The success of Dr. Madhukar Pai’s project to use simulated patient actors to assess the quality of tuberculosis care in clinics and regional health care facilities demonstrates the value of making early investments in transformative ideas.
Tuberculosis (TB) is one of the top 10 causes of death worldwide, with over 95% of deaths occurring in low- and middle-income countries. In 2015, 10.4 million people fell ill with TB, and despite tuberculosis being a curable infection, 1.8 million died – 170,000 of them children.
“Poor quality care is a major reason why TB is responsible for more deaths than malaria and HIV combined,” explained Dr. Pai, Canada Research Chair in Epidemiology & Global Health at McGill University and Director of McGill Global Health Programs. “A key piece to ending the TB epidemic – which is among the health targets of the Sustainable Development Goals – is to evaluate the quality of TB care and understand why TB patients are not being correctly diagnosed and treated.”
In 2013, Dr. Pai, and his collaborator Dr Jishnu Das from World Bank (their interdisciplinary team, called QuTUB, is pictured below), proposed using standardized patients – or “mystery patients” – to assess the quality of TB care in India, a country at the epicenter of the global TB epidemic, with half a million TB deaths annually.
Mystery patients are actors, trained to present a consistent case of illness to health providers in order to evaluate the quality of care. In one TB case, the mystery patient will walk into a clinic and explain that they have a persistent cough and fever that is not going away. If asked, the mystery patient will give every clue (e.g. weight loss, loss of appetite) that suggests TB.
With a $100,000 Stars in Global Health award in 2013 from Grand Challenges Canada, funded by the Government of Canada, Dr. Pai and the QuTUB team showed that the mystery patient method could be successfully applied to assess the quality of care for TB. Providers only figured out the mystery patients were actors in 5% of interactions, within the range of other published standardized patient studies.
In a pilot study in Delhi, 17 mystery patients were trained to present consistent tuberculosis case scenarios to 100 health providers, giving the project team 250 interactions to analyze. The study, published in the Lancet Infectious Diseases in November 2015, showed low adherence by health providers to established standards of tuberculosis care, despite markedly high levels of knowledge. Across all cases, only 21% of cases were correctly managed by either referring the patient or testing for TB. In another study published in Lancet Infectious Diseases in 2016, Dr Pai’s team revealed poor quality of TB care by pharmacists in India.
Based on promising findings from these studies, the QuTUB team received a $1.1 million grant from the Bill & Melinda Gates Foundation to conduct a large survey of the quality of TB care in the cities of Mumbai and Patna. In this study, standardized patients visited over 1,000 healthcare providers in the two cities. And that’s not all: the TB mystery patient method has now successfully been used in Kenya and China, and the QuTUB team has received additional funding from the Bill & Melinda Gates Foundation to further expand the study in India (totaling $2.4 million US) and conduct similar work in South Africa ($0.5 million US).
These studies in 3 countries have shown that most primary care providers don’t have the ability to diagnose TB – even when patients present with the exact set of symptoms that would be expected from an individual with TB. Very few of the mystery patients across all studies were referred for TB testing, and less than half were correctly managed. Combined, these studies provide important clues as to why over 4 million TB patients are ‘missing’ each year.
“Quality Improvement (QI) in TB is feasible, but efforts need to be deliberate. It’s not enough to simply increase coverage of TB care – we need to think about quality as well, and make sure all TB programs have QI integrated,” said Dr. Pai.
“I’m grateful for the early support of Grand Challenges Canada, and the Government of Canada. With their initial investment and encouragement, we conducted the first assessment of quality of care for TB using the mystery patient method. The study played an important role in demonstrating the effectiveness of the approach, and in convincing funders like the Gates Foundation.”
Dr. Pai’s success in using mystery patients to improve the quality of TB care is just one of the 90 innovations in Grand Challenges Canada’s Stars in Global Health portfolio that are scaling for impact.
Making early investments in transformational, outside-the-box ideas can play an important, catalytic role by demonstrating proof-of-concept and attracting other funding partners, paving the way to sustainably bring solutions to scale.
All publications, along with other resources on the quality of TB care, are available on the QuTUB website: https://www.qutubproject.org
For more information, watch Dr. Pai’s plenary talk at the October 2017 Conference of the International Union Against Tuberculosis and Lung Disease: