公私医疗合作策略在结核病防治与控制中的机制与效果的循证研究

发布时间：2018-08-27 08:46

【摘要】：研究背景结核病是全球公共卫生的巨大挑战之一。为加强结核病的治疗和控制,世界卫生组(WHO)提出公立与私立医疗机构合作策略(简称公私医疗合作),旨在动员所有医疗服务提供者共同开展以“直面督导下的短程化疗”(DOTS)为基础的结核病综合防治工作。我国在结核病防控的工作实践中,探索形成一套多元化的医疗卫生机构与结核病防治专业机构(结防所或疾控中心结防科)之间密切合作的结核病联合防控策略,简称医防合作策略。国际上对于结核病防控的公私医疗合作的特点和所取成效已开展一定研究,而国内也针对医防合作在结核病患者的发现、转诊和治疗方面的效果进行分析,但目前对于公私医疗合作策略及医防合作策略的机制总结、模式探讨以及实施效果综合分析评价研究还鲜见报道。研究目的全面系统地回顾全球范围内开展的结核病防控的公私医疗合作项目,总结公私医疗合作机制,描述其运作特点及参与合作机构之间的职能与分工,并对其结核病防控效果进行综合评价；深入探讨中国结核病医防合作策略的形成、发展、主要模式及其特点；探索重庆地区结核病医防合作模式的发展情况、优势及存在主要问题,掌握结核病患者归口诊治和管理现状,为针对性地解决医防合作过程中的具体问题及改善结核病患者的诊疗服务提供科学依据。研究方法 1.采用系统评价的方法,对全球结核病防控公私医疗合作项目的机制与效果进行总结与评价。全面检索14个电子数据库、2个灰色文献数据库以及6个相关网站截止2012年4月已发表的文献。纳入描述和评价已实施的结核病公私医疗合作项目原始研究。由两名研究员分别独立进行文献筛选、研究分类及数据提取,并交叉核对,讨论达成共识。采用定性描述与合并方法对纳入研究的信息和结果进行归纳,以总结公私医疗合作策略的运作机制并综合评价合作项目实施效果。 2.运用文献回顾、政策文件收集和专家咨询的方法,对我国结核病防控的医防合作策略及合作模式进行总结探讨。回顾与我国结核病医防合作相关的文献资料,收集整理相关政策法规文件,并咨询结核病防治机构的领导及国际国内相关领域的专家,以总结我国结核病医防合作策略的建立与发展情况,并对主要医防合作模式的特点、优势和局限进行全面总结分析。 3.采用机构调查、政策文件收集、问卷调查与定性访谈相结合的方法,对重庆地区主要的结核病医防合作模式的特点、优势、困难障碍及实施效果进行调查研究和比较分析。 (1)机构调查与政策文件收集：采用机构调查表对参与合作的结防机构和定点医院情况进行调查,查阅机构档案资料并获取相关政策法规文件。调查数据经提取和归纳后,对两种医防合作模式下结核病患者主动就诊、转诊和追踪情况差异进行描述性统计分析。 (2)定量调查：在研究地点选取2012年6月～12月之间确诊的494名新发结核病患者作为研究对象,采用自编调查问卷进行定量调查,了解患者基本信息就诊及转诊情况,调查结果双录入EpiData3.1数据库,并用SPSS17.0软件进行统计分析。 (3)定性访谈：目的性地在调查机构抽取10名领导干部及门诊医生,使用半结构式访谈提纲,对其进行关键人物访谈,了解医防合作模式发展过程、运作特点、工作中的主要优势与困难等信息。使用MAXQDA11软件管理定性资料,并采用主题框架分析法进行定性分析。研究结果 1.系统评价结果纳入分析的69篇原始研究,可被归纳为43个在15个国家开展的公私医疗合作项目。根据不同合作项目中参与机构的职责与分工,可将公私医疗合作策略的运作机制归纳为支持机制(包括经济、物资和人员支持)、合同机制(包括正式与非正式合同)以及工作组机制(工作指导委员会)。绝大多数研究肯定了公私医疗合作在DOTS实施、病例发现、治疗结局、患者管理、服务可及性与公平性、相关花费、技术能力、接受程度与合作水平方面具有积极促进作用。 2.中国结核病医防合作策略研究结果我国探索形成适宜国情的多元化结核病防治的医防合作策略,其合作模式主要分为结防机构模式、定点医院模式、专科医院模式及基层卫生服务网络模式四种,其中以结防机构模式和定点医院模式为主。医防合作策略在全国结核病防治实践工作中发挥了重要作用,但也存在诊治和转诊工作不规范、截留患者、医务人员有限、技术力量和管理能力不足等局限性。 3.重庆地区结核病医防合作模式研究结果目前重庆各区县开展的结核病防治医防合作主要属于结防机构模式和定点医院模式。结防机构模式可确保患者诊治和管理的系统性和连贯性；定点医院模式在诊疗条件和临床能力上具有明显优势。比较发现,结防所模式下患者转诊到位率较高,首诊更倾向选择指定结防机构；定点医院模式能在一定程度上促进结核病患者发现和追踪水平。两种模式下患者的治疗成功率和涂阳患者治愈率均在90%以上,结防所模式略高于定点医院模式。两种医防合作模式在结核病防治工作中都能发挥了重要作用,但仍然存在自身局限,主要体现在经费投入不足及其引起基础设施、设备条件、人才引进、人员培训、医生工资待遇、患者医疗保障等方的问题,以及综合医院管理协调和业务监督困难,医务人员院感风险高,患者依从性不高等。结论无论是全球公私医疗合作策略还是我国医防合作策略,存在不同的合作机制或模式。鉴于各自特点和优势,不同合作机制及模式在结核病防治实践的不同方面发挥作用。对于目前结核病防治实践中普遍存在的困难和障碍,可以从制定政策法规、改善机构工作和研发新型诊疗措施三个层面着手,加大经费投入、明确机构职责、建立监管体制、搭建信息平台、提高福利待遇、改善医疗保障、争取项目经费、促进协调联系、加强培训教育、改进工作方法,进一步促使全球公私医疗合作策略及我国医防合作策略在结核病防控工作中取得巨大成效。
[Abstract]:Research background
