“医防合作”综合模式下利福平耐药肺结核患者治疗结果及其影响因素研究

发布时间：2018-01-03 02:26

本文关键词：“医防合作”综合模式下利福平耐药肺结核患者治疗结果及其影响因素研究　出处：《中国疾病预防控制中心》2017年硕士论文　论文类型：学位论文

【摘要】：目的在基于“医防合作”综合模式、对患者予以90%医疗费用减免、使用国产抗结核药物的标准化疗方案的前提下,对患者近期治疗效果及其影响因素、远期复发情况进行分析,为推行适合我国国情的MDR-TB防治规划提供科学依据和参考意见。方法本研究依托于中国卫生与计划生育委员会-盖茨基金会结核病防治项目“医院与疾控系统合作管理耐多药肺结核试点研究”研究现场,基于经济发展状况,选择了中国四个中等三线城市来实施。纳入分析的168例利福平耐药肺结核患者为研究对象。运用横断面研究,通过专家咨询法及预调查,设计完成《利福平耐药肺结核患者治疗结果及其影响因素调查表》、《利福平耐药肺结核患者管理个案调查表》,使用问卷调查法,对纳入治疗的利福平耐药肺结核患者治疗结果及其影响因素数据信息进行收集、分析;运用前瞻性队列研究方法,使用《利福平耐药肺结核患者治疗完成后随访调查表》,对治疗成功(包括治愈和完成治疗)的患者进行2年的远期追踪随访调查,并进行数据收集分析,获得患者完成疗程2年后的复发情况。使用SAS 9.3进行统计分析;用统计图表与统计指标进行统计描述;对分类变量使用χ2检验,当理论频数1时,使用Fisher精确检验,检验水准α=0.10;选择在单因素分析中有统计学意义的变量,使用logistic回归检验进行多因素分析;对复发患者进行统计描述与个案信息描述。结果168例利福平耐药肺结核患者纳入分析;其中,男性占75.60%(127/168),45-59岁年龄组人数最多,占42.26%(71/168),农村户籍人口占82.14%(138/168),复治患者占80.36%(135/168);仅对利福平和异烟肼耐药患者占49.40%(83/168)。住院时间中位数为34天(IQR:24-52),治疗时间中位数为720天(IQR:240-732)。共有25.90%(43/168)患者治疗3月末出现痰培养阴转,共有67.26%(112/168)患者6月末出现痰培养阴转,3月末出现痰培养阴转的患者,在6月末痰培养仍为阴性。本次研究中,治疗成功率为46.43%,失败率为23.21%(因不良反应失败占69.23%);丢失率19.64%(因外出打工、家庭经济困难、医保问题等经济原因丢失占其51.52%);3.58%患者因收押、迁出等原因未评估。为进行因素分析,将研究对象(排除丢失及未评估患者)的近期治疗结果分为成功治疗(治愈、完成治疗患者78例)与不良治疗结果(死亡、失败患者51例),共计129例患者纳入因素分析。本次研究对象中,年龄(χ2=12.7956,P=0.0051)、教育程度(χ2=6.3449,P=0.0960)、登记分类(χ2=2.7454,P=0.0975)、耐药类型(P=0.0010)、首次诊断结核病距本次治疗的时间(χ3=7.6621,P=0.0535)、是否使用二线抗结核药物(χ2=8.9923,P=0.0027)、既往接受过不同抗结核治疗次数(χ2=9.5727,P=0.0083)、接受治疗时间长短(P0.0001)、随访复查及时性(χ2=13.1656,P=0.0003)、能否按时服药(DOT)(χ2=6.6608,P=0.0099)患者、RR-TB患者治疗方案是否加用异烟肼(P=0.0247)的患者间治疗结果的差异有统计学意义。经多因素Logistic回归分析结果显示,不良治疗结果的危险因素的变量有:首次诊断结核病距本次治疗时间长(OR=2.45,90%CI:1.27-4.74)、使用二线药物(OR=3.32,90%CI:1.81-6.11)、接受抗结核治疗次数多(OR=2.86,90%CI:1.41-5.88)、治疗时间少于中位数 730 天(OR=4.79,90%CI:1.72-13.31)。完成全部疗程后,共有78例患者治疗成功,跟踪随访2年,发现2例患者复发,2年复发率为2.56%。结论与WHO公布的全球均值及国内外研究结果相比,本研究的近期治疗成功率偏低,失败率偏高,远期复发率较低。患者年龄、教育程度、登记分类、耐药类型、首次诊断结核病-本次治疗时间(年)、是否使用二线抗结核药物、既往接受过抗结核治疗的次数、接受治疗时间长短、随访复查的及时性、能否按时服药(DOT)是治疗结果的影响因素;首次诊断结核病距本次治疗时间长、使用二线药物、接受抗结核治疗次数多、治疗时间少于中位数730天是不良治疗结果的危险因素。3月末及6月末痰培养情况可大致反应患者总体预后,因此应重视患者早期病情。治疗成功率偏低的可能原因包括经济问题,患者多为接受多次治疗的复治、耐多药肺结核患者,针对此类患者可供选择的治疗药物较少,国产药品剂量偏低;患者依从性偏差,丢失率较高。另外,在不确定异烟肼是否耐药的情况时,尽量使用异烟肼,若为单耐利福平肺结核患者需及时使用异烟肼治疗。
[Abstract]:Objective based on "medical anti cooperation" mode, with 90% reduction of medical expenses, the premise of using the standard chemotherapy of domestic anti tuberculosis drugs for patients under the short-term therapeutic effect and its influencing factors, analyze the long term recurrence, provide scientific basis and reference for the implementation of the MDR-TB control program for the situation of our country methods. This research is supported by the Chinese health and Family Planning Commission Gates foundation TB control project "hospitals and disease control system of cooperative management of multi drug resistant tuberculosis research field pilot study", economic development based on the situation, choose China four medium to implement the three line of the city. A total of 168 patients with rifampicin resistant pulmonary tuberculosis patients the analysis as the research object. Using cross-sectional study, through expert consultation and pre survey, completed the design of rifampin resistant pulmonary tuberculosis patients: results and influencing factors In the questionnaire >, < rifampin resistant pulmonary tuberculosis case management questionnaire ", using the questionnaire, included in the treatment of rifampin resistant tuberculosis treatment results and influencing factors in data collection and analysis; using prospective cohort study method, use the < rifampin resistant pulmonary tuberculosis patients completed follow-up questionnaire on treatment >. Success (including the cure and treatment completion) in patients with long-term follow-up 2 years of investigation, and data collection and analysis, patients completed the treatment of recurrence after 2 years. The use of SAS 9.3 for statistical analysis; statistical chart and statistical indicators for statistical description; for categorical variables using the 2 test, when the theory of the frequency of 1, using the Fisher exact test, a =0.10 level test; selection was statistically significant in the univariate analysis of variables, using logistic regression test for multivariate analysis; The information statistical description and description of a case of recurrent patients. Results 