A mixed method study to assess notification of tuberculosis patients by private practitioners in New Delhi, India.

Background: A staggering one million tuberculosis (TB) cases are missing from notification, most of them being diagnosed and treated in the private sector. To curb this issue, the Government of India declared TB as a notifiable disease and NIKSHAY was launched in 2012. However, even after years of implementation, as per the report published by TB India 2020, the proportion of private case notification of total TB cases is very low. Objectives: The objectives of the study were to assess the current practices related to TB Notification being followed by private practitioners of Delhi and to explore the enablers and barriers to TB notification among private-sector treatment providers. Methods: This cross-sectional study was done from January 2019 to January 2020. Six hundred doctors were line listed under the chosen TB unit, 375 gave consent and in depth interview was conducted among them. Data were collected on the reporting status and facilitators and barrier toward NIKSHAY reporting were assessed. For the qualitative component, focused group discussions were done. Results: Out of 375 private practitioners, over two-third (68%) practitioners reported that they were not treating TB patients. Out of 108 doctors treating patients only 50% were reporting the cases. Major reason cited for not reporting was "don't know how to" and major barrier considered was "lack of training." Conclusion: Strategies such as training and retraining, and one-to-one sensitization of private practitioners to address barriers may enhance TB notification.

Tuberculosis case notification by registered private medical practitioners in Kolkata: A mixed-methods study.

Background: Under-notification of tuberculosis (TB) cases remains a persistent problem that impedes accurate estimation of the disease burden. India's private health sector contributes to only one-fourth of the total TB notifications. Objectives: The present study was conducted among registered private practitioners in Kolkata to assess their knowledge, attitude and practice on TB notification, to find the socio-demographic and work-related factors associated with it, to identify the barriers faced by them in notifying TB cases and to elicit suggested solutions in overcoming these barriers. Materials and Methods: It was an observational study, cross-sectional in design following explanatory sequential mixed-methods approach conducted among 426 private practitioners in Kolkata Municipal Corporation area over 2 years (July 2019-October 2021). Quantitative data were analyzed using SPSS 25.0 with suitable descriptive and inferential statistics. Qualitative data were analyzed using Atlas.ti 7.1 and data were represented in the form of themes, codes, and verbatims. Results: Out of 426, 295 (69.2%) of the study population had adequate knowledge, 385 (90.4%) had positive attitude and only 115 (27.0%) had satisfactory practice. Lack of awareness, inadequate communication, and breaching patient confidentiality were the main barriers identified. Suggested solutions to improve engagement of private sector were organizing more continuing medical educations, active case finding, and acknowledgement to private practitioners on notification. Conclusion: Private practitioners had adequate knowledge on TB notification, their attitude was very positive but practice was poor. Training and sensitization of private practitioners on notification are recommended with feedback from both ends.

Magnitude of unreported kala-azar cases in a highly endemic district of Bihar, India: A positive impact of Indian elimination programme.

BACKGROUND & OBJECTIVES: In India, kala-azar surveillance is weak and no public-private partnership exists for disease containment. Estimate of disease burden is not reliably available and still cases are going to private providers for the treatment. The present study aimed to assess the magnitude of kala-azar cases actually detected and managed at private set-up and unreported to existing health management information system. METHODS: Institution based cross-sectional prospective pilot study was conducted. List of facilities was created with the help of key informants. The information about incidence of kala-azar cases were captured on monthly basis from July 2010 to June 2011. Rapid diagnostic strip test (rk-39) or bone marrow/splenic puncture were applied as laboratory methods for the diagnosis of kala-azar. Descriptive statistics as well as chi-square test for comparison between proportions was conducted. RESULTS: Overall availability of private practitioners (PPs) was 4.59/1,00,000 population and maximum PPs (46; 93.9%) were from qualified category. The median years of medical practice was 25 yr (inter quartile-range [18, 28]). Interestingly, only a small proportion (240; 19%) of cases was managed by PPs. Amongst the PPs, only low proportion (32; 18.2%) managed >2 cases per month. The mean number of kala-azar suspects and cases identified varied significantly between different PPs' professions with p <0.048 and p <0.032, respectively. A highly significant difference (p <0.0001) was observed for kala-azar case load between qualified and unqualified practitioners. A small proportion (38; 15.8%) of kala-azar cases was not present in the public health system record. INTERPRETATION & CONCLUSION: Still sizeable proportions of cases are going to PPs and unrecorded into government surveillance system. A mechanism need to be devised to involve at least qualified PPs in order to reduce treatment delay and increase case detection in the region.

