肺结核门诊辅助诊治按病例付费对患者发现与治疗的影响

Effects of case based payment for TB outpatient auxiliary diagnosis and treatment on TB patients' detection and treatment

目的探讨肺结核门诊辅助诊治按病例付费对患者发现与治疗的影响。方法根据研究现场入选条件,汩罗市和临湘市入选为试点县,华容县为对照县,3县市2008年末人口数分别为66.0万、50.2万和72.9万。试点县主要干预措施是新型农村合作医疗实施肺结核门诊辅助诊治按病例付费,通过比较试点前后1年及试点县与对照县肺结核患者初诊就诊率、患者发现、就诊延误率、患者丢失率来评价试点的实施对患者发现和治疗管理的影响,采用统计描述、χ2检验及Wilcoxon秩和检验对数据进行统计学处理,检验水准为0.05。结果研究期间汩罗市肺结核患者初诊就诊率为332.0/10万,去年同期为209.8/10万,增长58.2%,差异有统计学意义(χ2=182.852,P<0.001),临湘市肺结核患者初诊就诊率为491.2/10万,去年同期为407.2/10万,增长20.6%,差异有统计学意义(χ2=39.921,P<0.001)。研究期间汩罗市和临湘市登记活动性肺结核患者分别为478例和533例,去年同期分别为416例和409例,分别增长14.9%和30.3%。研究期汩罗市就诊延误率为40.2%,去年同期为57.2%,下降29.7%,差异有统计学意义(χ2=25.884,P<0.001),临湘市就诊延误率为41.8%,去年同期为49.4%,下降15.4%,差异有统计学意义(χ2=5.328,P<0.05)。研究期汩罗市和临湘市肺结核患者初诊就诊率分别为332.0/10万和491.2/10万,对照县为359.0/10万,汩罗市与对照县比较差异有统计学意义(χ2=7.253,P<0.01);临湘市与对照县比较差异有统计学意义(χ2=127.685,P<0.001)。研究期间汩罗市和临湘市就诊延误率分别为40.2%和41.8%,对照县为48.9%,汩罗市与对照县比较差异有统计学意义(χ2=7.881,P<0.01),临湘市与对照县比较差异有统计学意义(χ2=5.443,P<0.05)。研究期间汩罗市和临湘市登记的活动性肺结核患者丢失率分别为0.2%和0,对照县为1.8%,汩罗市与对照县比较差异有统计学意义(χ2=6.283,P<0.05),临湘市与对照县比较差异有统计学意义(Fisher确切概率法,P<0.01)。结论肺结核门诊辅助诊疗按病例付费提高了患者发现水平,减少了患者丢失,对患者的规范治疗管理具有促进作用。

Objective To analyze the effects of case based payment for TB outpatient auxiliary diagnosis and treatment on TB patients＇ detection and treatment. Methods According to selection criteria of the study site,Miluo county and Linxiang county were selected as the pilot counties,Huarong county as the control county,three counties＇ population respectively were 660000,502000 and 729000 at the end of 2008.Main intervention was case based payment for TB outpatient auxiliary diagnosis and treatment by the new rural cooperative medical scheme（NCMS） in pilot counties.The effect of the pilot on TB case detection and treatment was evaluated through comparison of the consultation rate of TB suspects,case detection rate,the rate of patients delay and the loss-rate of patients before and after the pilot and between pilot and control counties.Description,χ2 test and Wilcoxon rank sum test were used for statistical analysis,and the level of test was 0.05. Results The consultation rate of TB suspects in Miluo county was 332.0/100000 during the pilot period which was compared with 209.8/100000 during the same period last year,increasing by 58.2%,and the difference was statistically significant（χ2=182.852,P0.001）.The consultation rate of TB suspects in Linxiang county was 491.0/100000 in the pilot period which was compared with 407.2/100000 last year,increasing by 20.6%,and the difference was statistically significant（χ2=39.921,P0.001）.During the pilot period,478 and 533 cases of active TB patients were registered in Miluo and Linxiang respectively which corresponded with 416 and 409 cases last year,increasing by 14.9% and 30.3%,respectively.The rate of patients delay in Miluo county was 40.2% during the pilot corresponding with 57.2% last year,decreasing by 29.8%,and the difference was statistically significant（χ2=25.884,P0.001）.The rate of patients delay in Linxiang county was 41.8% during the pilot corresponding with 49.4% last year,decreasing by 15.3%,and the difference was statistically significant（χ2=5.328,P0.05）.The consultation rate of TB suspects in Miluo and Linxiang during the pilot period respectively was 332.0/100000,491.0/100000,while which was 359.0/100000 in the control county,the differences were statistically significant between Miluo and the control county（χ2=7.253,P0.01）,and Linxiang and the control county（χ2=127.685,P0.001）.The rate of patients delay in Miluo and Linxiang county respectively was 40.2%and 41.8%,while which was 48.9% in the control county,and the differences were statistically significant between Miluo and the control county（χ2=7.881,P0.01）,and Linxiang and the control county（χ2=5.443,P0.05）.The case-loss rate of active pulmonary TB patients registered in two pilot counties respectively was 0.2% and 0%,while which was 1.8% in the control county,the differences were statistically significant between Miluo and the control county（χ2=6.283,P0.05）,and Linxiang and the control county（Fisher＇s Exact P0.01）. Conclusion Case based payment for outpatient TB auxiliary diagnosis and treatment had improved the case detection level,reduced the number of case-loss and facilitated the standard treatment and management of TB patients.