease. CONCLUSION Our study highlights the significant physical and social distress that the children with TB and their families undergo along the TB care pathway. It also shows diagnostic delay in excess of a month during which multiple providers were met and the patients underwent several diagnostic tests, most of them being inappropriate. Efforts to make Xpert MTB/RIF testing more accessible and part of physicians' toolkit will be of considerable value to ease the complexity of TB diagnosis in children. In addition, communication strategy needs to be developed and implemented to generate awareness among general population around pediatric TB and its management.
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Affiliation(s)
- Neeraj Raizada
- Foundation for Innovative New Diagnostics, New Delhi, India
| | | | | | - K S Sachdeva
- Central TB Division, Government of India, New Delhi, India
| | | | - Raghuram Rao
- Central TB Division, Government of India, New Delhi, India
| | - T N Pavani
- Foundation for Innovative New Diagnostics, New Delhi, India
| | - S Sudha
- Foundation for Innovative New Diagnostics, New Delhi, India
| | | | - Y Mary Rebecca
- Foundation for Innovative New Diagnostics, New Delhi, India
| | | | | | | | | | | | - Sanjay Sarin
- Foundation for Innovative New Diagnostics, New Delhi, India
| | - Aakshi Kalra
- Foundation for Innovative New Diagnostics, New Delhi, India.
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Deo S, Jindal P, Papineni S. Integrating Xpert MTB/RIF for TB diagnosis in the private sector: evidence from large-scale pilots in Patna and Mumbai, India. BMC Infect Dis 2021; 21:123. [PMID: 33509114 PMCID: PMC7844908 DOI: 10.1186/s12879-021-05817-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 01/18/2021] [Indexed: 12/30/2022] Open
Abstract
Background Xpert MTB/RIF (Xpert) has been recommended by WHO as the initial diagnostic test for TB and rifampicin-resistance detection. Existing evidence regarding its uptake is limited to public health systems and corresponding resource and infrastructure challenges. It cannot be readily extended to private providers, who treat more than half of India’s TB cases and demonstrate complex diagnostic behavior. Methods We used routine program data collected from November 2014 to April 2017 from large-scale private sector engagement pilots in Mumbai and Patna. It included diagnostic vouchers issued to approximately 150,000 patients by about 1400 providers, aggregated to 18,890 provider-month observations. We constructed three metrics to capture provider behavior with regards to adoption of Xpert and studied their longitudinal variation: (i) Uptake (ordering of test), (ii) Utilization for TB diagnosis, and (iii) Non-adherence to negative results. We estimated multivariate linear regression models to assess heterogeneity in provider behavior based on providers’ prior experience and Xpert testing volumes. Results Uptake of Xpert increased considerably in both Mumbai (from 36 to 60.4%) and Patna (from 12.2 to 45.1%). However, utilization of Xpert for TB diagnosis and non-adherence to negative Xpert results did not show systematic trends over time. In regression models, cumulative number of Xpert tests ordered was significantly associated with Xpert uptake in Patna and utilization for diagnosis in Mumbai (p-value< 0.01). Uptake of Xpert and its utilization for diagnosis was predicted to be higher in high-volume providers compared to low-volume providers and this gap was predicted to widen over time. Conclusions Private sector engagement led to substantial increase in uptake of Xpert, especially among high-volume providers, but did not show strong evidence of Xpert results being integrated with TB diagnosis. Increasing availability and affordability of a technically superior diagnostic tool may not be sufficient to fundamentally change diagnosis and treatment of TB in the private sector. Behavioral interventions, specifically aimed at, integrating Xpert results into clinical decision making of private providers may be required to impact patient-level outcomes. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-05817-1.
