謝　娜，馬　艷，杜　建，謝仕恒，王紅紅，呂曉亞，林明貴，劉宇紅，李　亮

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134例復(fù)治肺結(jié)核患者既往史調(diào)查

謝娜1，馬艷2，杜建2，謝仕恒2，王紅紅2，呂曉亞2，林明貴4，劉宇紅2，李亮3

目的調(diào)查復(fù)治肺結(jié)核既往史信息，為國(guó)家制定和調(diào)整復(fù)治肺結(jié)核患者防治政策提供依據(jù)。方法使用統(tǒng)一設(shè)計(jì)的調(diào)查問卷，收集2010年9月11-21日期間在北京某兩家結(jié)核病?？漆t(yī)院經(jīng)所有住院的134例復(fù)治肺結(jié)核病患者相關(guān)信息，包括患者的基本信息、首次求醫(yī)行為、首次診斷和治療等內(nèi)容并進(jìn)行整理分析。結(jié)果與結(jié)核病?？漆t(yī)院等其他機(jī)構(gòu)相比，首次就診、確診機(jī)構(gòu)及治療都是縣級(jí)以上綜合醫(yī)院比例最高分別為55.22%(74/134)、61.19%(82/134)及53.73%(72/134)，首次檢查痰涂片檢出率為63.43%(85/134)；首次治療個(gè)體化方案和標(biāo)準(zhǔn)化方案分別為92.53%(124/134)及7.47%(10/134)；有28.36%(38/134)的患者在治療期間中斷治療，55.26%(21/38)的患者治療中斷原因是自認(rèn)為治愈而中斷治療；35.82%(48/134)的患者發(fā)生了不良反應(yīng)，因不良反應(yīng)中斷治療的患者為26.32%(10/38)。結(jié)論復(fù)治肺結(jié)核患者首次就診轉(zhuǎn)診不到位，診療不規(guī)范，應(yīng)加強(qiáng)多部分合作對(duì)轉(zhuǎn)診工作進(jìn)行監(jiān)督，規(guī)范診療，加強(qiáng)服藥監(jiān)督，提高患者治療依從性，減少治療中斷，從而減少耐藥及提高治愈率。

結(jié)核/肺；復(fù)治；診斷；治療

were not referring correctly and had not received standardized diagnosis and treatment. We should strengthen the multi-sectoral cooperation to supervise referral work, standardize diagnosis and treatment, strengthen medicine supervision and improve the patients’ treatment compliance, reduce treatment interruption improve the cure rate.

Supported by the National Science and Technology Mejor Project of China(No.2008ZX10003-008-02)(Xie Na and Ma Yan Contributed equally to this work)

Corresponding authors: Liu Yu-hong, Email: liuyuhong0516@126.com; Li Liang, Email: liliang69@hotmail.com

復(fù)治肺結(jié)核患者是指因結(jié)核病不合理或不規(guī)律用抗結(jié)核藥物治療≥1個(gè)月的患者或初治失敗和復(fù)發(fā)患者[1]，我國(guó)開展的5次全國(guó)流行病學(xué)調(diào)查表明復(fù)治肺結(jié)核的耐藥率均高于初治患者[2-3]，WHO第4次耐藥監(jiān)測(cè)報(bào)告結(jié)果[4]及其他多項(xiàng)研究[5-8]均表明復(fù)治肺結(jié)核患者的耐多藥發(fā)生率要遠(yuǎn)高于初治肺結(jié)核患者，因此了解復(fù)治肺結(jié)核患者的既往史情況，為制定有效治療政策、減少治療失敗和耐藥提供理論依據(jù)。課題組于2010年9月對(duì)北京市某兩家結(jié)核病?？漆t(yī)院對(duì)住院復(fù)治肺結(jié)核患者的既往史情況進(jìn)行調(diào)查，現(xiàn)報(bào)告如下。

1　資料和方法

1.1研究對(duì)象選取2010年9月11日至2010年9月21日期間在北京市某兩家結(jié)核病?？漆t(yī)院確診后所有住院的134例復(fù)治肺結(jié)核病患者。