Patients pathways to tuberculosis diagnosis and treatment in a fragmented health system: a qualitative study from a south Indian district.

BACKGROUND: India's Revised National Tuberculosis (TB) Control Programme (RNTCP) offers free TB diagnosis and treatment. But more than 50% of TB patients seek care from private practitioners (PPs), where TB is managed sub-optimally. In India, there is dearth of studies capturing experiences of TB patients when they navigate through health facilities to seek care. Also, there is less information available on how PPs make decisions to refer TB cases to RNTCP. We conducted this study to understand the factors influencing TB patient's therapeutic itineraries to RNTCP and PP's cross referral practices linked to RNTCP. METHODS: We conducted in-depth interviews on a purposive sample of 33 TB patients and 38 PPs. Patients were categorised into three groups: those who reached RNTCP directly, those who were referred by PPs to RNTCP and patients who took DOT from PPs. We assessed patient's experiences in each category and documented their journey from initial symptoms until they reached RNTCP, where they were diagnosed and started on treatment. PPs were categorised into three groups based on their TB case referrals to RNTCP: actively-referring, minimally-referring and non-referring. RESULTS: Patients had limited awareness about TB. Patients switched from one provider to the other, since their symptoms were not relieved. A first group of patients, self-medicated by purchasing get rid drugs from private chemists over the counter, before seeking care. A second group sought care from government facilities and had simple itineraries. A third group who sought care from PPs, switched concurrently and/or iteratively from public and private providers in search for relief of symptoms causing important diagnostic delays. Eventually all patients reached RNTCP, diagnosed and started on treatment. PP's cross-referral practices were influenced by patient's paying capacity, familiarity with RNTCP, kickbacks from private labs and chemists, and even to get rid of TB patients. These trade-offs by PPs complicated patient's itineraries to RNTCP. CONCLUSIONS: India aims to achieve universal health care for TB. Our study findings help RNTCP to develop initiatives to promote early detection of TB, by involving PPs and private chemists and establish effective referral systems from private sectors to RNTCP.

From habits of attrition to modes of inclusion: enhancing the role of private practitioners in routine disease surveillance.

BACKGROUND: Private practitioners are the preferred first point of care in a majority of low and middle-income countries and in this position, best placed for the surveillance of diseases. However their contribution to routine surveillance data is marginal. This systematic review aims to explore evidence with regards to the role, contribution, and involvement of private practitioners in routine disease data notification. We examined the factors that determine the inclusion of, and the participation thereof of private practitioners in disease surveillance activities. METHODS: Literature search was conducted using the PubMed, Web of Knowledge, WHOLIS, and WHO-IRIS databases to identify peer-reviewed and gray full-text documents in English with no limits for year of publication or study design. Forty manuscripts were reviewed. RESULTS: The current participation of private practitioners in disease surveillance efforts is appalling. The main barriers to their participation are inadequate knowledge leading to unsatisfactory attitudes and misperceptions that influence their practices. Complicated reporting mechanisms with unclear guidelines, along with unsatisfactory attitudes on behalf of the government and surveillance program managers also contribute to the underreporting of cases. Infrastructural barriers especially the availability of computers and skilled human resources are critical to improving private sector participation in routine disease surveillance. CONCLUSION: The issues identified are similar to those for underreporting within the Integrated infectious Disease Surveillance and Response systems (IDSR) which collects data mainly from public healthcare facilities. We recommend that surveillance program officers should provide periodic training, supportive supervision and offer regular feedback to the practitioners from both public as well as private sectors in order to improve case notification. Governments need to take leadership and foster collaborative partnerships between the public and private sectors and most importantly exercise regulatory authority where needed.

Coping with tuberculosis and directly observed treatment: a qualitative study among patients from South India.

BACKGROUND: In India, the Revised National TB control programme (RNTCP) offers free diagnosis and treatment for tuberculosis (TB), based on the Directly Observed Treatment Short course (DOTS) strategy. We conducted a qualitative study to explore the experience and consequences of having TB on patients enrolled in DOTS and their caretakers in Tumkur district, located in a southern state of India, Karnataka. METHODS: We conducted 33 in-depth interviews on a purposive sample of TB patients from three groups: (1) patients who reached RNTCP directly on their own and took DOTS at RNTCP; (2) patients who were referred by private practitioners (PPs) to RNTCP and took DOTS at RNTCP; and (3) patients diagnosed by RNTCP and took DOTS from PPs. Data was analyzed using a thematic approach with the support of NVivo9. RESULTS: The study revealed that TB and DOTS have a large impact on patient's lives, which is often extended to the family and caretakers. The most vulnerable patients faced the most difficulty in accessing and completing DOTS. The family was the main source of support during patient's recovery. Patients residing in rural areas and, taking DOTS from the government facilities had to overcome many barriers to adhere to the DOTS therapy, such as long travelling distance to DOTS centers, inconvenient timings and unfavorable attitude of the RNTCP staff, when compared to patients who took DOTS from PPs. Advantages of taking DOTS from PPs cited by the patients were privacy, flexibility in timings, proximity and more immediate access to care. Patients and their family had to cope with stigmatization and fear and financial hardships that surfaced from TB and DOTS. Young patients living in urban areas were more worried about stigmatisation, than elderly patients living in rural areas. Patients who were referred by PPs experienced more financial problems compared to those who reached RNTCP services directly. CONCLUSION: Our study provided useful information about patient's needs and expectations while taking DOTS. The development of mechanisms within RNTCP towards patient centered care is needed to enable patients and caretakers cope with disease condition and adhere to DOTS.

Assessment of Patients Referred to Specialty Dental Hospitals for Dental Implant Procedure: A Retrospective Cohort Analysis.

INTRODUCTION: One of the most common and effective ways of replacing missing teeth is by dental implants. Both quality and quantity of bone along with the area of implant placement govern the prognosis of the implant procedure. Certain risk factors predispose the implant treatment to high failure rate. Hence, we assessed the implant patients who were referred from private practitioners to the specialty hospitals from 2010 to 2014. MATERIALS AND METHODS: All the patients being referred from private clinics to the specialty dental hospital for the purpose of prosthetic rehabilitation by dental implants from June 2010 to July 2014 were included in the present study. Skilled oral and maxillofacial surgeons were appointed for performing the implant surgical procedures. Prosthetic rehabilitation was done after 6 to 8 weeks and after 10 to 14 weeks in implant cases without and with bone augmentation procedures respectively. Distribution of dental implants based on the indications, location, dimension of augmentation procedure, and complication of implants was analyzed and assessed for the level of significance. RESULTS: Of the patients, 712 were females, while the remaining were males. Most of the patients were in the age group of 50 to 59 years. As compared with completely edentulous patients, most of the patients required rehabilitation by a single implant. Maximum dental implants were placed in maxillary premolar region and mandibular first molar region. Over 1,000 cases in this study required rehabilitation by augmentation procedure. CONCLUSION: Partially edentulous patients are most commonly referred to specialized dental hospitals for prosthetic rehabilitation by dental implants, mostly with the purpose of implant placement. Failure rate can be minimized by following strict patient selection protocols along with following a standard surgical criterion. CLINICAL SIGNIFICANCE: Following standard surgical protocols and strict treatment planning, prognosis of the dental implant procedures can be improved to a greater extent, thereby increasing its clinical success rate.

Knowledge of Private Practitioners Regarding Revised National Tuberculosis Control Program- A Cross-Sectional Study from the Haryana state of India.

Background: India's aim to achieve tuberculosis (TB) eradication by 2025 necessitates the engagement of all stakeholders, encompassing both private and public sectors, across all phases of the TB program - spanning from diagnosis to the curative outcome. However, certain private practitioners pursue an individualized approach instead of adopting a collective strategy, thereby contributing to the emergence of multidrug-resistant tuberculosis. Consequently, in order to formulate an enhanced strategy that fosters improved collaboration and professional behavioral change among all partners, it is imperative to comprehensively assess their level of knowledge. This study aims to assess the knowledge level of private practitioners with regard to the diagnosis and management of pulmonary tuberculosis cases within the framework of the Revised National Tuberculosis Control Program (RNTCP). Methodology: A descriptive cross-sectional study was conducted among 78 selected private practitioners located in seven towns within the Sonepat district of Haryana State, India. The study was approved by the ethics committee of Bhagat Phool Singh Government Medical College for Women, Sonepat, Haryana. Data collection involved the utilization of a self-administered, pre-tested, semi-structured questionnaire. Descriptive analysis was applied, utilizing proportions and percentages. Results: The collective understanding of private practitioners concerning Tuberculosis and RNTCP was found to be deficient. Around one-third of the practitioners reported that they had not received any visits from health workers in relation to RNTCP. A mere 33% of the practitioners had attended any Continuing Medical Education (CME) sessions, and only a quarter of the participants expressed an intention to collaborate with the RNTCP program. Conclusions: In conclusion, this study underscores the necessity for RNTCP to focus on fostering the willingness of private practitioners to engage with the program, while simultaneously enhancing their knowledge about Tuberculosis and RNTCP.