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Affiliation(s)
- Sarang Deo
- Indian School of Business, AC 3, L1, #3113, ISB Campus, Gachibowli, Hyderabad, 500032, India.
| | - Pankaj Jindal
- Indian School of Business, AC 3, L1, #3113, ISB Campus, Gachibowli, Hyderabad, 500032, India.,UCLA Anderson School of Management, Los Angeles, United States
| | - Sirisha Papineni
- Harvard Medical School, Boston, United States.,World Health Partners, New Delhi, India
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8
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Deo S, Jindal P, Sabharwal M, Parulkar A, Singh R, Kadam R, Dabas H, Dewan P. Field sales force model to increase adoption of a novel tuberculosis diagnostic test among private providers: evidence from India. BMJ Glob Health 2020; 5:bmjgh-2020-003600. [PMID: 33376100 PMCID: PMC7778745 DOI: 10.1136/bmjgh-2020-003600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 11/30/2020] [Accepted: 12/03/2020] [Indexed: 11/16/2022] Open
Abstract
Background Impact of novel high-quality tuberculosis (TB) tests such as Xpert MTB/RIF has been limited due to low uptake among private providers in high-burden countries including India. Our objective was to assess the impact of a demand generation intervention comprising field sales force on the uptake of high-quality TB tests by providers and its financial sustainability for private labs in the long run. Methods We implemented a demand generation intervention across five Indian cities between October 2014 and June 2016 and compared the change in the quantity of Xpert cartridges ordered by labs in these cities from before (February 2013–September 2014) to after intervention (October 2014–December 2015) to corresponding change in labs in comparable non-intervention cities. We embedded this difference-in-differences estimate within a financial model to calculate the internal rate of return (IRR) if the labs were to invest in an Xpert machine with or without the demand generation intervention. Results The intervention resulted in an estimated 60 additional Xpert cartridges ordered per lab-month in the intervention group, which yielded an estimated increase of 11 500 tests over the post-intervention period, at an additional cost of US$13.3–US$17.63 per test. Further, we found that investing in this intervention would increase the IRR from 4.8% to 5.5% for hospital labs but yield a negative IRR for standalone labs. Conclusions Field sales force model can generate additional demand for Xpert at private labs, but additional strategies may be needed to ensure its financial sustainability.
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Affiliation(s)
- Sarang Deo
- Max Institute of Healthcare Management, Indian School of Business, Mohali, Punjab, India .,Operations Management, Indian School of Business, Hyderabad, Telangana, India
| | - Pankaj Jindal
- Operations Management, Indian School of Business, Hyderabad, Telangana, India
| | | | | | - Ritu Singh
- Clinton Health Access Initiative, New Delhi, India
| | | | | | - Puneet Dewan
- Bill and Melinda Gates Foundation, New Delhi, India
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9
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Newtonraj A, Purty AJ, Natesan M, Manikandan M. Ten years Trend in Pediatric Tuberculosis Diagnosis in a South Indian State Under Programmatic Setting. Indian J Pediatr 2020; 87:768-769. [PMID: 32671638 DOI: 10.1007/s12098-020-03447-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 07/07/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Ariarathinam Newtonraj
- Department of Community Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India.
| | - Anil Jacob Purty
- Department of Community Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India
| | - Murugan Natesan
- Department of Community Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India
| | - Mani Manikandan
- Department of Community Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India
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10
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Kalra A, Parija D, Raizada N, Sachdeva KS, Rao R, Swaminathan S, Khanna A, Chopra KK, Hanif M, Singh V, Umadevi KR, Sheladia KN, Rao R, Vasundhara N, S. A, A. R. N, Azeem A, Chhajlani V, Khurana J, Das NJ, Choudhury B, Nair SA, Mall S, Sen R, Chadha SS, Denkinger CM, Boehme C, Sarin S. Upfront Xpert MTB/RIF for diagnosis of pediatric TB-Does it work? Experience from India. PLoS One 2020; 15:e0236057. [PMID: 32756559 PMCID: PMC7406076 DOI: 10.1371/journal.pone.0236057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 06/27/2020] [Indexed: 01/02/2023] Open
Abstract
