综合干预措施下耐多药肺结核诊疗服务评价研究

发布时间：2018-04-15 21:29

本文选题：耐多药结核病 + 诊疗服务　；参考：《山东大学》2013年硕士论文

【摘要】：研究背景耐多药结核病(Multi-drug resistant tuberculosis, MDR-TB)是由至少对两种有效抗结核药物——利福平和异烟肼同时耐药的结核分支杆菌感染引起的疾病。我国是世界上22个结核病高负担国家之一,同时也是27个耐药结核病高负担国家之一。我国耐多药肺结核控制工作长期存在着发现率低、诊断和治疗不及时,治疗不规范,治疗依从性差,患者治疗疾病经济负担重等问题。由于这些问题的存在,我国耐药结核病控制面临着巨大的挑战。中国疾控中心和盖茨基金会合作的结核病控制项目试图通过在试点地区实施一系列综合干预措施,探索建立一种与医保相结合的医院及疾控系统合作新模式,为完善我国耐多药结核病控制规划提供思路及经验。改善耐多药肺结核诊疗服务的措施在其中占有很重要的地位,其中包括对耐多药肺结核患者发现、治疗管理和疾病经济负担的干预。研究目的本研究将从耐多药肺结核患者的发现、治疗管理以及疾病经济负担三个方面对综合干预措施实施后的耐多药肺结核诊疗服务进行评价,为进一步完善耐多药结核病控制规划提供建议。研究方法本研究根据全国各省耐药肺结核基线调查数据、结核病控制工作水平和社会经济条件等,选择河南开封市、江苏连云港市、重庆永川区和内蒙古呼和浩特市作为项目地区,评价各项目地区综合干预措施实施一年期间的耐多药肺结核诊疗服务。收集每个项目地区地市级结防机构、定点医院和县级结防机构有关耐多药肺结核可疑者筛查、耐多药肺结核治疗的项目常规监测资料,分析耐多药肺结核患者发现情况及影响因素,评估项目市医院治疗耐多药肺结核患者的及时性、规范性和患者治疗的依从性。在每个项目地区选择定点医院为研究现场,调查纳入项目治疗满6个月的患者。通过结构化问卷收集患者治疗信息,分析患者在项目治疗的疾病经济负担,现场共调查耐多药肺结核患者73例。此外,本研究还访谈了项目地区地市级和县级结防机构项目工作人员,定点医院负责人、医生和实验室人员,管理患者的村医等关键人物,共访谈39人。常规监测资料、机构表等定量资料在Excel中整理储存,使用SPSS18.0对资料进行描述性统计分析和统计推断,使用的统计方法包括秩和检验、卡方检验、生存分析和广义线性模型等。访谈资料根据录音整理成Word格式,使用Nvivo7软件分析。研究结果 1.耐多药肺结核患者发现项目总体筛查率达到83.93%,开封、连云港和重庆三地筛查率均在90%以上。快速诊断技术检出MDR-TB患者检出率为6.22%,呼和浩特快诊MDR-TB患者检出率仅为2.95%,明显低于其他三地。总体上,结防机构来源的涂阳肺结核患者发现时间间隔为7天,呼和浩特发现时间间隔为14天,明显长于其余三地。50.19%的患者发现时间间隔在7天之内,呼市这一比例只有11.33%。送痰、快速诊断和信息反馈时间间隔分别为2、5、0天,呼和浩特的信息反馈时间为5天,明显长于其他地区。 2.耐多药肺结核患者治疗管理耐多药肺结核患者总体纳入率为70.78%。快诊结果为耐多药的肺结核的患者纳入率为76.16%,高于快诊结果为耐利福平的肺结核患者的纳入率62.50%。新患者的纳入率(55.22%)低于非新患者(76.70%)。家庭年收入在5000-10000元间的患者纳入率高于家庭年收入低于5000元和家庭年收入高于10000元的患者。 172例纳入项目治疗的耐多药肺结核患者治疗延迟为5天,长于规定的时间。49.42%的患者治疗延迟在4天以内。卫生系统治疗延迟和患者治疗延迟分别为0天和7天。 138例耐药肺结核患者坚持治疗率由1月末的0.934下降至6月末的0.787。快速诊断结果为单耐利福平的患者坚持治疗率低于耐多药肺结核患者；无保险的患者坚持治疗率低于有保险的患者。不良反应、死亡和经济困难是影响患者治疗依从性的主要因素。 3.耐多药肺结核患者疾病经济负担干预后耐多药肺结核患者次均住院费用为3819.49元,日均住院费用为97.84元,分别为干预前的52.51%和44.23%；患者住院药品费用所占比例由59.93%下降到26.59%。干预后患者的登记分类、定点医院床位数和住院天数对患者住院费用影响有统计学意义。耐多药肺结核患者治疗全疗程的总费用为23430.82元,直接医疗费用为15166.68元,直接非医疗费用为6056.00元,间接费用为437.00元。患者治疗全疗程的直接医疗费用占患者2年家庭收入的比例为65.58%,有84.90%的患者家庭的非食品支出占家庭总支出的比例超过40%,给家庭带来了灾难性医疗支出。按照目前的补偿方案,补偿后患者全疗程的总费用为7659.14元,降低了67.31%。直接医疗费用为1560.08元,降低了89.71%：直接非医疗费用为4756.00元,仅降低了21.74%。如果没有随访和注射期的项目补偿,补偿后患者全疗程的总费用为10759.14元,降低了54.08%；直接医疗费用的中位数为3360.08元,降低了77.85%；直接非医疗费用无变化,仍为6056.00元。按照目前的补偿方案,补偿后总费用占两年家庭收入的37.58%,与补偿前相比下降了74%。虽然与补偿前相比,造成灾难性医疗支出的家庭比例降低了约18%,但仍有65.75%的家庭因为治疗耐多药肺结核而给家庭带来了灾难性医疗支出。但是如果没有随访和注射期的项目补偿,补偿后患者全疗程总费用占两年家庭收入的比例为64.41%,造成家庭灾难性支出的家庭比例为82.19%。结论与建议中盖结核病控制项目从耐多药肺结核患者发现、诊断、治疗、管理和筹资等方面进行了综合性干预,改善了耐药肺结核诊疗服务。但是在项目实施过程中还存在有的地区可疑者筛查率低、患者治疗依从性差、保险政策持续性差等问题。根据以上结论,本研究提出以下建议： 1.推行项目实行的耐多药肺结核患者发现策略,在医院和结防机构合作的基础上使用快速诊断技术对涂阳肺结核患者进行筛查。 2.采用标准化治疗方案与个体化治疗方案相结合的治疗方法,保证定点医院药品的供应和质量,降低不良反应的发生。加强对督导员的培训,及时发现和处理不良反应。 3.进一步完善定点医院和结防机构之间的合作,特别要加强合作机构间的信息沟通,在耐多药肺结核患者的发现、诊断、治疗和管理的各个环节保证信息交流的畅通和及时。 4.建立完善的可持续的耐多药肺结核防治经费筹资机制,在项目结束后要保证城乡三种医疗保险制度对耐多药肺结核治疗的补偿政策继续执行。对确实贫困的患者可以介入民政部门救助,保证患者不因经济原因无法接受治疗。
[Abstract]:Background of the study

