县（区）级结核病定点医院结核病发现和治疗现况调查分析

发布时间：2018-04-08 20:20

本文选题：肺结核　切入点：定点医院　出处：《中国疾病预防控制中心》2014年硕士论文

【摘要】：目的：了解县(区)级结核病定点医院基本情况和结核病发现和治疗的现况,描述定点医院转型4年结核病发现和治疗转归的趋势,并与定点医院转型前结核病发现和治疗转归数据进行比较。发现定点医院存在的问题,为今后进一步完善结核病定点医院结核病诊疗工作提供参考依据。方法：采用现况调查的方法,对县(区)级结核病定点医院的现况进行描述和分析。通过问卷调查收集县(区)基本情况和定点医院的基本情况,通过现场调查收集患者发现和治疗现况；通过回顾性分析比较定点医院转型前后结核病发现和治疗转归的变化以及描述定点医院转型4年结核病发现和治疗转归的变化趋势,综合分析以上四部分内容,总结提炼定点医院现状及存在问题,得出结论并提出建议。结果：本次调查研究在江苏省镇江市、湖北省宜昌市、陕西省汉中市三个地市的7个县(区)开展。从7个县(区)2011年的社会经济学情况分析,东部镇江3个县(区)经济收入水平高于全国同期人均收入水平,西部汉中则低于全国同期人均收入水平。中部宜昌宜都市和东部镇江句容市活动性肺结核登记率高于全国同期活动性肺结核登记水平。其余5个地区则低于全国同期登记水平。新农合医保在镇江句容和丹徒普通门诊统筹给予30%-40%的门诊补偿,慢性病门诊补偿在中部宜昌宜都和五峰两地补偿额度为200元-540元,中西部地区住院补偿比例为65%-80%。城镇职工镇江门诊可报销20%-40%,宜昌实行限额补助,患者自付25%,汉中城职医保没有将结核病纳入了结核病慢病门诊报销范围。城镇居民医保在镇江报销比例同新农合,在汉中则实行限额补助800元/年,宜昌报销比例为40%。城镇职工报销比例根据医疗费用分段报销,汉中则报销92%。城镇居民住院报销在宜昌和汉中地区报销比例均为60%。 7家定点医院设立时间不同,其中6家医院经过验收,6家达到二级甲等。定点医院承担结核病诊断与治疗、结核病登记与报告、初诊患者健康教育和密切接触者筛查工作。痰涂片费用在镇江由中央转移支付经费和地方配套共同支付,宜昌宜都和汉中勉县均无地方配套,由医院支付缺口部分。各地胸片价格变化较大,从35-139元不等,镇江和宜昌由地方配套和全球基金补齐缺口经费,但汉中勉县仍需要患者支付部分费用。7家定点医院实验室均能开展痰涂片检查,3家能开展痰培养检查。7家定点医院结核菌感染控制整体薄弱,门诊、实验室和病房布局合理率分别为22%、56%和25%；门诊、实验室和病房通风量达到标准的分别占89%、56%、88%；门诊、实验室紫外线照射强度达到标准分别为33%和44%,医务人员口罩佩戴率仅11%。定点医院院内转诊较为顺畅,网络直报率为97.11%。肺结核患者住院率为25%,次均住院费用6160元,住院天数中位数为20天,规范化治疗方案使用率为58.94%,64.63%的普通肺结核患者使用二线药物。选择宜昌市第一人民医院描述转型后4年结核病发现和治疗转归的变化。结果如下：2010-2012年,初诊患者痰检率呈逐渐降低趋势。因症就诊构成比逐年增加。转诊来源构成2010-2011年下降12.71%,2011-2012年则上升2.4%。初治涂阳患者登记率下降24.31%。非定点医院网络报告转诊到位率无明显差异(x2=18.8098P0.05)追踪到位率无明显差异(Z2=6.8207P=0.0778),总体到位率无明显差异(x2=2.3926P=0.4950),登记肺结核患者治疗转归无明显变化(X2=7.5151P=0.0572)。分别选择东部句容、中部枝江、西部勉县3个县(区)进行转型前后患者发现和治疗转归变化的比较,结果如下：转型前后初诊患者占人口的比例分别为291.41/10万、272.27/10万,转型后下降6.57%。转型前后活动性肺结核患者率分别为70.66/10万和63.96/10万,转型后登记率下降9.48%。转型前后初治涂阳患者登记率分别为24.24/10万、8.05/10万,转型后降低66.79%。转型后因症就诊构成比增加19.95%,转诊构成下降59.43%。转型前后涂阳和涂阴患者治疗成功率变化无统计学意差异(X2=1.9620P=0.1613X2=2.6892P=0.1010)。结论：县(区)级定点医院承担结核病诊断治疗工作后,没有造成结核病发现和治疗转归的下滑。定点医院就诊更适合患者的就诊习惯。定点医院内部转诊流程较为顺畅,网络报告数据完整性较好,网络直报率高。但定点医院结核病诊疗过程中也存在一些问题,主要表现在可疑者筛查经费不足、诊疗行为不规范、结核杆菌感染控制整体薄弱和转型初期活动性肺结核患者和初治涂阳患者登记率下降,尤其是初治涂阳患者下降明显。因此,为保障定点医院模式持续有效的开展,建议增加定点医院经费投入,保障肺结核患者免费筛查政策的落实。建立行政监管机制,加强对定点医院诊疗行为的监管和考核,加强对实验室的考核和评估。提高各类医疗保险门诊报销比例,有助于控制住院比例。加强结核病定点医院结核杆菌感染控制,减少医务人员和患者交叉感染的风险。
[Abstract]:Purpose :