Background Diagnosis of TB in pediatric population poses several challenges. A novel initiative was implemented in several major cities of India aimed at providing upfront access to free-of-cost Xpert MTB/RIF to presumptive pediatric TB cases. This paper aims to describe the experience of implementing this large initiative and assess feasibility of the intervention in high TB burden settings. Methods Data were drawn from the pediatric TB project implemented in 10 major cities of India between April 2014 and March 2018. In each city, providers, both public and private, were engaged and linked with a high throughput Xpert MTB/RIF lab (established in that city) through rapid specimen transportation and electronic reporting system. Rates and proportions were estimated to describe the characteristics of this cohort. Results Of the total 94,415 presumptive pediatric TB cases tested in the project, 6,270 were diagnosed positive for MTB (6.6%) on Xpert MTB/RIF (vs 2% on smear microscopy). Among MTB positives, 545 cases were rifampicin resistant (8.7%). The median duration between collection of specimens and reporting of results was 0 days (same day) and >89% cases were initiated on treatment. Approximately 50% of the specimens tested were non-sputum. The number of providers/facilities engaged under the project increased >10-fold (from 124 in Q2’14 to 1416 in Q1’18). Conclusion This project, which was one of the largest initiatives globally among pediatric population, demonstrated the feasibility of sustaining rapid and upfront access to free-of-cost Xpert MTB/RIF testing. The project underscores the efficiency of this rapid diagnostic assay in tackling several challenges in pediatric TB diagnosis, identifies opportunities for further interventions as well as brings to light scope for effective engagement with healthcare providers. The findings have facilitated a policy decision by National TB Programme mandating the use of Xpert MTB/RIF as a primary diagnostic tool for TB diagnosis in children, which is being scaled-up.
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Affiliation(s)
- Aakshi Kalra
- Foundation for Innovative New Diagnostics, New Delhi, India
- * E-mail:
| | | | - Neeraj Raizada
- Foundation for Innovative New Diagnostics, New Delhi, India
| | - K. S. Sachdeva
- Central TB Division, Government of India, New Delhi, India
| | - Raghuram Rao
- Central TB Division, Government of India, New Delhi, India
| | | | - Ashwani Khanna
- State TB office, Govt of National Capital Territory, Delhi, India
| | | | - M. Hanif
- New Delhi TB Centre, New Delhi, India
| | - Varinder Singh
- Lady Hardinge Medical College and Assoc Kalawati Saran Children's Hospital, New Delhi, India
| | - K. R. Umadevi
- National Institute of research in Tuberculosis, Chennai, India
| | - K. N. Sheladia
- District TB Centre, Surat Municipal Corporation, Gujarat, India
| | - Rama Rao
- State TB Office, Vijayawada, Andhra Pradesh, India
| | - N. Vasundhara
- District TB Centre, Visakhapatnam, Andhra Pradesh, India
| | - Anil S.
- State TB Training and Demonstration Centre/Intermediate Reference Laboratory, Bangalore, Karnataka, India
| | - Nirmala A. R.
- State TB Training and Demonstration Centre/Intermediate Reference Laboratory, Bangalore, Karnataka, India
| | - Abdul Azeem
- State TB Training and Demonstration Centre/Intermediate Reference Laboratory, Bangalore, Karnataka, India
| | | | - Jyoti Khurana
- Intermediate Reference Laboratory, Indore, Madhya Pradesh, India
| | - N. J. Das
- Office of the Jt. Director of Health Services (TB), Directorate of Health Services, Assam, India
| | | | | | - Shalini Mall
- Foundation for Innovative New Diagnostics, New Delhi, India
| | - Rajashree Sen
- Foundation for Innovative New Diagnostics, New Delhi, India
| | | | | | | | - Sanjay Sarin
- Foundation for Innovative New Diagnostics, New Delhi, India
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Engel N, Krumeich A. Valuing Simplicity: Developing a Good Point of Care Diagnostic. FRONTIERS IN SOCIOLOGY 2020; 5:37. [PMID: 33869444 PMCID: PMC8022531 DOI: 10.3389/fsoc.2020.00037] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 04/27/2020] [Indexed: 06/12/2023]
Abstract
Point-of-care testing promises laboratory-based precision in settings that do not have easy access to laboratories or where processing tests takes too long or is too costly. Developers and global health actors stress values and norms such as simplicity, rapidity and accuracy for realizing diagnostic innovations that work at point of care and are aligned to the specific requirements of point-of-care settings. This paper uses fieldwork among diagnostic manufacturers, scientists, donors, members of civil society, industry consultants, international organizations, regulators, policymakers, programme officers, lab technicians, and clinicians involved in development and implementation of tuberculosis and HIV diagnostics, to examine how norms and values of what constitutes a good point-of-care diagnostic are operating in practice through both top-down and bottom-up dynamics. It draws the link between design, evidence and adoption of diagnostics and how the different actors interpret the values underpinning the new practice. The analysis draws on literature on valuation practices, evidence-making and technology design in science and technology studies and medical sociology. The findings reveal how these values constitute innovation, implementation, and evaluation practices across global and local (India) sites, with important consequences for funding of health infrastructure, capacity, and training resources for addressing some of the existing structural inequalities. Dominant values currently defining point of care diagnostics risk exacerbating health inequalities between those who do and do not have the necessary social and financial resources to access better equipped and functioning healthcare facilities, especially in resource constrained settings.
