Irrational Use of Medicine in the Treatment of Presumptive Asthma Among Rural Primary Care Providers in Southwestern China

Abstract

Poor knowledge, scarce resources, and lack of or misaligned incentives have been widely documented as drivers of the irrational use of medicine (IUM), which significantly challenges the efficiency of health systems across the globe. However, there is limited understanding of the influence of each factor on IUM. We used detailed data on provider treatment of presumptive asthma cases in rural China to assess the contributions of provider knowledge, resource constraints, and provider behavior on IUM. This study enrolled 370 village providers from southwest China. All providers responded to a clinical vignette to test their knowledge of how to treat presumptive asthma. Resource constraints ("capacity") were defined as the availability of the prescribed medicines in vignette. To measure provider behavior ("performance"), a subset of providers (104 of 370) were randomly selected to receive unannounced visits by standardized patients (SPs) who performed of presumptive asthma symptoms described in the vignette. We found that, 54% (201/370) of providers provided the vignette-based patients with prescriptions. Moreover, 67% (70/104) provided prescriptions for the SPs. For the vignette, only 10% of the providers prescribed the correct medicines; 38% prescribed only unnecessary medicines (and did not provide correct medicine); 65% prescribed antibiotics (although antibiotics were not required); and 55% prescribed polypharmacy prescriptions (that is, they prescribed five or more different types of drugs). For the SP visits, the numbers were 12%, 51%, 63%, and 0%, respectively. The lower number of medicines in the SP visits was due, in part, to the injections' not being allowed based on ethical considerations (in response to the vignette, however, 65% of providers prescribed injections). The difference between provider knowledge and capacity is insignificant, while a significant large gap exists between provider performance and knowledge/capacity (for 11 of 17 indicators). Our analysis indicated that capacity constraints play a minor role in driving IUM compared to provider performance in the treatment of asthma cases in rural China. If similar findings hold for other disease cases, this suggests that policies to reduce the IUM in rural China have largely been unsuccessful, and alternatives for improving aligning provider incentives with appropriate drug use should be explored.

Keywords: asthma; clinical vignette; irrational use of medicine; primary care providers; standardized patients.

FIGURE 1

Strobe flowchart.

FIGURE 2

Prescriptions in the Treatment of Presumptive Asthma. k, c, and d represent know, can, and do, respectively. The know gap is not measured because no well-recognized target performance is available. The distance between k and c is the know-can gap, and the distance between c and d is the can-do gap. We use t-tests to examine whether the gaps are statistically significant and report the significance of the know-can gap and the can-do gap in parentheses. †p > 0.05, *p < 0.05, **p < 0.01, ***p < 0.001. We did not consider Chinese patent medicines in measuring the outcomes. Injection included intravenous drip and intramuscular injection.

FIGURE 3

Irrational Use of Medicine in the Treatment of Presumptive Asthma. k, c, and d represent know, can, and do, respectively. The distance between 0 and d and the distance between 0 and k is the total gap and the know gap, respectively, except that the total gap and know gap of only correct medicines prescribed is the distance between 100% and d or k. The distance between k and c is the know-can gap, and the distance between c and d is the can-do gap. We use t-tests to examine whether the gaps are statistically significant and report the significance of total gap, know gap, know-can gap, and can-do gap in parentheses. †p > 0.05, *p < 0.05, **p < 0.01, ***p < 0.001. We did not consider Chinese patent medicines in measuring the outcomes. Injection included intravenous drip and intramuscular injection.