Tuberculosis notification: An inquiry among private practitioners in Pimpri-Chinchwad municipal corporation area of Maharashtra, India.

BACKGROUND: The Government of India implemented mandatory TB notification policy since 2012. After that India's TB notifications from the private sector steadily increased; however, less is known about private practitioners' (PP's) experiences with TB notification. The present study aims to fulfil this gap. METHODS: We conducted a cross-sectional study during November 2019 to March 2020 in Pimpri-Chinchwad Municipal Corporation (PCMC) area of Maharashtra State. We used a mixed methods approach which involved a survey of 200 PPs and in-depth interviews (IDIs) with 7 PPs and 8 National TB Elimination Program (NTEP) staff. The data were presented in the form of frequencies and percentages and thematic analysis was performed on the qualitative data. RESULTS: The study revealed that most PPs (194 of 200; 97%) were aware of TB notification and 75% reported that they notify TB cases to the NTEP. Of those who notify, majority (129 of 145; 89%) reported that they use paper-based notification being the convenient method due to in-person visit and help by the NTEP staff. Only a third of PPs were aware of electronic notification methods. The main reasons behind low utilization of web based and mobile application were unfamiliarity and technical issues such as poor network connectivity. A third of PPs were aware about monetary incentives for notification and only 17% reported actual receipt of incentive at some point. CONCLUSIONS: Our study identifies several areas where the NTEP can undertake interventions to strengthen the implementation of mandatory TB notification policy. Low awareness about electronic notification methods and preference for paper-based notification in this Study area suggest that more efforts are necessary for successful transitioning from paper-based to electronic notification system.

Voices of Those Who Bear the Brunt - Experiences of Programme Personnel Concerning Private Sector Tuberculosis Notifications in Bengaluru City, India.

This study aims to assess private and public sector contributions to Tuberculosis (TB) notification in Bengaluru city (2011 to 2016) and identify challenges of program personnel in their interaction with private practitioners and procedural barriers for TB notification from the private sector as perceived by them. A mixed methods study was carried out in Bengaluru city, India with TB notification data obtained from TB Units in addition to in-depth interviews with key program implementers. Results showed the contribution of private practitioners to TB notification to be about 20%. Barriers and challenges were: the private practitioners' hesitancy to refer the patients to public sector due to their fear of losing patients and dishonoring of diagnosis from private practitioners, lack of awareness about TB notification, lack of legal punitive measures and constant glitches on the notification website. These need to be resolved on priority to achieve the national target of TB elimination by 2025.

Awareness & utilization of NIKSHAY and perceived barriers for tuberculosis case notification among the private practitioners in Udupi district, Karnataka.

BACKGROUND: NIKSHAY is a web-based TB case notification & management portal. The study aimed to assess the awareness and utilization of NIKSHAY among the private practitioners in Udupi district and identify the operational barriers to TB notification. METHODS: The study was conducted between January to May 2019. Allopathic doctors were included in the study. Interviewer-administered structured validated questionnaire was used. The doctors were interviewed at their clinics/hospital. RESULT: Out of 206 doctors, 138 were included in the study. Most of the participants were males (88.4%).Whereas, majority of the doctors were specialists (73.2%). 99% of the doctors knew that TB notification is mandatory. The awareness of NIKSHAY was low (21.7%) among them. Of those aware, 51.9% of the doctors were registered on NIKSHAY. 92.7% of the doctors who were registered had notified at least one case in last 6 months. Training programs were effective in increasing awareness of NIKSHAY but not utilization. Factors like out-patient load, number of presumptive and diagnosed TB cases seen were associated with the awareness and utilization of NIKSHAY. The major perceived barriers for notification were difficult to treat TB, ignorance of TB burden, complicated notification system, patient stigma and loss to follow up, lack of acknowledgement from the government. CONCLUSION: The awareness and utilization of NIKSHAY was low. Patient load was positively associated with the utilization of NIKSHAY. Private practitioners face various barriers which needs to be addressed to increase the notification rates.

