Times of India
24 March 2011
By Umesh Isalkar
Pune, India

A Study Says General Practitioners Are Not Following national Medication Plan
A Regulatory Approach Can Give Treatment at Approved Outlets Parallel mechanisms set up in private sector can help mission

The correct drug regimen, as specified in the Revised National Tuberculosis Control Programme (RNTCP), is not being followed by general practitioners thus increasing the burden of drug–resistant tuberculosis, a Mumbaibased study, published in the medical research journal Plos One, has said.

The survey, which sought responses from 106 general practitioners, including 46 allopaths and 60 others trained in alternative systems of medicine like homeopathy, ayurveda and unani, found that only six of the respondents wrote a prescription with a correct drug regimen for TB treatment.

Just three doctors among the respondents could write an appropriate prescription for treatment of multidrugresistant TB. All 106 doctors prescribed 63 different drug regimens while no practitioner wrote an intermittent drug regimen currently recommended by the RNTCP.

Experts from the department of respiratory diseases at PD Hinduja National Hospital and Medical Research Centre, Mumbai and WHO carried out the study. The findings were published in August 2010 in the journal.

The study was called Tuberculosis Management by Private Practitioners in Mumbai, India: Has Anything Changed in Two Decades? It revisited the concerns that an earlier study of the same issue at Dharavi in Mumbai in 1991 had raised. These results showed that 100 practitioners had prescribed 80 different drug regimens for treatment of TB. The study highlighted the magnitude of poor prescribing practices of private medical practitioners.

Last year's study found that little had changed in 20 years. Over half the prescriptions in the survey were still inappropriate when compared with the observations recorded in the 1991 survey.

Two factors aroused the authors' interest in exploring the change in prescribing practices by private practitioners. "First, we found an alarming trend of increasing incidence of multidrug–resistant (MDR) TB among samples sent to the laboratory at P D Hinduja Hospital. The incidence of MDR–TB among treated cases was 60 per cent. Secondly, these patients had received a significant number of irrational prescriptions prior to consulting our hospital. The need for another audit of private practitioners' prescriptions for TB seemed as pertinent as it was two decades ago," the authors said.

A poor prescribing practice is responsible for fuelling the MDR–TB cases, the study said. Over a third of respondents added a single second–line drug, a fluoroquinolone, in 70% of prescriptions. "It is not surprising that our centre reported 30% of all MTB cultures to be fluoroquinolone–resistant.

This combination of MDR and additional fluoroquinolone resistance – pre–extensively drug–resistant (XDR) TB – is a direct result of inappropriate and indiscriminate fluoroquinolone use. A majority of the prescriptions reported by the practitioners would serve only to amplify resistance," the study said.

Drug–regimen prescribing practices among general practitioners are erroneous, Pradip Gaikwad, joint director (TB) of state health services, said. "Some drugs from the second–line of medication are given to patients even before the firstline treatment is introduced, which is wrong. Over treatment and inappropriate regimen is leading to drug resistance among patients," he added.

"Strategies to control TB through the public sector health services will have little impact if inappropriate management of patients in private clinics continues. Large–scale implementation of publicprivate mixed approaches should be the programme's top priority. The study underlines the fact that ignoring the private sector could worsen the MDR and XDR forms of TB," Pradip Gaikwad, joint director (TB) of state health services, said.

The drug regimens in the RNTCP are simple to follow, Avinash Bhondwe, member of managing committee of the General Practitioners' Association, Pune branch and ex–president of IMA, said.

"Private doctors do not follow the regimen because the drugs are not available in the market. They often prescribe a different drug regimen. The difference is in how and when the medicine has to be taken. Under the Directly Observed Therapy, Short–course (DOTS) regimen, the drugs are given intermittently, whereas those prescribed in the private regimens are given daily," Bhondwe added.

Combination drugs available in market for the regimens are followed by private practitioners. Some doctors follow a five–drug regimen, while others advise a four–drug regimen. In children, a three drug–regimen is followed. Practitioners trash regimens they do not subscribe to. "Efforts to educate and orient general practitioners about following correct regimen must be made," Bhondwe said.

Did You Know?
India accounts for about one–fifth of the global burden of tuberculosis (TB). Even though there is an aggressive government–run TB eradication programme, almost 80% of patients prefer to visit private clinics Aspecific drug regimen has been prescribed in the Directly Observed Therapy, Short–course (DOTS) based programme. It has been successful in achieving global targets of detecting 70% of the estimated TB cases and curing 85% of them. DOTS is one of the planks in WHO’s global plan to eliminate TB

Multi–drug resistant TB develops during treatment of a fully–sensitive case when the course of antibiotics is interrupted and the levels of drug in the body cannot kill 100% bacteria due to inappropriate treatment, patients missing doses or incomplete treatment ACTION PLAN

The solution is to raise awareness levels among general practitioners. Sanjay Juvekar, research scientist at KEM Hospital in Pune, said, "General practitioners' knowledge and their practice is usually based on what they learn during their medical education. Very little is taught to them about the national TB programme. Other than what books on TB have, the curriculum itself must have details of diagnosis and treatment in tune with the programme. This will help doctors know the TB programme better and use this knowledge in their regular practice.

"The national TB programme must be linked to the academics and making academicians aware of the management practices. The programme strategies must be decided in consultation with academicians and not be a copy of any model WHO puts up," said Juvekar. He has been associated with a study on awareness levels among general practitioners about drug regimen

Helping Hand

• Each public sector tuberculosis unit can identify practitioners and support best–practice clinics and hospitals
• Training and orientation of practicing doctors by both RNTCP experts and private chest physicians who believe in evidencebased practice