1.2調(diào)查方法

1.2.1抽樣方法采用方便抽樣方法，抽取北京市兩家結(jié)核病?？漆t(yī)院，于2010年9月11日至2010年9月21日對(duì)住院的所有復(fù)治肺結(jié)核患者共134例進(jìn)行調(diào)查；通過專家咨詢法，并填寫通過專家咨詢法自行設(shè)計(jì)住院肺結(jié)核患者信息調(diào)查表，問卷內(nèi)容主要包括患者基本信息、首次就診情況、首次診斷、治療及轉(zhuǎn)歸等。

1.2.2質(zhì)量控制所有進(jìn)行問卷調(diào)查的人員(人員來自兩家結(jié)核病專科醫(yī)院的結(jié)核科醫(yī)生)均由研究組統(tǒng)一培訓(xùn)，培訓(xùn)內(nèi)容包括初治、復(fù)治肺結(jié)核患者國(guó)家統(tǒng)一的標(biāo)準(zhǔn)化方案、診斷、督導(dǎo)服藥及轉(zhuǎn)歸等。對(duì)進(jìn)行資料錄入的人員進(jìn)行系統(tǒng)培訓(xùn)。對(duì)每份調(diào)查問卷進(jìn)行雙錄入，錄入完畢用軟件進(jìn)行全部變量符合率的檢查，以確保數(shù)據(jù)的準(zhǔn)確性。

1.2.3統(tǒng)計(jì)學(xué)分析使用EpiData 3.0進(jìn)行數(shù)據(jù)錄入并建立數(shù)據(jù)庫(kù)。使用SAS9.1軟件進(jìn)行數(shù)據(jù)分析。

2　結(jié)　果

2.1復(fù)治肺結(jié)核患者社會(huì)學(xué)特征共發(fā)放問卷134份，回收有效問卷134份，有效率為100%。其中，男性68.18%(86/134)，女性35.82%(48/134)，男女比例為1.79:1；年齡以15～40歲比例最多占35.07%(47/134)，最大年齡85歲，最小年齡14歲，平均年齡(41.3±13.8)歲；職業(yè)以企事業(yè)單位比例最多，占46.27% (62/134)；來京就醫(yī)人口比例最高，占58.21%(78/134)；文化程度以中學(xué)比例最高，占55.97%(75/134)；參加醫(yī)療保險(xiǎn)(簡(jiǎn)稱“醫(yī)保”)的比例最高，占56.72%(76/134)(表1)。

表1134例復(fù)治肺結(jié)核患者的社會(huì)學(xué)特征

Tab.1Demographic characteristics of 134 retreatment pulmonary tuberculosis

社會(huì)學(xué)特征Demographiccharacteristics例數(shù)Number(N=134)構(gòu)成比(%)Constituentratio(%)性別Sex 男Male8664.18 女Female4835.82年齡(歲)Age 0～96.72 15～4735.07 40～4130.60 60～3727.61職業(yè)Vocation 農(nóng)民及外來務(wù)工人員Farm-ersandmigrantworkers1410.45 企事業(yè)單位職工Employees6246.27 學(xué)生Students1813.43 其他Others4029.85戶籍類型Censusregister 北京戶籍人口Beijingperma-nentresidents4029.85 長(zhǎng)住流動(dòng)人口Permanentfloatingpopulation1611.94 來京就醫(yī)人口PopulationwhocometoBeijingformedicine7858.21文化程度Educationlevel 文盲Illiteracy139.70 小學(xué)Primaryschool107.46 中學(xué)Juniormiddleschoolandhighschool7555.97 大專、本科及以上Collegede-greeandabove3626.87醫(yī)療費(fèi)用支出類型medicalex-pensestype 自費(fèi)Self-paying2518.66 公費(fèi)醫(yī)療Socializedmedicine139.70 醫(yī)療保險(xiǎn)Medicalinsurance7656.72 新農(nóng)村合作醫(yī)療Newtruralcooperativemedical1611.94 其他Others42.99

2.2首次求醫(yī)行為及診斷情況在調(diào)查的134例患者當(dāng)中，咳嗽癥狀比例最多48.51%(65/134)，其次為盜汗、低熱42.54%(57/134)，咯血比例最低8.96%(12/134)；首次就診及確診機(jī)構(gòu)都是縣級(jí)以上綜合醫(yī)院比例最高分別為55.22%(74/134)及61.19%(82/134)；做過痰涂片檢查的比例為63.43%(85/134)(表2)。