Patient pathways and delays to diagnosis and treatment of tuberculosis in an urban setting in Indonesia.

BACKGROUND: Understanding patient pathways can help align patient preferences and tuberculosis (TB) related services. We investigated patient pathways, and diagnostic and treatment delays among TB patients in Indonesia, which has one of the highest proportions of non-notified TB cases globally. METHODS: We conducted a study of TB patients recruited from Community Health Centers (CHCs), public and private hospitals, and private practitioners from 2017 to 2019 in Bandung City, regarding general characteristics and symptoms, and health-seeking, diagnostic and treatment pathways. FINDINGS: We recruited 414 TB patients: 138 (33%) in CHCs, 210 (51%) in hospitals, 66 (20%) in private practitioners. Most patients (74·6%) first sought care at an informal or private provider and experienced a complex pathway visiting both public and private providers to obtain a diagnosis. The median number of health provider visits pre-diagnosis was 6 (IQR 4-8). From start of symptoms, it took a median 30 days (IQR 14-61) to present to a health provider, 62 days (IQR 35-113) to reach a TB diagnosis, and 65 days (IQR 37-119) to start treatment. Patient delay was longer among male, lowly-educated and uninsured individuals. There were longer diagnostic delays among uninsured individuals, those who initially visited private providers, and those with multiple visits prior to diagnosis. Longer treatment delays were found in those with multiple pre-diagnosis visits or diagnosed by private practitioners. INTERPRETATION: Patient pathways in Indonesia are complex, involving the public and private sector, with multiple visits and long delays, especially to diagnosis. A widely available accurate diagnostic test for TB could have a dramatic effect on reducing delays, onward transmission and mortality. FUNDING: This project was funded by the Partnership for Enhanced Engagement in Research (PEER) grant under Prime Agreement Number AID-OAA-A-11-00,012 by National Academy of Sciences (NAS); the United States Agency for International Development (USAID); University of Otago, New Zealand, and the Indonesian Endowment Fund for Education (LPDP).

Acceptability of mandatory tuberculosis notification among private practitioners in Yogyakarta, Indonesia.

OBJECTIVE: Indonesia ranks second globally in the number of cases not reported to the National Tuberculosis Control Program, accounting for 11% of the total cases lost worldwide. In 2016, the Ministry of Health has issued Regulation Number 67 on tuberculosis control, which requires mandatory tuberculosis notification. We aimed to assess the prospective acceptability of mandatory tuberculosis notification among solo private practitioners and private primary care clinics in Yogyakarta. RESULTS: Our study highlighted critical issues which need to be addressed in ensuring acceptability of mandatory tuberculosis case notification. We found that that private practitioners do not notify tuberculosis cases due to a lack of policy knowledge. Mandatory tuberculosis notification and its potential penalties were also felt as burdensome by private practitioners. There were ethical concerns among the private practitioners in our study about patient's privacy and patients potentially lost to other healthcare facility. Private practitioners emphasized the need for intervention coherence and cooperation. We also observed pattern variations of these constructs across characteristics of private practitioners.

Management practices of tuberculosis in children among pediatric practitioners in Mangalore, South India.

