'Mystery clients' reveal weaknesses of tuberculosis care in rural China

Many health care providers in China—especially those at village clinics and township health centers—fail to correctly manage tuberculosis (TB) cases, according to a study involving standardized patients published this week in PLOS Medicine by Sean Sylvia of the University of North Carolina at Chapel Hill, USA, Chengchao Zhou of Shangdong University, China, and colleagues at the World Bank, McGill University, Stanford University and other institutions in China.

Despite recent reductions in prevalence, China still faces a significant TB burden, especially in poor rural areas of the country. In the new study, researchers sent unannounced standardized patients (SPs) presenting with classic pulmonary TB symptoms to providers in 46 village clinics, 207 township health centers and 21 county hospitals. In all, 247 interactions with providers were assessed against international and national standards of TB care.

Overall, 41% (111 of 274 SPs) were correctly managed, with a referral, chest X-ray or sputum test ordered based on the symptoms. Antibiotics unrelated to the treatment of TB were prescribed in 168 interactions (61.3%; 95% confidence interval [CI] 55-67%). Correct management proportions were higher at county hospitals compared to township health centers (odds ratio [OR] 0.06, CI 0.01-0.25, p<0.001) and compared to village clinics (OR 0.02, CI 0.0-0.17, p<0.001). When the researchers tested the same physicians on their knowledge about TB, they were aware of correct management 45% more often than they had carried out these correct practices.

"Given significant deficits in quality of care, reforms encouraging first contact with village providers in rural areas would undermine further progress against tuberculosis in China unless substantial efforts are also made to improve the management of patients with suspected TB in village clinics and township health centers," the authors say.

The current study builds on earlier work by Jishnu Das and Madhukar Pai, co-authors on the current study, which found similar deficits among providers in India.

In an accompanying Perspective, Carlton Evans of Imperial College London and colleagues discuss the need to close the "know-do gap," the disconnect between provider's knowledge of TB recommendations and what they actually do in the clinic. The new research, they point out, highlights the fact that new TB interventions aren't the only challenge to addressing the disease. "To be effective, better tests, pills and TB policies should be integrated with interventions addressing the factors limiting access to TB care and urgently require a greater emphasis on assessing and improving TB care as an integrated component of the basic universal healthcare that people receive in the real world," they write.