Tweaked pharmacy referral model increases TB case-finding in Patna


Tweaking the existing pharmacy referral system in Patna brought huge benefits. Instead of referring symptomatic TB patients to doctor for consultation, referring them for an X-ray before consulting a doctor increased the referral rate by 62 times and increased TB diagnosis 25 times.

By slightly changing the way private pharmacies help people with symptomatic TB to get diagnosed early and start treatment, McGill University researchers have been able to increase the rate of referral 62 times and increase TB diagnosis 25 times. Of the 1,674 persons with TB symptoms who were referred by pharmacies, 255 were diagnosed with TB.

The pilot study, which was riding piggyback on an existing TB intervention public-private programme (Universal Access to TB Care or UATBC) in Patna, involved 105 pharmacies and was carried out between December 2015 and June 2017. The UATBC programme was operated through World Health Partners.

Shortcoming of the old system

One of the shortcomings of the UATBC programme, which was meant to improve referral, testing and treatment for TB, was that pharmacies were required to refer patients to a doctor or a direct observation of treatment (DOT) centre. Testing for TB was only after completing doctor consultation. This meant that patients had to pay doctor consultation fee before being tested for TB, which led to fewer people consulting a doctor.

“Besides consultation fee that people had to pay, there was no incentive for pharmacies to send symptomatic TB patients to doctors. Patients too wanted immediate resolution and there was fear and stigma of TB among people. All these led to fewer people consulting a doctor and getting diagnosed,” says Dr. Amrita Daftary from McGill University and first author of a paper published in the journal BMJ Global Health.

Tweaking the model

To increase pharmacy referrals, the researchers tweaked the model. Instead of directly referring patients to doctors, 105 pharmacies were asked to first refer symptomatic TB patients for an X-ray followed by doctor consultation. Children, pregnant mothers, and those with recent history of TB were still asked to consult a doctor directly. All the 105 pharmacy providers were trained by the researchers.

About 700 pharmacies that were not included in the pilot programme served as the control group.

The researchers found stark differences between the intervention and control groups. In the intervention group, 86% of 1,529 patients referred by a pharmacy underwent a chest X-ray and 96% of 809 patients referred to a doctor completed the consultation. In contrast, in the control group, only 54% referred to a doctor without undergoing a chest X-ray completed consultation.

It was also found that in the intervention group, 66% with abnormal X-ray consulted a doctor compared with just 39% when the X-ray was normal.

“Of the 1,674 persons identified with symptoms and referred by pharmacies, 255 were diagnosed with TB. TB diagnosis in the intervention group was 25 times higher than the control group,” says Dr. Daftary. Also, in the intervention group, 24% were microbiologically confirmed for TB while in the control group it was only 11%. “So it’s a win-win situation for all — pharmacies, patients and doctors,” she says.

Microbiological confirmation shot up

“Microbiological testing for TB bacteria is a confirmatory test. Patients who went through the pharmacy referral pathway were much more likely to have TB microbiologically confirmed,” she says. “The reasonable guess we can make for the higher microbiologically confirmed cases is that sputum is the only test left for doctors to ask for especially when the X-ray is suggestive of TB.”

Pharmacies received Rs.100 as incentive if a referred person completes chest X-ray and another Rs.200 if the referred person is diagnosed with TB. “In our study, the approximate cost incurred to detect one TB case is just $100 which would be considered cost-effective per TB case detected in India,” says Daftary.

In India, pharmacies are the first point of medical contact for about 40% of people with TB symptoms and 25% of patients already diagnosed with TB continue to seek advice from pharmacies. Hence targeting pharmacies becomes particularly important to identify new cases and cut the delay in seeking medical attention.

Published in The Hindu on May 18, 2019