借助实际病例对北京市中心城区医院乙型肝炎诊治能力的调查

A Survey on the Capability of Hepatitis B Diagnosis and Treatment among Beijing Urban Hospitals

目的了解北京市中心城区医疗机构乙型肝炎诊治的实际能力,分析存在的问题并提出建议。方法采用现况调查与非参与观察法相结合的方法,于2009年12月借助5名实际肝病志愿者,在北京市中心城区抽取3家三级医院、2家二级医院、2家一级医院进行诊疗体验,分析这些医疗机构与医务人员对乙型肝炎的实际诊治能力。结果 (1)三级、二级、一级医院整体诊疗人员和设备比较完善,基础条件较好。均有专科或全科医师出诊,能进行肝功能、乙型肝炎和丙型肝炎等病毒性肝炎血清免疫学和腹部超声检查。(2)存在的问题:①门诊医师诊断能力:三级医院过于依赖仪器检查而物理查体少,门诊诊断不够具体;二级中医医院查体缺乏西医体征,中医和西医医院恰当诊断率和恰当处理率都偏低;三级医院与一、二级医院医师询问乙型肝炎患者现病史的合格率比较,差异无统计学意义(χ2=0.05,P>0.05);三级医院与一、二级医院医师对乙型肝炎患者恰当诊断、恰当处理的合格率比较,差异均有统计学意义(χ2值分别为7.70及5.04,P<0.05)。一级医院均没有肝病专科医师,从病史采集、体检到诊断基本不能完成,不具备对血吸虫肝病等少见肝病诊断与鉴别诊断的能力;②超声诊断:作为肝胆常用检查的手段基本能够普及,但检测指标普遍不够细化,导致结论笼统;③肝功能检查:各级医院基本能够普及检查,各家测定值差别不大;个别一级医院检查项目过于简单,参考价值有限;④HBV血清学标志五项检查:基本能够普及,但所用试剂不统一,个别检查结果有误。HBVDNA定量等检查需要依靠专科医院或个别三级医院来检测,二级、一级医院开出的申请单不足。结论北京市中心城区虽基本具备较强的乙型肝炎诊治能力,但诊疗过程中普遍存在询问病史简单、查体不仔细、门诊诊断欠准确、鉴别诊断不足等问题,需要加强专科知识培训。超声以及肝功能、病毒学等实验室检查,存在检测项目开展数量不足、同一指标因试剂不同导致检测结果存在差异无法互认等问题,需要进一步规范化和标准化。本研究结果为"十一五"国家传染病示范区课题的实施提供了参考信息。

Objective To investigate the capability of hepatitis B diagnosis and treatment among Beijing urban hospitals.Methods Using a non-participant observation method combined with cross-sectional investigation,we invited five volunteers with liver disease to receive diagnosis and treatment in 3 Grade-III hospitals,2 Grade-Ⅱhospitals,and 2 Grade-Ⅰhospitals in December.2009.The capability of hepatitits B diagnosis and treatment among these hospitals was analyzed.Results Generally,all these hospitals had qualified personnel and good equipment in this area.Specialists or general practitioners were available to provide medical services.Liver biochemistry,hepatitis B and hepatitis C etiology screening,and abdominal ultrasonography are available in these hospitals.However,some problems still existed.During the diagnosis,doctors in Grade-III hospitals relied too much on instruments rather than physical examinations.In the Grade-Ⅱ hospitals,less medical signs were noted,making the rate of improper diagnosis and treatment relatively high.Compared with the Grade-Ⅱhospitals and Grade-Ⅰhospitals,the qualification rate of doctors′ enquiring medical history in Grade-III hospitals was not significantly different（χ2=0.05,P0.05）;however,the qualification rates of proper diagnosis and management were significantly higher （χ2=7.70 or χ2=5.04,P0.05）.In the Grade-Ⅰhospitals,there usually had no liver disease specialists.The history taking,physical examination,and diagnose basically can not be independently completed.The uncommon liver diseases such as schistosomiasis liver disease could not be diagnosed.Ultrasound examination was universally used as a basic measure for liver and gallbladder diseases.However,the detection indicators were generally not well defined and therefore could not support accurate diagnosis.Liver biochemistry examinations were commonly available with less differences.However,the examination items provided by some Grade-Ⅰhospitals were too simple and therefore with limited diagnostic values.Hepatitis B serologic hallmark test was universally performed,while the reagents used were diverse.Some test results were wrong.HBV DNA quantification still was only provided in specialist hospitals or a few Grade-III hospitals.The physicians in Grade-Ⅱ hospitals gave described limited application for this test.Conclusion Beijing Urban hospitals basically have good capability of hepatitis B diagnosis and treatment,although there are still many place to be improved.Further specific training on hepatitis B is needed.Supportive examinations such as ultrasound diagnosis,biochemistry,virological examination require further optimization and standardization.