本文關(guān)鍵詞：“醫(yī)防合作”綜合模式下利福平耐藥肺結(jié)核患者治療結(jié)果及其影響因素研究　出處：《中國(guó)疾病預(yù)防控制中心》2017年碩士論文　論文類型：學(xué)位論文

  更多相關(guān)文章： 結(jié)核 肺 結(jié)核 抗多種藥物性 治療結(jié)果 影響因素

【摘要】：目的在基于“醫(yī)防合作”綜合模式、對(duì)患者予以90%醫(yī)療費(fèi)用減免、使用國(guó)產(chǎn)抗結(jié)核藥物的標(biāo)準(zhǔn)化療方案的前提下,對(duì)患者近期治療效果及其影響因素、遠(yuǎn)期復(fù)發(fā)情況進(jìn)行分析,為推行適合我國(guó)國(guó)情的MDR-TB防治規(guī)劃提供科學(xué)依據(jù)和參考意見(jiàn)。方法本研究依托于中國(guó)衛(wèi)生與計(jì)劃生育委員會(huì)-蓋茨基金會(huì)結(jié)核病防治項(xiàng)目“醫(yī)院與疾控系統(tǒng)合作管理耐多藥肺結(jié)核試點(diǎn)研究”研究現(xiàn)場(chǎng),基于經(jīng)濟(jì)發(fā)展?fàn)顩r,選擇了中國(guó)四個(gè)中等三線城市來(lái)實(shí)施。納入分析的168例利福平耐藥肺結(jié)核患者為研究對(duì)象。運(yùn)用橫斷面研究,通過(guò)專家咨詢法及預(yù)調(diào)查,設(shè)計(jì)完成《利福平耐藥肺結(jié)核患者治療結(jié)果及其影響因素調(diào)查表》、《利福平耐藥肺結(jié)核患者管理個(gè)案調(diào)查表》,使用問(wèn)卷調(diào)查法,對(duì)納入治療的利福平耐藥肺結(jié)核患者治療結(jié)果及其影響因素?cái)?shù)據(jù)信息進(jìn)行收集、分析;運(yùn)用前瞻性隊(duì)列研究方法,使用《利福平耐藥肺結(jié)核患者治療完成后隨訪調(diào)查表》,對(duì)治療成功(包括治愈和完成治療)的患者進(jìn)行2年的遠(yuǎn)期追蹤隨訪調(diào)查,并進(jìn)行數(shù)據(jù)收集分析,獲得患者完成療程2年后的復(fù)發(fā)情況。使用SAS 9.3進(jìn)行統(tǒng)計(jì)分析;用統(tǒng)計(jì)圖表與統(tǒng)計(jì)指標(biāo)進(jìn)行統(tǒng)計(jì)描述;對(duì)分類變量使用χ2檢驗(yàn),當(dāng)理論頻數(shù)1時(shí),使用Fisher精確檢驗(yàn),檢驗(yàn)水準(zhǔn)α=0.10;選擇在單因素分析中有統(tǒng)計(jì)學(xué)意義的變量,使用logistic回歸檢驗(yàn)進(jìn)行多因素分析;對(duì)復(fù)發(fā)患者進(jìn)行統(tǒng)計(jì)描述與個(gè)案信息描述。結(jié)果168例利福平耐藥肺結(jié)核患者納入分析;其中,男性占75.60%(127/168),45-59歲年齡組人數(shù)最多,占42.26%(71/168),農(nóng)村戶籍人口占82.14%(138/168),復(fù)治患者占80.36%(135/168);僅對(duì)利福平和異煙肼耐藥患者占49.40%(83/168)。住院時(shí)間中位數(shù)為34天(IQR:24-52),治療時(shí)間中位數(shù)為720天(IQR:240-732)。共有25.90%(43/168)患者治療3月末出現(xiàn)痰培養(yǎng)陰轉(zhuǎn),共有67.26%(112/168)患者6月末出現(xiàn)痰培養(yǎng)陰轉(zhuǎn),3月末出現(xiàn)痰培養(yǎng)陰轉(zhuǎn)的患者,在6月末痰培養(yǎng)仍為陰性。