To understand the basic condition and the status of tuberculosis diagnosis and treatment in county ( district ) grade tuberculosis , describe the trend of tuberculosis discovery and treatment outcome in 4 years of transformation of fixed - point hospital , compare with the data of tuberculosis detection and treatment before transformation of fixed - point hospital .

Method :

This paper describes and analyzes the status of county ( district ) tuberculosis order hospitals by means of current investigation . Through questionnaire investigation , the basic situation of county ( district ) and the basic condition of the hospital are collected , and the status of patients ' discovery and treatment is collected through field investigation .
Through a retrospective analysis , the author compares the changes of tuberculosis discovery and treatment before and after transformation of fixed - point hospital and describes the trend of tuberculosis discovery and treatment outcome in four years of transformation of fixed - point hospitals , comprehensively analyzes the above four parts , summarizes the present situation and existing problems of refining and ordering hospitals , and draws a conclusion and puts forward suggestions .

Results :

The research is carried out in seven counties ( districts ) in three cities of Zhen Jiang City , Yichang City in Hubei Province and Hanzhong City in Shaanxi Province . The economic income level of three counties ( districts ) in the eastern town is higher than that of the same period in the same period in the same period of the whole country .

There are seven hospitals to set up different hospitals . Six hospitals have been accepted and 6 have reached Grade 2 , etc . There are no local supporting facilities for tuberculosis diagnosis and treatment , tuberculosis registration and reporting , health education and close contact screening .
89 % , 56 % and 88 % of the standard of ventilation in clinic , laboratory and ward were 89 % , 56 % and 88 % , respectively .
The clinic and laboratory ultraviolet irradiation intensity reached the standard of 33 % and 44 % , and the wear rate of medical personnel gauze mask was only 11 % . The hospital referral rate was 97.11 % . The hospitalization rate of patients with pulmonary tuberculosis was 25 % , the average hospitalization expense was 6160 RMB , the number of hospitalization days was 20 days , the utilization rate of standardized treatment regimen was 58.94 % , 64.63 % of ordinary pulmonary tuberculosis patients used two - line medicine .

Results : In 2010 - 2012 , the rate of sputum examination decreased by 12.71 % from 2010 to 2012 , and by 2.4 % in 2011 - 2012 . There was no significant difference in the rate of follow - up ( x2 = 2.3926P = 0.4950 ) . There was no significant difference in the treatment outcome of patients with pulmonary tuberculosis ( X2 = 7.5151P = 0.072 ) .

The results were as follows : The percentage of patients before and after transformation was 291.41 / 100000 , 272.27 / 100000 and 6.57 % respectively before and after transformation . The rate of patients with active pulmonary tuberculosis before and after transformation was 24.24 / 100000 , 8.05 / 100000 and 66.79 % after transformation respectively .

There are some problems in the diagnosis and treatment of tuberculosis patients . There are some problems in the diagnosis and treatment of tuberculosis patients . It is suggested to increase the fund input of hospitals and ensure the implementation of free screening policy in patients with 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】：2014
【分类号】：R52

【参考文献】