本文選題：耐多藥結(jié)核病 + 診療服務(wù)��； 參考：《山東大學(xué)》2013年碩士論文

【摘要】：研究背景 耐多藥結(jié)核病(Multi-drug resistant tuberculosis, MDR-TB)是由至少對(duì)兩種有效抗結(jié)核藥物——利福平和異煙肼同時(shí)耐藥的結(jié)核分支桿菌感染引起的疾病。我國是世界上22個(gè)結(jié)核病高負(fù)擔(dān)國家之一,同時(shí)也是27個(gè)耐藥結(jié)核病高負(fù)擔(dān)國家之一。我國耐多藥肺結(jié)核控制工作長期存在著發(fā)現(xiàn)率低、診斷和治療不及時(shí),治療不規(guī)范,治療依從性差,患者治療疾病經(jīng)濟(jì)負(fù)擔(dān)重等問題。由于這些問題的存在,我國耐藥結(jié)核病控制面臨著巨大的挑戰(zhàn)。中國疾控中心和蓋茨基金會(huì)合作的結(jié)核病控制項(xiàng)目試圖通過在試點(diǎn)地區(qū)實(shí)施一系列綜合干預(yù)措施,探索建立一種與醫(yī)保相結(jié)合的醫(yī)院及疾控系統(tǒng)合作新模式,為完善我國耐多藥結(jié)核病控制規(guī)劃提供思路及經(jīng)驗(yàn)。改善耐多藥肺結(jié)核診療服務(wù)的措施在其中占有很重要的地位,其中包括對(duì)耐多藥肺結(jié)核患者發(fā)現(xiàn)、治療管理和疾病經(jīng)濟(jì)負(fù)擔(dān)的干預(yù)。 研究目的 本研究將從耐多藥肺結(jié)核患者的發(fā)現(xiàn)、治療管理以及疾病經(jīng)濟(jì)負(fù)擔(dān)三個(gè)方面對(duì)綜合干預(yù)措施實(shí)施后的耐多藥肺結(jié)核診療服務(wù)進(jìn)行評(píng)價(jià),為進(jìn)一步完善耐多藥結(jié)核病控制規(guī)劃提供建議。 研究方法 本研究根據(jù)全國各省耐藥肺結(jié)核基線調(diào)查數(shù)據(jù)、結(jié)核病控制工作水平和社會(huì)經(jīng)濟(jì)條件等,選擇河南開封市、江蘇連云港市、重慶永川區(qū)和內(nèi)蒙古呼和浩特市作為項(xiàng)目地區(qū),評(píng)價(jià)各項(xiàng)目地區(qū)綜合干預(yù)措施實(shí)施一年期間的耐多藥肺結(jié)核診療服務(wù)。 收集每個(gè)項(xiàng)目地區(qū)地市級(jí)結(jié)防機(jī)構(gòu)、定點(diǎn)醫(yī)院和縣級(jí)結(jié)防機(jī)構(gòu)有關(guān)耐多藥肺結(jié)核可疑者篩查、耐多藥肺結(jié)核治療的項(xiàng)目常規(guī)監(jiān)測資料,分析耐多藥肺結(jié)核患者發(fā)現(xiàn)情況及影響因素,評(píng)估項(xiàng)目市醫(yī)院治療耐多藥肺結(jié)核患者的及時(shí)性、規(guī)范性和患者治療的依從性。在每個(gè)項(xiàng)目地區(qū)選擇定點(diǎn)醫(yī)院為研究現(xiàn)場,調(diào)查納入項(xiàng)目治療滿6個(gè)月的患者。通過結(jié)構(gòu)化問卷收集患者治療信息,分析患者在項(xiàng)目治療的疾病經(jīng)濟(jì)負(fù)擔(dān),現(xiàn)場共調(diào)查耐多藥肺結(jié)核患者73例。此外,本研究還訪談了項(xiàng)目地區(qū)地市級(jí)和縣級(jí)結(jié)防機(jī)構(gòu)項(xiàng)目工作人員,定點(diǎn)醫(yī)院負(fù)責(zé)人、醫(yī)生和實(shí)驗(yàn)室人員,管理患者的村醫(yī)等關(guān)鍵人物,共訪談39人。 