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Do private providers give patients what they demand, even if it is inappropriate? A randomised study using
Ada Kwan1,2, Claire E Boone2, Giorgia Sulis3
1Department of Medicine, University of California San Francisco, San Francisco, California, USA ada.kwan@ucsf.edu.
Insights
When patients demand inappropriate medicines like albendazole for childhood diarrhea, private clinics are more likely to dispense them, potentially impacting quality of care and antimicrobial resistance. This study highlights the need for further research into provider decision-making.
Area of Science:
- Global Health
- Health Services Research
- Infectious Disease Epidemiology
Background:
- Childhood illness care quality is often low in low- and middle-income countries.
- Patient demands for medicines can lead to inappropriate use and antimicrobial resistance.
- This study investigates the impact of patient demands for specific inappropriate medicines on healthcare quality.
Purpose of the Study:
- To examine how demanding specific inappropriate medicines affects the quality of care provided by private primary care clinics.
- To assess the influence of patient requests for amoxicillin versus albendazole on prescribing practices for childhood diarrhea.
Main Methods:
- An experiment using 200 unannounced standardized patients (SPs) in private clinics in Kenya.
- SPs simulated caretakers of a child with watery diarrhea, randomly demanding either amoxicillin or albendazole.
- Logistic and linear regression models analyzed the effects on case management outcomes.
Main Results:
- Demanding albendazole significantly increased its dispensing rate from 3% to 34%.
- Demanding amoxicillin did not significantly alter its dispensing rate compared to no demand.
- Neither demand significantly improved correct management outcomes like appropriate treatment or referral.
Conclusions:
- Private providers' prescribing decisions may balance business incentives with patient health.
- Further research is needed on provider knowledge and perceptions regarding profit versus health trade-offs.
- Understanding patient demand's role is crucial for improving quality of care and combating antimicrobial resistance.
Introduction:
Low and varied quality of care has been demonstrated for childhood illnesses in low-income and middle-income countries. Some quality improvement strategies focus on increasing patient engagement; however, evidence suggests that patients demanding medicines can favour the selection of resistant microbial strains in the individual and the community if drugs are inappropriately used. This study examines the effects on quality of care when patients demand different types of inappropriate medicines.
Methods:
We conducted an experiment where unannounced standardised patients (SPs), locally recruited individuals trained to simulate a standardised case, present at private clinics. Between 8 March and 28 May 2019, 10 SPs portraying caretakers of a watery diarrhoea childhood case scenario (in absentia) conducted N=200 visits at 200 private, primary care clinics in Kenya. Half of the clinics were randomly assigned to receive an SP demanding amoxicillin (an antibiotic); the other half, an SP demanding albendazole (an antiparasitic drug often used for deworming), with other presenting characteristics the same. We used logistic and linear regression models to assess the effects of demanding these inappropriate medicines on correct and unnecessary case management outcomes.
Results:
Compared with 3% among those who did not demand albendazole, the dispensing rate increased significantly to 34% for those who did (adjusted OR 0.06, 95% CI 0.02 to 0.22, p<0.0001). Providers did not give different levels of amoxicillin between those demanding it and those not demanding it (adjusted OR 1.73, 95% CI 0.51 to 5.82). Neither significantly changed any correct management outcomes, such as treatment or referral elsewhere.
Conclusion:
Private providers appear to account for both business-driven benefits and individual health impacts when making prescribing decisions. Additional research is needed on provider knowledge and perceptions of profit and individual and community health trade-offs when making prescription decisions after patients demand different types of inappropriate medicines.
Trial Registration Numbers:
American Economic Association Registry (#AEARCTR-0000217) and Pan African Clinical Trial Registry (#PACTR201502000770329).
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