Multi - drug resistant tuberculosis ( MDR - TB ) is a disease caused by at least two kinds of effective anti - tuberculosis drugs , rifampicin and isolazide . Our country is one of the 22 countries with high burden of tuberculosis and is one of the 27 countries with high burden of drug - resistant tuberculosis .

Purpose of study

This study will evaluate the diagnosis and treatment service of multi - drug resistant pulmonary tuberculosis after comprehensive intervention measures from three aspects : discovery , treatment management and disease economic burden of multi - drug resistant pulmonary tuberculosis patients , so as to provide suggestions for further improving the control plan of MDR - TB control .

Research Methods

According to the baseline survey data of drug - resistant pulmonary tuberculosis in all provinces of China , the level of tuberculosis control work and socio - economic conditions , the author chose Henan Kaifeng City , Jiangsu LianYungang City , Chongqing Yongchuan District and Inner Mongolia Huluhaote City as the project area , and evaluated the comprehensive intervention measures of each project area to implement multi - drug resistant tuberculosis diagnosis and treatment service during one year .

To collect the information of patients with multi - drug - resistant pulmonary tuberculosis ( TB ) in each project area and to analyze the compliance of patients with multi - drug - resistant pulmonary tuberculosis .

Routine monitoring data , institutional tables and other quantitative data were stored in Excel . SPSS 18.0 was used to carry out descriptive statistical analysis and statistical inference . The statistical methods used include rank sum test , chi - square test , survival analysis and generalized linear model , etc . The interview data was compiled into Word format according to the recording and analyzed by Nvivo7 software .

Results of the study

1 . Detection of multi - drug resistant pulmonary tuberculosis patients

The overall screening rate of the project reached 83.93 % , and the screening rate was above 90 % . The detection rate of MDR - TB patients was 6.22 % , and the rate of MDR - TB patients was only 2.95 % , which was significantly lower than that of other three sites .

On the whole , patients with smear - positive pulmonary tuberculosis from the source of anti - tuberculosis were found to have a time interval of 7 days , and the time interval of the discovery interval was 14 days , which was obviously longer than that of the other three . 50.19 % of patients found the interval of time to be within 7 days , the proportion of the city was 11.33 % . The time interval of the sputum , the rapid diagnosis and the information feedback was 2 , 5 , 0 days respectively .

