Use of standardised patients to assess antibiotic dispensing for tuberculosis by pharmacies in urban India

a cross-sectional study

Srinath Satyanarayana, Ada Kwan, Benjamin Daniels, Ramnath Subbaraman, Andrew McDowell, Sofi Bergkvist, Ranendra K. Das, Veena Das, Jishnu Das, Madhukar Pai

Research output: Contribution to journalArticle

33 Citations (Scopus)

Abstract

Background India's total antibiotic use is the highest of any country. Patients often receive prescription-only drugs directly from pharmacies. Here we aimed to assess the medical advice and drug dispensing practices of pharmacies for standardised patients with presumed and confirmed tuberculosis in India. Methods In this cross-sectional study in the three Indian cities Delhi, Mumbai, and Patna, we developed two standardised patient cases: first, a patient presenting with 2–3 weeks of pulmonary tuberculosis symptoms (Case 1); and second, a patient with microbiologically confirmed pulmonary tuberculosis (Case 2). Standardised patients were scheduled to present each case once to sampled pharmacies. We defined ideal management for both cases a priori as referral to a health-care provider without dispensing antibiotics or steroids or both. Findings Between April 1, 2014, and Nov 29, 2015, we sampled 622 pharmacies in Delhi, Mumbai, and Patna. Standardised patients completed 1200 (96%) of 1244 interactions. We recorded ideal management (defined as referrals without the use of antibiotics or steroids) in 80 (13%) of 599 Case 1 interactions (95% CI 11–16) and 372 (62%) of 601 Case 2 interactions (95% CI 58–66). Antibiotic use was significantly lower in Case 2 interactions (98 [16%] of 601, 95% CI 13–19) than in Case 1 (221 [37%] of 599, 95% CI 33–41). First-line anti-tuberculosis drugs were not dispensed in any city. The differences in antibiotic or steroid use and number of medicines dispensed between Case 1 and Case 2 were almost entirely attributable to the difference in referral behaviour. Interpretation Only some urban Indian pharmacies correctly managed patients with presumed tuberculosis, but most correctly managed a case of confirmed tuberculosis. No pharmacy dispensed anti-tuberculosis drugs for either case. Absence of a confirmed diagnosis is a key driver of antibiotic misuse and could inform antimicrobial stewardship interventions. Funding Grand Challenges Canada, Bill & Melinda Gates Foundation, Knowledge for Change Program, and World Bank Development Research Group.

Original languageEnglish
Pages (from-to)1261-1268
Number of pages8
JournalThe Lancet Infectious Diseases
Volume16
Issue number11
DOIs
Publication statusPublished - 01-11-2016

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Pharmacies
India
Tuberculosis
Cross-Sectional Studies
Anti-Bacterial Agents
Referral and Consultation
Steroids
Pulmonary Tuberculosis
Pharmaceutical Preparations
Prescription Drugs
United Nations
Case Management
Health Personnel
Canada
Research

All Science Journal Classification (ASJC) codes

  • Infectious Diseases

Cite this

Satyanarayana, Srinath ; Kwan, Ada ; Daniels, Benjamin ; Subbaraman, Ramnath ; McDowell, Andrew ; Bergkvist, Sofi ; Das, Ranendra K. ; Das, Veena ; Das, Jishnu ; Pai, Madhukar. / Use of standardised patients to assess antibiotic dispensing for tuberculosis by pharmacies in urban India : a cross-sectional study. In: The Lancet Infectious Diseases. 2016 ; Vol. 16, No. 11. pp. 1261-1268.
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title = "Use of standardised patients to assess antibiotic dispensing for tuberculosis by pharmacies in urban India: a cross-sectional study",
abstract = "Background India's total antibiotic use is the highest of any country. Patients often receive prescription-only drugs directly from pharmacies. Here we aimed to assess the medical advice and drug dispensing practices of pharmacies for standardised patients with presumed and confirmed tuberculosis in India. Methods In this cross-sectional study in the three Indian cities Delhi, Mumbai, and Patna, we developed two standardised patient cases: first, a patient presenting with 2–3 weeks of pulmonary tuberculosis symptoms (Case 1); and second, a patient with microbiologically confirmed pulmonary tuberculosis (Case 2). Standardised patients were scheduled to present each case once to sampled pharmacies. We defined ideal management for both cases a priori as referral to a health-care provider without dispensing antibiotics or steroids or both. Findings Between April 1, 2014, and Nov 29, 2015, we sampled 622 pharmacies in Delhi, Mumbai, and Patna. Standardised patients completed 1200 (96{\%}) of 1244 interactions. We recorded ideal management (defined as referrals without the use of antibiotics or steroids) in 80 (13{\%}) of 599 Case 1 interactions (95{\%} CI 11–16) and 372 (62{\%}) of 601 Case 2 interactions (95{\%} CI 58–66). Antibiotic use was significantly lower in Case 2 interactions (98 [16{\%}] of 601, 95{\%} CI 13–19) than in Case 1 (221 [37{\%}] of 599, 95{\%} CI 33–41). First-line anti-tuberculosis drugs were not dispensed in any city. The differences in antibiotic or steroid use and number of medicines dispensed between Case 1 and Case 2 were almost entirely attributable to the difference in referral behaviour. Interpretation Only some urban Indian pharmacies correctly managed patients with presumed tuberculosis, but most correctly managed a case of confirmed tuberculosis. No pharmacy dispensed anti-tuberculosis drugs for either case. Absence of a confirmed diagnosis is a key driver of antibiotic misuse and could inform antimicrobial stewardship interventions. Funding Grand Challenges Canada, Bill & Melinda Gates Foundation, Knowledge for Change Program, and World Bank Development Research Group.",
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Satyanarayana, S, Kwan, A, Daniels, B, Subbaraman, R, McDowell, A, Bergkvist, S, Das, RK, Das, V, Das, J & Pai, M 2016, 'Use of standardised patients to assess antibiotic dispensing for tuberculosis by pharmacies in urban India: a cross-sectional study', The Lancet Infectious Diseases, vol. 16, no. 11, pp. 1261-1268. https://doi.org/10.1016/S1473-3099(16)30215-8

