Table 3. Evaluation of private practitioners' practices and concordance with the International Standards for TB Care, Chennai, India.
| Concordance with ISTC n(%) | ||||||
|---|---|---|---|---|---|---|
| Practitioner Level of Training | ||||||
| International Standards for TB Care | Mechanism for evaluation | All (n = 228) | Chest Physicians (n = 39) | Other MD/MS (n = 108) | MBBS (n = 81) | P**° |
| Diagnostic Practices | ||||||
| ISTC 1: Evaluation of cough lasting ≥2 weeks to suspect TB | Sends >5% patients with cough >2 weeks for lab testing | 93 (52) | 23 (73) | 38 (44) | 32 (53) | 0.77 |
| ISTC 2: Evaluation of sputum specimens for those with CXR findings suggestive of TB | Uses smear and chest x-ray for PTB diagnosis | 185 (81) | 35 (90) | 89 (82) | 61 (75) | 0.09 |
| ISTC 3: Assessment of ≥2 sputum specimens for microbiological examination | Uses smear for PTB | 188 (83) | 36 (92) | 91 (84) | 61 (75) | 0.04° |
| ISTC 4: Examination of appropriate specimens (and diagnostic tests) for presumptive EP TB | Uses biopsy/FNAC to obtain specimens for EP-TB diagnostic testing | 150 (66) | 34 (87) | 80 (74) | 36 (44) | <0.001° |
| ISTC 5: Diagnosis of smear-negative TB based on bacterial culture or molecular testing | Uses culture or Xpert MTB/RIF for TB diagnosis | 57 (25) | 25 (64) | 16 (15) | 16 (20) | 0.17 |
| Treatment and Management Practices | ||||||
| ISTC 8: Treatment with 2HRZE and 4HR fixed doses for new TB patients*†Ŧ | Regimen of H, R, and either Z or E for 6–8 months for hypothetical patient with new PTB | 125 (78) | 20 (54) | 67 (87) | 38 (83) | 0.41 |
| ISTC 9: Patient-centered approach to treatment; includes DOTS for treatment administration | Supported treatment via RNTCP, PPM, or PPM Community DOTS reported for PTB | 92 (40) | 3 (8) | 39 (36) | 50 (62) | <0.001° |
| ISTC 10: Assessment of patient response to therapy for pulmonary TB with sputum microscopy | Performs treatment monitoring using smear, culture, or Xpert MTB/RIF | 76 (33) | 27 (69) | 23 (21) | 26 (32) | 0.77 |
| ISTC 11: Drug-resistance testing using molecular tests and/or bacterial culture based on patient history and risk factors | Assesses MDR based on appropriate risk factors | 43 (19) | 29 (74) | 8 (7) | 6 (7) | <0.001° |
| Addressing HIV Infection and other Co-morbid Conditions | ||||||
| ISTC 14: HIV testing and counseling recommended to all patients with suspected TB | Performs HIV testing done Always or Often for TB patients | 87 (38) | 25 (64) | 34 (32) | 28 (35) | 0.41 |
| Standards for Public Health | ||||||
| ISTC 21: All providers must report TB cases and treatment outcomes to public health authorities. | Reports notifying TB cases to RNTCP in the past year | 49 (22) | 16 (41) | 16 (15) | 17 (21) | 0.89 |
| Mean ISTC score, mean(SD)**Ŧ | Sum out of 10 standards evaluated | 4.5 (1.9) | 6.5 (2.0) | 4.0 (1.5) | 4.1 (1.8) | 0.03° |
*Abbreviations used: Smear, sputum smear microscopy; PTB, pulmonary TB; EP-TB, extrapulmonary TB; FNAC,fine needle aspiration cytology; DOTS, directly observed therapy short course.
**Pearson's chi-squared (or Fisher's exact) test for categorical variables comparing chest physicians plus other MD/MS practitioners versus MBBS practitioners in the private sector; mean ISTC score assessed using linear regression.
°Remains significant risk factor (P≤0.05) for ISTC adherence comparing practitioner level of training after adjustment for sex, years practicing, facility type, and total patient volume.
†H = isoniazid, R = rifampicin, Z = pyrazinamide, and E = ethambutol, irrespective of whether the regimen was daily or intermittent.
Ŧ Data for 68 private practitioners who refer all patients with TB for treatment were excluded from evaluation for ISTC8. This standard was excluded from the calculation of the ISTC score.