表2首次求醫(yī)行為及診斷情況

Tab.2Health seeking behavior and diagnosis at the first time

類別Cateory例數(shù)Cases構(gòu)成比(%)Constituentratio(%)癥狀Symptoms 咳嗽Cough6548.51 咳痰Expectoration3929.10 咯血Hemoptysis128.96 盜汗、低熱Nightsweatandlow-gradefever5742.54 其他Others1712.69第一次就診地點(diǎn)Patients’firstvisitingfacility 縣級(jí)以上綜合醫(yī)院Countygeneralhospi-talsandabove7455.22 縣疾控中心結(jié)防門診TBclinicsofcountyCenterfordiseasecontrolandprevention96.72 結(jié)核病?？漆t(yī)院TBspecializedhospital139.70 其他Others3828.36入院前確診機(jī)構(gòu)Diagnosisinstitutions 縣級(jí)以上綜合醫(yī)院Countygeneralhospi-talsandabove8261.19 縣疾控中心結(jié)防門診TBclinicsofcountyCenterfordiseasecontrolandpreven-tion1410.45 結(jié)核病?？漆t(yī)院TBspecializedhospital3022.39 其他Others85.97痰菌檢查Sputumbacteriatest 是Yes8563.43 否No4936.57

2.3患者首次治療及轉(zhuǎn)歸情況在調(diào)查的134例患者當(dāng)中，到縣級(jí)以上綜合醫(yī)院治療比例最多53.73%(72/134)；6.72%(9/134)及0.75%(1/134)的患者分別應(yīng)用2HRZES/6HRE及2H3R3Z3E3 S3/6H3R3E3方案進(jìn)行治療；14.18%(19/134)及22.39%(30/134)的患者首次治療時(shí)間分別為< 1個(gè)月(30天)及>8個(gè)月；35.82%(48/134)的患者在家人督導(dǎo)服藥，29.85%(40/134)的患者無人監(jiān)督服藥；44.03%(59/134)的患者強(qiáng)化期及73.88%(99/134)的患者繼續(xù)期在家中服藥；有28.36%(38/134)的患者在治療期間中斷治療，55.26%(21/38)的患者自認(rèn)為好轉(zhuǎn)或治愈中斷治療，35.82%(48/134)的患者發(fā)生了不良反應(yīng)；第1次治療自己認(rèn)為治好的比例最高為26.32%(10/38)(表3)。

表3患者首次治療及轉(zhuǎn)歸情況

Tab.3Treatment and treatment outcome of patients at the first time

類別Category例數(shù)Cases構(gòu)成比(%)Constituentratio(%)首次治療單位Treatmentunitatthefirsttime 縣級(jí)以上綜合醫(yī)院Countygeneralhospi-talsandabove7253.73 縣疾控中心結(jié)防門診TBclinicsofcountyCenterfordiseasecontrolandprevention1712.69 結(jié)核病?？漆t(yī)院TBspecializedhospital3324.63 其他Others128.96治療方案Treatmentregi-men 2H3R3Z3E3/4H3R385.97 2HRZE/4HR2417.91 2HRZES/6HRE96.72 2H3R3Z3E3S3/6H3R3E310.75 3H3R3Z3E3S3/6H3R3E300.00 其他個(gè)體化方案Individu-alizedtreatmentregimen9268.65首次治療時(shí)間Treatmentcourseatthefirsttime <1個(gè)月(30天)Lessthanonemonth(thirtydays)1914.18 1-8個(gè)月Onetoeightmonths5641.79 >8個(gè)月Morethaneightmonths3022.39 記不清Notremember2921.64

表3(續(xù))

類別Category例數(shù)Cases構(gòu)成比(%)Constituentratio(%) 醫(yī)生認(rèn)為治好Thinktobecuresbydoctors4533.58 醫(yī)生認(rèn)為未治好自己認(rèn)為治好Doctorsdon’tthinktocurebutpatientsthinktobecuredbythemselves2921.64 自己認(rèn)為未治好Think-ingtreatmentunsuccess-fullybythemselves4231.34 不清楚Notclear1813.44