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Affiliation(s)
- Nora Engel
- Department of Health, Ethics & Society, Care and Public Health Research Institute, Maastricht University, Maastricht, Netherlands
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12
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Saria V. New Machine, Old Cough: Technology and Tuberculosis in Patna. FRONTIERS IN SOCIOLOGY 2020; 5:18. [PMID: 33869427 PMCID: PMC8022787 DOI: 10.3389/fsoc.2020.00018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 02/27/2020] [Indexed: 06/12/2023]
Abstract
In 2013, a new technology, GeneXpert, was introduced in India, which, in addition to testing for TB, could also diagnose whether the detected strain was drug resistant. By detecting the bacterium more effectively than other available tests and simultaneously testing for resistance, GeneXpert promised to reduce the delay in diagnosis and hence ineffective treatments. The new test was introduced to multiple cities via a coalition that included global health funding bodies, the government of India, the World Health Organization, and non-governmental organizations. Despite the concerted effort of the coalition, among formal providers (those trained in biomedicine) in the private sector, the new technology was not adopted as quickly as had been hoped. Examining formal providers' initial responses to the technology's introduction in the city of Patna reveals how the adoption of new technology can be influenced by the particularities of the local medical market such as the availability of diagnostic tests, presence of informal providers, and reputation of formal providers. While protocols and operations might seem standardized across implementation plans, the work that is required to ensure success must take into account the particular role that the market plays from site to site.
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Affiliation(s)
- Vaibhav Saria
- Department of Gender, Sexuality, and Women's Studies, Simon Fraser University, Burnaby, BC, Canada
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13
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Engel N. Aligning in the dark: Variable and shifting (user-) settings in developing point-of-care diagnostics for tuberculosis and HIV. SOCIAL STUDIES OF SCIENCE 2020; 50:50-75. [PMID: 31928147 DOI: 10.1177/0306312719900545] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
To be effective, healthcare technologies should be attuned to particular contexts of use. This article examines how such attuning is articulated in global innovation practices for tuberculosis and HIV diagnostics, and to what effect. It examines the development of point-of-care (POC) diagnostics - promised to be designed for users outside laboratories or in resource constrained settings - to study what developers and implementers do to align diagnostic technologies to the POC. Fieldwork among global health actors involved in diagnostic development, including manufacturers, donors, industry consultants, international organizations, policymakers, regulators and researchers, is combined with fieldwork among users of diagnostics in India, including decision-makers, NGOs, program officers, laboratory technicians and nurses. The article adds to STS's theory of alignment and user interaction, where the setting and user to which developers and implementers of global health diagnostics align are multiple, varied, emerging and keep shifting. The characteristics of a local user setting include multiple engaged and imagined user settings, but also the settings of developers, of global intermediaries, competitors and diseases. As such, alignment is happening across multiple dimensions and scales and has an important temporal dimension. The results reveal how alignment happens to some extent in the dark, characterized by uncertainty about the elements that should align. Standardizing elements, politics and scarce resources cause frictions in the temporalities of aligning and over what constitutes a well-aligned diagnostic.
