【作者】 杨天池；

【导师】 姜世闻；

【作者基本信息】 中国疾病预防控制中心 ， 公共卫生， 2011， 硕士

【摘要】 一、研究目的探讨医疗机构网络报告的肺结核病例没有去结核病防治机构就诊的影响因素,为制定相应对策,提高医疗机构网络报告病例的总体到位率提供科学依据。二、研究方法以北京的朝阳区和通州区、新疆的喀什市和英吉沙县、贵州的遵义县和兴义市、广东的宝安区和龙岗区,为调查现场。采用成组设计病例对照研究和定性访谈相结合的研究方法。(一)病例对照研究1、病例的选择：选取国家疾病监测信息报告管理系统中医疗机构报告的226例未到位肺结核病例作为病例组,采用自行设计的问卷进行调查。2、对照的选择：选取国家疾病监测信息报告管理系统中医疗机构报告的235例到位肺结核病例作为对照组,采用同一问卷进行调查。3、资料分析：使用SPSS 18.0进行分析,采用χ2检验进行单因素分析,采用Logistic回归进行多因素分析。(二)定性访谈1、访谈对象选择：选取与结核病防治工作相关的医疗卫生部门人员,对导致病例未到结核病防治机构就诊的原因进行访谈。2、资料分析：对不同对象的访谈结果进行比较,归纳出若干主要影响因素。三、研究结果病例对照研究发现,暂住人口(OR=6.89)、认可或不清楚自我医疗对肺结核的疗效(OR=3.13)、大专及以上文化程度(OR=2.24)、怀疑或不清楚结核病防治机构的诊疗水平(OR=2.16)、去结核病防治机构就诊所需交通费用在10元及以上(OR=2.09)、在医疗机构多次就诊(OR=2.03)、去结核病防治机构路程耗时在45分钟及以上(OR=1.90)会妨碍病例到结核病防治机构就诊；而在医疗机构没有进行痰涂片检查(OR=0.56)、接诊医生建议去结核病防治机构诊治(OR=0.30)、实验室诊断为肺结核(OR=0.21)有助于促使病例到结核病防治机构就诊。定性访谈资料分析显示,医院截留病人、医院转诊工作不规范、外地户籍病例返回原籍地、存在民间土方治疗和自我医疗现象、结核病防治机构服务得不到社会认同、去结核病防治机构交通不方便等,是导致医疗机构网络报告肺结核病例未到结核病防治机构就诊的原因。四、研究结论暂住人口、文化程度高、对结核病防治机构不信任、去结核病防治机构路程远等因素,会妨碍病例到结核病防治机构就诊；而接诊医生建议转诊、明确肺结核诊断等因素,有助于促使病例到结核病防治机构就诊。五、建议(一)卫生行政部门：1、根据辖区面积和交通情况,合理设置结核病诊疗定点机构,方便患者转诊、就诊和治疗；2、规范医疗机构结核病转诊程序和医生转诊行为,建立健全相应的监督、考核及奖惩机制；3、联合药品监督部门,加强对抗结核药品流通和使用环节的监管,从源头上杜绝肺结核自我医疗现象的发生。(二)结核病防治机构：1、加强对外地户籍人口的结核病防治知识宣传教育；2、加强自身结核病诊治方面能力建设,加大社会宣传力度,扩大社会影响力；3、提高病例追踪及时性,尤其是对暂住人口,并在追踪时告知当地结核病防治机构的地理位置和联系方式。(三)医疗机构：在开展痰涂片检查的同时,要做好对患者痰涂片检查目的及痰涂片检查结果的解释工作,督促痰菌阴性的可疑肺结核患者主动到结核病防治机构作进一步的检查和诊断。更多还原

【Abstract】 ObjectiveTo explore the influencing factors of tuberculosis patients reported by hospitals failed to visit designated tuberculosis clinics, and to provide scientific evidence for government to help develop tuberculosis prevention and control measures.MethodsEight counties were selected in the study, including Chaoyang District and Tongzhou District of Beijing, Kashgar City and Yengisar County of Xinjiang, Zunyi county and Xingyi City of Guizhou, Baoan District and Longgang District of Guangdong. Case-control study and qualitative interviewing were used in the study.1. Case-control studySelection of cases:226 patients reported by hospitals failed to visit designated tuberculosis clinics in China Information System For Disease Control and Prevention in these eight counties were selected as cases, and were administered a structured questionnaire. Selection of controls:235 patients reported by hospitals succeeded to visit designated tuberculosis clinics in China Information System For Disease Control and Prevention in these eight counties, were administered a same structured questionnaire. Analysis of data:Data were analyzed using Pearson chi-square test and logistic regression in SPSS 18.2. qualitative interviewingStaffs from local health administrative departments, general hospitals and designated tuberculosis clinics were interviewed on influencing factors of tuberculosis patients reported by hospitals failed to visit designated tuberculosis clinics.Analysis of data:Main influencing factors were concluded by comparing the different interview.ResultsCase-control study showed that ten influencing factors were related to tuberculosis patients reported by hospitals failed to visit designated tuberculosis clinics, including floating population (OR=6.89), self-treatment (OR=3.13), high education level (OR=2.24), mistrusting designated tuberculosis clinics (OR=2.16), transportation cost≥10 yuan (OR=2.09), time-consuming distance>45 minutes (OR=1.90) and going to hospital many times (OR=2.03). Three protect factors were having no test of sputum smear in hospitals (OR=0.56), having an advice from doctors for referral (OR=0.30) and laboratory diagnosis (OR=0.21).Interview data analysis showed that the common causes of tuberculosis patients and suspects not being referred to designated tuberculosis clinics included hospitals retaining cases, doctors not performing standardized referral operation, floating population returning to hometown, folk prescription or self-therapy, the service of designated tuberculosis clinics not gaining social acceptance, inconvenient to the traffic of going to designated tuberculosis clinics.ConclusionFloating population, patients with high education level, or having mistrust of designated tuberculosis clinics, or traveling long distance to designated tuberculosis clinics were unlikely to visit designated tuberculosis clinics, whereas patients advised to refer to designated hospitals, and laboratory diagnosed tuberculosis cases were more prone to seek medical care in designated tuberculosis clinics.Recommendations For Health Administrative Department1. By taking account of the size of the area and the local transportation status, designated tuberculosis clinics should be located where is convenient for patients to visit doctors or refer.2. Relevant inspection, performance evaluation and reward and punishment systems should be established so as to standardize the doctor’s medical practices.3. Circulation of antitubercular agents should be under strict inspection, united with drug administration institute, to avoid self-treatment phenomenon.For Designated Tuberculosis Clinics1. To enhance health education towards floating population regarding tuberculosis prevention and control knowledge.2. To improve the ability of tuberculosis treatment, and to strengthen the publicity of designated tuberculosis clinics.3. To enhance the timeliness of tuberculosis case-tracing, especially towards those floating population, and to inform the address and contact information of the designated tuberculosis clinic simultaneously.For Medical InstitutionsWhile conducting sputum smear, doctors should explain to the patients very patiently regarding the purpose and results of the test, and those suspected patient with smear-negative result should be encouraged to seek further examination at designated tuberculosis clinics.更多还原