3　討　論

2010年我國(guó)第5次全國(guó)流行病學(xué)調(diào)查顯示[3]，有癥狀就診的346例結(jié)核病患者中首診單位為綜合醫(yī)院及其他醫(yī)療單位就診者的比例為93.1%，首診單位為結(jié)核病防治機(jī)構(gòu)簡(jiǎn)稱結(jié)防機(jī)構(gòu)6.9%。本次對(duì)134例復(fù)治肺結(jié)核患者調(diào)查顯示首次就診單位為縣醫(yī)院及市級(jí)以上綜合醫(yī)院等機(jī)構(gòu)達(dá)83.6%(112/134)(其中縣級(jí)以上綜合醫(yī)院占55.22%(74/134))，到結(jié)核病?？漆t(yī)院和縣疾控中心結(jié)防門診就診的比例分別為9.70%(13/134)及6.72%(9/134)，與此對(duì)應(yīng)的是患者首次確診和治療機(jī)構(gòu)在縣級(jí)以上綜合醫(yī)院等機(jī)構(gòu)達(dá)67.16%(90/134)(其中縣級(jí)以上綜合醫(yī)院61.19%(90/134))和62.69%(84/134)(其中綜合醫(yī)院53.73%(72/134))，到結(jié)核病?？漆t(yī)院和縣疾控中心結(jié)防門診治療的比例分別為24.63%(33/134)及12.69%(17/134)由此可見，醫(yī)療機(jī)構(gòu)尤其是綜合醫(yī)院是患者發(fā)現(xiàn)的重要場(chǎng)所，在肺結(jié)核患者發(fā)現(xiàn)中具有重要、不可替代的作用，因此應(yīng)促進(jìn)綜合醫(yī)院結(jié)核病診斷水平的提高，另外本次調(diào)查也表明綜合醫(yī)院轉(zhuǎn)診這一環(huán)節(jié)存在較大問題，與轉(zhuǎn)診有關(guān)的登記報(bào)告環(huán)節(jié)也將不可避免受到影響，因此綜合醫(yī)院應(yīng)加強(qiáng)轉(zhuǎn)診，對(duì)綜合醫(yī)院發(fā)現(xiàn)并轉(zhuǎn)診肺結(jié)核患者給予激勵(lì)，同時(shí)轉(zhuǎn)診工作進(jìn)行監(jiān)督，需要加強(qiáng)出院患者管理，同時(shí)加強(qiáng)綜合醫(yī)院及結(jié)核病專科醫(yī)院與結(jié)防機(jī)構(gòu)/社區(qū)的密切配合，建立合作機(jī)構(gòu)，實(shí)現(xiàn)優(yōu)勢(shì)互補(bǔ)，促進(jìn)患者早期發(fā)現(xiàn)、早治療有著重要作用。

根據(jù)肺結(jié)核診斷標(biāo)準(zhǔn)(WS288—2008)[9]，肺結(jié)核的診斷原則是以細(xì)菌學(xué)實(shí)驗(yàn)室檢查為主，結(jié)合胸部影像學(xué)、流行病學(xué)和臨床表現(xiàn)、必要的輔助檢查及鑒別診斷，綜合分析進(jìn)行診斷。而本次調(diào)查僅有63.43%(85/134)的患者進(jìn)行了痰涂片檢查，同時(shí)僅有7.47%(10/134)的患者按照全國(guó)標(biāo)準(zhǔn)方案進(jìn)行治療的，衛(wèi)平等[10]對(duì)住院肺結(jié)核患者調(diào)查發(fā)現(xiàn)95.2%的患者沒有使用國(guó)家統(tǒng)一標(biāo)準(zhǔn)化療方案，王倪等[11]在對(duì)374例住院肺結(jié)核診治調(diào)查發(fā)現(xiàn)，多數(shù)患者沒有按照全國(guó)標(biāo)準(zhǔn)化方案進(jìn)行治療，周林等[12]調(diào)查發(fā)現(xiàn)住院肺結(jié)核患者非規(guī)范治療達(dá)到52.5%，而首次治療時(shí)間分別為< 1個(gè)月(30天)及>8個(gè)月的患者分別為14.18%(19/134)及22.39%(30/134)，無人督導(dǎo)服藥達(dá)到29.85%(40/134)，治療中斷達(dá)到了26.4%，同時(shí)治療期間患者發(fā)生了不良反應(yīng)發(fā)生率為35.82%(48/134)。已有多項(xiàng)研究表明不規(guī)范、不規(guī)律的治療造成結(jié)核病復(fù)發(fā)的高危因素[13-19]，而同時(shí)耐藥的發(fā)生與肺結(jié)核的復(fù)發(fā)有著密切相關(guān)[20-21]。因此為減少結(jié)核病患者的復(fù)發(fā)，除了使用正確的抗結(jié)核藥物及合理的化療方案外，一定要遵循“早期、規(guī)律、適量、聯(lián)合、全程”原則，治療過程中除了藥物不良反應(yīng)可進(jìn)行藥物調(diào)整及停藥外，患者不可隨意擅自停藥致治療中斷，本次研究結(jié)果表明134例患者中有29.85%(40/134)的患者無人督導(dǎo)服藥，55.26%(21/38)患者自認(rèn)為好轉(zhuǎn)或治愈而擅自停藥造成治療中斷，對(duì)此應(yīng)服藥加強(qiáng)監(jiān)督，提高患者治療依從性，確?；颊叻庂|(zhì)量，提高督導(dǎo)員(包括家庭督導(dǎo)員)業(yè)務(wù)能力以及與患者溝通能力，減少治療中斷。同時(shí)應(yīng)規(guī)范落實(shí)醫(yī)療機(jī)構(gòu)初治肺結(jié)核患者使用標(biāo)準(zhǔn)治療方案的策略，對(duì)綜合醫(yī)院呼吸科、門診以及實(shí)驗(yàn)室等人員開展定期、不同形式的培訓(xùn)(包括結(jié)核病臨床診療路徑、診斷及治療等培訓(xùn))和宣傳，加強(qiáng)肺結(jié)核治療和管理，規(guī)范診療行為，在提高診斷水平的同時(shí)提高肺結(jié)核患者治愈水平、降低耐藥結(jié)核病發(fā)生具有重要意義。