INTRODUCTION: In spite of having BCG vaccination and tuberculosis control program for the last 50 years, prevalence of tuberculosis continues to be high in India. Inadequate diagnostic methods, suboptimal treatment and monitoring, and the lack of vigilant reporting system are some of the contributing factors for the failure of TB control. OBJECTIVES: To know the current practices among local pediatricians regarding management of TB. MATERIALS AND METHODS: Field based cross sectional study. All the registered pediatricians who were practicing in Mangalore, (list - local IAP branch) were included in the study. A structured Questionnaire on signs and symptoms of TB, diagnosis, strategies adopted in treatment, MDR tuberculosis and reporting of cases to RNTCP was asked. Management practice standards according to the Updated National Guidelines for Pediatric Tuberculosis in India, 2012, RNTCP guidelines in consensus with IAP, latest at the time of the study. RESULTS: 50 pediatricians participated in the study with 62% having an attachment to the teaching institution. More than 50% identified all the symptoms of TB. 64% were sending chest X-ray, Mantoux test and gastric lavage/induced sputum examination for AFB to diagnose TB. 22% were not stressing for AFB examination. Still 16% told serological tests as one of the diagnostic modality. 52% were not aware about the diagnosis of latent TB. In 16% of their cases ATT was on a trial basis. Only 52% of the clinicians are adhering to updated national (RNTCP) guidelines. 30% felt still there are drawbacks in the current RNTCP guidelines. 72% knew the correct definition of MDR tuberculosis. But only 36% of them knew the diagnostic method (gene expert/CB NAAT) of confirming the MDR TB. CONCLUSION: Management practices are found to be still suboptimum. Better engagement of the private sector is urgently required to improve TB management practices and to prevent diagnostic delay and drug resistance.

Tuberculosis diagnostic and treatment practices in private sector: Implementation study in an Indian city.

SETTING: Implementation study in private health facilities in an Indian metropolis. OBJECTIVES: Improve Tuberculosis (TB) care by private practitioners (PPs). METHODS: PPs from a defined city area were imparted short training in TB care and linkages made with public facilities; subsequent practices were recorded. RESULTS: Of 364 presumptive TB patient records, 70 (19.3%) did not conform to its definition. Of the conforming, 174 (59.2%) had presumptive pulmonary TB (PTB), 53 (18%) presumptive extra-pulmonary (EPTB) and 67 (24%) had both. Of conforming presumptive PTB, most underwent Chest X-ray and sputum examination in private laboratories. Tissue based diagnostics were not advised for most presumptive EPTB patients. Of 101 cases diagnosed with TB, 82% were new, 23% known diabetic and 4.7% human immune deficiency virus (HIV) reactive out of 64 tested. Most were notified and initiated treatment within 15 days of diagnosis. One-fourth was prescribed standard treatment regimen and treatment was not directly observed for most. One third was initial defaulters or lost during treatment; 62% of PTB and 46% EPTB cases initiated on treatment in private were successfully treated. Of successfully treated PTB cases, 61% had undergone follow-up sputum examination. CONCLUSION: Much intensified support mechanisms are needed to improve TB care in private sector.

Seeking mental health care from private health practitioners among individuals with alcohol dependence/abuse; results from a study in the French general population.

INTRODUCTION: Better knowledge of the factors that have an impact on pathways to mental health care may contribute greatly to organizing optimum health-care delivery. However, surveillance systems concerning alcohol problems in the French general population are suboptimal. The objectives of this study were to investigate: 1) the prevalence of mental health-care seeking in individuals with alcohol abuse/dependence in France, 2) which category of medical practitioner was consulted, and 3) psychological and socio-environmental factors associated with mental health-care seeking. METHODS: A total sample of 22,138 individuals was interviewed in a telephone survey. Individual data on alcohol dependence/abuse and other mental health disorders were collected using the Composite International Diagnosis Interview - short form. Mental health-care seeking was assessed, together with data on living conditions, deprivation, and self-reported drinking problems. Only respondents meeting criteria for alcohol dependence/abuse were included in analyses. RESULTS: Less than half of the 722 respondents with alcohol abuse/dependence had sought mental health care in the preceding 12 months, of whom 90.5% consulted their general practitioner (GP) (56.1%), or both a general practitioner and a psychiatrist (34.4%). Mental health-care seeking was associated with female sex, previous alcohol discussion with a doctor, and the presence of psychiatric comorbidities arising in the preceding 12 months. Living environment, socio-economic status, or self-reported drinking problems had no influence. DISCUSSION: A minority of people with alcohol abuse/dependence sought mental health care, mainly in relation to psychiatric comorbidities. In addition, most people consulting a GP were not referred to a psychiatrist. However, social deprivation and living in rural areas did not hinder mental health-care seeking among respondents. Adequate protocols to treat alcohol disorders could be implemented among private health-care providers to improve management of alcohol problems in France.

Evaluation of Hand Written and Computerized Out-Patient Prescriptions in Urban Part of Central Gujarat.

