Tuberculosis Management Practices of Private Practitioners in Pune Municipal Corporation, India

<div><p>Background</p><p>Private Practitioners (PP) are the primary source of health care for patients in India. Limited representative information is available on TB management practices of Indian PP or on the efficacy of India’s Revised National Tuberculosis Control Programme (RNTCP) to improve the quality of TB management through training of PP.</p><p>Methods</p><p>We conducted a cross-sectional survey of a systematic random sample of PP in one urban area in Western India (Pune, Maharashtra). We presented sample clinical vignettes and determined the proportions of PPs who reported practices consistent with International Standards of TB Care (ISTC). We examined the association between RNTCP training and adherence to ISTC by calculating odds ratios and 95% confidence intervals.</p><p>Results</p><p>Of 3,391 PP practicing allopathic medicine, 249 were interviewed. Of these, 55% had been exposed to RNTCP. For new pulmonary TB patients, 63% (158/249) of provider responses were consistent with ISTC diagnostic practices, and 34% (84/249) of responses were consistent with ISTC treatment practices. However, 48% (120/249) PP also reported use of serological tests for TB diagnosis. In the new TB case vignette, 38% (94/249) PP reported use of at least one second line anti-TB drug in the treatment regimen. RNTCP training was not associated with diagnostic or treatment practices.</p><p>Conclusion</p><p>In Pune, India, despite a decade of training activities by the RNTCP, high proportions of providers resorted to TB serology for diagnosis and second-line anti-TB drug use in new TB patients. Efforts to achieve universal access to quality TB management must account for the low quality of care by PP and the lack of demonstrated effect of current training efforts.</p></div

Association between exposure to Public Private Mix (PPM) and self-reported investigation methods used for diagnosis of new pulmonary TB among private providers – Pune Municipal Corporation, India, 2010.

<p>*Exposed to RNTCP training- Attended training programme.</p><p>**Odds ratio relates to doctors who reported choice of a particular investigation, by history of attendance of CME relative to those who did not attend.</p

Characteristics of private providers participating in the study – Pune Municipal Corporation, India, 2010.

+<p>Allopathy doctor (Bachelor of Medicine and Bachelor of Surgery).</p>++<p>Doctors practicing homeopathy, Ayurveda, Unani.</p>+++<p>Number of years in clinical practice after completion of medical training.</p>†<p>Information not available for two study participants.</p

Characteristics of private providers based on reported exposure to RNTCP training in Pune Municipal Corporation, India, 2010.

<p>*Exposure to RNTCP was defined as participating in a RNTCP training module of at least 4 hours at any time from 1999 through 2010.</p><p>**Revised National TB Control Programme of India.</p>+<p>Allopathy practitioner (Bachelor of Medicine and Bachelor of Surgery).</p>++<p>Doctors practicing homeopathy, Ayurveda, Unani.</p>+++<p>Number of years in clinical practice after completion of medical training.</p>†<p>Information not available for two study participants.</p

Association between exposure of private providers to Public Private Mix (PPM) and self-reported TB clinical treatment and diagnostic practices that are in accordance with international standards-Pune Municipal Corporation, India 2010.

<p>*Exposed to RNTCP training- Attended training programme.</p><p>**International Standards of TB Care.</p>†<p>Odds ratio relates to doctors who adhered to guidelines, by attendance of training relative to those who did not attend.</p

HIV seroprevalence among tuberculosis patients in 15 districts in India, 2006–2007.

a<p>Districts stratified by mean HIV seroprevalence in antenatal clinic (ANC) surveillance sites, 2003–2005. Low <0.5%, Medium = 0.51–1.0%, High >1.0%.</p

Trends in HIV seroprevalence among tuberculosis patients in 4 districts, 2005–6 survey and 2006–7 surveys.

<p>Trends in HIV seroprevalence among tuberculosis patients in 4 districts, 2005–6 survey and 2006–7 surveys.</p

Survey enrollment and inclusion, with reasons for non-eligibility and non-enrollment into survey.

<p>Survey enrollment and inclusion, with reasons for non-eligibility and non-enrollment into survey.</p

Districts selected for the survey.

<p>District selection stratified by mean HIV seroprevalence in antenatal clinic (ANC) surveillance sites, 2003–2005. Districts shaded blue had mean 2003–2005 ANC HIV seroprevalence 0–0.5%, yellow districts had ANC HIV seroprevalence 0.51–1.0%, and red districts had ANC HIV seroprevalence >1.0%. The districts of Davangere, Guntur, Nasik, and Tiruvanamalai were selected in the previous years' survey, and were purposively selected again for trend analysis.</p

Association between demographic variables and type of TB with the history of previous source of treatment, India.

<p>Association between demographic variables and type of TB with the history of previous source of treatment, India.</p