"Before Xpert I only had my expertise": A qualitative study on the utilization and effects of Xpert technology among pediatricians in 4 Indian cities
"Before Xpert I only had my expertise": A qualitative study on the utilization and effects of Xpert technology among pediatricians in 4 Indian cities
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DOI：
10.1371/journal.pone.0193656
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发表时间：
2018-03-16
期刊：
影响因子：
3.7
通讯作者：
Denkinger, Claudia M.
中科院分区：
文献类型：
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作者：
McDowell, Andrew;Raizada, Neeraj;Denkinger, Claudia M.
背景儿童结核病的诊断具有相当大的挑战性。Xpert(R)MTB/RIF(‘Xpert’)是一种灵敏度和特异度高的快速分子检测方法，按照印度修订后的国家结核病控制计划(RNTCP)的建议，对儿童推定结核病患者进行Xpert(R)MTB/RIF(‘Xpert’)预先检测，可以为早期结核病诊断铺平道路。作为创新新诊断基金会(FIND)正在实施的一个项目的一部分，该项目致力于为寻求公共和私营部门护理的儿童提供前期免费(FOC)Xpert检测，旨在了解国家结核病诊断指南和Xpert技术如何被整合到不同医疗保健提供者的儿科结核病护理实践中。方法我们对印度4个主要城市参与正在进行的儿科项目的公共和私营部门的卫生保健提供者进行了半结构化访谈。提供者是从基于实践部门、XPERT转诊数量和转诊中的结核病检测率的干预数据中抽样的。共有55家供应商接受了不同水平的FOC Xpert测试。数据由一位医学人类学家利用主题内容分析和叙事分析进行转录和归纳分析。结果观察到，尽管RNTP对Xpert的使用提供了指导，Find和州当局也做出了巨大努力来传播这些指南，但不同的医疗保健提供者在执行这些指南时存在显著差异。Xpert除了如预期的那样被用作儿童的第一个诊断试验外，还被不同地用作初步筛查试验(以排除结核病)、确证试验(一旦根据抗生素试验或临床确定结核病诊断)和/或仅在确诊结核病诊断后用于药敏试验。大多数使用Xpert的提供者经常报告说，Xpert是管理儿童结核病病例的重要工具，它减少了仅因临床怀疑而被诊断的病例比例，并预先提供了儿童很少被怀疑的耐药性信息。尽管非标准使用，这些结果表明Xpert Access有助于提高认识，帮助抗生素管理，并减少对儿童结核病诊断和治疗的依赖。结论为所有推定的儿科结核病患者提供免费和快速的Xpert检测，对儿科医生诊断和治疗结核病产生了多重积极影响。它对结核病治疗初学者的诊断速度、经验性治疗和耐药意识有重要影响。此外，我们的研究表明，获得公共部门的XPERT机器可能是鼓励公私一体化和促进患者从私营部门转移到公共部门进行抗结核病治疗的重要方式。尽管有快速免费的Xpert测试，但我们的研究显示，随着时间的推移，不同提供商之间Xpert使用策略的多样性令人担忧，这些提供商可能正在转向建议的实践。这里报告的儿童结核病诊断方法的多样性程度突出表明，迫切需要共同努力，将Xpert早期应用于诊断算法，以积极影响儿科结核病护理途径。随着持续的宣传、时间和更多的机会，诊断算法的积极变化是可能的。
BackgroundDiagnosing tuberculosis (TB) in children presents considerable challenges. Upfront testing on Xpert (R) MTB/RIF ('Xpert')-a rapid molecular assay with high sensitivity and specificity- for pediatric presumptive TB patients, as recommended by India's Revised National Tuberculosis Control Program (RNTCP), can pave the way for early TB diagnosis. As part of an ongoing project implemented by Foundation for Innovative New Diagnostics (FIND) dedicated to providing upfront free-of-cost (FOC) Xpert testing to children seeking care in the public and private sectors, a qualitative assessment was designed to understand how national guidelines on TB diagnosis and Xpert technology have been integrated into the pediatric TB care practices of different health providers.MethodsWe conducted semi-structured interviews with a sample of health providers from public and private sectors engaged in the ongoing pediatric project in 4 major cities of India. Providers were sampled from intervention data based on sector of practice, number of Xpert referrals, and TB detection rates amongst referrals. A total of 55 providers were interviewed with different levels of FOC Xpert testing uptake. Data were transcribed and analyzed inductively by a medical anthropologist using thematic content analysis and narrative analysis.ResultsIt was observed that despite guidance from RNTCP on the use of Xpert and significant efforts by FIND and state authorities to disseminate these guidelines, there was notable diversity in their implementation by different health care providers. Xpert, apart from being utilized as intended, i.e. as a first diagnostic test for children, was utilized variably-as an initial screening test (to rule out TB), confirmatory test (once TB diagnosis is established based on antibiotic trial or clinically) and/or only for drug susceptibility testing after TB diagnosis was confirmed. Most providers who used Xpert frequently reported that Xpert was an important tool for managing pediatric TB cases, by reducing the proportion of cases diagnosed only on clinical suspicion and by providing upfront information on drug resistance, which is seldom suspected in children. Despite non-standard use, these results showed that Xpert access helped raise awareness, aided in antibiotic stewardship, and reduced dependence on clinical diagnosis among those who diagnose and treat TB in children.ConclusionAccess to free and rapid Xpert testing for all presumptive pediatric TB patients has had multiple positive effects on pediatricians' diagnosis and treatment of TB. It has important effects on speed of diagnosis, empirical treatment, and awareness of drug resistance among TB treatment naive children. In addition, our study shows that access to public sector Xpert machines may be an important way to encourage Public-Private integration and facilitate the movement of patients from the private to public sector for anti-TB treatment. Despite availability of rapid and free Xpert testing, our study showed an alarming diversity of Xpert utilization strategies across different providers who may be moving toward suggested practice over time. The degree of diversity in TB diagnostic approaches in children reported here highlights the urgent need for concerted efforts to place Xpert early in diagnostic algorithms to positively impact the pediatric TB care pathway. A positive change in diagnostic algorithms may be possible with continued advocacy, time, and increased access.