Why cheap and effective diarrhea treatments are underutilized

“The gap between knowing the right thing and doing the right thing is a deep problem,” said David Levine, a health economist at the University of California, Berkeley. That gap is highlighted by research published today. science¹.

Each year, 500,000 children under the age of 5 die from diarrhea worldwide. However, doctors and pharmacists often do not prescribe inexpensive, life-saving treatments for this condition. A large study in India suggests that this happens because prescribers believe that patients do not want the treatment.

Most practitioners and pharmacists who participated in this study understand the benefits of oral rehydration solutions (ORS). This treatment, which involves premixed salt and sugar in a sachet and mixed with water, has been around for more than half a century. Prevents dehydration and significantly reduces the risk of death from diarrhea in children.

To better understand why more children are not receiving ORS, he and Zachary Wagner, a health economist at the Rand Corporation, a nonprofit research and policy organization in Santa Monica, California, colleagues have launched a large-scale intervention in two Indian states. Karnataka and Bihar.

They sent an actor pretending to be the father of a sick 2-year-old to more than 2,000 randomly selected medical practitioners and pharmacists in a medium-sized town. Three-quarters of Indian caregivers seek help for their sick children from private clinics and pharmacies.

Assess whether this interaction is due to low levels of ORS prescribing due to lack of supply, incentives to sell more expensive drugs such as antibiotics, or sensitivity to patient demand. It is designed to.

Each actor arrived at the facility unannounced and explained that the child had been suffering from diarrhea for two days. Some told the provider that he had previously used ORS to treat their child and asked if they should use it again. Some mentioned antibiotics instead, while others did not bring up early treatments. Some actors said they had no plans to buy drugs at the facility and just wanted advice. Researchers also sent a six-week supply of ORS to half of the facilities.

Researchers found that patients' treatment preferences are far more important than financial incentives or available inventory in clinics and pharmacies in explaining why ORS is underprescribed. did.

Actors who expressed a preference for ORS were twice as likely to develop ORS compared to actors who indicated they would not receive treatment. A survey of more than 1,000 caregivers and representatives from clinics and pharmacies in both states found that 48% of caregivers felt ORS was the best treatment for diarrhea but were less likely to visit a clinic. It was revealed that only 16% of respondents expressed this desire. On the other hand, only 18% of physicians and pharmacists believe that patients want their ORS.

“This is a very elegant study,” Levine says.

happy client

Karen Grepin, a health economist at the University of Hong Kong, said the results “somewhat contradict the belief among economists that financial incentives are very important.” Rather, the information barrier was more important.

But Ramanan Rachminarayan, an epidemiologist at Princeton University in New Jersey, says it can be difficult to separate financial incentives from other motivations. “We think of doctors as neutral decision makers based on what's best for the patient, but that's often not the case,” Lakshminarayan says. “Doctors make decisions based on what makes patients happy,” he says, and there is an underlying economic motive. “If a patient isn’t happy with you, they won’t be able to come back.”

Overall, Grepin says the research is impressive, but there's still a lot to learn. For example, it is not clear why some patients do not tell their health care provider that they would like her ORS. The study also doesn't provide a clear path to how to improve ORS uptake, she says. “I have no idea what to do next.”

Professor Wagner plans studies to test interventions to change the perceptions of doctors and pharmacists, as well as how patients express their preferences. “Just telling people that ORS is a life-saving drug is reaching the limits of what we can do.”