INTRODUCTION: Prescription order is an important therapeutic transaction between physician and patient. A good quality prescription is an extremely important factor for minimizing errors in dispensing medication and it should be adherent to guidelines for prescription writing for benefit of the patient. AIM: To evaluate frequency and type of prescription errors in outpatient prescriptions and find whether prescription writing abides with WHO standards of prescription writing. MATERIALS AND METHODS: A cross-sectional observational study was conducted at Anand city. Allopathic private practitioners practising at Anand city of different specialities were included in study. Collection of prescriptions was started a month after the consent to minimize bias in prescription writing. The prescriptions were collected from local pharmacy stores of Anand city over a period of six months. Prescriptions were analysed for errors in standard information, according to WHO guide to good prescribing. STATISTICAL ANALYSIS: Descriptive analysis was performed to estimate frequency of errors, data were expressed as numbers and percentage. RESULTS: Total 749 (549 handwritten and 200 computerised) prescriptions were collected. Abundant omission errors were identified in handwritten prescriptions e.g., OPD number was mentioned in 6.19%, patient's age was mentioned in 25.50%, gender in 17.30%, address in 9.29% and weight of patient mentioned in 11.29%, while in drug items only 2.97% drugs were prescribed by generic name. Route and Dosage form was mentioned in 77.35%-78.15%, dose mentioned in 47.25%, unit in 13.91%, regimens were mentioned in 72.93% while signa (direction for drug use) in 62.35%. Total 4384 errors out of 549 handwritten prescriptions and 501 errors out of 200 computerized prescriptions were found in clinicians and patient details. While in drug item details, total number of errors identified were 5015 and 621 in handwritten and computerized prescriptions respectively. CONCLUSION: As compared to handwritten prescriptions, computerized prescriptions appeared to be associated with relatively lower rates of error. Since out-patient prescription errors are abundant and often occur in handwritten prescriptions, prescribers need to adapt themselves to computerized prescription order entry in their daily practice.

Engaging private providers and Ayurvedic practitioners in Bilaspur, India: did it increase TB case detection?

To find 'missing' tuberculosis (TB) cases, in November 2014 we trained private practitioners (PPs) and Ayurvedic practitioners (APs; Indian system of medicine) in Bilaspur district, India, to identify patients with presumptive TB and refer them to sputum microscopy centres. To reinforce this training, we sent weekly text message reminders during January-March 2015. All 50 APs and 23 of 29 PPs participated. The number of patients with presumptive TB referred by the PPs and APs increased from 38 (January-March 2014) to 104 (January-March 2015), and the number of smear-positive TB patients diagnosed increased from 5 to 16, a 220% increase. While the intervention increased the number of referrals, it did not impact case detection at district level, due to the short duration of the intervention and the non-dominant private sector.

Dans le but de trouver des cas de tuberculose (TB) « manquants ¼, nous avons formé des praticiens privés (PP) et des praticiens ayurvédiques (AP ; médecine indienne) du district de Bilaspur, Inde, en novembre 2014 afin d'identifier des patients avec une TB présumée et de les référer dans des centres de microscopie de crachats. Pour renforcer cette formation, nous avons envoyé des messages sous forme de texto chaque semaine comme aide-mémoire de janvier à mars 2015. Tous les 50 AP et 23 des 29 PP ont participé. Le nombre de patients présumés TB référés par les PP et AP a augmenté de 38 (janvier­mars 2014) à 104 (janvier­mars 2015) et le nombre de patients à frottis de TB positifs diagnostiqués a augmenté de 5 à 16 (augmentation de 220%). Si l'intervention a augmenté la référence de patients au laboratoire, elle n'a pas eu d'impact sur la détection des cas au niveau du district à cause de sa durée brève et du fait que le secteur privé n'est pas dominant dans la région.

Con el propósito de detectar los casos de tuberculosis (TB) que 'se pasan por alto', se llevó a cabo una capacitación de los médicos del sector privado (PP) y los médicos del sistema Ayurveda (AP) de medicina tradicional de la India; la formación, realizada en el distrito de Bilaspur en noviembre del 2014, buscó mejorar el reconocimiento de los pacientes con presunción clínica de TB y su remisión a los centros de examen microscópico del esputo. Con el objeto de reforzar la capacitación, se enviaron mensajes recordatorios por SMS de enero a marzo del 2015. Participaron en el estudio todos los 50 AP y 23 de los 29 PP del distrito. El cociente del número de pacientes con presunción de TB remitidos por los PP y los AP de 38 (entre enero y marzo del 2014) a 104 (entre enero y marzo del 2015) y el número de casos diagnosticados de TB con baciloscopia positiva aumentó de cinco a 16 (incremento del 220%). Si bien la intervención aumentó el número de remisiones, la detección de casos a escala del distrito no se modificó, debido a la corta duración de la intervención y a que el sector privado no es predominante en este distrito.

