Impact of the COVID-19 pandemic on quality of tuberculosis care in private facilities in Bandung, Indonesia: a repeated cross-sectional standardized patients study

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Abstract

Background

Indonesia has the second highest incidence of tuberculosis in the world. While 74% of people with tuberculosis in Indonesia first accessed the private health sector when seeking care for their symptoms, only 18% of tuberculosis notifications originate in the private sector. Little is known about the impact of the COVID-19 pandemic on the private sector. Using unannounced standardized patient visits to private providers, we aimed to measure quality of tuberculosis care during the COVID-19 pandemic.

Methods

A cross-sectional study was conducted using standardized patients in Bandung City, West Java, Indonesia. Ten standardized patients completed 292 visits with private providers between 9 July 2021 and 21 January 2022, wherein standardized patients presented a presumptive tuberculosis case. Results were compared to standardized patients surveys conducted in the same geographical area before the onset of COVID-19.

Results

Overall, 35% (95% confidence interval (CI): 29.2–40.4%) of visits were managed correctly according to national tuberculosis guidelines. There were no significant differences in the clinical management of presumptive tuberculosis patients before and during the COVID-19 pandemic, apart from an increase in temperature checks (adjusted odds ratio (aOR): 8.05, 95% CI: 2.96–21.9, p < 0.001) and a decrease in throat examinations (aOR 0.16, 95% CI: 0.06–0.41, p = 0.002) conducted during the pandemic.

Conclusions

Results indicate that providers successfully identify tuberculosis in their patients yet do not manage them according to national guidelines. There were no major changes found in quality of tuberculosis care due to the COVID-19 pandemic. As tuberculosis notifications have declined in Indonesia due to the COVID-19 pandemic, there remains an urgent need to increase private provider engagement in Indonesia and improve quality of care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-023-17001-y.

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Most cited references 31

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Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support.

Paul A. Harris, Robert Taylor, Robert Thielke … (2009)

Research electronic data capture (REDCap) is a novel workflow methodology and software solution designed for rapid development and deployment of electronic data capture tools to support clinical and translational research. We present: (1) a brief description of the REDCap metadata-driven software toolset; (2) detail concerning the capture and use of study-related metadata from scientific research teams; (3) measures of impact for REDCap; (4) details concerning a consortium network of domestic and international institutions collaborating on the project; and (5) strengths and limitations of the REDCap system. REDCap is currently supporting 286 translational research projects in a growing collaborative network including 27 active partner institutions.

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Anticipating the impact of the COVID-19 pandemic on TB patients and TB control programmes

Toyin Togun, Beate Kampmann, Neil Graham Stoker … (2020)

The COVID-19 pandemic has currently overtaken every other health issue throughout the world. There are numerous ways in which this will impact existing public health issues. Here we reflect on the interactions between COVID-19 and tuberculosis (TB), which still ranks as the leading cause of death from a single infectious disease globally. There may be grave consequences for existing and undiagnosed TB patients globally, particularly in low and middle income countries (LMICs) where TB is endemic and health services poorly equipped. TB control programmes will be strained due to diversion of resources, and an inevitable loss of health system focus, such that some activities cannot or will not be prioritised. This is likely to lead to a reduction in quality of TB care and worse outcomes. Further, TB patients often have underlying co-morbidities and lung damage that may make them prone to more severe COVID-19. The symptoms of TB and COVID-19 can be similar, with for example cough and fever. Not only can this create diagnostic confusion, but it could worsen the stigmatization of TB patients especially in LMICs, given the fear of COVID-19. Children with TB are a vulnerable group especially likely to suffer as part of the “collateral damage”. There will be a confounding of symptoms and epidemiological data through co-infection, as happens already with TB–HIV, and this will require unpicking. Lessons for COVID-19 could be learned from the vast experience of running global TB control programmes, while the astonishingly rapid and relatively well co-ordinated response to COVID-19 demonstrates how existing programmes could be significantly improved.

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Variations in the quality of tuberculosis care in urban India: A cross-sectional, standardized patient study in two cities

Ada Kwan, Benjamin Daniels, Vaibhav Saria … (2018)

