OBJECTIVES: To study the factors associated with quality of sexually transmitted infection (STI) care among private general practitioners in Gauteng. METHODS: We analysed 1 194 records of patients attending 26 randomly selected GP practices in the first 3 months of 2000 and 2002, for 3 STI syndromes, namely urethral discharge, pelvic inflammatory disease and genital ulcers. We assessed adherence to nationally accepted STI treatment guidelines and analysed the influence of patient and practice-level variables on effectiveness of STI drug regimens and trends over time. RESULTS: After controlling for syndrome mix, district and time period, appropriate drug treatment for STIs was significantly associated with the client having medical aid (p < 0.001), recent graduation as a medical practitioner (p < 0.001) and male GP gender (p = 0.007). Between 2000 and 2002, STI care improved for clients with medical aids but for not cash clients. CONCLUSIONS: There was variation in the quality of prescribing for STIs among GPs and positive trends in this prescribing. There is a need for interventions that address the financial incentives that may hamper quality of STI care for cash clients

Blaauw, D

Brugha, R

Chabikuli, N

Funani, I

Schneider, H

English

Objectives: To study the factors associated with quality of sexually transmitted infection (STI) care among private general practitioners in Gauteng.Methods: We analysed 1 194 records of patients attending 26 randomly selected GP practices in the first 3 months of 2000 and 2002, for 3 STI syndromes, namely urethral discharge, pelvic inflammatory disease and genital ulcers. We assessed adherence to nationally accepted STI treatment guidelines and analysed the influence of patient and practice-level variables on effectiveness of STI drug regimens and trends over time.Results: After controlling for syndrome mix, district and time period, appropriate drug treatment for STIs was significantly associated with the client having medical aid (

