ORS (Oral Rehydration Salts) is a lifesaver. Healthcare providers know it well but yet don’t prescribe it. A new study by the Indian Institute of Management Bangalore (IIMB) underlines this paradox: despite ORS being a lifesaving and inexpensive treatment for child diarrhoea, less than 20% of providers prescribe it. The underprescription of ORS for child diarrhoea, costs nearly 500,000 young lives each year.
Several bacterial, viral, and parasitic species can cause diarrhoea, an illness of the digestive tract. Prevention measures including drinking clean water, using better sanitation, and washing your hands with soap, can lower your risk of contracting an illness.
What the study says?
ORS – a mixture of clean water, sugar, and salt, can be used to cure diarrhoea. Furthermore, a 10- to 14-day course of further treatment with dispersible zinc tablets reduces the length of diarrhoea and enhances results.
The study done by Wagner, Z., M. Mohanan, R. Zutshi, Arnab Mukherji, and N. Sood sheds light on a critical yet often overlooked public health challenge. This alarming ‘know-do gap’ has puzzled experts for decades, but a controlled trial across 253 towns in Karnataka and Bihar offered a clear answer.
Almost 2000 providers from 253 medium-sized municipalities in the states of Bihar and Karnataka were studied. The authors of the study enabled actors to play the role of carers of a 2-year-old child. These carers sought care for their ward in order to assess the impact of the first barrier—perceived patient preferences. They were randomly assigned by the authors to assess whether they preferred antibiotics, ORS, or neither.
According to the study, some of the standardised patients in the no-preference group informed the provider that they would purchase their medicines from another vendor, eliminating the financial motivation for the provider to recommend more profitable courses of action. This was carried out in order to evaluate the effects of financial incentives, the second barrier. Finally, to measure the impact of the third barrier—ORS stock-outs—the researchers randomly assigned all providers in half of the 253 towns to receive a 6-week supply of ORS.
Estimating the impact
“To improve our understanding of why this know-do gap exists, we conducted a set of randomized experiments in Karnataka and Bihar. The goal was to estimate the extent to which ORS underprescription is driven by perceptions that patients do not want ORS, provider’s financial incentives, and ORS stock-outs (out-of-stock events). Patients expressing a preference for ORS increased ORS prescribing by 27 percentage points. Eliminating stock-outs increased ORS provision by 7 percentage points. Removing financial incentives did not affect ORS prescribing on average but did increase ORS prescribing at pharmacies. We estimate that perceptions that patients do not want ORS explain 42% of underprescribing. Whereas stock-outs and financial incentives explain only 6 and 5%, respectively,” says one of the researchers, Prof. Arnab Mukherji, Public Policy, Chairperson, and Chairperson of the PGPPM program, IIM Bangalore.
According to the WHO, diarrhoeal disease is the third leading cause of death in children 1–59 months of age. It is both preventable and treatable. Each year diarrhoea kills around 443832 children under 5 and an additional 50851 children aged 5 to 9 years. As of 7th March 2024, diarrhoea is the 3rd leading cause of death in children 1-59 months of age.
How misconception affects decisions?
When standardised patients expressed a preference for ORS, ORS prescription increased by 27 percentage points, according to the study. When standardised patients expressed no preference, 28% of ORS were prescribed or dispensed. And when standardised patients expressed a preference for ORS, 55% of ORS were prescribed or dispensed, seeing a 96% increase. The study found it pertinent to demonstrate that this is mostly because, although ORS was the most popular treatment reported by patients in household surveys, physicians believe that just 18% of their patients want it on average.
Due to the presence of hurdles, it has been estimated that 42% of underprescribing can be explained by provider misconceptions that patients do not desire ORS. While only 6% and 5% can be explained by stock-outs and financial incentives, respectively.
“Our study highlights the importance of patient preference in the doctor-patient relationship. Strategies and behaviour change that helps the doctor understand patient preferences or technologies that help the doctor understand more about the disease may offer important ways to encourage appropriate care both from a disease perspective as well as from a patient and customer satisfaction perspective. Thus, our research opens the pathway to asking several interesting themes on how health-seeking care may be reorganized. Nudges, cues, and other strategies to reveal patient conditions and patient expectations are important, as are diagnostic tools in the search for improved practice of healthcare,” Prof. Mukherji explains.
Final thoughts
Provider misperceptions drive the underprescription of ORS. Given the potential to significantly enhance ORS use, these findings imply that efforts to correct provider misconceptions about patients’ ORS preferences should be explored aggressively. These interventions might directly target clinicians and let them know that ORS preferences are more frequent than they may realise. They could also target patients or carers and encourage them to declare an ORS preference when they seek care.
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