Sunday, 23 March 2014

Undercover patients reveal poor standards of care in rural clinics

by Michael Woodhead
Rural health clinics provide poor medical care because the clinicians working in them have inadequate training, little equipment and poor working practices, a study based on sending 'undercover' patients has revealed.
Researchers at Shaanxi Normal University tested the quality of  care provided at village and township health clinics by measuring the responses to undercover patients who had been trained to mimic patients with angina or dysentery.
In an analysis of the content of  72 patient visits to 36 different clinics, the quality of the consulation was found to be very poor. The average length of each consultation was seven minutes, but only one and a half minutes was spent interacting with the patients - most of the time was spent writing prescriptions.
The village doctors made a correct diagnosis in only 26% of the consultations and were completely wrong in 41% of interactions. The most common incorrect diagnoses were ‘indigestion’ for the dysentery patients and ‘sprain’ for the angina patients.
Village clinicians asked less than 20% of the recommended questions for the health condition and  performed only 15% of the necessary examinations for the condition. Most of the questions were focused on prescribing a medicine. For the patients with chest pain, clinicians did not ask the crucial question about whether pain was radiating, and only 11% measured blood pressure.
Rural clinicians were poorly equipped to deal with conditions such as heart attack. For heart problems,  less than half said  they had the necessary equipment to treat moderate cases. Most had a stethoscope and blood pressure measuring equipment, but few clinics had an ECG monitor.
Medications were prescribed in 75% of consultations, but they were either unnecessary or harmful 64% of the time. The village clinicians often failed to refer serious cases, even when they got the diagnosis right.
The average cost to the patient was between 10 and 15 yuan, with most of this cost being for medicines prescribed.
Only 20% of the village clinicians had completed high school and most had only a rural physician certificate as a qualification. Most of their income was made from selling drugs or devices, with only only 351 yuan per their monthly income of 1355 yuan not coming from sales.
The researchers said it was clear that rural clinicians were not yet ready to act as the front line fighters in China’s primary care system.
"If recent reforms that expand access to rural health care are to lead to actual gains in population health, more attention should be paid to improving the quality of care delivered by the rural health system," they said.
"China has recently made enormous strides in providing access to health care for rural residents; however, efforts focused on improving the quality of care delivered by grassroots providers will be essential for reforms to lead to actual gains in health."
The findings are published in Health Policy and Planning.

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