Concordance and Discordance of Orthopedicians with Revised National Tuberculosis Control Program with Reference to Musculoskeletal Tuberculosis: A Qualitative Inquiry

Abstract

Background

Musculoskeletal tuberculosis (TB) continues to share the major burden of extrapulmonary TB. This burden up to some extent may be attributed to the implementation gap which is reasonably broadest at the level of the immediate point of care. As an orthopedic physician is an important stakeholder at this juncture, it is imperative to recognize their experiences, perceptions, and anticipations to fill this gap. This qualitative inquiry tries to explore these attributes in the context of the recent development at the policy level in Revised National Tuberculosis Control Program.

Methodology

Type of Study Qualitative inquiry with framework approach.

Settings

Orthopedic surgeons working in different work settings.

Sampling Method

Purposive sampling. An iterative topic guide for an in-depth interview was prepared by reviewing the literature and expert opinions. The questions were contextual, diagnostic, evaluative, and strategic. This study adopted a framework approach as the issue was near to evaluative and strategic policy research. The recorded interviews were transcribed and coded into axial and serial codes. A framework matrix was created and thematic mapping was done to understand the phenomena and to offer the solution framework.

Results

The investigators detected an element of unawareness of the current context coupled with the perceived previous stringency of the program. This is in conjunction with already multifaceted diagnostic and prognostic complexity. This leads to mutual dissociation and skepticism.

Conclusion

This qualitative inquiry explored an element of dissociation between programmatic objectives and individualistic concerns of the caregivers. An integrated ecosystem which may take care of synergistic reciprocation among the two is imperative for successful implementation.

Introduction

Tuberculosis (TB) continues to pose a major challenge to achieve sustainable development goal globally and in India [1]. Indian government through Revised National Tuberculosis Control Program (RNTCP) has made some significant achievement in recent years [2]. However, despite these efforts, the current programmatic indicators show a relatively little improvement in performance which indirectly endorses the requirement to rethink and reorganize the programmatic strategies [1, 3, 4].

However, the proportional morbidity in extrapulmonary tuberculosis (EPTB) especially when involving bones and joints is comparable to pulmonary TB if not even more [5]. Due to the paucity in the literature on the contribution of musculoskeletal tuberculosis (MSTB) to disability adjusted life year and impairment in the quality of life, an assumption on its impact could be drawn based on our knowledge regarding the sequelae of bone and joint TB when left untreated or when treatment is delayed [6–9]. From the epidemiological perspective, reproductive age group shares a significant portion of EPTB cases, and among the HIV positive individuals, it accounts for 40%-50% of new cases [10, 11]. To achieve any significant success toward the proposed elimination of TB, it would be naive to overlook this significant form of the disease. Accordingly, the Government of India has taken several policy decisions recently to deal with TB inclusive of EPTB. The Index TB guidelines (launched in 2016) for uniform, evidence-informed practices in EPTB may be visualized in the same direction [12]. Similarly, National Strategic Plan (2017-2025) and Aayushman Bharat also create an opportunity to receive anti tubercular medications at the point of care [13–15].

Nevertheless, it is equally important to gap the bridge between formulations and implementations to achieve the desired end result. The literature reports that one of the major reasons behind any policy breakdown is the inability to understand the requirement and expectations of those who are involved as a caregiver at the point of care [16]. The concern mentioned above is intuitive which may be linked logically further with associated factors. This linkage may lead to the emergence of “practice patterns” and allegorical reasons behind emerged patterns. This supposition indicates further that this issue is nearer to understanding the subjective perceptions/experiences and “sense making” out of the complexity which makes it suitable for qualitative inquiry. Several studies across the globe also utilized qualitative methodology to understand factors behind treatment defaults and to identify the barriers to early diagnosis and optimal care in TB from caregivers’ perspectives [17–19].

With this framework, this qualitative study was conducted with the objective of capturing the orthopedic surgeons’ (different workplace settings) experiences in diagnosing and managing MSTB and their perceptions/extent of agreements about the programmatic strategies. The idea is to identify the areas of conflicts (if any) between formulated policies and its implementation from the stance of the caregivers.

