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

基本信息

批准号：
10649723
负责人：
Zachary Wagner
金额：
$ 38.4万
依托单位：
RAND CORPORATION
依托单位国家：
美国
项目类别：
财政年份：
2020
资助国家：
美国
起止时间：
2020-08-01 至 2025-06-30
项目状态：
未结题

项目摘要

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.

项目概要/摘要腹泻是世界各地儿童的第二大死亡原因，尽管事实上几乎所有儿童都患有腹泻。可以通过一种简单且廉价的解决方案来预防此类死亡：口服补液盐（ORS）。治疗低收入和中等收入国家 (LMIC) 大部分儿童疾病的医疗服务提供者尤其相反，提供者不太可能向腹泻儿童发放 ORS。认识到这一重大挑战，一些国际组织（包括美国国际开发署）已投入巨资在缺乏证据说明 ORS 为何如此不一致的情况下，试图增加私营部门的 ORS 配发。然而，一些促进私营部门 ORS 分配的干预措施已经显然，下一步关键且紧迫的步骤是检查 ORS 处方不足的关键驱动因素和私营部门抗生素处方过量，以便为改善腹泻护理的努力提供信息。研究私营部门儿童腹泻护理质量差的几种主要解释首先，患者。对 ORS 替代品（例如抗生素）的偏好可能会导致 ORS 处方不足。通过让匿名标准化患者 (SP) 冒充患者的看护者来观察患者偏好的因果效应（目标 1）患有腹泻并表达不同（随机分配）治疗偏好的儿童（要求 ORS、要求抗生素，或者让供应商决定）其次，私人供应商可能会响应财政激励措施来销售更多产品。 ORS 的盈利替代品（例如抗生素）为了估计经济激励的因果效应（目标 2），我们将指示一部分 SP 告知提供者他们可以在亲戚的药店获得折扣治疗。消除了提供者推荐特定治疗的经济动机，并允许我们估计这种治疗的效果最后，私营供应商可能不会直接分配 ORS，或者可能会频繁缺货。由于缺货的因果影响（目标 3），我们将随机分配一半的供应商接收三个月的 ORS 供应。这会产生缺货的外生变化，从而使我们能够隔离缺货对 ORS 和结合 (a) 每个因素对处方影响的因果估计，以及 (b) 人群对每个因素的普遍性的估计，将使我们能够估计实施措施对人口水平的影响针对每个因素的干预措施（目标 4）本研究将提供迄今为止最全面的证据来说明原因。历史上最重要的健康技术之一往往没有规定，其结果将为设计提供依据。如果此类干预措施具有针对性适当地，可以挽救数百万年轻的生命。