AJOL - African Journals Online

October 2005, Vol. 95, No. 10  SAMJORIGINAL ARTICLES782It is estimated that half or more of sexually transmittedinfection (STI) care episodes in the South African formal healthsector are treated by private general practitioners (GPs).1 Poor-quality STI care has been well documented in this setting andhas been the subject of some debate and policy responses.1-4 Inthe Department of Health’s HIV/AIDS and STD Strategic Planfor 2000 - 2005,5 the first objective for STI control is ensuringeffective syndromic management in the private sector.However, intervening in the private GP sector to improvemanagement of diseases of public health importance iscomplex. Particularly in poor areas, GPs are often solopractitioners operating in a highly autonomous manner, eventhough they may be networked with other GPs in localpractitioner associations. Moreover, the sector is facing manypressures resulting from changes in the regulatoryenvironment (around dispensing, drug prices and certificatesof need), an over-saturated market and declining profitmargins. These challenges are not unique to South Africa6 andcall for a far greater understanding of private providers andthe influences on their practice. We report on a study of private practices using recordreviews to measure quality of care for patients with STIs. Inparticular, the sample sizes achieved with such an approachmade an analysis of prediction of quality possible.  In the hard-to-reach private sector, valid and reliable measures of STItreatment quality, let alone predictors of this quality, aredifficult to achieve. Self-reported practice will overestimatequality, and observations of provider-client interactions anduse of simulated or ‘mystery’ clients are costly if adequatesample sizes are to be obtained to conduct stratified analyses.7,8The latter two techniques may also be difficult to negotiatewith independent providers. MethodsAs part of a project to improve the quality of STI care amongprivate GPs, we studied the records of GPs based in threedistricts (referred to as D1, D2 and D3) in Gauteng. The 64 GPsin D1 (N = 26) and D2 (N = 38) were the subject of amultifaceted intervention centred on a continuing medicaleducation (CME) seminar series, while the GPs in D3 (N = 34)formed a reference group. All three groups were organised intolocal independent practitioner associations (IPAs) and all GPsdispensed drugs from their practices. At the end of the intervention period we obtained consentfrom 26 of 45 randomly selected GP practices (15 in eachdistrict) to examine retrospectively records of patientsattending their practices for two 3-month periods, viz. January - March 2000 and 2002. Using practice registers andwith the assistance of practice receptionists we identified 1 194records of patient visits fitting 3 STI syndromes – urethraldischarge (UD) in men, pelvic inflammatory disease (PID) inwomen, and genital ulcers (GU) in both men and women.Given the complexity of interpreting prescribing, we did notextract data on women with vaginal discharge. Each GPcontributed a mean of 46 records (median 50, range 8 - 98).Two of the 26 GPs were women.While ensuring patient anonymity and confidentiality, datawere extracted on syndrome, drugs prescribed and medical aidstatus of the clients. Drug combinations were categorised intoSexually transmitted infections – factors associated withquality of care among private general practitioners H Schneider, N Chabikuli, D Blaauw, I Funani, R BrughaObjectives. To study the factors associated with quality ofsexually transmitted infection (STI) care among private generalpractitioners in Gauteng.Methods. We analysed 1 194 records of patients attending 26randomly selected GP practices in the first 3 months of 2000and 2002, for 3 STI syndromes, namely urethral discharge,pelvic inflammatory disease and genital ulcers. We assessedadherence to nationally accepted STI treatment guidelines andanalysed the influence of patient and practice-level variableson effectiveness of STI drug regimens and trends over time.Results. After controlling for syndrome mix, district and timeperiod, appropriate drug treatment for STIs was significantlyassociated with the client having medical aid (p < 0.001), recentgraduation as a medical practitioner (p < 0.001) and male GPgender (p = 0.007). Between 2000 and 2002, STI care improvedfor clients with medical aids but for not cash clients.Conclusions. There was variation in the