Private Practitioners' Perspectives on Their Involvement With the Tuberculosis Control Programme in a Southern Indian State.

BACKGROUND: Public and private health sectors both play a crucial role in the health systems of low- and middle-income countries (LMICs). The tuberculosis (TB) control strategy in India encourages the public sector to actively partner with private practitioners (PPs) to improve the quality of front line service delivery. However, ensuring effective and sustainable involvement of PPs constitutes a major challenge. This paper reports the findings from an empirical study focusing on the perspectives and experiences of PPs towards their involvement in TB control programme in India. METHODS: The study was carried out between November 2010 and December 2011 in a district of a Southern Indian State and utilised qualitative methodologies, combining observations and in-depth interviews with 21 PPs from different medical systems. The collected data was coded and analysed using thematic analysis. RESULTS: PPs perceived themselves to be crucial healthcare providers, with different roles within the public-private mix (PPM) TB policy. Despite this, PPs felt neglected and undervalued in the actual process of implementation of the PPM-TB policy. The entire process was considered to be government driven and their professional skills and knowledge of different medical systems remained unrecognised at the policy level, and weakened their relationship and bond with the policy and with the programme. PPs had contrasting perceptions about the different components of the TB programme that demonstrated the public sector's dominance in the overall implementation of the DOTS strategy. Although PPs felt responsible for their TB patients, they found it difficult to perceive themselves as 'partners with the TB programme.' CONCLUSION: Public-private partnerships (PPPs) are increasingly utilized as a public health strategy to strengthen health systems. These policies will fail if the concerns of the PPs are neglected. To ensure their long-term involvement in the programme the abilities of PPs and the important perspectives from other Indian medical systems need to be recognised and supported.

Analysis of Out Door Patients' Prescriptions According to World Health Organization (WHO) Prescribing Indicators Among Private Hospitals in Western India.

BACKGROUND: Prescription is document through which doctor, patient and pharmacist are communicated. Many a times if these documents are not properly written or misinterpreted it can affect management of patients. WHO established prescribing indicators to analyse prescription and promoted rational use of drugs and better management of patients. AIM: To study the prescription pattern according to WHO prescribing indicators among private hospitals. SETTINGS AND DESIGN: The observational, prospective study carried out at different private hospitals at metro city in Western India to study the prescription pattern among private hospital. MATERIALS AND METHODS: Study was conducted at different private hospitals of metro city. A total of 250 prescriptions of outdoor patients from various departments of private hospitals were collected for a period of three months (August to October) 2012 and evaluated. STATISTICAL ANALYSIS: The study was analysed using Z-test. RESULTS: Patient details like age and gender was not written in all (100%) prescriptions. It was noticed that dose, direction of drug and duration of treatment was not completely written in 90%, 74% and 80% of prescriptions respectively. Abbreviations were used in all (100%) prescriptions. Doctor's medical registration number was mentioned in 0% prescriptions. Total 869 drugs were prescribed in 250 prescriptions. Average number of drug prescribed was 3.38±1.79 (Mean±SD). It was reported that Group II (3 to 4 encoutner) was significantly higher as compared to Group I (less than or equal to 2 encoutner) and Group III( more than four encounter). It was significantly (p<0.05) prescribed brand name prescriptions (93.33%) as compared to generic name prescriptions (6.7%). Percentage of encounter with antibiotics and injections was 54% and 18% respectively. Approximately 70% drugs were prescribed according to Essential Medicine List (EML) of State. Antibiotics accounted 30% of prescribed drugs which was significantly higher as compared to other group of prescribed drugs. CONCLUSION: Our study revealed that prescription errors were most commonly observed at private hospitals and antibiotics was commonly prescribed in private sector. Therefore, strict policy to good prescribing practice and strict antibiotic policy in outdoor patients are required to promote rational use of drugs.