Consistency in the quality of care provided by healthcare professionals is a hot topic right now, and major healthcare insurers and providers in the US are adopting pay-for-performance models. A new study conducted by researchers at Duke University’s Sanford School of Public Policy recommends the adoption of incentive or pay-for-performance models in rural India to help enforce quality standards in the treatment of childhood illness.
According to a recent press release: "Few health care providers in rural India know the correct treatments for childhood diarrhea and pneumonia - two leading killers of young children worldwide. But even when they do, they rarely prescribe them properly, according to a new Duke University Study." The study was published in the Journal of the American Medical Association (JAMA) Pediatrics.
"Researchers conducted 'vignette' interviews with 340 healthcare practitioners in Bihar, India to assess how they would diagnose and treat a hypothetical case. Later, standardized patients - individuals who portrayed patients presenting the same symptoms as in the interviews - made unannounced visits. This strategy enabled researchers to measure the gap between what providers know and what they actually do - the 'know-do' gap."
Approximately 80% of providers in the study had no medical degree. According to Professor Manoj Mohanan, lead author of the study, much of the rural population in India receives care from untrained – or undertrained – providers.
The release notes that "Providers exhibited low levels of knowledge about both diarrhea and pneumonia during the interviews and performed even worse in practice...The study found that even providers with formal medical training had large gaps between what they knew and did, but were significantly less likely to prescribe harmful medical treatments."
According to Mohanan,
In order to reduce child mortality, we need new strategies to improve diagnosis and treatment of these key childhood illnesses. Our evidence on the gap between knowledge and practice suggests that training alone will be insufficient. We need to understand what incentives cause providers to diverge from proper diagnosis and treatment.
Commonly Available Oral Rehydration Salts Rarely Prescribed for Diarrhea in India
Despite great progress in treating childhood diarrhea – the death toll for children under 5 decreased by 50% from over 1.2 million in 2000 to fewer than 0.6 million in 2013 – diarrhea remains a leading cause of death for children under 5. Worldwide, diarrhea accounted for approximately 9% of deaths in this age group in 2013.
Many of these deaths could be avoided if the World Health Organization’s (WHO) treatment recommendations were followed. The WHO recommends treatment with commonly available oral rehydration salts (ORS) combined with zinc supplementation.
In 2013, only 40% of children diagnosed with diarrhea received ORS, according to UNICEF. UNICEF states that the areas of lowest coverage by ORS are Sub-Saharan Africa (36%) and South Asia (38%). These statistics are much higher than the Duke study, which found that only 17% of healthcare practitioners actually prescribed ORS treatment when needed.
Few Practitioners Prescribed Antibiotics for Children with Pneumonia
Pneumonia is the leading cause of death for children worldwide, accounting for 15% of deaths among children under 5. Deaths of children under 5 caused by pneumonia decreased from 1.7 million in 2000 to 945,000 in 2013, according to UNICEF. Many more could be saved though.
Although viruses, fungi, or bacteria can cause pneumonia, antibiotic treatment is recommended in most cases. Oxygen supplementation may be needed. Hospitalization, according to the WHO, is only required in the most severe cases, but is recommended for all infants under 2 months diagnosed with pneumonia.
The recommended antibiotic, amoxicillin, is commonly available in most countries. Despite this, only about one-third of children receive the antibiotics they need. This disparity may be at least partially attributed to poverty – the poorest families in the poorest countries are least likely to seek treatment – and access to care, especially in rural areas.
The Duke study found that when care is sought for children with pneumonia symptoms in rural India, 59% of healthcare practitioners made the correct diagnosis. However, only 8.9% prescribed antibiotic treatment. Additionally 43.8% of practitioners prescribed antibiotic therapy along with other unnecessary, and potentially harmful, drugs.
In an opinion article published along with the Duke study in JAMA Pediatrics, James Tielsch, PhD, a professor from the Department of Global Health at George Washington University wrote:
The findings demonstrate that even practitioners’ basic knowledge regarding the diagnosis and appropriate treatment for these 2 very common pediatric disorders is low.
It seems that improving the knowledge and training of practitioners would not be adequate to improve the outcomes for children in this environment. Mohanan suggests incentives, but even incentives may not be enough to improve the quality of care provided. For Tielsch, the Duke study is
a stark reminder that there remains a large, difficult-to-address, unfinished agenda for child health and survival in underserved populations around the world.
Note: Featured image courtesy of Thessaly La Force (Creative Commons).