2 . Treatment management of multi - drug resistant pulmonary tuberculosis patients

The overall inclusion rate of patients with multi - drug - resistant pulmonary tuberculosis was 70.78 % . The rate of inclusion in patients with MDR - resistant pulmonary tuberculosis was 76.16 % , which was higher than that of non - new patients ( 76.70 % ) . The inclusion rate of new patients ( 55.22 % ) was lower than that of non - new patients ( 76.70 % ) . The rate of patients with family income between 5000 - 10000 yuan was higher than that of patients with family income below 5000 yuan and family income above 10,000 yuan .

The treatment delay for the 172 patients with MDR - TB included in the project was 5 days , longer than the specified time . 49.42 % of the patients had a delay of less than 4 days . The treatment delay for the health system and the patient treatment delay were 0 days and 7 days , respectively .

In 138 patients with drug - resistant pulmonary tuberculosis , the rate of treatment was decreased from 0.934 at the end of January to 0.787 at the end of June .
Patients who have no insurance insist that the treatment rate is lower than those with insurance . Adverse reactions , death and economic difficulties are the main factors that affect the patient ' s treatment compliance .

3 . Economic burden of multi - drug resistant pulmonary tuberculosis patients

The hospitalization expenses of the patients with multi - drug - resistant pulmonary tuberculosis after intervention were 3819.49 yuan , 97.84 yuan for each day , 52.51 % and 44.23 % respectively before intervention .
The proportion of inpatient drug costs in patients decreased from 59.93 % to 26.59 % . The registration classification of patients after intervention , the number of beds in order hospitals and the number of days in hospital were statistically significant .

The total cost of the patients treated with multi - drug - resistant pulmonary tuberculosis was 234.82 yuan , the direct medical expense was 156.68 yuan , the direct non - medical expense was RMB 6056.00 yuan , the indirect cost was RMB 37.00 yuan . The proportion of the patients who treated the whole course of treatment accounted for 65.58 % , 84.90 % of the patients with non - food expenses accounted for more than 40 % of total household expenditure , which brought catastrophic medical expenditure to the family .

According to the current compensation scheme , the total cost of the whole course of treatment for the patients after compensation is 7659.14 yuan , the decrease of 67.31 % . The direct medical expense is $ 156.08 , the decrease of 89.71 % , the direct non - medical expense is 4756.00 yuan , the total cost of the whole course of treatment after compensation is 10759.14 yuan , which is reduced by 54.08 % .
The median of direct medical expenses was 336.08 yuan , which decreased by 77.85 % ;
There is no change in direct non - medical expenses , still 6056.00 yuan .

According to the current compensation programme , the total cost of compensation was 37.58 per cent of the total two - year household income , a decrease of 74 per cent compared with the previous compensation . While the proportion of households resulting in catastrophic medical expenditure was reduced by approximately 18 per cent compared with prior compensation , 65.75 per cent of families still had catastrophic medical expenses for families because of the treatment of multi - drug resistant tuberculosis . However , there were still 65.75 per cent of the total course of treatment of patients after compensation as 64.41 per cent of the total two years of family income and 82.19 per cent of family catastrophic expenditure .

Conclusions and Recommendations

The tuberculosis control project in China covers comprehensive intervention from the aspects of the detection , diagnosis , treatment , management and financing of multi - drug resistant pulmonary tuberculosis patients , which improves the diagnosis and treatment services of drug - resistant tuberculosis . However , there are some problems such as low screening rate of suspicious persons in the region , poor compliance of treatment compliance and persistence of insurance policies in the course of project implementation .

Based on the above conclusions , the following recommendations are proposed for this study :

1 . The drug - resistant pulmonary tuberculosis patients who carry out the project have found a strategy to use the rapid diagnostic technique to screen patients with smear positive pulmonary tuberculosis on the basis of cooperation between hospitals and anti - tuberculosis institutions .

2 . The treatment method combined with the individualized treatment plan is adopted to ensure the supply and quality of the medicine in order to reduce the occurrence of adverse reaction . The training of the supervisor should be strengthened , and the adverse reaction can be found and treated in time .

3 . To further improve the cooperation between the fixed - point hospitals and the anti - agency institutions , in particular to strengthen the information communication among the cooperation agencies , to ensure the smooth and timely communication of information in various aspects of the discovery , diagnosis , treatment and management of multi - drug - resistant pulmonary tuberculosis patients .

4 . Establish a sound and sustainable fund - raising mechanism for the prevention and treatment of multi - drug - resistant pulmonary tuberculosis . After the project is completed , it is necessary to ensure that the three medical insurance systems in both urban and rural areas will continue to implement the compensation policy for the treatment of multi - drug resistant pulmonary tuberculosis . Patients who are in poverty can intervene in the civil affairs department for assistance and ensure that the patient cannot be treated for economic reasons .

【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2013
【分类号】：R521

【参考文献】