Tuberculosis is one of the great challenges of global public health. To strengthen the treatment and control of tuberculosis, the World Health Group (WHO) has proposed a public-private partnership strategy to mobilize all health service providers to work together on tuberculosis based on DOTS. Comprehensive prevention and control. In the practice of tuberculosis prevention and control, China has explored the formation of a set of joint tuberculosis prevention and control strategies with close cooperation between medical and health institutions and tuberculosis prevention and control professional institutions (tuberculosis control centers or TB departments of CDC). Some studies have been carried out on the characteristics and effects of the research, and the effects of medical and preventive cooperation on the detection, referral and treatment of tuberculosis patients have been analyzed in China. However, there are few reports on the mechanism, mode and implementation of public-private medical cooperation and medical and preventive cooperation strategies.
research objective
This paper reviews the public-private medical cooperation projects for tuberculosis prevention and control in the world, summarizes the public-private medical cooperation mechanism, describes its operational characteristics, functions and division of labor among participating cooperative organizations, and evaluates the effectiveness of tuberculosis prevention and control. Main modes and their characteristics; Explore the development, advantages and main problems of the TB medical and preventive cooperation mode in Chongqing, master the current situation of centralized diagnosis, treatment and management of TB patients, and provide scientific basis for solving the specific problems in the process of medical and preventive cooperation and improving the diagnosis and treatment services of TB patients.
research method
1. To summarize and evaluate the mechanism and effect of global public-private medical cooperation project for tuberculosis prevention and control by means of systematic evaluation.
A total of 14 electronic databases, 2 grey literature databases and 6 related websites were searched. The original study describing and evaluating the implementation of the public-private TB medical cooperation project was included. Consensus was reached. Qualitative descriptions and mergers were used to summarize the information and results included in the study, to summarize the operational mechanism of public-private medical cooperation strategy and to evaluate the implementation effect of cooperative projects.