常規(guī)監(jiān)測資料、機(jī)構(gòu)表等定量資料在Excel中整理儲(chǔ)存,使用SPSS18.0對(duì)資料進(jìn)行描述性統(tǒng)計(jì)分析和統(tǒng)計(jì)推斷,使用的統(tǒng)計(jì)方法包括秩和檢驗(yàn)、卡方檢驗(yàn)、生存分析和廣義線性模型等。訪談資料根據(jù)錄音整理成Word格式,使用Nvivo7軟件分析。 研究結(jié)果 1.耐多藥肺結(jié)核患者發(fā)現(xiàn) 項(xiàng)目總體篩查率達(dá)到83.93%,開封、連云港和重慶三地篩查率均在90%以上�？焖僭\斷技術(shù)檢出MDR-TB患者檢出率為6.22%,呼和浩特快診MDR-TB患者檢出率僅為2.95%,明顯低于其他三地。 總體上,結(jié)防機(jī)構(gòu)來源的涂陽肺結(jié)核患者發(fā)現(xiàn)時(shí)間間隔為7天,呼和浩特發(fā)現(xiàn)時(shí)間間隔為14天,明顯長于其余三地。50.19%的患者發(fā)現(xiàn)時(shí)間間隔在7天之內(nèi),呼市這一比例只有11.33%。送痰、快速診斷和信息反饋時(shí)間間隔分別為2、5、0天,呼和浩特的信息反饋時(shí)間為5天,明顯長于其他地區(qū)。 2.耐多藥肺結(jié)核患者治療管理 耐多藥肺結(jié)核患者總體納入率為70.78%�？煸\結(jié)果為耐多藥的肺結(jié)核的患者納入率為76.16%,高于快診結(jié)果為耐利福平的肺結(jié)核患者的納入率62.50%。新患者的納入率(55.22%)低于非新患者(76.70%)。家庭年收入在5000-10000元間的患者納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例納入項(xiàng)目治療的耐多藥肺結(jié)核患者治療延遲為5天,長于規(guī)定的時(shí)間。49.42%的患者治療延遲在4天以內(nèi)。衛(wèi)生系統(tǒng)治療延遲和患者治療延遲分別為0天和7天。 138例耐藥肺結(jié)核患者堅(jiān)持治療率由1月末的0.934下降至6月末的0.787�？焖僭\斷結(jié)果為單耐利福平的患者堅(jiān)持治療率低于耐多藥肺結(jié)核患者；無保險(xiǎn)的患者堅(jiān)持治療率低于有保險(xiǎn)的患者。不良反應(yīng)、死亡和經(jīng)濟(jì)困難是影響患者治療依從性的主要因素。 3.耐多藥肺結(jié)核患者疾病經(jīng)濟(jì)負(fù)擔(dān) 干預(yù)后耐多藥肺結(jié)核患者次均住院費(fèi)用為3819.49元,日均住院費(fèi)用為97.84元,分別為干預(yù)前的52.51%和44.23%；患者住院藥品費(fèi)用所占比例由59.93%下降到26.59%。干預(yù)后患者的登記分類、定點(diǎn)醫(yī)院床位數(shù)和住院天數(shù)對(duì)患者住院費(fèi)用影響有統(tǒng)計(jì)學(xué)意義。 耐多藥肺結(jié)核患者治療全療程的總費(fèi)用為23430.82元,直接醫(yī)療費(fèi)用為15166.68元,直接非醫(yī)療費(fèi)用為6056.00元,間接費(fèi)用為437.00元�；颊咧委熑煶痰闹苯俞t(yī)療費(fèi)用占患者2年家庭收入的比例為65.58%,有84.90%的患者家庭的非食品支出占家庭總支出的比例超過40%,給家庭帶來了災(zāi)難性醫(yī)療支出。 