本次研究中,治療成功率為46.43%,失敗率為23.21%(因不良反應(yīng)失敗占69.23%);丟失率19.64%(因外出打工、家庭經(jīng)濟(jì)困難、醫(yī)保問(wèn)題等經(jīng)濟(jì)原因丟失占其51.52%);3.58%患者因收押、遷出等原因未評(píng)估。為進(jìn)行因素分析,將研究對(duì)象(排除丟失及未評(píng)估患者)的近期治療結(jié)果分為成功治療(治愈、完成治療患者78例)與不良治療結(jié)果(死亡、失敗患者51例),共計(jì)129例患者納入因素分析。本次研究對(duì)象中,年齡(χ2=12.7956,P=0.0051)、教育程度(χ2=6.3449,P=0.0960)、登記分類(χ2=2.7454,P=0.0975)、耐藥類型(P=0.0010)、首次診斷結(jié)核病距本次治療的時(shí)間(χ3=7.6621,P=0.0535)、是否使用二線抗結(jié)核藥物(χ2=8.9923,P=0.0027)、既往接受過(guò)不同抗結(jié)核治療次數(shù)(χ2=9.5727,P=0.0083)、接受治療時(shí)間長(zhǎng)短(P0.0001)、隨訪復(fù)查及時(shí)性(χ2=13.1656,P=0.0003)、能否按時(shí)服藥(DOT)(χ2=6.6608,P=0.0099)患者、RR-TB患者治療方案是否加用異煙肼(P=0.0247)的患者間治療結(jié)果的差異有統(tǒng)計(jì)學(xué)意義。經(jīng)多因素Logistic回歸分析結(jié)果顯示,不良治療結(jié)果的危險(xiǎn)因素的變量有:首次診斷結(jié)核病距本次治療時(shí)間長(zhǎng)(OR=2.45,90%CI:1.27-4.74)、使用二線藥物(OR=3.32,90%CI:1.81-6.11)、接受抗結(jié)核治療次數(shù)多(OR=2.86,90%CI:1.41-5.88)、治療時(shí)間少于中位數(shù) 730 天(OR=4.79,90%CI:1.72-13.31)。完成全部療程后,共有78例患者治療成功,跟蹤隨訪2年,發(fā)現(xiàn)2例患者復(fù)發(fā),2年復(fù)發(fā)率為2.56%。結(jié)論與WHO公布的全球均值及國(guó)內(nèi)外研究結(jié)果相比,本研究的近期治療成功率偏低,失敗率偏高,遠(yuǎn)期復(fù)發(fā)率較低。患者年齡、教育程度、登記分類、耐藥類型、首次診斷結(jié)核病-本次治療時(shí)間(年)、是否使用二線抗結(jié)核藥物、既往接受過(guò)抗結(jié)核治療的次數(shù)、接受治療時(shí)間長(zhǎng)短、隨訪復(fù)查的及時(shí)性、能否按時(shí)服藥(DOT)是治療結(jié)果的影響因素;首次診斷結(jié)核病距本次治療時(shí)間長(zhǎng)、使用二線藥物、接受抗結(jié)核治療次數(shù)多、治療時(shí)間少于中位數(shù)730天是不良治療結(jié)果的危險(xiǎn)因素。3月末及6月末痰培養(yǎng)情況可大致反應(yīng)患者總體預(yù)后,因此應(yīng)重視患者早期病情。治療成功率偏低的可能原因包括經(jīng)濟(jì)問(wèn)題,患者多為接受多次治療的復(fù)治、耐多藥肺結(jié)核患者,針對(duì)此類患者可供選擇的治療藥物較少,國(guó)產(chǎn)藥品劑量偏低;患者依從性偏差,丟失率較高。另外,在不確定異煙肼是否耐藥的情況時(shí),盡量使用異煙肼,若為單耐利福平肺結(jié)核患者需及時(shí)使用異煙肼治療。
[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.

【學(xué)位授予單位】：中國(guó)疾病預(yù)防控制中心
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R521

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本文編號(hào)：1371975