Quality of tuberculosis care in India: a systematic review

Abstract

Background: While Indian studies have assessed care providers' knowledge and practices, there is no systematic review on the quality of tuberculosis (TB) care.

Methods: We searched multiple sources to identify studies (2000-2014) on providers' knowledge and practices. We used the International Standards for TB Care to benchmark quality of care.

Results: Of the 47 studies included, 35 were questionnaire surveys and 12 used chart abstraction. None assessed actual practice using standardised patients. Heterogeneity in the findings precluded meta-analysis. Of 22 studies evaluating provider knowledge about using sputum smears for diagnosis, 10 found that less than half of providers had correct knowledge; 3 of 4 studies assessing self-reported practices by providers found that less than a quarter reported ordering smears for patients with chest symptoms. In 11 of 14 studies that assessed treatment, less than one third of providers knew the standard regimen for drug-susceptible TB. Adherence to standards in practice was generally lower than correct knowledge of those standards. Eleven studies with both public and private providers found higher levels of appropriate knowledge/practice in the public sector.

Conclusions: Available evidence suggests suboptimal quality of TB care, particularly in the private sector. Improvement of quality of care should be a priority for India.

Figure A.1

Forest plot of studies on ISTC Standard 1 in India (awareness/suspicion of TB in persons with cough of 2–3 weeks), ISTC Standard 5 (awareness/use of a combination of chest X-ray and sputum examination for diagnosis of sputum-negative pulmonary TB) and ISTC Standard 10 (awareness/use of sputum microscopy to monitor response to treatment). ES = effect size (proportion meeting standard); CI = confidence interval; ISTC = International Standards of TB care (2^nd ed); TB = tuberculosis.

Figure A.2

Forest plot of studies in India on ISTC Standard 13 (maintenance of a written record of TB patients initiated on treatment) and ISTC Standard 18 (screening household contacts for TB). ES = effect size (proportion meeting standard); CI = confidence interval; ISTC = International Standards of TB care (2^nd ed); TB = tuberculosis.

Figure A.3

Comparison of public vs. private health care providers’ awareness/practice on ISTC Standards 1, 10 and 13 in India. ES = effect size (proportion meeting standard); CI = confidence interval; ISTC = International Standards of TB care (2^nd ed); TB = tuberculosis.

Figure 1

Flow diagram indicating the process of selecting the studies for a systematic review on tuberculosis management in India. ISTC = International Standards of Tuberculosis Care.

Figure 2

Forest plot of studies on ISTC Standard 2 (awareness/use of sputum smear for persons with presumptive pulmonary TB). ES = effect size (proportion meeting standard); CI = confidence interval; ISTC = International Standards of Tuberculosis Care; TB = tuberculosis.

Figure 3

Forest plot of studies in India on ISTC Standard 8 (awareness/use of the correct treatment regimen for a new case of TB). ES = effect size (proportion meeting standard); CI = confidence interval; ISTC = International Standards of Tuberculosis Care; TB = tuberculosis.

Figure 4

Forest plot of studies in India on ISTC Standard 9 (awareness/use of a supervised approach, including DOT, for the treatment of TB). ES = effect size (proportion meeting standard); CI = confidence interval; ISTC = International Standards of Tuberculosis Care; DOT = directly observed therapy; TB = tuberculosis.

Figure 5

Comparison of public vs. private health care providers’ awareness/practice with ISTC Standards 2 (awareness/use of sputum smear for persons with presumptive pulmonary TB), 8 (awareness/use of the correct treatment regimen for a new case of TB) and 9 (awareness/use of a supervised approach, including DOT, for the treatment of TB) in India. ES = effect size (proportion meeting standard); CI = confidence interval; ISTC = International Standards of Tuberculosis Care.