陕西省新型结核病防治管理模式实施前后能力建设与诊治效果分析

Analysis on the capacity building and diagnosis and treatment effect of implementation of new tuberculosis prevention and management mode in Shaanxi Province

目的 分析陕西省新型结核病防治管理模式实施前后结核病防治能力建设及诊治效果,为进一步完善我省结核病防控政策和措施提供参考。方法 本研究采用描述性研究,对全省10个地级市、108个县（区）结核病防治能力建设情况,以及患者发现、治疗管理等指标变化情况进行对比分析。能力建设情况以2014年和2017年数据作对比,分别来源于《陕西省“十二五”结核病防治规划》评估和2017年全省结核病防治工作联合大检查。患者发现、治疗管理指标来源于《结核病信息管理系统》,以实施前3年（2012—2014年）与实施后3年（2015—2017年）的数据作对比。运用SPSS 19.0处理数据,率和构成比的比较采用χ 2检验,以P〈0.05为差异有统计学意义。 结果 2014年和2017年全省设有结核病定点医院的数量分别为20家和107家,2017年较2014年增加了87家。2014年全省共有结核病防治人员923名,其中疾病预防控制中心（CDC）656名,定点医院267名。2017年全省共有结核病防治人员1200名,其中CDC 403名,定点医院797名;与2014年相比,CDC人员减少了38.57%,定点医院人员增加了198.50%。2014年全省有3个地级市开展了分子生物学耐药检测,5.56%（6/108）的县（区）开展了分子生物学检测,12.04%（13/108）的县（区）开展了痰培养。2017年全省有8个地级市开展了分子生物学耐药检测,49.07%（53/108）的县（区）开展了分子生物学检测,55.56%（60/108）的县（区）开展了痰培养。新型防治模式实施前3年全省初诊查痰率为98.50%（329981/335014）,发现肺结核患者63892例（其中结核性胸膜炎患者4089例）,发现病原学阳性患者14087例,病原学阳性率为23.56%（14087/59803）。实施后3年全省初诊查痰率为95.00%（312503/328948）,发现肺结核患者61583例（其中结核性胸膜炎5295例）,病原学阳性患者10588例,病原学阳性率为18.81%（10588/56288）。新型防治模式实施前后初诊查痰率降低（χ 2=6484.178,P=0.000）,病原学阳性率降低（χ 2=390.104,P=0.000）。实施前3年因症就诊发现肺结核患者占29.43%（18805/63892）,转诊发现患者占43.90%（28047/63892）。实施后3年因症就诊发现肺结核患者占25.38%（15628/61583）,转诊发现患者占57.79%（35586/61583）。转型后因症就诊发现患者的构成比下降（χ 2=259.002,P=0.000）,转诊发现患者的构成比上升（χ 2=2419.762,P=0.000）。新模式实施前后3年非结核病防治机构报告患者总体到位率分别为93.18%（62177/66726）和89.96%（61323/68169）,实施后总体到位率下降（χ 2=453.550,P=0.000）。新模式实施前后患者治疗成功率分别为95.04%（60464/63619）和94.97%（57872/60939）,实施前后比较差异无统计学意义（χ 2=0.356,P=0.551）。 结论 我省新型结核病防治管理模式推进顺利,防治能力加强,但部分患者诊治及管理指标有所下滑,实施质量仍需提升。

Objective To analyze the capacity building and diagnosis and treatment effect of implementation of the new tuberculosis prevention and management mode （new mode） in Shaanxi Province, and to provide suggestions regarding policy and measures for further prevention and control.Methods We analyzed the changes in tuberculosis system construction, capacity building, patient discovery, treatment and management index after implementing the new tuberculosis prevention and management mode in 10 prefecture-level cities and 108 counties （districts） in the province. Comparison in capacity building between 2014 and 2017 was conducted using the data derived from the “12th Five-Year Plan for Tuberculosis Prevention and Control in Shaanxi Province” and the joint inspection of tuberculosis prevention and treatment work in 2017. Comparisons in patient discovery and treatment management between the three years before implementation （2012-2014） and the three years after implementation （2015-2017） were conducted using the data derived from the “Tuberculosis Information Management System”. Statistical analysis was performed using SPSS 19.0. Chi-square test was used to compare the rate and ratio. P〈0.05 was statistically significant.Results There were 20 and 107 designated tuberculosis hospitals in 2014 and 2017, respectively. The number of designated hospitals was increased by 87 in 2017 compared with 2014. In 2014, there were 923 tuberculosis control staff in the province, including 656 in the Centers for Disease Control and Prevention （CDC） and 267 in the designated hospitals. In 2017, there were 1200 tuberculosis control staff, including 403 in the CDC and 797 in the designated hospitals. Compared with 2014, staff in the CDC decreased by 38.57%, and staff in the designated hospital increased by 198.50%. In 2014, tuberculosis drug resistance molecular biology testing was carried out in 3 prefecture-level cities, molecular biology testing was carried out in 5.56% （6/108） counties （districts）, and sputum culture was carried out in 12.04% （13/108） of counties （districts）. In 2017, tuberculosis drug resistance molecular biology testing was carried out in 8 prefecture-level cities, molecular biology testing was carried out in 49.07% （53/108） counties （districts）, and sputum culture was carried out in 55.56% （60/108） of counties （districts）. In the three years before implementing the new mode, the sputum rate was 98.50% （329981/335014）, 63 892 patients were reported with pulmonary tuberculosis （of whom, 4089 had tuberculous pleurisy）, and 14087 patients were pathogenic positive with a positive rate of 23.56% （14087/59803）. In the three years after implementing the new mode, the sputum rate was 95.00% （312503/328948）, 61583 patients were reported with pulmonary tuberculosis （of whom, 5295 had tuberculous pleurisy）, and 10588 patients were pathogenic positive with a positive rate of 18.81% （10588/56288）. The sputum rate and pathogenic positive rate were decreased after the implementation of the new prevention and treatment mode （sputum rate： χ 2=6484.178, P=0.000; pathogenic positive rate： χ 2=390.104, P=0.000）. Among all of the pulmonary tuberculosis cases, the ratio of symptomatic treatment was 29.43% （18805/63892） and 25.38% （15628/61583） before and after the implementation of the new mode, respectively. The ratio of transfer treatment of pulmonary tuberculosis was 43.90% （28047/63892） and 57.79% （35586/61583） before and after the implementation of the new mode, respectively. The ratio of patients from symptomatic treatment decreased （χ 2=259.002, P=0.000）, and the ratio of patients from transfer treatment increased （χ 2=2419.762, P=0.000） after the implementation of the new mode. The overall arrival rates of reported patients or suspected patients were 93.18% （62177/66726） and 89.96% （61323/68169）, respectively, which was decreased after implementation of the new mode （χ 2=453.550, P=0.000）. The successful treatment rates of patients were 95.04% （60464/63619） and 94.97% （57872/60939） before and after implementing the new mode, respectively. There was no significant difference in successful treatment rate after implementing the new mode （χ 2=0.356, P=0.551）. Conclusion The new tuberculosis prevention and control management model has been initially established and implementing well, and the prevention and control capacity has been strengthened in Shaanxi Province. However, some indexes of the diagnosis treatment management of patients have declined, and thus the quality of implementation needs to be improved.