Use of standardised patients to assess antibiotic dispensing for tuberculosis by pharmacies in urban India : a cross-sectional study. / Satyanarayana, Srinath; Kwan, Ada; Daniels, Benjamin; Subbaraman, Ramnath; McDowell, Andrew; Bergkvist, Sofi; Das, Ranendra K.; Das, Veena; Das, Jishnu; Pai, Madhukar.

In: The Lancet Infectious Diseases, Vol. 16, No. 11, 01.11.2016, p. 1261-1268.

Research output: Contribution to journalArticle

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T1 - Use of standardised patients to assess antibiotic dispensing for tuberculosis by pharmacies in urban India

T2 - a cross-sectional study

AU - Satyanarayana, Srinath

AU - Kwan, Ada

AU - Daniels, Benjamin

AU - Subbaraman, Ramnath

AU - McDowell, Andrew

AU - Bergkvist, Sofi

AU - Das, Ranendra K.

AU - Das, Veena

AU - Das, Jishnu

AU - Pai, Madhukar

PY - 2016/11/1

Y1 - 2016/11/1

N2 - Background India's total antibiotic use is the highest of any country. Patients often receive prescription-only drugs directly from pharmacies. Here we aimed to assess the medical advice and drug dispensing practices of pharmacies for standardised patients with presumed and confirmed tuberculosis in India. Methods In this cross-sectional study in the three Indian cities Delhi, Mumbai, and Patna, we developed two standardised patient cases: first, a patient presenting with 2–3 weeks of pulmonary tuberculosis symptoms (Case 1); and second, a patient with microbiologically confirmed pulmonary tuberculosis (Case 2). Standardised patients were scheduled to present each case once to sampled pharmacies. We defined ideal management for both cases a priori as referral to a health-care provider without dispensing antibiotics or steroids or both. Findings Between April 1, 2014, and Nov 29, 2015, we sampled 622 pharmacies in Delhi, Mumbai, and Patna. Standardised patients completed 1200 (96%) of 1244 interactions. We recorded ideal management (defined as referrals without the use of antibiotics or steroids) in 80 (13%) of 599 Case 1 interactions (95% CI 11–16) and 372 (62%) of 601 Case 2 interactions (95% CI 58–66). Antibiotic use was significantly lower in Case 2 interactions (98 [16%] of 601, 95% CI 13–19) than in Case 1 (221 [37%] of 599, 95% CI 33–41). First-line anti-tuberculosis drugs were not dispensed in any city. The differences in antibiotic or steroid use and number of medicines dispensed between Case 1 and Case 2 were almost entirely attributable to the difference in referral behaviour. Interpretation Only some urban Indian pharmacies correctly managed patients with presumed tuberculosis, but most correctly managed a case of confirmed tuberculosis. No pharmacy dispensed anti-tuberculosis drugs for either case. Absence of a confirmed diagnosis is a key driver of antibiotic misuse and could inform antimicrobial stewardship interventions. Funding Grand Challenges Canada, Bill & Melinda Gates Foundation, Knowledge for Change Program, and World Bank Development Research Group.

AB - Background India's total antibiotic use is the highest of any country. Patients often receive prescription-only drugs directly from pharmacies. Here we aimed to assess the medical advice and drug dispensing practices of pharmacies for standardised patients with presumed and confirmed tuberculosis in India. Methods In this cross-sectional study in the three Indian cities Delhi, Mumbai, and Patna, we developed two standardised patient cases: first, a patient presenting with 2–3 weeks of pulmonary tuberculosis symptoms (Case 1); and second, a patient with microbiologically confirmed pulmonary tuberculosis (Case 2). Standardised patients were scheduled to present each case once to sampled pharmacies. We defined ideal management for both cases a priori as referral to a health-care provider without dispensing antibiotics or steroids or both. Findings Between April 1, 2014, and Nov 29, 2015, we sampled 622 pharmacies in Delhi, Mumbai, and Patna. Standardised patients completed 1200 (96%) of 1244 interactions. We recorded ideal management (defined as referrals without the use of antibiotics or steroids) in 80 (13%) of 599 Case 1 interactions (95% CI 11–16) and 372 (62%) of 601 Case 2 interactions (95% CI 58–66). Antibiotic use was significantly lower in Case 2 interactions (98 [16%] of 601, 95% CI 13–19) than in Case 1 (221 [37%] of 599, 95% CI 33–41). First-line anti-tuberculosis drugs were not dispensed in any city. The differences in antibiotic or steroid use and number of medicines dispensed between Case 1 and Case 2 were almost entirely attributable to the difference in referral behaviour. Interpretation Only some urban Indian pharmacies correctly managed patients with presumed tuberculosis, but most correctly managed a case of confirmed tuberculosis. No pharmacy dispensed anti-tuberculosis drugs for either case. Absence of a confirmed diagnosis is a key driver of antibiotic misuse and could inform antimicrobial stewardship interventions. Funding Grand Challenges Canada, Bill & Melinda Gates Foundation, Knowledge for Change Program, and World Bank Development Research Group.

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