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.

项目摘要/摘要腹泻是世界各地儿童的第二大死亡原因。这是真正的目的地可以通过简单且廉价的解决方案来预防这种死亡：口服补液盐（ORS）。私人医疗保健在低收入和中等收入国家（LMIC）中治疗大多数儿童疾病的提供者尤其是不太可能将腹泻儿童分配。取而代之的是，提供者通常不适当地分配抗生素。认识到这一重大挑战，几个国际组织（包括美国国际开发署）都投资了试图增加私营部门的ORS分配。在没有证据的情况下，为什么ORS如此不一致然而，由私人提供者分配，有几种促进私营部门分配的干预措施已经无效。显然，关键而紧迫的下一步是检查基础ORS的关键驱动力和私营部门的抗生素过度处方，以便为改善腹泻护理的努力提供帮助。在这项研究中，我们检查私营部门儿童腹泻质量不佳的几种主要解释。首先，病人 ORS替代品（例如抗生素）的偏好可能会推动ORS的处方不足。我们将确定通过让匿名标准化患者（SP）姿势作为患者偏好的因果影响（AIM 1）作为看护人患有腹泻的儿童并表达治疗的不同（随机分配）偏好（要求ORS，要求抗生素，或让提供者决定）。其次，私人提供商可能会回应经济激励措施以出售更多 ORS的盈利替代品（例如抗生素）。为了估算财务激励措施的因果影响（AIM 2），我们将指示SP的一部分通知提供者，他们可以在亲戚的药店获得折扣治疗。这取消提供商的财务动力，推荐给定治疗，并允许我们估计激励措施。最后，私人提供商可能不会直接分发OR，也可能经常有库存。估计库存的因果效应（AIM 3），我们将随机分配一半的提供商，以获得三个月的ORS供应。这会产生库存量的外源性变化，从而使我们能够隔离库存对ORS的因果影响抗生素处方。组合，（a）每个因素对处方的影响的因果估计，以及（b）人口估计每个因素的患病率，将使我们能够估计实施人口水平的影响解决每个因素的干预措施（目标4）。这项研究将为迄今为止提供最全面的证据历史上最重要的健康技术之一通常不开处方。结果将为设计旨在增加OR分配和减少抗生素分配的干预措施。如果针对此类干预措施适当地，可以挽救数百万年轻的生命。