本文選題：肺結(jié)核　切入點(diǎn)：定點(diǎn)醫(yī)院　出處：《中國(guó)疾病預(yù)防控制中心》2014年碩士論文

【摘要】：目的： 了解縣(區(qū))級(jí)結(jié)核病定點(diǎn)醫(yī)院基本情況和結(jié)核病發(fā)現(xiàn)和治療的現(xiàn)況,描述定點(diǎn)醫(yī)院轉(zhuǎn)型4年結(jié)核病發(fā)現(xiàn)和治療轉(zhuǎn)歸的趨勢(shì),并與定點(diǎn)醫(yī)院轉(zhuǎn)型前結(jié)核病發(fā)現(xiàn)和治療轉(zhuǎn)歸數(shù)據(jù)進(jìn)行比較。發(fā)現(xiàn)定點(diǎn)醫(yī)院存在的問(wèn)題,為今后進(jìn)一步完善結(jié)核病定點(diǎn)醫(yī)院結(jié)核病診療工作提供參考依據(jù)。 方法： 采用現(xiàn)況調(diào)查的方法,對(duì)縣(區(qū))級(jí)結(jié)核病定點(diǎn)醫(yī)院的現(xiàn)況進(jìn)行描述和分析。通過(guò)問(wèn)卷調(diào)查收集縣(區(qū))基本情況和定點(diǎn)醫(yī)院的基本情況,通過(guò)現(xiàn)場(chǎng)調(diào)查收集患者發(fā)現(xiàn)和治療現(xiàn)況；通過(guò)回顧性分析比較定點(diǎn)醫(yī)院轉(zhuǎn)型前后結(jié)核病發(fā)現(xiàn)和治療轉(zhuǎn)歸的變化以及描述定點(diǎn)醫(yī)院轉(zhuǎn)型4年結(jié)核病發(fā)現(xiàn)和治療轉(zhuǎn)歸的變化趨勢(shì),綜合分析以上四部分內(nèi)容,總結(jié)提煉定點(diǎn)醫(yī)院現(xiàn)狀及存在問(wèn)題,得出結(jié)論并提出建議。 結(jié)果： 本次調(diào)查研究在江蘇省鎮(zhèn)江市、湖北省宜昌市、陜西省漢中市三個(gè)地市的7個(gè)縣(區(qū))開(kāi)展。從7個(gè)縣(區(qū))2011年的社會(huì)經(jīng)濟(jì)學(xué)情況分析,東部鎮(zhèn)江3個(gè)縣(區(qū))經(jīng)濟(jì)收入水平高于全國(guó)同期人均收入水平,西部漢中則低于全國(guó)同期人均收入水平。中部宜昌宜都市和東部鎮(zhèn)江句容市活動(dòng)性肺結(jié)核登記率高于全國(guó)同期活動(dòng)性肺結(jié)核登記水平。其余5個(gè)地區(qū)則低于全國(guó)同期登記水平。新農(nóng)合醫(yī)保在鎮(zhèn)江句容和丹徒普通門(mén)診統(tǒng)籌給予30%-40%的門(mén)診補(bǔ)償,慢性病門(mén)診補(bǔ)償在中部宜昌宜都和五峰兩地補(bǔ)償額度為200元-540元,中西部地區(qū)住院補(bǔ)償比例為65%-80%。城鎮(zhèn)職工鎮(zhèn)江門(mén)診可報(bào)銷(xiāo)20%-40%,宜昌實(shí)行限額補(bǔ)助,患者自付25%,漢中城職醫(yī)保沒(méi)有將結(jié)核病納入了結(jié)核病慢病門(mén)診報(bào)銷(xiāo)范圍。城鎮(zhèn)居民醫(yī)保在鎮(zhèn)江報(bào)銷(xiāo)比例同新農(nóng)合,在漢中則實(shí)行限額補(bǔ)助800元/年,宜昌報(bào)銷(xiāo)比例為40%。城鎮(zhèn)職工報(bào)銷(xiāo)比例根據(jù)醫(yī)療費(fèi)用分段報(bào)銷(xiāo),漢中則報(bào)銷(xiāo)92%。城鎮(zhèn)居民住院報(bào)銷(xiāo)在宜昌和漢中地區(qū)報(bào)銷(xiāo)比例均為60%。 7家定點(diǎn)醫(yī)院設(shè)立時(shí)間不同,其中6家醫(yī)院經(jīng)過(guò)驗(yàn)收,6家達(dá)到二級(jí)甲等。定點(diǎn)醫(yī)院承擔(dān)結(jié)核病診斷與治療、結(jié)核病登記與報(bào)告、初診患者健康教育和密切接觸者篩查工作。痰涂片費(fèi)用在鎮(zhèn)江由中央轉(zhuǎn)移支付經(jīng)費(fèi)和地方配套共同支付,宜昌宜都和漢中勉縣均無(wú)地方配套,由醫(yī)院支付缺口部分。各地胸片價(jià)格變化較大,從35-139元不等,鎮(zhèn)江和宜昌由地方配套和全球基金補(bǔ)齊缺口經(jīng)費(fèi),但漢中勉縣仍需要患者支付部分費(fèi)用。7家定點(diǎn)醫(yī)院實(shí)驗(yàn)室均能開(kāi)展痰涂片檢查,3家能開(kāi)展痰培養(yǎng)檢查。