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Providers' Knowledge of Diagnosis and Treatment Best Practices for Acute Myocardial Infarction (
 AMI
 ): Evidence from India Using Clinical Vignettes

Research Objective: Cardiovascular diseases (CVDs) are a leading cause of death worldwide, and 80% of CVD deaths occur in lowand middle-income countries (LMICs). The Global Burden of Disease Study estimates that CVDs contribute 28 1% of total deaths in India. Acute Myocardial Infarctions (AMI) make up a large share of these deaths. Early diagnosis and correct treatment of AMI is critical to preventing CVD-related deaths. This study aims to assess the competence of primary care providers in India to diagnose and treat AMI and examine differences between public and private sector providers. Study Design: We conducted a cross-sectional study of healthcare providers' knowledge of diagnosis and treatment for AMI. Data collection took place in Odisha, one of the poorest states in India, from August 2019 to March 2020. Using data from vignette-based interviews with primary care providers in the public and private sectors, we assessed providers' knowledge of best practices in clinical care. The public sector providers within this study included physicians at government-run primary health centers, and the private sector providers were engaged in solo-practice, irrespective of medical qualifications. The vignette-responses were evaluated against standard treatment guidelines (STGs) for AMI at the primary care level. Population Studied: 110 primary care providers working in Odisha, India a state with ~47 million people, of which 32.5% earn < $1.90/ day and ~ 60% belong to indigenous or vulnerable social groups. Principal Findings: Overall, providers demonstrated low levels of knowledge: only 67.27% diagnosed AMI correctly, and 0% recommended the correct treatment as per STGs. Providers seldom asked key diagnostic questions such as family and medical history (6.36% of cases) and the nature of the chest pain (10.91%) or results from diagnostic tests like ECG and EKG (30%), lipid profile (1.82%), or angiograms (3.64%). Private sector providers showed higher competence in making a correct diagnosis than public providers (difference of 32.73 percentage points). In line with STGs, 82.43% of providers referred AMI cases to hospitals, with more private than public providers making these referrals. 55.41% of providers prescribed at least one correct drug (in combination with unnecessary drugs). More private providers prescribed at least one correct drug than public sector providers. 44.74% of public providers prescribed only unnecessary drugs, without a single medicine recommended for angina. Conclusions: Healthcare providers in Odisha, India, have low levels of knowledge regarding AMI diagnosis and treatment, with public providers showing lower competence than private providers. Implications for Policy or Practice: Our findings indicate strikingly poor quality of care for AMI at the primary care level. The widespread misdiagnosis of AMI, the prescription of unnecessary drugs, and a lack of appropriate referral raise concerns for India's efforts to address rising rates of CVD. Our findings suggest addressing CVD in LMIC contexts is complex and requires improving the baseline knowledge of providers in both public and private sectors; which may be particularly relevant in contexts with little de facto regulation. Primary Funding Source: Bill and Melinda Gates Foundation.