2015—2017年四川省自贡市耐多药结核病分级诊疗实施效果初步评价

Effectiveness evaluation of hierarchical diagnosis model for multidrug-resistant tuberculosis from 2015 to 2017 in Zigong City

目的 初步评价2015—2017年四川省自贡市耐多药结核病（MDR-TB）分级诊疗的实施效果。方法 收集2015—2017年四川省自贡市自流井区、大安区、沿滩区和富顺县、荣县、贡井区6个试点区县的结核病患者登记和疫情报告资料。医防联合体定点医疗机构（包括自流井区、大安区、沿滩区）共登记4418例结核病患者,各区县医院定点医疗机构（包括富顺县、荣县、贡井区）共登记4922例结核病患者。对MDR-TB患者的发现诊断、治疗管理和经济负担进行分析。结果 医防联合体定点医疗机构模式和区县医院定点医疗机构模式下,结核病患者中MDR-TB的发现率分别为9.2%（54/587）和5.4%（37/684）;培阳患者开展传统药物敏感性试验的比率分别为93.9%（460/490）和84.1%（402/478）;MDR-TB患者的治疗覆盖率分别为13.0%（7/54）和59.5%（22/37）;差异均具有统计学意义（χ 2值分别为6.83、23.72、21.86,P值均〈0.05）。治疗成功率分别为5/7和77.3%（17/22）,差异无统计学意义（χ 2=0.10,P〉0.05）。MDR-TB患者承担的人均直接经济负担分别为（28006.90±2.83）元和（26395.70±5.15）元,其中人均自付住院费用（住院费用可报销70%）分别占41.8%（11696.53/28006.90）和40.6%（10719.40/26395.70）。 结论 自贡市部分地区实施分级诊疗在MDR-TB诊治中的整体效果较好,建议重点加强转诊和追踪的管理,提高治疗覆盖率,强化医疗支付方式改革。

Objective To evaluate the effectiveness of hierarchical diagnosis model for multidrug-resistant tuberculosis （MDR-TB） from 2015 to 2017 in Zigong City.Methods The patients’ routine registration and report records in Ziliujing district, Daan district, Yantan district, Fushun county, Rong county and Gongjing district from 2015 to 2017 were collected. All of 4418 patients were registered in designated Centers for disease control and prevention （CDC）-hospital mixed institutions （Ziliujing district, Daan district and Yantan district）. 4922 patients were registered in designated district/county hospitals （Fushun county, Rong county and Gongjing district）. The detection, diagnosis, management, and economic expenses of MDR-TB patients were analyzed.Results In the model of designated CDC-hospital mixed institutions and designated district/county hospitals, the MDR-TB detection rate in tuberculosis were 9.2% （54/587） and 5.4% （37/684）, the proportion of traditional drug susceptibility testing among sputum culture positive patients were 93.9% （460/490） and 84.1% （402/478）, and the treatment rate of MDR-TB patients were 13.0% （7/54） and 59.5% （22/37）; differences were all significant （χ 2 value were 6.83, 23.72 and 21.86, respectively, all P values were 〈0.05）. The treatment success rate were 5/7 and 77.3% （17/22）, respectively, and the difference was not statistically significant （χ 2=0.10, P〉0.05）. The average direct economic burden per capita were （28006.90±2.83） and （26395.70±5.15） yuan, among which out-of-pocket hospitalization expenses （being reimbursed 70%） accounted for 41.8% （11696.53/28006.90） and 40.6% （10719.40/26395.70）, respectively. Conclusion Despite the generally satisfactory effectiveness of hierarchical diagnosis model for MDR-TB in Zigong City, the management of referral and tracking in place, treatment rate, and healthcare payment pattern are recommended to be improved further.