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Survey on history of 134 retreatment pulmonary tuberculosis patients

XIE Na1, MA Yan2, DU Jian2, Xie Shi-heng2, Wang Hong-hong2,LYU Xiao-ya2,Lin Ming-gui4, LIU Yu-hong2, LI Liang3

(1.HumanResourceDepartment,BeijingChestHospital,CapitalMedicalUniversity,Beijing101149,China；2.Centeroffice,BeijingTuberculosisandThoracicTumorResearchInstitute,Beijing101149,China；3.BeijingChestHospital,CapitalMedicalUniversity,Beijing101149,China；4.The309thhospitalofChinesePeople’sLiberationArmy,Beijing100193,China.)

To investigate history of retreatmeat pulmonary tuberculosis(TB) patients, in order to provide evidence to adjust and develop the policy for retreated tuberculosis prevention and treatment. We used unified questionnaire for collecting treating histories of 134 hospitalized retreated pulmonary tuberculosis patients who had been admitted during 11-21 September 2012, and then carried out analysis. Results showed that compared with specialized tuberculosis hospitals and other health facilities, patients’ first visiting facility, diagnosing and receiving treating facility were mainly general hospitals above county level, the percentages were 55.22% (74/134), 61.19% (82/134) and 53.73% (72/134) respectively. 63.43% (85/134) of patients received sputum bacteria examination on the first visiting. For the first treatment, 92.53% (124/134) patients adopted individualized treatment regimen and 7.47% (10/134) received standardized treatment regimen. Treatment interruption rate was 28.36% (38/134) during treating period, 55.26% (21/38) of them had interrupted treatment because they thought they had been cured. 35.82% (48/134) of patients had adverse drug reactions. 26.32% (10/38) of treatment interrupted patients had interrupted treatment because of adverse reactions. Thus, we concluded that those treatment pulmonary tuberculosis patients

tuberculosis/pulmonary; retreatment; diagnosis; treatment

劉宇紅，Email: liuyuhong0516@126.com;

李亮，Email: liliang69@hotmail.com

1.首都醫(yī)科大學(xué)附屬北京胸科醫(yī)院人力資源處，北京101149；2.北京市結(jié)核病胸部腫瘤研究所中心辦公室，北京101149；3.首都醫(yī)科大學(xué)附屬北京胸科醫(yī)院，北京101149；4.解放軍第309醫(yī)院，北京100193

R378.91

B

1002-2694(2016)06-0589-06

2016-02-03；

2016-05-10

DOI：10.3969/j.issn.1002-2694.2016.06.015

“十一五”國(guó)家科技重大專項(xiàng)(2008ZX10003-008-02)資助(謝娜、馬艷同等貢獻(xiàn))