quality of prescribingfor STIs among GPs and positive trends in this prescribing.There is a need for interventions that address the financialincentives that may hamper quality of STI care for cash clients. S Afr Med J 2005; 95: 782-785.Centre for Health Policy, University of the Witwatersrand, Johannesburg H Schneider, MB ChB, MMedN Chabikuli, MB ChB, MFamMed, MscD Blaauw, MB BCh, FCPHM, MMI Funani, MB ChBLondon School of Hygiene and Tropical Medicine, UKR Brugha, MB BCh, MSc, FFPHMI, MDCorresponding author: H Schneider (helen.schneider@nhls.ac.za)Pg 782-788 TIB  10/4/05  10:56 AM  Page 782ORIGINAL ARTICLES783October 2005, Vol. 95, No. 10  SAMJeffective and ineffective (the latter including partially effectiveregimens), utilising national guidelines developed by the STIReference Centre, National Health Laboratory Service. We alsorecorded practice-level variables, namely gender and year ofqualification of the GP and whether s/he had worked as asessional doctor in the public sector (where GPs would havebeen exposed to syndromic management of STIs). We pooled all the 1 194 records and entered patient andpractice-level variables into a forward step-wise logisticalregression model in order to assess factors associated witheffective STI prescriptions. Also entered into the model wereSTI diagnosis (UD, PID or GU) to control for syndrome mix,and GP district and time period (2000 or 2002) to control forarea and secular effects associated with the intervention. Thebefore and after analyses assessing the effectiveness of theintervention are reported elsewhere,9 although trends over time(between 2000 and 2002) for 2 syndromes (UD, PID) byexplanatory factor are provided. A chi-squared test wasperformed on changes by sub-factor (e.g. medical aid status)over the time period. Analysis was performed using theStatistical Package for Social Sciences (SPSS). The project wasapproved by the University of the Witwatersrand’s Committeefor Research on Human Subjects (Medical).ResultsThe results of the logistical regression analysis are presented inTable I. Records were more or less evenly distributed betweentime periods and across districts. PID diagnoses constitutednearly two-thirds of records and GU only 7.5%. More than halfthe STI clients (53.4%) were cash paying. STI care was less thanoptimal – depending on the syndrome, one-third or less ofdrug combinations was judged effective. Characteristics significantly associated with effective drugtreatment (having controlled for syndrome, time period andarea) were as follows: (i) recent qualification – GPs whoqualified in the era of modern syndromic management (after1993) were 3.5 times more likely to prescribe the correcttreatment than those who qualified before 1993 (p < 0.001); (ii)client medical aid – STI clients with a medical aid were 2.64times more likely to receive effective treatment than cashclients (p < 0.001); and (iii) male gender of GP – although on bi-variate analysis women GPs had slightly higher rates ofeffective treatment, when controlling for other factors, maleGPs had double the odds of providing effective treatment (p = 0.007). Exposure to sessional work in the public sector did notpredict quality of prescribing.Table I. Associations with effective drug combinations for STI syndrome and adjusted odds ratio after multivariate analysis (N = 1 194) N (% % effective Adjusted 95% CI of total sample) drug treatment odds ratio* adjusted odds ratio p-valueInsurance (medical aid) status (datamissing on 6 cases, N = 1 188)Uninsured 634 (53.4) 16.6 2.64 1.95 - 3.58 < 0.001Insured 554 (46.6) 31.4GP genderFemale 149 (12.5) 26.1 2.13 1.23 - 3.68 0.007Male 1 045 (87.5) 23.1GP year of qualificationBefore 1993 854 (71.5) 18.1 3.47 2.39 - 5.01 < 0.001After 1993 340 (28.5) 36.8Public-sector sessionsNo 791 (66.2) 27.0 0.72 0.51 - 1.02 0.063Yes 403 (33.8) 21.6STI diagnosisPID 787 (65.9) 22.5 1.00 - -Urethral discharge 318 (26.6) 34.6 2.53 1.84 - 3.47 < 0.001Genital ulcer 89 (7.5) 19.1 1.54 0.88 - 2.72 0.134AreaDistrict 3 303 (25.4) 20.5 1.00 - -District 1 419 (35.1) 24.1 1.70 1.14 - 2.53 0.009District 2 472 (39.5) 24.8 1.78 1.16 - 2.74 0.009Period2000 598 (50.1) 20.7 1.57 1.18 - 2.10 0.0022002 596 (49.9) 26.2*Reference category first.CI = confidence interval; PID = pelvic inflammatory disease.Pg 782-788 TIB  10/4/05  10:57 AM  Page 783October 2005, Vol. 95, No. 10  SAMJORIGINAL ARTICLES784There was an overall increase of effective scripts (from 20.7%to 26.2%) between 2000 and 2002. When controlling for otherfactors, GPs were 1.57 times more likely to prescribeappropriate antibiotics for STIs in 2002 than in 2000. Of thefactors identified above, medical aid status emerged as themost consistent predictor of treatment change in UD and PID,the 2 syndromes where sample sizes allowed for analyses overtime (Table II). There was statistically significant improvementin quality of prescribing for medical aid clients with UD (p < 0.001) and PID (p = 0.019) between 2000 and 2002, whereasthe quality of care for cash clients remained static.   