“Before Xpert I only had my expertise”: A qualitative study on the utilization and effects of Xpert technology among pediatricians in 4 Indian cities

Abstract

BackgroundDiagnosing tuberculosis (TB) in children presents considerable challenges. Upfront testing on Xpert® 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 strat...

A prospective study evaluating the impact of cartridge-based nucleic acid amplification test (CBNAAT) on the management of tuberculosis in a low-resource high-burden Indian rural setting

“…It can also ensure new clinicians have confidence in the diagnosis, where a patient moves between health providers. [ 17 ]…”

“…In a recent study spanning four Indian cities, clinicians were interviewed to explore their perspectives on the utility of CBNAAT in children with presumptive TB. [ 17 ] Interestingly, despite CBNAAT being made available free of cost, clinicians diverged in various ways from RNTCP guidance that recommends its use “upfront” as a replacement for smear in children. Instead, some clinicians reported using CBNAAT only after Mantoux and chest X-ray were suggestive; others used it post-smear and in some cases CBNAAT was used only after a trial of empirical treatment.…”

New Machine, Old Cough: Technology and Tuberculosis in Patna

“…I thank Stefan Ecks for this point who has written on this issue (Ecks, 2004(Ecks, , 2013. 7 For another example of how different cities with their own particular arrangement of actors and network produce different reactions to GeneXpert, please see McDowell et al (2018). the overworked and underpaid field officers) were tied to not just GeneXpert utilization but also positive diagnosis yielded by that new piece of technology.…”

“…It must also be mentioned that this was specific to the landscape of Patna; other cities where the multiple actors have a different relation to each other have resulted in a different pattern on how GX is used. For example, seeMcDowell et al (2018) for how GX was utilized by informal providers in Mumbai.Frontiers in Sociology | www.frontiersin.org…”

New technologies in microbiology and their potential impact on paediatric practice

“…In a study carried out in India, the degree of diversity in TB diagnostic approaches reported in children, the author highlights an urgent need for concerted efforts to place GeneXpert early in diagnostic algorithms. This would improve speed of diagnosis, empirical treatment and awareness of drug resistance among TB treatment-naive children 24…”