Background India has the highest burden of tuberculosis (TB). Although most patients with TB in India seek care from the private sector, there is limited evidence on quality of TB care or its correlates. Following our validation study on the standardized patient (SP) method for TB, we utilized SPs to examine quality of adult TB care among health providers with different qualifications in 2 Indian cities. Methods and findings During 2014–2017, pilot programs engaged the private health sector to improve TB management in Mumbai and Patna. Nested within these projects, to obtain representative, baseline measures of quality of TB care at the city level, we recruited 24 adults to be SPs. They were trained to portray 4 TB “case scenarios” representing various stages of disease and diagnostic progression. Between November 2014 and August 2015, the SPs visited representatively sampled private providers stratified by qualification: (1) allopathic providers with Bachelor of Medicine, Bachelor of Surgery (MBBS) degrees or higher and (2) non-MBBS providers with alternative medicine, minimal, or no qualifications. Our main outcome was case-specific correct management benchmarked against the Standards for TB Care in India (STCI). Using ANOVA, we assessed variation in correct management and quality outcomes across (a) cities, (b) qualifications, and (c) case scenarios. Additionally, 2 micro-experiments identified sources of variation: first, quality in the presence of diagnostic test results certainty and second, provider consistency for different patients presenting the same case. A total of 2,652 SP–provider interactions across 1,203 health facilities were analyzed. Based on our sampling strategy and after removing 50 micro-experiment interactions, 2,602 interactions were weighted for city-representative interpretation. After weighting, the 473 Patna providers receiving SPs represent 3,179 eligible providers in Patna; in Mumbai, the 730 providers represent 7,115 eligible providers. Correct management was observed in 959 out of 2,602 interactions (37%; 35% weighted; 95% CI 32%–37%), primarily from referrals and ordering chest X-rays (CXRs). Unnecessary medicines were given to nearly all SPs, and antibiotic use was common. Anti-TB drugs were prescribed in 118 interactions (4.5%; 5% weighted), of which 45 were given in the case in which such treatment is considered correct management. MBBS and more qualified providers had higher odds of correctly managing cases than non-MBBS providers (odds ratio [OR] 2.80; 95% CI 2.05–3.82; p < 0.0001). Mumbai non-MBBS providers had higher odds of correct management than non-MBBS in Patna (OR 1.79; 95% CI 1.06–3.03), and MBBS providers’ quality of care did not vary between cities (OR 1.15; 95% CI 0.79–1.68; p = 0.4642). In the micro-experiments, improving diagnostic certainty had a positive effect on correct management but not across all quality dimensions. Also, providers delivered idiosyncratically consistent care, repeating all observed actions, including mistakes, approximately 75% of the time. The SP method has limitations: it cannot account for patient mix or care-management practices reflecting more than one patient–provider interaction. Conclusions Quality of TB care is suboptimal and variable in urban India’s private health sector. Addressing this is critical for India’s plans to end TB by 2025. For the first time, we have rich measures on representative levels of care quality from 2 cities, which can inform private-sector TB interventions and quality-improvement efforts.

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Author and article information

Contributors

Bachti Alisjahbana: b.alisjahbana@unpad.ac.id

Journal

Journal ID (nlm-ta): BMC Public Health

Journal ID (iso-abbrev): BMC Public Health

Title: BMC Public Health

Publisher: BioMed Central (London )

ISSN (Electronic): 1471-2458

Publication date (Electronic): 5 January 2024

Publication date PMC-release: 5 January 2024

Publication date Collection: 2024

Volume: 24

Electronic Location Identifier: 102

Affiliations

[1 ]Department of Epidemiology, Biostatistics, and Occupational Health, and McGill International TB Centre, McGill University, ( https://ror.org/01pxwe438) Montreal, Canada

[2 ]Research Center for Care and Control of Infectious Disease, Universitas Padjadjaran, ( https://ror.org/00xqf8t64) Bandung, Indonesia

[3 ]Department of Public Health, Universitas Padjadjaran, ( https://ror.org/00xqf8t64) Bandung, Indonesia

[4 ]Department of Public Health, Universitas Nahdlatul Ulama Surabaya, ( https://ror.org/00wbwde85) Surabaya, Indonesia

[5 ]School of Public Health Sciences, University of Waterloo, ( https://ror.org/01aff2v68) Waterloo, Canada

[6 ]Department of Medicine, McGill University, ( https://ror.org/01pxwe438) Montreal, Canada

[7 ]McCourt School of Public Policy, Georgetown University, ( https://ror.org/05vzafd60) Washington, DC, USA

[8 ]Department of Internal Medicine, Dr. Hasan Sadikin General Hospital, ( https://ror.org/003392690) Bandung, Indonesia

Article

Publisher ID: 17001

DOI: 10.1186/s12889-023-17001-y

PMC ID: 10771004

PubMed ID: 38183023

SO-VID: a2bdf9c1-1f5d-497d-8b29-05821d6cd69c

License:

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

History

Date received : 3 July 2023

Date accepted : 16 October 2023

Funding

Funded by: FundRef http://dx.doi.org/10.13039/100000865, Bill and Melinda Gates Foundation;

Award ID: INV-022420

Funded by: University of Padjadjaran

Open Access :

Open access funding provided by University of Padjadjaran

Custom metadata

ScienceOpen disciplines: Public health

Keywords: tuberculosis,covid-19,quality of care,indonesia,private sector

Data availability:

ScienceOpen disciplines: Public health

Keywords: tuberculosis, covid-19, quality of care, indonesia, private sector

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Impact of the COVID-19 pandemic on quality of tuberculosis care in private facilities in Bandung, Indonesia: a repeated cross-sectional standardized patients study

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Novel Coronavirus Disease COVID-19

Most cited references 31

Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support.

Anticipating the impact of the COVID-19 pandemic on TB patients and TB control programmes

Variations in the quality of tuberculosis care in urban India: A cross-sectional, standardized patient study in two cities

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