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Affiliation(s)
- Nora Engel
- Department of Health, Ethics & Society and Care and Public Health Research Institute, Maastricht University, The Netherlands
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14
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McDowell A, Engel N, Daftary A. In the eye of the multiple beholders: Qualitative research perspectives on studying and encouraging quality of TB care in India. J Clin Tuberc Other Mycobact Dis 2019; 16:100111. [PMID: 31497654 PMCID: PMC6716552 DOI: 10.1016/j.jctube.2019.100111] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
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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Affiliation(s)
- Andrew McDowell
- Department of Anthropology, Tulane University, New Orleans, USA
- CERMES3, Institute National de la Santé et la Recherché Médicale, Paris, France
| | - Nora Engel
- Department of Health, Ethics and Society, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
| | - Amrita Daftary
- McGill International TB Centre and Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
- Centre for the AIDS Programme of Research (CAPRISA), University of KwaZulu Natal, Durban, South Africa
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15
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Narayanan M. New technologies in microbiology and their potential impact on paediatric practice. Arch Dis Child 2019; 104:513-517. [PMID: 30154181 DOI: 10.1136/archdischild-2017-314189] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 07/12/2018] [Accepted: 07/18/2018] [Indexed: 11/04/2022]
Affiliation(s)
- Manjusha Narayanan
- Department of Microbiology, Infection Prevention and Control, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, UK
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16
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Newtonraj A, Venables E, Selvaraj K, Kundu D, Purty AJ, Manikandan M, Shewade HD. Xpert negative means no TB: A mixed-methods study into early implementation of Xpert in Puducherry, India. J Family Med Prim Care 2019; 8:1379-1385. [PMID: 31143725 PMCID: PMC6510069 DOI: 10.4103/jfmpc.jfmpc_421_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Xpert MTB/RIF was implemented in 2016 as the initial diagnostic test for extrapulmonary, pediatric, and human immunodeficiency virus-associated tuberculosis (TB) and as an add-on test for sputum microscopy-negative patients under Revised National TB Control Programme, Puducherry, India. We intended to study the change in TB case notification rates (CNRs) after 2015 and explore the enablers and barriers for implementation of Xpert. MATERIALS AND METHODS Sequential mixed-methods study, quantitative phase followed by a descriptive qualitative phase (key informant interviews with healthcare providers in the program). RESULTS The TB (all forms) CNR increased in 2016 followed by a drop to 2015 levels in 2017. There was a reduction in patients notified as sputum-negative pulmonary TB and pediatric TB during 2016-2017. Healthcare providers used a negative Xpert result in ruling out TB among patients who would previously get diagnosed clinically. Perceived benefits of Xpert were efficiency, rapid results, and detecting resistance. Barriers included poor awareness among medical colleges and the private sector, difficulty in motivating sputum microscopy-negative patients for Xpert, and incompletely filled referral forms. CONCLUSION Xpert-negative results should be interpreted cautiously after clinical assessment. Identified barriers should be addressed to ensure that all eligible undergo testing.
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Affiliation(s)
- Ariarathinam Newtonraj
- Department of Community Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India
| | - Emilie Venables
- Luxembourg Operational Research Unit, Médecins Sans Frontières, Luxembourg City, Luxembourg
| | | | - Debashish Kundu
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
| | - Anil Jacob Purty
- Department of Community Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India
| | - Mani Manikandan
- Department of Community Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India
| | - Hemant Deepak Shewade
- International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, New Delhi, India
- International Union Against Tuberculosis and Lung Disease (The Union), Paris, France
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Kost GJ. Molecular and point-of-care diagnostics for Ebola and new threats: National POCT policy and guidelines will stop epidemics. Expert Rev Mol Diagn 2018; 18:657-673. [DOI: 10.1080/14737159.2018.1491793] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Gerald J. Kost
- Point-of-Care Center for Teaching and Research (POCT•CTRTM), School of Medicine, UC Davis, and Knowledge Optimization®, Davis, CA
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