2. By using the methods of literature review, policy document collection and expert consultation, this paper summarizes and discusses the cooperation strategy and mode of tuberculosis prevention and control in China.
To review the literature related to tuberculosis medical and preventive cooperation in China, collect and collate relevant policy and regulatory documents, and consult the leaders of tuberculosis prevention and control institutions and experts in relevant fields at home and abroad, so as to summarize the establishment and development of tuberculosis medical and preventive cooperation strategies in China, and carry out the characteristics, advantages and limitations of the main medical and preventive cooperation models. Comprehensive summary and analysis.
3. The characteristics, advantages, difficulties and implementation effects of the main TB medical and preventive cooperation modes in Chongqing were investigated and compared by means of institutional investigation, policy document collection, questionnaire survey and qualitative interview.
(1) Institutional Survey and Policy Documents Collection: An institutional questionnaire was used to investigate the situation of TB prevention institutions and designated hospitals participating in the cooperation, to consult the archives of the institutions and to obtain relevant policy and regulatory documents. Descriptive statistics analysis was conducted.
(2) Quantitative survey: 494 new-onset tuberculosis patients diagnosed in the study site from June to December 2012 were selected as the research object, and a self-designed questionnaire was used to investigate the basic information of the patients and referral. The results of the survey were entered into EpiData 3.1 database and analyzed by SPSS17.0 software.
(3) Qualitative interviews: Ten leading cadres and outpatient doctors were selected from the survey institutions. Semi-structured interview outlines were used to interview key persons to understand the development process, operation characteristics, main advantages and difficulties in the work of the medical and preventive cooperation model. Qualitative analysis was carried out by analysis.
Research results
1. results of systematic reviews
The 69 original studies included in the analysis can be summarized into 43 public-private medical cooperative projects in 15 countries. According to the responsibilities and division of labor of the participating agencies in different cooperative projects, the operational mechanism of public-private medical cooperative strategies can be summarized as support mechanism (including economic, material and personnel support), contract mechanism (including formal and informal). The overwhelming majority of studies confirm the positive role of public-private medical cooperation in DOTS implementation, case detection, treatment outcome, patient management, service accessibility and fairness, related costs, technical competence, acceptance and level of cooperation.
2. China tuberculosis prevention and treatment cooperation strategy research results
China has explored the formation of diversified tuberculosis prevention and control cooperation strategies suited to China's national conditions. The cooperation models are mainly divided into four types: tuberculosis prevention organization model, designated hospital model, specialized hospital model and grass-roots health service network model. Practice has played an important role, but there are also some limitations, such as non-standard diagnosis, treatment and referral, interception of patients, limited medical staff, lack of technical strength and management ability.
3. research results of tuberculosis prevention and treatment cooperation mode in Chongqing
At present, the tuberculosis prevention and treatment cooperation among the districts and counties in Chongqing mainly belongs to the TB prevention organization model and designated hospital model. The success rate of treatment and the cure rate of smear positive patients were above 90%, and the TB cooperative mode was slightly higher than the designated hospital mode. The prevention and control work can play an important role, but there are still their own limitations, mainly reflected in inadequate funding and the infrastructure, equipment conditions, talent introduction, personnel training, doctors'wages, patients' medical security and other aspects of the problem, as well as the general hospital management coordination and business supervision difficulties, medical staff hospital risk. High, patient compliance is not high.
conclusion
In view of their respective characteristics and advantages, different cooperative mechanisms and modes play a role in different aspects of tuberculosis prevention and control practice. For the difficulties and obstacles that exist in the current tuberculosis prevention and control practice, we can formulate policies. Policies and regulations, improvement of institutional work and research and development of new diagnostic and therapeutic measures should be carried out at three levels: increasing funding input, clarifying institutional responsibilities, establishing a regulatory system, setting up an information platform, improving welfare benefits, improving medical security, striving for project funding, promoting coordination, strengthening training and education, improving working methods, and further promoting global public-private medical care. Cooperation strategy and China's medical and defense cooperation strategy have made great achievements in TB prevention and control.
【学位授予单位】：重庆医科大学
【学位级别】：博士
【学位授予年份】：2013
【分类号】：R197.1;R52

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