發(fā)布時間：2018-08-27 08:46

【摘要】：研究背景 結(jié)核病是全球公共衛(wèi)生的巨大挑戰(zhàn)之一。為加強(qiáng)結(jié)核病的治療和控制,世界衛(wèi)生組(WHO)提出公立與私立醫(yī)療機(jī)構(gòu)合作策略(簡稱公私醫(yī)療合作),旨在動員所有醫(yī)療服務(wù)提供者共同開展以“直面督導(dǎo)下的短程化療”(DOTS)為基礎(chǔ)的結(jié)核病綜合防治工作。我國在結(jié)核病防控的工作實踐中,探索形成一套多元化的醫(yī)療衛(wèi)生機(jī)構(gòu)與結(jié)核病防治專業(yè)機(jī)構(gòu)(結(jié)防所或疾控中心結(jié)防科)之間密切合作的結(jié)核病聯(lián)合防控策略,簡稱醫(yī)防合作策略。國際上對于結(jié)核病防控的公私醫(yī)療合作的特點和所取成效已開展一定研究,而國內(nèi)也針對醫(yī)防合作在結(jié)核病患者的發(fā)現(xiàn)、轉(zhuǎn)診和治療方面的效果進(jìn)行分析,但目前對于公私醫(yī)療合作策略及醫(yī)防合作策略的機(jī)制總結(jié)、模式探討以及實施效果綜合分析評價研究還鮮見報道。 研究目的 全面系統(tǒng)地回顧全球范圍內(nèi)開展的結(jié)核病防控的公私醫(yī)療合作項目,總結(jié)公私醫(yī)療合作機(jī)制,描述其運(yùn)作特點及參與合作機(jī)構(gòu)之間的職能與分工,并對其結(jié)核病防控效果進(jìn)行綜合評價；深入探討中國結(jié)核病醫(yī)防合作策略的形成、發(fā)展、主要模式及其特點；探索重慶地區(qū)結(jié)核病醫(yī)防合作模式的發(fā)展情況、優(yōu)勢及存在主要問題,掌握結(jié)核病患者歸口診治和管理現(xiàn)狀,為針對性地解決醫(yī)防合作過程中的具體問題及改善結(jié)核病患者的診療服務(wù)提供科學(xué)依據(jù)。 研究方法 1.采用系統(tǒng)評價的方法,對全球結(jié)核病防控公私醫(yī)療合作項目的機(jī)制與效果進(jìn)行總結(jié)與評價。 全面檢索14個電子數(shù)據(jù)庫、2個灰色文獻(xiàn)數(shù)據(jù)庫以及6個相關(guān)網(wǎng)站截止2012年4月已發(fā)表的文獻(xiàn)。納入描述和評價已實施的結(jié)核病公私醫(yī)療合作項目原始研究。由兩名研究員分別獨立進(jìn)行文獻(xiàn)篩選、研究分類及數(shù)據(jù)提取,并交叉核對,討論達(dá)成共識。采用定性描述與合并方法對納入研究的信息和結(jié)果進(jìn)行歸納,以總結(jié)公私醫(yī)療合作策略的運(yùn)作機(jī)制并綜合評價合作項目實施效果。 2.運(yùn)用文獻(xiàn)回顧、政策文件收集和專家咨詢的方法,對我國結(jié)核病防控的醫(yī)防合作策略及合作模式進(jìn)行總結(jié)探討。 回顧與我國結(jié)核病醫(yī)防合作相關(guān)的文獻(xiàn)資料,收集整理相關(guān)政策法規(guī)文件,并咨詢結(jié)核病防治機(jī)構(gòu)的領(lǐng)導(dǎo)及國際國內(nèi)相關(guān)領(lǐng)域的專家,以總結(jié)我國結(jié)核病醫(yī)防合作策略的建立與發(fā)展情況,并對主要醫(yī)防合作模式的特點、優(yōu)勢和局限進(jìn)行全面總結(jié)分析。 3.采用機(jī)構(gòu)調(diào)查、政策文件收集、問卷調(diào)查與定性訪談相結(jié)合的方法,對重慶地區(qū)主要的結(jié)核病醫(yī)防合作模式的特點、優(yōu)勢、困難障礙及實施效果進(jìn)行調(diào)查研究和比較分析。 (1)機(jī)構(gòu)調(diào)查與政策文件收集：采用機(jī)構(gòu)調(diào)查表對參與合作的結(jié)防機(jī)構(gòu)和定點醫(yī)院情況進(jìn)行調(diào)查,查閱機(jī)構(gòu)檔案資料并獲取相關(guān)政策法規(guī)文件。調(diào)查數(shù)據(jù)經(jīng)提取和歸納后,對兩種醫(yī)防合作模式下結(jié)核病患者主動就診、轉(zhuǎn)診和追蹤情況差異進(jìn)行描述性統(tǒng)計分析。 (2)定量調(diào)查：在研究地點選取2012年6月～12月之間確診的494名新發(fā)結(jié)核病患者作為研究對象,采用自編調(diào)查問卷進(jìn)行定量調(diào)查,了解患者基本信息就診及轉(zhuǎn)診情況,調(diào)查結(jié)果雙錄入EpiData3.1數(shù)據(jù)庫,并用SPSS17.0軟件進(jìn)行統(tǒng)計分析。 (3)定性訪談：目的性地在調(diào)查機(jī)構(gòu)抽取10名領(lǐng)導(dǎo)干部及門診醫(yī)生,使用半結(jié)構(gòu)式訪談提綱,對其進(jìn)行關(guān)鍵人物訪談,了解醫(yī)防合作模式發(fā)展過程、運(yùn)作特點、工作中的主要優(yōu)勢與困難等信息。使用MAXQDA11軟件管理定性資料,并采用主題框架分析法進(jìn)行定性分析。 研究結(jié)果 1.系統(tǒng)評價結(jié)果 納入分析的69篇原始研究,可被歸納為43個在15個國家開展的公私醫(yī)療合作項目。根據(jù)不同合作項目中參與機(jī)構(gòu)的職責(zé)與分工,可將公私醫(yī)療合作策略的運(yùn)作機(jī)制歸納為支持機(jī)制(包括經(jīng)濟(jì)、物資和人員支持)、合同機(jī)制(包括正式與非正式合同)以及工作組機(jī)制(工作指導(dǎo)委員會)。絕大多數(shù)研究肯定了公私醫(yī)療合作在DOTS實施、病例發(fā)現(xiàn)、治療結(jié)局、患者管理、服務(wù)可及性與公平性、相關(guān)花費(fèi)、技術(shù)能力、接受程度與合作水平方面具有積極促進(jìn)作用。 2.中國結(jié)核病醫(yī)防合作策略研究結(jié)果 我國探索形成適宜國情的多元化結(jié)核病防治的醫(yī)防合作策略,其合作模式主要分為結(jié)防機(jī)構(gòu)模式、定點醫(yī)院模式、�？漆t(yī)院模式及基層衛(wèi)生服務(wù)網(wǎng)絡(luò)模式四種,其中以結(jié)防機(jī)構(gòu)模式和定點醫(yī)院模式為主。醫(yī)防合作策略在全國結(jié)核病防治實踐工作中發(fā)揮了重要作用,但也存在診治和轉(zhuǎn)診工作不規(guī)范、截留患者、醫(yī)務(wù)人員有限、技術(shù)力量和管理能力不足等局限性。 3.重慶地區(qū)結(jié)核病醫(yī)防合作模式研究結(jié)果 目前重慶各區(qū)縣開展的結(jié)核病防治醫(yī)防合作主要屬于結(jié)防機(jī)構(gòu)模式和定點醫(yī)院模式。結(jié)防機(jī)構(gòu)模式可確保患者診治和管理的系統(tǒng)性和連貫性；定點醫(yī)院模式在診療條件和臨床能力上具有明顯優(yōu)勢。比較發(fā)現(xiàn),結(jié)防所模式下患者轉(zhuǎn)診到位率較高,首診更傾向選擇指定結(jié)防機(jī)構(gòu)；定點醫(yī)院模式能在一定程度上促進(jìn)結(jié)核病患者發(fā)現(xiàn)和追蹤水平。兩種模式下患者的治療成功率和涂陽患者治愈率均在90%以上,結(jié)防所模式略高于定點醫(yī)院模式。兩種醫(yī)防合作模式在結(jié)核病防治工作中都能發(fā)揮了重要作用,但仍然存在自身局限,主要體現(xiàn)在經(jīng)費(fèi)投入不足及其引起基礎(chǔ)設(shè)施、設(shè)備條件、人才引進(jìn)、人員培訓(xùn)、醫(yī)生工資待遇、患者醫(yī)療保障等方的問題,以及綜合醫(yī)院管理協(xié)調(diào)和業(yè)務(wù)監(jiān)督困難,醫(yī)務(wù)人員院感風(fēng)險高,患者依從性不高等。 結(jié)論 無論是全球公私醫(yī)療合作策略還是我國醫(yī)防合作策略,存在不同的合作機(jī)制或模式。鑒于各自特點和優(yōu)勢,不同合作機(jī)制及模式在結(jié)核病防治實踐的不同方面發(fā)揮作用。對于目前結(jié)核病防治實踐中普遍存在的困難和障礙,可以從制定政策法規(guī)、改善機(jī)構(gòu)工作和研發(fā)新型診療措施三個層面著手,加大經(jīng)費(fèi)投入、明確機(jī)構(gòu)職責(zé)、建立監(jiān)管體制、搭建信息平臺、提高福利待遇、改善醫(yī)療保障、爭取項目經(jīng)費(fèi)、促進(jìn)協(xié)調(diào)聯(lián)系、加強(qiáng)培訓(xùn)教育、改進(jìn)工作方法,進(jìn)一步促使全球公私醫(yī)療合作策略及我國醫(yī)防合作策略在結(jié)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.
【學(xué)位授予單位】：重慶醫(yī)科大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2013
【分類號】：R197.1;R52

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本文編號：2206724