What Drives Poor Care for Child Diarrhea?: A Standardized Patient Experiment

是什么导致儿童腹泻护理不善？：标准化患者实验

• 批准号: 10220964
• 负责人: Zachary Wagner
• 金额: $ 53.21万
• 依托单位: RAND CORPORATION
• 依托单位国家: 美国
• 财政年份: 2020
• 资助国家: 美国
• 起止时间: 2020-08-01 至 2024-06-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10220964
• 关键词: Address; Antibiotics; Automobile Driving; Awareness; Caring; Cause of Death; Cessation of life; Child; Child Care; Childhood; Data; Diarrhea; Enrollment; Hand; Health Personnel; Health Technology; Incentives; India; International; Intervention; Knowledge; Medical; Methods; Oral; Patient Preferences; Patients; Pharmaceutical Preparations; Population; Prevalence; Private Sector; Privatization; Provider; Public Sector; Quality of Care; Randomized; Recommendation; Recording of previous events; Rehydrations; Research; Salts; Side; Standardization; USAID; Variant; Visit; arm; care seeking; design; effective intervention; experimental study; financial incentive; improved; low and middle-income countries; preference; prevent; therapy design; work-study

PROJECT SUMMARY/ABSTRACT Diarrhea is the second leading cause of death for children around the world. This is true despite the fact that nearly all such deaths could be prevented with a simple and inexpensive solution: oral rehydration salts (ORS). Private health care providers, who treat the majority of childhood illness in low- and middle-income countries (LMICs), are particularly unlikely to dispense ORS to children with diarrhea. Instead, providers often dispense antibiotics inappropriately. Recognizing this significant challenge, several international organizations (including USAID) have invested heavily in trying to increase ORS dispensing in the private sector. In the absence of evidence on why ORS is so inconsistently dispensed by private providers, however, several interventions to promote private sector ORS dispensing have been ineffective. Clearly, a critical and urgent next step is to examine the key drivers of underprescription of ORS and overprescription of antibiotics in the private sector in order to inform efforts to improve diarrhea care. In this study, we examine several leading explanations for poor quality of care for child diarrhea in the private sector. First, patient preferences for ORS alternatives (e.g., an antibiotic) could be driving underprescription of ORS. We will identify the causal effect of patient preferences (Aim 1) by having anonymous standardized patients (SPs) pose as caretakers of children with diarrhea and express different (randomly assigned) preferences for treatment (ask for ORS, ask for antibiotics, or let provider decide). Second, private providers could be responding to financial incentives to sell more profitable alternatives to ORS (e.g., an antibiotic). To estimate the causal effect of financial incentives (Aim 2), we will instruct a subset of SPs to inform providers that they can get discounted treatments at a relative’s drug shop. This eliminates the provider’s financial incentive to recommend a given treatment and allows us to estimate the effect of such incentives. Finally, private providers might not directly distribute ORS or could have frequent stock-outs. To estimate the causal effect of stock-outs (Aim 3), we will randomly assign half of the providers to receive a three-month supply of ORS. This generates exogenous variation in stock outs and thus enables us to isolate the causal effect of stock outs on ORS and antibiotic prescribing. Combining, (a) causal estimates of the impact of each factor on prescribing, and (b) population estimates of the prevalence of each factor, will allow us to estimate the population level impact of implementing interventions that address each factor (Aim 4). This study will provide the most comprehensive evidence to date on why one of the most important health technologies in history is often not prescribed. The results will inform the design of interventions aimed at increasing ORS dispensing and reducing antibiotic dispensing. If such interventions are targeted appropriately, millions of young lives could be saved.

项目摘要/摘要 腹泻是世界各地儿童死亡的第二大原因。这是真的，尽管几乎所有 这种死亡可以通过一种简单而廉价的解决方案来预防：口服补液盐(ORS)。私营医疗保健 在低收入和中等收入国家(LMIC)治疗大多数儿童疾病的提供者尤其 不太可能给腹泻的儿童分发口服避孕药。取而代之的是，供应商经常不适当地分发抗生素。 认识到这一重大挑战，几个国际组织(包括美国国际开发署)在 努力增加私营部门的口服避孕药配药。在没有证据表明为什么ORS如此不一致的情况下 然而，由私营提供者分发的几项促进私营部门ORS分发的干预措施 效果不佳。显然，关键和紧迫的下一步是检查口服避孕药处方不足的关键驱动因素和 在私营部门过度使用抗生素，以便为改善腹泻护理提供信息。在这项研究中，我们 研究私营部门对儿童腹泻护理质量差的几个主要解释。第一，病人 对口服避孕药替代品(例如抗生素)的偏好可能是导致口服避孕药处方不足的原因。我们将确定 患者偏好的因果效应(目标1)：让匿名标准化患者(SP)伪装成 患有腹泻的儿童并表达不同的(随机分配的)治疗偏好(要求ORS，要求 抗生素，或让供应商决定)。其次，私营供应商可能会对出售更多产品的财务激励做出反应 ORS的有利可图的替代品(例如，抗生素)。为了评估财务激励的因果效应(目标2)，我们将 指示SPS的一个子集通知提供者，他们可以在亲戚的药店获得折扣治疗。这 消除了提供者推荐特定治疗的财务激励，并允许我们估计这种治疗的效果 激励措施。最后，私营供应商可能不会直接分销ORS，或者可能经常缺货。要估计 缺货的因果影响(目标3)，我们将随机分配一半的供应商获得三个月的ORS供应。 这产生了缺货的外生变化，从而使我们能够隔离缺货对ORS和ORS的因果影响 开抗生素处方。合并，(A)对每个因素对处方的影响的因果估计，和(B)人口 对每个因素流行率的估计，将使我们能够估计实施 针对每个因素的干预措施(目标4)。这项研究将提供迄今为止最全面的证据来解释为什么 历史上最重要的健康技术之一往往没有处方。结果将为设计提供参考 旨在增加口服补液剂调剂和减少抗生素调剂的干预措施。如果这种干预是有针对性的 适当地，数以百万计的年轻生命可以被拯救。