7家定點(diǎn)醫(yī)院結(jié)核菌感染控制整體薄弱,門(mén)診、實(shí)驗(yàn)室和病房布局合理率分別為22%、56%和25%；門(mén)診、實(shí)驗(yàn)室和病房通風(fēng)量達(dá)到標(biāo)準(zhǔn)的分別占89%、56%、88%；門(mén)診、實(shí)驗(yàn)室紫外線照射強(qiáng)度達(dá)到標(biāo)準(zhǔn)分別為33%和44%,醫(yī)務(wù)人員口罩佩戴率僅11%。定點(diǎn)醫(yī)院院內(nèi)轉(zhuǎn)診較為順暢,網(wǎng)絡(luò)直報(bào)率為97.11%。肺結(jié)核患者住院率為25%,次均住院費(fèi)用6160元,住院天數(shù)中位數(shù)為20天,規(guī)范化治療方案使用率為58.94%,64.63%的普通肺結(jié)核患者使用二線藥物。 選擇宜昌市第一人民醫(yī)院描述轉(zhuǎn)型后4年結(jié)核病發(fā)現(xiàn)和治療轉(zhuǎn)歸的變化。結(jié)果如下：2010-2012年,初診患者痰檢率呈逐漸降低趨勢(shì)。因癥就診構(gòu)成比逐年增加。轉(zhuǎn)診來(lái)源構(gòu)成2010-2011年下降12.71%,2011-2012年則上升2.4%。初治涂陽(yáng)患者登記率下降24.31%。非定點(diǎn)醫(yī)院網(wǎng)絡(luò)報(bào)告轉(zhuǎn)診到位率無(wú)明顯差異(x2=18.8098P0.05)追蹤到位率無(wú)明顯差異(Z2=6.8207P=0.0778),總體到位率無(wú)明顯差異(x2=2.3926P=0.4950),登記肺結(jié)核患者治療轉(zhuǎn)歸無(wú)明顯變化(X2=7.5151P=0.0572)。 分別選擇東部句容、中部枝江、西部勉縣3個(gè)縣(區(qū))進(jìn)行轉(zhuǎn)型前后患者發(fā)現(xiàn)和治療轉(zhuǎn)歸變化的比較,結(jié)果如下：轉(zhuǎn)型前后初診患者占人口的比例分別為291.41/10萬(wàn)、272.27/10萬(wàn),轉(zhuǎn)型后下降6.57%。轉(zhuǎn)型前后活動(dòng)性肺結(jié)核患者率分別為70.66/10萬(wàn)和63.96/10萬(wàn),轉(zhuǎn)型后登記率下降9.48%。轉(zhuǎn)型前后初治涂陽(yáng)患者登記率分別為24.24/10萬(wàn)、8.05/10萬(wàn),轉(zhuǎn)型后降低66.79%。轉(zhuǎn)型后因癥就診構(gòu)成比增加19.95%,轉(zhuǎn)診構(gòu)成下降59.43%。轉(zhuǎn)型前后涂陽(yáng)和涂陰患者治療成功率變化無(wú)統(tǒng)計(jì)學(xué)意差異(X2=1.9620P=0.1613X2=2.6892P=0.1010)。結(jié)論： 縣(區(qū))級(jí)定點(diǎn)醫(yī)院承擔(dān)結(jié)核病診斷治療工作后,沒(méi)有造成結(jié)核病發(fā)現(xiàn)和治療轉(zhuǎn)歸的下滑。定點(diǎn)醫(yī)院就診更適合患者的就診習(xí)慣。定點(diǎn)醫(yī)院內(nèi)部轉(zhuǎn)診流程較為順暢,網(wǎng)絡(luò)報(bào)告數(shù)據(jù)完整性較好,網(wǎng)絡(luò)直報(bào)率高。但定點(diǎn)醫(yī)院結(jié)核病診療過(guò)程中也存在一些問(wèn)題,主要表現(xiàn)在可疑者篩查經(jīng)費(fèi)不足、診療行為不規(guī)范、結(jié)核桿菌感染控制整體薄弱和轉(zhuǎn)型初期活動(dòng)性肺結(jié)核患者和初治涂陽(yáng)患者登記率下降,尤其是初治涂陽(yáng)患者下降明顯。因此,為保障定點(diǎn)醫(yī)院模式持續(xù)有效的開(kāi)展,建議增加定點(diǎn)醫(yī)院經(jīng)費(fèi)投入,保障肺結(jié)核患者免費(fèi)篩查政策的落實(shí)。建立行政監(jiān)管機(jī)制,加強(qiáng)對(duì)定點(diǎn)醫(yī)院診療行為的監(jiān)管和考核,加強(qiáng)對(duì)實(shí)驗(yàn)室的考核和評(píng)估。提高各類醫(yī)療保險(xiǎn)門(mén)診報(bào)銷(xiāo)比例,有助于控制住院比例。加強(qiáng)結(jié)核病定點(diǎn)醫(yī)院結(jié)核桿菌感染控制,減少醫(yī)務(wù)人員和患者交叉感染的風(fēng)險(xiǎn)。
[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 .

【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】：2014
【分類號(hào)】：R52

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