按照目前的補(bǔ)償方案,補(bǔ)償后患者全療程的總費(fèi)用為7659.14元,降低了67.31%。直接醫(yī)療費(fèi)用為1560.08元,降低了89.71%：直接非醫(yī)療費(fèi)用為4756.00元,僅降低了21.74%。如果沒有隨訪和注射期的項(xiàng)目補(bǔ)償,補(bǔ)償后患者全療程的總費(fèi)用為10759.14元,降低了54.08%；直接醫(yī)療費(fèi)用的中位數(shù)為3360.08元,降低了77.85%；直接非醫(yī)療費(fèi)用無變化,仍為6056.00元。 按照目前的補(bǔ)償方案,補(bǔ)償后總費(fèi)用占兩年家庭收入的37.58%,與補(bǔ)償前相比下降了74%。雖然與補(bǔ)償前相比,造成災(zāi)難性醫(yī)療支出的家庭比例降低了約18%,但仍有65.75%的家庭因?yàn)橹委熌投嗨幏谓Y(jié)核而給家庭帶來了災(zāi)難性醫(yī)療支出。但是如果沒有隨訪和注射期的項(xiàng)目補(bǔ)償,補(bǔ)償后患者全療程總費(fèi)用占兩年家庭收入的比例為64.41%,造成家庭災(zāi)難性支出的家庭比例為82.19%。 結(jié)論與建議 中蓋結(jié)核病控制項(xiàng)目從耐多藥肺結(jié)核患者發(fā)現(xiàn)、診斷、治療、管理和籌資等方面進(jìn)行了綜合性干預(yù),改善了耐藥肺結(jié)核診療服務(wù)。但是在項(xiàng)目實(shí)施過程中還存在有的地區(qū)可疑者篩查率低、患者治療依從性差、保險(xiǎn)政策持續(xù)性差等問題。 根據(jù)以上結(jié)論,本研究提出以下建議： 1.推行項(xiàng)目實(shí)行的耐多藥肺結(jié)核患者發(fā)現(xiàn)策略,在醫(yī)院和結(jié)防機(jī)構(gòu)合作的基礎(chǔ)上使用快速診斷技術(shù)對(duì)涂陽肺結(jié)核患者進(jìn)行篩查。 2.采用標(biāo)準(zhǔn)化治療方案與個(gè)體化治療方案相結(jié)合的治療方法,保證定點(diǎn)醫(yī)院藥品的供應(yīng)和質(zhì)量,降低不良反應(yīng)的發(fā)生。加強(qiáng)對(duì)督導(dǎo)員的培訓(xùn),及時(shí)發(fā)現(xiàn)和處理不良反應(yīng)。 3.進(jìn)一步完善定點(diǎn)醫(yī)院和結(jié)防機(jī)構(gòu)之間的合作,特別要加強(qiáng)合作機(jī)構(gòu)間的信息溝通,在耐多藥肺結(jié)核患者的發(fā)現(xiàn)、診斷、治療和管理的各個(gè)環(huán)節(jié)保證信息交流的暢通和及時(shí)。 4.建立完善的可持續(xù)的耐多藥肺結(jié)核防治經(jīng)費(fèi)籌資機(jī)制,在項(xiàng)目結(jié)束后要保證城鄉(xiāng)三種醫(yī)療保險(xiǎn)制度對(duì)耐多藥肺結(jié)核治療的補(bǔ)償政策繼續(xù)執(zhí)行。對(duì)確實(shí)貧困的患者可以介入民政部門救助,保證患者不因經(jīng)濟(jì)原因無法接受治療。
[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 .

【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2013
【分類號(hào)】：R521

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本文編號(hào)：1755871