Methodology

The question under inquiry was observed nearer to “evaluative” and “strategic” where we interested to appraise the effectiveness of relationship among orthopedic surgeons and the program. We also interested to create a future plan of action in the natural world. Thus, the analysis paradigm was perceived to describe the phenomenon by looking into both concordance and discordance (if any) and then to explore the possible relationship and attributes to such structure. The key issue in this study can be typified as an applied policy issue in a relatively homogenous environment (physicians exposed to MSTB). Framework analysis was chosen as an analytical approach. The authors wanted to understand the experience of physicians (without being constrained by diagnostic categories) toward exposure to program and further how they could make sense and assigned their own meaning to this exposure. We chose the framework approach to balance depth with breadth. The potential advantage of choosing this approach lies in its ability of being independent of any epistemological privations and the capacity to accommodate the emerging themes through the database.

The investigator included four types of questions in the topic guide: contextual, diagnostic, evaluative, and strategic. Data were collected through in-depth interviews. The questions (and probes) addressed the experiences, perceptions, and expectations of orthopedicians having exposure to MSTB. The study used iterative approach for preparation of topic guide in which probes and questions were first added by deductive approach and later in the background of new emerging facts, new probes/questions were added to topic guide (inductive approach). The data thus obtained were transcribed first by Google Voice to Text Conversion facility and then corrected manually by listening to the audio tapes for any typographical error. These transcripts were read again by two investigators, and notions and clues were written as analytical notes. In the next step, the data were classified by “open coding” by three investigators independently. From this classification, investigators identified the “axial codes.” These axial codes constructed categories around the core phenomenon (experiences of caregiver with RNTCP). As per the nature of questions, the resultant categories were a mix of causal, strategic, and contextual conditions. This paradigm was used to create a working analytical framework. This framework was used to index other transcripts using a cut and paste technique. By an iterative process, this analytical framework was refined periodically during the process. The data were condensed further by creating a matrix and charting the pieces of data in the matrix. This summarization offered a consolidated description and explanation of phenomenon both as per theme (column-wise) and as per case (row-wise).

The validity and reliability of the study were preserved by following three measures: First, two out of five researchers are orthopedicians from academic settings and may have skewed preconceived notions about the issue under inquiry. This fact was neutralized by creating two separate teams from heterogeneous disciplines for in-depth interviews and for subsequent analysis. Second, investigators also incorporated views from participants having different work environments and professional commitments. Third, the whole process was systematized by making an explicitly structured decision trail before the collection of data by making of a comparison sheet for looking into the divergence and convergence of perceptual experiences. Wherever possible, investigators interpretations were supplemented by participants verbatim. After the interim analysis, a respondent validation was also done to understand the discrepancy in understanding if any.

The whole process is summarized through flowchart [Figure 1] where bidirectional arrows between some segments denote an iterative process.

Fig. 1.

Process diagram showing methodology adopted for qualitative inquiry

Results

The data after consolidation and synthesis were arranged into framework matrix first which is shown in Table 1. This matrix can be read into two directions. The rows are arranged by case where the very first column provides attributes of a specific participant (nature of working environment, controlling agency, and experience) while the other cells of the same rows show the piece of selected verbatim (statement), the derived meaning in italics, and the bracketed reference to coded source materials linked to the transcription. Vertically, this matrix can be read thematically or domain-wise manner. There themes are arranged as per natural flow of events from encounter to patents to experiential impressions with the RNTCP to permanent belief formation. Accordingly, these themes are named as underdiagnostic dilemmas (inherent issues), gray zone conflicts (clinical decision-making), prejudices and biased opinion (subjectivism), bewilderment and unawareness (unfamiliarity), and disconnection and dissociation (lack of cohesion).

Table 1.

