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Improving Quality of Care

Jishnu Das(World Bank, Washington DC and

Centre for Policy Research, New Delhi)Institute of Medicine, January 2015

Problem

• Improve quality of care “at scale” in a cost-effective manner

• Six Strategies: Service based, facility and context specific labor intensive methodologies

– RCT evidence not available

– Key questions about what constitutes quality of care

Here

Three Issues

Policy or Product

Health Related

Non-health related

Study Population

What is measured

How is it evaluated

Further observations

• Overarching: How much does it cost

• Question: What are the implicit assumptions for scaled up quality improvement efforts

• Caveat: Most results here from India and primary care

Current Situation

• 4.4 providers per village, 77% with no formal medical training, <10% public

• 40% of public doctors absent on any given day, 2-3% decline over 10 years

• 4% of patients get the correct treatment “only”, fully trained doctors give the correct treatment “plus” 40% of the time, give at least one incorrect treatment 75% of the time

Data are from the Medical Advice, Quality and Availability in Rural India (MAQARI) project, joint with AlakaHolla (World Bank), Karthik Muralidharan (UCSD), Michael Kremer (Harvard University) and Aakash Mohpal(Michigan)

Current Situation

Health care providers appear to do what they say they would do around half the timeCorrect treatment increases with effort, and knowledgeReplicated in Tanzania, Rwanda, Canada, Netherlands

Current Situation: Data

Standardized patients for asthma (young adult), angina (older man), diarrhea (child, at home). In public health facilities, records don’t match what patients came or what they reported with. Most private facilities in our sample don’t have patient records.

Symptoms Indicative of Case Presented

Symptoms Listed

SP Listed

SP VisitsTotal, 231

(100%)

Yes, 171 (74%)

Yes, 75 (32%)

Yes, 57 (25%)

No, 18 (8%)

No, 96 (42%)

No, 60 (26%)

Question: What can be done• Five asks

–Private Sector: no de facto regulation

– Informal providers without formal training

–Multiple topics

– Evaluate under and over treatment

–Costs less than $150 per provider

• Attempt training intervention, with AbhijitBanerjee and Reshmaan Hussam (MIT) and Abhijit Chowdhury (P.G. Hospital, Kolkata)

Start simple but relevant

Quality: When a patient goes to a health care provider he/she receives the correct diagnosis and treatment (could include referral) and a minimum level of guaranteed safety. He/she should not receive treatments that are not required, or worse, harmful.

Use Standardized patients: People recruited from local community and extensively trained (120 hours) by a cross-disciplinary team to depict the same medical condition to multiple providers. Debriefed with a structured questionnaire after interaction, allows to elicit whether providers did what they were supposed to and did not do what they were not supposed to

Evaluation and Design

• Multi-topic, long duration training among 304 participating providers, randomized into a treatment group (offered training) and a control group (not offered training)

– Liver Foundation, West Bengal

– 2 days a week, 4 hours a day, 9 months

– Multiple trainers, multiple approaches

• Standardized patients for asthma, angina and childhood dysentery sent 3 months after completion (6 months after topics were taught)

• Compare providers allocated to training to control group

• Compare providers in study (from 203 villages) to full census of 11 public health centers in these villages

• Implementers firewalled from evaluators

• Implementers did not know what (trained) providers would be evaluated on

Attendance

Preliminary Results from: “The Impact of Training Informal Providers on Medical Practice in West Bengal, India: A Randomized Controlled Trial”, joint with Abhijit Banerjee (MIT), Abhijit Chowdhury (PG Hospital, Kolkata and Liver Foundation) and ReshmaanHusssam (MIT)

Process outcomes• Likelihood of correct treatment for SPs increased 7-8

percentage points (Intention to treat) on base of 52%– 13-14 percentage points (Instrumental variables)

• Adherence to checklist increased by 4-7 percentage points (ITT and IV) on base of 27 percent

• No change in “things that they should not do”– Antibiotic use, polypharmacy, injection use

• 2000+ patient observations confirm more examinations and history taking

• Cost of intervention of $175 per provider could be fully recovered within 6 months as demand increased by 2 patients per day


Process Outcomes

PHC Control Treatment

Checklist - All 0.202 0.273 0.313

Correct Treatment 0.667 0.520 0.594

Average Quality Treatment 0.182 0.114 0.174

Correct Diagnosis 0.182 0.136 0.188

Consultation Length (Mins) 1.735 3.252 3.495

Gave Antibiotics 0.667 0.477 0.480

Antibiotics (Asthma and MI) 0.636 0.331 0.332

Offered injection 0.045 0.011 0.019

Treatment - Polypharmacy 2.758 2.162 2.208


Evaluation lessons

• Possible to evaluate in an RCT context a complex, long-duration, multi-topic training intervention

• One benchmark for QI as costs were $175 per provider

– 12-13 percentage point increase in correct treatment (Instrumental variables estimates)

– Closes gap with public sector in treatment, which was in 11 of 203 villages where providers came from

• Informal providers performed better on all other measures without training


Implicit assumptions in USAID programs?

• Problem has been correctly diagnosed as a front-line issue that is independent of potential policy changes or changes in institutional structure

• Public sector interventions carry over to private sector OR will shrink private sector

• Costs are sufficiently low for large and sustained scale-up within country budgets

• There is sufficient capacity and external validity for scale-up

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