168 cases of pulmonary tuberculosis were included in the analysis of rifampin resistant; among them, men accounted for 75.60% (127/168), 45-59 age group the largest number, accounted for 42.26% (71/168), the rural household population accounted for 82.14% (138/168), retreatment patients accounted for 80.36% (135/168); only rifampicin and isoniazid resistant patients accounted for 49.40% (83/168). The median duration of hospitalization was 34 days (IQR:24-52), for a median of 720 days (IQR:240-732). A total of 25.90% (43/168) patients with 3 month sputum culture conversion (112/168), a total of 67.26% patients with 6 month sputum negative conversion, at the end of 3 patients with negative sputum culture, at the end of the 6 sputum cultures remained negative. In this study, the treatment success rate was 46.43%, the failure rate was 23.21% (due to adverse reaction failure accounted for 69.23%; (19.64%) loss rate for migrant workers, family economic difficulties, health problems by The economic reasons for the loss accounted for 51.52%); 3.58% patients with out of custody, and other reasons not evaluation. For factor analysis, the research object (excluding missing and not evaluated patients) recent treatment were divided into treatment success (cure, 78 patients completed the treatment and adverse outcome (death), failure in 51 cases), a total of 129 patients were included in the analysis. The object of this study, age (x 2=12.7956, P=0.0051), education level (2=6.3449, P=0.0960), registration classification (x 2=2.7454, P=0.0975), the type of drug resistance (P=0.0010), for the first time from the diagnosis of TB treatment time (3=7.6621, P=0.0535). Whether the use of second-line anti TB drugs (2=8.9923, P=0.0027), who had received different anti tuberculosis treatment times (2=9.5727, P=0.0083), treatment time (P0.0001), the follow-up time (2=13.1656, P=0.0003), can take the medicine on time (DOT) (x 2=6.6608, P=0.0099 ) patients, treatment with isoniazid plus RR-TB (P=0.0247) there were statistically significant differences in treatment outcomes among patients. Multivariate Logistic regression analysis showed that the risk factors of adverse outcome variables: for the first time from the diagnosis of tuberculosis treatment for a long time (OR=2.45,90%CI:1.27-4.74), the use of second-line drugs (OR=3.32,90%CI:1.81-6.11). An anti tuberculosis treatment number (OR=2.86,90%CI:1.41-5.88), the treatment time is less than the median of 730 days (OR=4.79,90%CI:1.72-13.31). To complete the full treatment, a total of 78 patients were treated successfully, 2 years of follow-up, 2 patients relapsed, 2 year recurrence rate for the global mean 2.56%. conclusion with the release of WHO and the domestic and foreign research results compared in this study, the therapeutic success rate is low, the failure rate is high, the recurrence rate is low. The patients age, level of education, registration and classification, the type of drug resistance, the first A diagnosis of tuberculosis - the treatment time (years), whether the use of second-line anti TB drugs, who had accepted the number of anti tuberculosis treatment, treatment time, follow up timely, timely medication (DOT) are the factors influencing the results of treatment; the first diagnosis of tuberculosis from the treatment for a long time, the use of second-line drugs many times, received anti tuberculosis treatment, treatment time was less than the median 730 days is a risk factor for adverse outcomes and.3 at the end of 6 at the end of the sputum culture can be the overall prognosis of patients, so we should pay attention to patients with early stage disease. Possible reasons for the low success rate of treatment including economic problems, patients are receiving retreatment multiple treatment. Patients with multi drug resistant pulmonary tuberculosis, drug treatment for such patients to choose less, domestic drug dose; patient compliance deviation, loss rate is high. In addition, the isonicotinyl uncertain Isoniazid is used as much as possible when hydrazine is resistant, and isoniazid should be used in time for patients with single rifampicin resistant pulmonary tuberculosis.

【学位授予单位】：中国疾病预防控制中心
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R521

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