Framework matrix

Key domains Participants	Diagnostical dilemmas	Grey Zone conflicts	Prejudices and biased opinion	Bewilderment and unawareness	Disconnection and dissociation
Participant 1 (PVPH) Private Health care provider (At Private Nursing home) Experience: 12 years	Most of the patients refuse for biopsy …. have to start ATT on clinical grounds [P4,246]	When routine lab test are not suggestive of infective pathology but there is a strong clinical suspicion and patient refuses for biopsy, then we are in a dilemma whether to start ATT or not (Quandary) [P1,39]	I prefer to treat patients myself as daily dose therapy is not given through DOTS centre (sovereignty) [P3,126]	If I sent patients to DOTS centre I will not know what happens to him after that, specifically his adherence to the treatment and if any complication develops due to disease as in pott’s spine how will DOTS centre manage it (speculative stance) [P4,259]	There is no cohesion between the DOTS centre and private practitioners [P5,287]
Participant 2 (AVMC) Government Health care provider (At govt medical college) Experience: 18 years	Many a times I am not able to find objective evidence of disease and has to start treatment on clinical grounds (objectivism versus subjective decision) [P7,356]		There are no guidelines on when to stop ATT in MST [P5,291]	I am not aware of newer guidelines, previous guidelines were inadequate (ignorance leading to determinism) [P7,385]
Participant 3 (APMC) Government Health care provider (At govt medical college) Experience: 14 years	Tissue biopsy may not be always feasible due to cost and technical difficulty (Accessibility and affordability) [P9,457]		DOTS centre will not give treatment beyond 6 month and patient will be left with incomplete treatment (projections) [P8,416]	I am not aware if patients get correct doses as per the body weight therefore I ask them to buy from private (ill–informed) [P8,409]	Sensitisation of orthopaedic fraternity in important [P9,478]
Participant 4 (ANPH) Private Health care provider (Hospital based) Experience: 12 years	Reliable non–invasive diagnostic tools are not available (diagnostic ease) [P12,598]		Patients will not get proper response from DOTS centre ATT from DOTS centre may not be of good quality (false belief) [P10,505]		There should be more workshops and practical demonstrations involving orthopaedic surgeons [P12,608]
Participant 5 (SGPC) Private Health care provider (Clinic based) Experience: 12 years	Non–invasive tests are unreliable in MST[P14,765]	What to do if TBPCR is positive but it does not appear to be tuberculosis clinically (polyarticular involvement) (real time complexity involved) [P12,623]	Patients are not given daily dose from DOTS centre[P13,655]	There are multiple guidelines on the duration of ATT in MST which keeps changing from time to time (defence mechanism) [P14,776]	Patient should have a choice as to where he wants the treatment, private or public [P13,648]
Participant 6 (SSMC)	Patients present very late [P16,786]	What to do if tissue biopsy is negative but there is a strong clinical suspicion (regression) [P15,707]	As per RNTCP, duration of ATT for MST is 6 months Patient has to visit every alternate day to collect drugs (reaction formation) [P16,798]	RNTCP is well conceived program but poorly executed (notional thinking) [P16,802]	Program should be made patient friendly so as to keep them adhered to the treatment [p17,804]
Participant 7 (RGMC) Government Health care provider (At govt medical college) Experience: 8 years	Although tissue biopsy is gold standard, it may still be not confirmatory as the disease is paucibacillary (diagnostic complexity) [P18,834]	There are no objective criteria regarding the duration of ATT in MST Except for spinal tuberculosis there are no MRI based criteria of healed disease for other MST’s (algorithmic issues) [P18,844]	RNTCP focuses only on pulmonary tuberculosis [P19,881]	The duration of treatment keeps on changing from time to time and remains ambiguous (rationalism) [P19,890]	There should be a separate strategy for MST Financial incentive may not be the right answer Internet based learning module should be prepared and link it to patient registry system [P20,991]
Participant 8 (JSMC) Government Health care provider (At govt medical college) Experience: 24 years	CDC guidelines say tissue diagnosis is necessary but index guidelines say one can start ATT on clinical grounds CBNAAT may not be available at your place and then travel becomes an issue (quandary and accessibility) [P21,1012]	What should i do with the patients who have already been started on some random ATT (multifaceted problems)) [P21,1022]	CBNAAT may not be equally effective for tissue samples because of homogenisation issues [P21,1031]	MST has never been the thrust area for RNTCP therefore I am not very much aware of recent guidelines (reaction formation) [P21,1038]	RNTCP should focus more on MST related research so that we can have evidence based guidelines like in pulmonary tuberculosis
Participant 9 (PKMC) Government Health care provider (At govt medical college) Experience: 9 years	Non–invasive test like TBPCR are expensive in private (cost concerns) [P22, 1153]		DOTS do not cover farfetched areas Treatment is not properly monitored in DOTS centre (Pseudo–rationalistic attitude) [P22,1166]	Patients of MST are often in distress and I don’t know if they will be given proper and timely care in DOTS centre (scepticism) [P23,1246]	Patients should be sent back to treating orthopaedic surgeon for evaluation before contemplating end of ATT Details of all DOTS centre including a contact number of responsible personnel should be made available to us so that we can get in touch with them if there is any problem with the treatment [P24,1382]
Participant 10 (MPPH) Private Health care provider (Hospital based) Experience: 15 years	It is often difficult to convince patient for tissue biopsy (acceptance by patient) [P24,1373]		Patient will not get ATT for longer duration needed in MST (denial) [P23,1346]	Cost of treatment is high therefore patients are lost to follow-up I am not aware of the newer guidelines [P24,1382]	It would be appreciable if we get a feedback of the referred patient (compliance, outcome of treatment) [P25,1399]
Participant 11 (NBPH) Private Health care provider (Hospital based) Experience: 16 years	Although tissue diagnosis is imperative, given an option patient usually do not agree for tissue biopsy [P26,1498]	Immune status decides when the disease will heal so fixed duration treatment may not be right How do you decide that the disease is completely healed (prognostic predicament) [P25,1446]	There are lot of stories floating around that the drugs form DOTS centre may be of substandard quality (pseudo–rationalisation) [P25,1456]	I do not stop people from taking treatment through DOTS centre but I ask them to take medicines in correct dose and of reasonable good quality (Defence) I am not aware of any lab services from RNTCP [P26,1523]	There is so much emphasis on disseminating knowledge to public, doctors should be made aware of guidelines through workshops and lectures as you never get time to read print guidelines (parallel arguments) [P27,1586]
Participant 12 (ASPH) Private Health care provider (Hospital based) Experience: 18 years	Tissue biopsy can be financially challenging for poor patients in private institutes (empathetic concern) [P28,1619]		How will a patient who are bed ridden due to pott’s spine go to DOTS centre to collect drugs (empathetic concern) (defensive attitude) [P27,1613]		Patient registry system should be improved so that we can know the final treatment outcome [P28,1667]