AmongGPs, recent graduates showed higher baseline levels ofappropriate treatment than older graduates. They were alsomore likely to change their treatment regimen for UD (p =0.003) than older GPs (p = 0.039).DiscussionThere is variation in the quality of prescribing within theprivate sector. Of the 4 factors measured, 3 emerged assignificantly associated with prescribing, namely year ofqualification and gender of the GP, and medical aid status ofthe patient.The generational differences in quality suggest thatundergraduate education effectively sets the patterns for futurepractice. Alternatively, younger GPs may have less fixedrepertoires of prescribing, making them more receptive to newknowledge received through CME than older GPs. Gender variation may reflect difficulties for women GPs inbalancing domestic roles with the need to update professionalknowledge. However, possible clustering effects from the small number of women GPs in the study may limit the ability todraw firm conclusion on gender differences in quality. Client insurance status influenced quality of care,independent of GP knowledge. There was selectiveimplementation of new knowledge in favour of medical aidclients. For insured clients, the costs of drugs are recoupedfrom third-party payers, whereas cash clients pay an all-inclusive fee that includes both the consultation and drugs. Inmanaging the latter, there is a financial incentive for GPs tominimise costs by prescribing cheaper and less effective drugs. While methods to ensure greater access to updatedknowledge in the private sector is of key importance, it is ourview that without clear financial incentives the state haslimited leverage in ensuring quality private-sector treatment ofdiseases of public health importance. Targeted subsidies (suchas provision of STI drugs for cash clients) to GPs in carefullydesigned contracts may be one way not only to improve thequality of STI care but to involve GPs more actively in thedistrict health system.Finally, patient record systems were sufficiently developed inGP practices to conduct record reviews; with the necessarytrust this may prove to be a viable form of routine qualitymonitoring in the private health sector in South Africa.However, doing this is premised on building trusting and co-operative relationships between public and private sectors, asituation that does not always obtain in South Africa.This project was funded by a grant from the Wellcome Trust (Refno. 058607/Z/99/Z). We gratefully acknowledge the GPs and thelocal health facilities and communities who participated in thestudy.Table II. Trends in quality of STI care for UD and PID between 2000 and 2002 by predictive factor (N = 1 105)2000 2002Effective Ineffective Effective Ineffective p-valueFactor Rx (%) Rx (%) Total Rx (%) Rx (%) Total (x2 test)Urethral dischargeMedical aid 19 (28.4) 48 (71.6) 67 40 (58.0) 29 (42.0) 69 <0.001Cash 27 (25.2) 80 (74.8) 107 23 (31.1) 51 (68.9) 74 0.243Male GP 39 (25.2) 116 (74.8) 155 52 (40.0) 78 (60.0) 130 0.005Female GP 8 (40.0) 12 (60.0) 20 11 (84.6) 2 (15.4) 13 0.013Qualified before 1993 24 (19.0) 102 (81.0) 126 30 (30.0) 70 (70.0) 100 0.039Qualified after 1993 23 (46.9) 26 (53.1) 49 33 (76.7) 10 (23.3) 43 0.003Pelvic inflammatory diseaseMedical aid 48 (22.6) 164 (77.4) 212 57 (32.6) 118 (67.4) 175 0.019Cash client 16 (10.0) 144 (90.0) 160 29 (12.3) 207 (87.7) 236 0.296Male GP 52 (16.5) 263 (83.5) 315 78 (21.9) 278 (78.1) 356 0.047Female GP 12 (20.0) 48 (80.0) 60 8 (14.3) 48 (85.7) 56 0.286Qualified before 1993 28 (11.0) 226 (89.0) 254 54 (17.6) 252 (82.4) 306 0.018Qualified after 1993 36 (29.8) 85 (70.2) 121 32 (30.2) 74 (69.8) 106 0.529Pg 782-788 TIB  10/4/05  10:57 AM  Page 784ORIGINAL ARTICLES785October 2005, Vol. 95, No. 10  SAMJReferences 1. Schneider H, Blaauw D, Dartnall E, et al. STD care in the South African private health sector.S Afr Med J 2001; 91: 151-156.2. Connolly