Everything works? Bangladeshi patients' evaluation of informal medical care quality is independent of treatment quality

Abstract

Background: Medical overuse - the provision of ineffective or unnecessary medical care - is a globally important problem. In low income countries like Bangladesh where much primary care is administered by practitioners without formal training and is free from regulatory oversight, the problem may be particularly acute. The objective of this project was to examine the psychological processes which may shape medical overuse in rural Bangladesh. We hypothesise that feedback from patients to medical practitioners about treatment effectiveness is positively biased. Methods. We conducted a cross-sectional study of 41 informal primary care practitioners and 241 of their patients. Exit questionnaires with patients assessed symptoms and the treatment administered. At follow-up 7 to 10 days later, the patient was interviewed again and self-reported recovery, satisfaction with care, and feedback to practitioner were measured. A medical doctor assessed each drug for appropriateness using established guidelines. Results. Of the 550 drugs administered, 50.00% were judged to be inappropriate yet most patients (89.76%) were satisfied or very satisfied with the treatment. An ordinal logistic regression suggested that satisfaction with treatment at follow-up was predicted by patient recovery (OR: 3.07, 95% CI: 2.01 to 4.85) but not by treatment appropriateness (OR: 0.88, 95% CI: 0.58 to 1.34). Conclusion Medical overuse is common in this setting. Results are consistent with the suggestion this is driven in part by the misattribution of recovery to the treatment rather than to regression to mean / natural recovery. This attribution error may perpetuate medical overuse.