Investigators further arranged the key characteristics of transcribed data (derived through analytical framework and matrix) into a thematic diagram which is shown in Figure 2. This diagram divides the detected issues pertaining to MSTB into three broad domains—innate element of diagnostic and prognostic uncertainty in MSTB, unawareness among the caregiver leading to idiosyncratic opinions, and perceived inflexibility for MSTB in RNTCP. All three domains interact at physician–patient interface with limited opportunities for communications and sharing. The resultant subjectivism and skepticism prevail, and with the accumulation of such distorted experiences, the gap of distrust becomes wider.

Fig. 2.

Thematic diagram

Discussion

The optimal decision-making in the best interest of a patient has always been a complex issue. The nonlinear interaction of several factors in the psychobehavioral and environmental planes makes it difficult to come at an optimal decision. Understanding these phenomena is imperative for any population-based intervention strategy to achieve the desired outcome. However, identifying and understanding these factors and phenomena need an unconventional approach rather than by simple deterministic rules. In the current study, we tried to understand and evaluate the orthopedic surgeon’s perception regarding the diagnostic dilemma, treatment guidelines, and incoherence between a healthcare provider and programmatic guidelines in cases of bone and joint TB. Interviewees expressed their diagnostic dilemma when confronted with a suspected case of MSTB.

Difficulty in obtaining tissue samples due to the invasive nature of MSTB, patient’s reluctance, cost involved, and lack of resources along with the uncertainty surrounding the efficacy and reliability of noninvasive diagnostic modalities were some of the reasons cited for diagnostic dilemma by the majority of the participants. The inherent nature of the disease, such as late radiological appearance and difficulty in obtaining tissue samples for PCR-based tests such as Xpert MTB/RIF [12], warrants the need of an magnetic resonance imaging (MRI) for early detection and assessing the extent of disease [9]. However, in a low-resource setting like India, the availability and accessibility to diagnostic modalities like MRI are scarce and in turn increase the patient costs. Moreover, the extent of disease is a complex individualized outcome of the product of virulence of the organism with the variable immunological status. Hence, a conducive macroenvironment embedded in resource allocations, research, and capacity building is required.

Looking from the treatment perspective, there appears to be a lack of consensus on what constitutes healed status of the disease in the literature [12, 20]. Due to the paucity of convincing evidence, the decision on optimal drug combination and duration of therapy remains ambiguous and usually driven by an individual’s past knowledge and experiences, leading to variable and suboptimal treatment. It is a welcome sign that in India, a new guideline for the treatment of EPTB has been developed through a collaborative effort between all the stakeholders [12], but its comprehensiveness in bone and joint TB seems inferior compared to other EPTB. This may be the reason for the reported “skepticism” in this study. The technical advisory committee performed a brief review regarding the duration of treatment in bone and joint TB, but a systematic review was not performed [12].

