Many TB prescriptions outside national programme do not follow treatment guidelines, study finds

Plenty of TB prescriptions outside national programme do not follow treatment guidelines, study finds A systematic review of 34 studies identified 53.3% of anti-TB prescriptions in non-programmatic settings were faulty, with substantial variation throughout States and an estimated 2-3 million potentially inappropriate prescriptions annually.

Key points

• Published in the Indian Journal of Tuberculosis, the PRAMAN India study analysed 34 studies conducted between 1991 and 2024, covering 3, 834 real-world anti-TB treatment records.
• In the regional analysis of 3, 817 prescriptions, Madhya Pradesh, Haryana, Gujarat, Karnataka, Uttar Pradesh, Delhi, Maharashtra and Uttarakhand recorded faulty-prescription rates above the overall crude prevalence of 50.8%.
• Five of the 10 States with the highest TB case notifications, Uttar Pradesh, Maharashtra, Madhya Pradesh, Gujarat and Delhi were among those with rates above this overall prevalence.
• The researchers estimated that regarding 2-3 million anti-TB prescriptions could be incorrect every year in India's non-programmatic healthcare sector, based on private-sector treatment volumes.
• Nevertheless, the difference was not statistically significant (p=0.74), meaning the study does not establish that one provider group had a higher rate of inappropriate prescribing.

In practice, a systematic review discovered widespread gaps in TB prescribing outside the national programme, with substantial variation throughout States and reservations concerning treatment quality in private-sector care Image applied for representational purpose only Photo Credit: AFP.

More than one in two anti-tuberculosis prescriptions assessed in healthcare settings outside India's National Tuberculosis Elimination Programme (NTEP) did not conform to recommended treatment standards, according to a new systematic review and meta-analysis.

Published in the Indian Journal of Tuberculosis, the PRAMAN India study analysed 34 studies conducted between 1991 and 2024, covering 3, 834 real-world anti-TB treatment records. The pooled prevalence of faulty prescriptions was 53.3% (95% CI: 42.2-64.1%).

Notably, the study additionally identified a significant long-term decline in faulty prescribing. Weighted linear regression indicated an average reduction of 1.38 percentage points a year (P=0.013). The crude prevalence fell from 68.6% in studies from 1990-1999 to 32.6% during 2020-2024.

For context, the researchers estimated that regarding 2-3 million anti-TB prescriptions could be incorrect every year in India's non-programmatic healthcare sector, based on private-sector treatment volumes. This translates to roughly four to five potentially faulty prescriptions every minute.

Meanwhile, the estimate is not a direct count of prescriptions issued nationally, but an extrapolation based on the volume of TB treatment provided in the private sector.

For context, the burden was not uniform nationwide. In the regional analysis of 3, 817 prescriptions, Madhya Pradesh, Haryana, Gujarat, Karnataka, Uttar Pradesh, Delhi, Maharashtra and Uttarakhand recorded faulty-prescription rates above the overall crude prevalence of 50.8%.

Five of the 10 States with the highest TB case notifications, Uttar Pradesh, Maharashtra, Madhya Pradesh, Gujarat and Delhi were among those with rates above this overall prevalence. The study notes that these States additionally account for a disproportionate share of private-sector TB drug sales, giving them particular importance for TB control.

In practice, the study additionally examined whether prescription quality differed according to provider type. Faulty prescribing was 59% in studies that included both allopathic and indigenous practitioners, compared with 51.1% in studies involving allopathic practitioners alone.

Gyanshankar P. Mishra, associate professor of respiratory medicine at Indira Gandhi Administration Medical College, Nagpur, and corresponding author of the study, stated the reasons for inappropriate prescribing may be more complex than deliberate deviation from treatment guidelines.

"Some gaps may reflect evolving evidence, changes in treatment guidelines and inadequate access to updated recommendations, " he remarked.

This is particularly relevant in TB, where treatment recommendations have evolved over time and standardised regimens are periodically updated.

In practice, the researchers additionally employed machine-learning-based modelling to estimate future trends. For 2025-2030, the projected prescription error rate was 49.7% ± 9.0%, with a median of 50.7% and a modelled range of 37.1% to 62.1%.

Notably, the authors stress that this is a model-based projection and not an observed national prescription rate.

Meanwhile, the concern is not only whether a prescription matches a guideline. The study's discussion notes that faulty prescriptions can compromise treatment efficacy, prolong infectiousness and contribute to drug resistance, potentially undermining TB elimination efforts.

In practice, the researchers therefore recommend strengthening links between private providers and the NTEP, including Public-Private Mix models, continuing medical education, prescription-quality audits and feedback, digital clinical decision-support tools and timely referral to programme-based services.

"For every patient with TB, irrespective of where they seek care, the treatment needs to be standardised, " Dr. Mishra remarked.

He remarked sustained engagement with private providers and dissemination of updated treatment recommendations could assist address prescription gaps.

For now, many TB prescriptions outside national programme do not follow treatment guidelines, study remains the part of the story worth watching, and further updates are likely as more details are confirmed.