AM, Wilkinson D, Harrison A, Lurie M, Abdool Karim SS. Inadequate treatment forsexually transmitted diseases in the South African private health sector. Int J STD AIDS 1999;10: 324-327.3. Chabikuli N, Schneider H, Blaauw D, et al. Equity in the provision of private primary care:the case of sexually transmitted diseases in South Africa. Health Policy Plan 2002; 17: suppl 1,40-46.4. Wilkinson D, Abdool Karim SS, Lurie M, Harrison A. Public-private health sectorpartnerships for STD control in South Africa – perspectives from the Hlabisa experience. S Afr Med J 2001; 91: 17-20.5. Department of Health. HIV/AIDS and STD Strategic Plan for South Africa: 2000 - 2005. Pretoria:DOH, 2000.6. Brugha R, Zwi A. Sexually transmitted disease control in developing countries: the challengeof involving the private sector. Sex Transm Infect 1999; 75: 283-285.7. Madden JM, Quick JD, Ross-Degnan D, Kafle KK.  Undercover careseekers: Simulated clientsin the study of health provider behaviour in developing countries.  Soc Sci Med 1997; 45:1465-1482.8. Franco LM, Daly CC, Chilongozi D, Dallabetta G. Quality of case management of sexuallytransmitted diseases: comparison of the methods of assessing the performance of providers.Bull World Health Organ 1997; 75: 523-532.9. Schneider H, Chabikuli N, Blaauw D, Funani I, Brugha R. Improving the quality of STI careby private general practitioners: A South African case study. Sex Transm Infect (in press).Accepted 10 June 2005.A view of paediatric outcomes researchAlan D Rothberg Costs of health care in the 21st century are on the increase.Whether delivering previously unavailable primary care todeveloping communities, treatment for resurgent malaria andtuberculosis in Africa, antiretrovirals for rampant HIV in theThird World, or newly developed technology and drugs totreat diseases of lifestyle and degeneration in affluent societies,health funding systems are having to decide on what isaffordable.  To make the necessary decisions one requireshealth economic data in the form of cost-effectiveness and/orcost-utility analyses.1 The former provide information on thecosts of achieving a clinical endpoint such as blood pressurereduction, whereas the latter typically inform on the costs perquality-adjusted life-year (QALY) gained.By using QALYs one is able to assess clinical, economic andhumanistic outcomes, and convert the results into a value thatcan be compared with other treatments for the same clinicalsituation, or even with other conditions altogether (Figs 1 and 2).  One can, for example, look at the QALYs gained as aresult of neonatal intensive care for 1 000 g babies and comparethese with QALYs gained through placement of drug-elutingstents for the treatment of coronary artery disease, potentiallyenabling decision makers to rank one above the other when itcomes to prioritisation of health care expenditure.  This allsounds relatively simple and straightforward; however beforewe can ask whether we can afford what we are doing it isimperative that we know what we are actually achieving invarious clinical situations.There is usually a far greater demand for health economicinformation around complex, chronic and potentially costlyproblems than is the case for simple, short-term, inexpensiveinterventions, and one should therefore note that there aresome very real issues in paediatrics.  For example, and asshown in Figs 1 and 2, real costs in paediatrics extend waybeyond the patient.  Parents are involved to a greater or lesserextent, and depending on the chronicity and severity of thechild’s problem, employers may be affected through lost timeand productivity.  There may also be costs to society forinstitutional care and/or lost productivity on the part of theIntervention Use of healthcare resourcesChange in health status Change in productivityQuality of life Patient satisfactionClinical outcomesEconomic outcomesFig. 1. Measuring value in health care.Direct costsMedical Non-medicalHospitalisationDoctors etc. Drugs Pathology testsSupplies DiagnosticsTransportationAccomodationFamily careIndirect costs*UnemploymentLost productivityPremature deathPain Suffering Inconvenience*Apply to patient and parentsIntangible costs*Fig. 2. Economic parameters in cost utility analyses.School of Therapeutic Sciences, University of the Witwatersrand, JohannesburgAlan D Rothberg, MB BCh, FCPaed, PhDCorresponding author: Alan D Rothberg (rothbergd@therapy.wits.ac.za)Pg 782-788 TIB  10/4/05  10:57 AM  Page 785