Multiple suggestions were received to improve awareness about newer programmatic guidelines. An orthopedic surgeon with 13 years of experience working in a corporate hospital said:

“There is so much emphasis on disseminating knowledge to the public, doctors should be made aware of guidelines through workshops and lectures as you never get time to read print guidelines.” – P12, 632

Academic platforms such as national, state, and city orthopedic meetings can be utilized for the dissemination of current guidelines and strategy. Internet-based modules can be prepared which on completion can be linked to Medical Council of India (MCI) credit points or a certification. The success and acceptance of case-based modules on TB in training of healthcare providers have been well demonstrated in Africa [21–24]. However, this avenue of the capacity building remains unexplored and unutilized in the Indian context. The integration of case-based training modules into the existing web-based portal for TB (NIKSHAY) provides a viable solution for the better quality of care and capacity building.

In this day and age of information technology, social media plays a huge role in the dissemination of information and may be used to help not only in updating the knowledge of the healthcare providers but also in bringing the community together. For instance, the social media campaign by the Indian Orthopaedic Association, an official body of orthopedic surgeons in India appealed for free surgeries (one member one free surgery) on bone and joint day celebration in 2016, resulted in 1374 free surgeries done across 24 states in 3 days [25].

An orthopedic surgeon working in an academic institute commented that:

“Financial incentive may not be the right answer, more correct approach would be an internet-based brief training module to be completed by every treating doctor in which objective criteria of diagnosis and management should be put up and most of us will stick to it.” – P16, 790

Incentivization in health sector reform has only been looked through limited channels (financial). Studies suggest that addressing multiple channels for worker motivation such as appreciation and recognition may positively affect the organizational culture, reporting structures, and human resource management [26–29]. As reported in this study, orthopedic surgeons do not consider monetary incentive to be a driving force for better participation; rather appreciate an acknowledgment of the work. Since the majority of health services in India are provided by the private sector, there are a dire need of their inclusion into the mainstream program and an establishment of a reciprocating relationship to maintain the continuum of care. Private practitioners who wish to work in collaboration with RNTCP may be offered performance-based incentives in different forms such as “significant contributor” status or official rating. The incitement should be dynamic enough to commensurate with the contribution made.

The importance of an orthopedic surgeon undoubtedly holds a paramount position in the treatment of an MSTB patient. Apart from his/her visible contribution in the diagnosis and management of such cases, there seems to be a very imperative role to ensure the adherence to the prescribed treatment. As the adherence to treatment is also influenced by several clinical, social, macroenvironmental, and individual factors, an orthopedician (being a primary caregiver and holding the trust of the patient) may always turn these factors for the maximum beneficence of the patient. The patient support strategies under the RNTCP should embrace the importance of the orthopedic surgeon in achieving the desired outcome, taking into account the complex nature of disease presentation, progression, and outcome of bone and joint TB as there is a chance of lifelong morbidity despite the disease being healed.

The investigators propose to include all the “thematic solutions” offered through this study within the existing system ensuring sustainability of the intervention. For this purpose, all these solutions may be integrated with the existing web-based notification system (NIKSHAY) introduced by the RNTCP. We propose a solution framework as to how these interventions may be delivered through NIKSHAY [Figure 3]. NIKSHAY has huge potential in becoming a one-stop solution for integrated action on TB in India providing both support and training to healthcare providers and policymakers alike.

Fig. 3.

Solution framework

Apart from the unique ability of this framework to utilize information technology, this model also offers a potential opportunity to nurture public–private partnership. Considering the huge burden of TB in India, it would be difficult for any one entity (public sector or private sector) to deal with the situation on their own. Inevitably, a model based on public–private partnership may the potential recourse. However, policymakers must take an unconventional out-of-the-box approach, take into consideration the factors and phenomena identified, and involve the stakeholders in the decision-making process so as to have a program that is uniform and acceptable to all concerned.

Conclusion

This study attempts to understand this phenomenon in its clinicosocial context. Healthcare delivery systems (like RNTCP) operate in a complex nonlinear world where all the involved stakeholders may perceive the phenomenon as per their experiences and understanding of reality. This ingrained complexity in the question under inquiry made it ideal to explore it through a qualitative methodology. The outcome of this study may be assimilated in terms of generation of a hypothesis in reference with interconnectedness (as sensed by investigators) amongst the epistemic clinical uncertainties, individualistic psychobehavioral attributes, and macroenvironment influences and how this interconnectedness may influence both positively and negatively the conception and implementation of any en masse interventional strategy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.