结核病论文：结防机构与结核病定点医院合作试点实施效果评价

结核病论文：结防机构与结核病定点医院合作试点实施效果评价

【中文摘要】为充分发挥综合医疗机构在结核病防治中的作用,在综合医疗机构中实施现代结核病策略,提高患者发现率和治愈率。探索适合我国国情的结防机构与定点医院合作模式,并加以推广。在既往经验的基础上,中国结控中心在陕西、广西和湖南3省各选择了1个县,开展了结防机构与定点医院合作模式的试点。各试点地区已完成了试点工作,为评价试点效果,了解相关利益方对试点的看法,进一步完善合作模式,特开展此研究。研究了解试点地区结防机构与定点医院合作的运行模式和运行过程中存在的问题及影响因素,评价试点的实施效果,并提出完善结防机构与定点医院合作模式的建议。研究方法采用查阅资料和个人访谈,收集与结防机构与定点医院合作相关的政策信息,进行政策描述和分析；采用现场调查和文献回顾相结合的方法,对政策的执行情况和效果进行分析评价,并提出建议。研究结果广西省隆安县、陕西省榆阳区和湖南省石峰区开展了试点工作。3个试点地区均由卫生局选择当地一家医院作为结核病定点医院,下发了相关文件,明确了运行机制和结防机构、定点医院、非定点医院和村卫生所之间的职责。但3个地区在具体的运行机制上有一定的差异。试点地区在病人发现方面,试点前后没有变化；在病人转诊、追踪方面,试点前后,总体到位率有明显提高；在病人转归方面,初治涂阳病人的治疗成功率和治愈率试点后均比试点前有所提高。在利益相 关者的可接受和满意度调查方面,利益提供方和利益接受方均对政策表示认可,但对具体措施提出意见。在接受访问的3个县区的14名医务人员中,有9人认为政策执行不顺利。在访问的15例患者中,仅3例是通过主动就诊前往定点医院就医,其余12例均通过转诊前往定点医院接受结核病治疗。这些患者均按照国家结核病防治规划的要求接受了6个月免费抗结核药物治疗。3县区的患者治疗费用之间存在较大差异。在访问的15名患者中,有12名均表示愿意在定点医院接受诊疗。主要原因是定点医院的医疗条件更好以及看病较方便。被访者中大多数认为合作模式有助于提高患者发现,可发挥各自专业优势,有助于各项工作质量的提高。而分析试点前后结核病防治工作指标表明,患者发现及转归的各项指标变化不明显。结论1、与定点医院合作模式与我国医疗改革的方向一致,充分发挥了双方的优势,得到了服务提供方和服务接受方的认同。2、合作试点对完成结核病防治目标起到了重要的作用。3、试点地区实施措施中的差异直接影响了实施效果。如卫生行政部门的重视程度和定点医院的选择等,对于合作模式的效果具有十分重要的影响。建议1、加强卫生行政部门的管理力度,制定相关配套政策,保证与定点医院合作模式的开展。如卫生局应建立考核制度,将结核病纳入医保或新农合的报销范畴等。2、进一步完善定点医院的选择标准,同时对定点医院给予适当补偿,提高定点医院的配合程度。如选择管辖范围内的区县级医院,选择业务量不是特别繁忙的医院等。3、认真总结,在条件具备的地区及时推广好的经验与做法,不断加强和完善体系建设。 【英文摘要】BackgroundThe National Center for Tuberculosis Control and Prevention, China CDC piloted models for collaboration between TB dispensary and designated hospital systems in three counties respectively in Shaanxi, Guangxi and Hunan based on previous experiences and under the support of China Global Fund TB Program Round 4, in a bid to leverage the role of general hospitals in TB control, promote the implementation of DOTS in general hospitals, increase the case detection rate and cure rate, explore effective models for collaboration between TB dispensary and designated hospital systems and replicate good practices. The pilot work has been concluded. To evaluate the effect of pilot work, understand the attitudes of stakeholders towards collaboration and improve the model, this study was conducted.This study aimed to understand the operational models for collaboration between TB dispensaries and designated hospitals in pilot sites, evaluate the effect of pilot work, identify existing problems and influencing factors and put forward recommendations on the improvement of models for collaboration between TB dispensaries and designated hospitals.MethodA variety of methods were used for different components of the study. Consultation of data and government documents, interview, comparison, classification, analysis and summarization were used to describe the collaboration policy. Qualitative research, quantitative research, field survey and literature review were used to analyze and evaluate the implementation and sustainability of this policy.Results1. Policy promulgation process and operational modelsThe pilot work was implemented respectively in Long’an County of Guangxi Province, Yuyang District of Shaanxi Province and Shifeng District of Hunan Province. The health bureau in each pilot site selected a local hospital as the designated TB hospital, issued an official document, developed the operational mechanism and defined the division of responsibilities among TB dispensaries, designated TB hospital, non-designated hospitals and village clinics. Nevertheless, there is a difference in operational mechanisms in the three pilot sites.2. Policy implementation processMost interviewees thought the policy made contribution to the NTP to some extent, including the increase of case detection rate and the improvement of quality by leveraging respective professional advantages. Service providersAmong all medical staff interviewed in the three pilot sites, only five interviewees in Long’an County thought the collaboration was a success. All nine interviewees in the other two pilot sites thought the policy was of poor implementation. ClientsAmong all patients interviewed in the three pilot sites, only three patients actively resorted to designated hospitals for TB treatment, and all other 12 patients were referred to designated hospitals for TB treatment. All patients received six-month TB treatment in accordance with the NTP. There is a difference in treatment costs in the three pilot sites.3. Satisfaction level of clients about policyAmong the 15 patients interviewed in the three pilot sites,12 patients expressed their willingness to receive diagnosis and treatment at designated hospitals in view of better infrastructure and convenience.Recommendations1. Strengthen the administrative role of health authorities and develop support policies to ensure smooth implementation of models for collaboration between TB dispensaries and designated hospitals. For example, health bureaus can develop perform assessment systems to incorporate TB services into medical insurance or new rural cooperative medical scheme. 2. Improve criteria for selecting designated hospitals and subsidize designated hospitals to promote their cooperation. For example, local county/district hospitals that are not crowded can be selected as designated hospitals.3. Summarize and replicate good practices in a timely