Sexually transmitted infections - factors associated with quality of care among private general practitioners

LSHTM Research Online

A comparison of frameworks, theories, and models of policy processes. In: Sabatier PA (ed). Theories of the policy process.

Activists beyond borders.

Agendas and instability in American politics. Chicago and London:

Agendas, alternatives and public policies.

Analyzing the decentralization of health systems in developing countries: decision space, innovation and performance.

Case studies and the limits of the quantitative worldview. In:

Case studies and theory development in the social sciences.

Case study research: design and methods. 2nd ed. Thousand Oaks,

Cesarean birth trends in Chile 1986–1994.

Comparing policy networks.

Consumption matters.

Deliberative policy analysis. Cambridge:

Dilemmas in drug development for tropical diseases. Experiences with praziquantel.

Disobedient distributors: street-level bureaucrats and would-be patrons in community-based family planning programs in rural Kenya.

Emerging criteria for quality in qualitative and interpretive research.

Evidence-based policy and practice: riding for a fall?

Factors influencing implementation of the Community Health Fund in Tanzania. Health Policy and Planning

Facts and myths about research on public policy implementation: out-of-fashion, allegedly dead, but still very much alive and relevant.

Family planning policies and programmes in eight low-income countries: a comparative policy analysis.

Feminism, praxis and human geography.

GAVI, the first steps: lessons for the Global Fund.

Generating political priority for maternal mortality reduction in 5 developing countries.

Getting health reform right. A Guide to improving performance and equity.

Global Fund Tracking Study: a cross-country comparative analysis.

Health policy in a globalizing world. Cambridge:

Health sector development: from aid coordination to resource management.

Health systems and the implementation of disease programmes: case studies from South Africa.

How to do a stakeholder analysis.

Illuminating unintended consequences: a case study using retrospective policy analysis linking the macro, meso, and micro. Paper presented to a Workshop on Health Policy Analysis,

Implementation structures: a new unit of administrative analysis.

Implementing public policy: governance in theory and practice.

Institutional rational choice: an assessment of the institutional analysis and development framework. In: Sabatier PA (ed.) Theories of the policy process. 2nd edition.

Introduction: epistemic communities and international policy coordination.

Making health policy. Milton Keynes, UK:

Paper presented to a Workshop on Health Policy Analysis,

Policy analysis for the real world.

Policy Processes underlying Health and Equity Initiatives in a rapidly globalizing context – a case study from

Policy to tackle the social determinants of health: using conceptual frameworks to understand the policy process.

Power and positionality: negotiating insider/outsider status within and across cultures.

Public choice and policy change.

Public policy.

Qualitative research in health care: analysing qualitative data.

Reforming the health sector in developing countries: the central role of policy analysis.

Rethinking social inquiry: diverse tools, shared standards.

Situating knowledges: positionality, reflexivity and other tactics.

Social construction and policy design.

Street-level bureaucracy: dilemmas of the individual in public services.

The case study anthology. Thousand Oaks, CA: Sage Publications.

The decision process. College Park, MD:

The development of policy network analyses.

The emergence of global disease control priorities.

The foundations of policy analysis.

The Global Fund: managing great expectations.

The politics of ‘branding’ in policy transfer: the case of DOTS for tuberculosis control.

The politics of agenda setting in international health: child health versus adult health in developing countries.

The politics of AIDS in South Africa: beyond the controversies (Education and Debate).

The promotion of private health insurance and the implications for the social organisation of healthcare: a case study of private sector obstetric practice in Chile.

The terrain of health policy analysis in low and middle income countries: a review of the literature 1994–2005. Paper presented to a Workshop on Health Policy Analysis,

The Ugandan success story? Evidence and claims of HIV-1 Prevention.

Theories of the policy process.

Top down policy making.

What is a case? Exploring the foundations of social enquiry. New York:

Sexually transmitted infections -- factors associated with quality of care among private general practitioners.

http://researchonline.lshtm.ac.uk/7369/1/czn024.pdf

Sexually transmitted infections -- factors associated with quality of care among private general practitioners.

Abstract

Similar works

Full text

Available Versions

AJOL - African Journals Online

LSHTM Research Online