关键词: 结核, 肺, 费用, 医疗, 患病代价, 队列研究

Abstract:

Objective To analyze the direct medical expenses and payment methods for smear-positive pulmonary tuberculosis outpatients in some counties in Jiangsu and Sichuan provinces, and to trace the source of medical examination expenses of patients.Methods From 2014 to 2016, the diagnosed smear-positive pulmonary tuberculosis patients in two counties in City A in Jiangsu Province and three districts in City B in Sichuan Province that were included for 24 consecutive months at designated medical instructions were set as subjects, including 430 cases: 313 patients from Jiangsu Province and 117 from Sichuan Province, with the average age of (49.0±21.2) years. The sociodemographic characteristics and general treatment information of patients were obtained by baseline questionnaire survey. The cohort of patients was followed up to the end of treatment, and information such as the direct medical expenses, drug adverse reactions, complications and treatment outcomes during the follow-up were collected by hospital outpatient information system and medical record card.Results The median direct medical expenses per patient (M(Q₁, Q₃)) were 1609.0 (1160.5, 2534.0) and 1761.0 (839.5, 3052.0) yuan in Jiangsu and Sichuan, respectively. The out-of-pocket payments (M(Q₁, Q₃)) were 1186.0 (829.5, 2092.0) yuan in Jiangsu Province, accounting for 73.7% (1186.0/1609.0) of the direct medical expenses; and those in Sichuan Province were 1302.0 (36.0, 2158.5) yuan, accounting for 73.9% (1302.0/1761.0) of direct medical expenses. The out-of-pocket payment per patient in Sichuan Province was significantly higher than that in Jiangsu Province (Z=1.98, P=0.047). It was estimated that the incidence of catastrophic health costs (the ratio of out-of-pocket payment per patient to annual household income ≥40%) was 18.1% (78/430). The average out-of-pocket payments (M(Q₁,Q₃)) of treatment-naive and relapsed patients were 1208.0 (689.0, 2085.3) and 1008.0 (684.8, 2292.5) yuan, respectively, without significant difference (Z=0.04, P=0.971). There were 41 treatment-naive patients prolonged the course of treatment. The average out-of-pocket payments (M(Q₁, Q₃)) per patient for medical examinations and other drug-related expenses of 99 patients with drug adverse reactions were 635.0 (528.0, 925.0) and 515.5 (0.0, 1545.0) yuan, respectively, which were significantly higher than those of 331 patients without drug adverse reactions: 585.0 (210.0, 829.0) yuan for medical examinations (Z=3.07, P<0.01) and 40.0 (0.0, 518.0) yuan for other drug-related expenses (Z=4.88, P<0.01). The average medical examination expenses per patient and the corresponding out-of-pocket payments (M(Q₁,Q₃)) of 98 patients with chronic comorbidities such as diabetes and chronic pulmonary disease (COPD) were 1009.5 (732.5, 1278.5) and 680.0 (394.5, 905.3) yuan, which were significantly higher than those of 332 patients without chronic comorbidities: 936.0 (588.5, 1183.8) yuan for average medical examination expense (Z=-2.29, P=0.022) and 585.0 (281.3, 835.5) for the out-of-pocket payment (Z=-2.17, P=0.030). Compared to the service package of tuberculosis patients recommended by the “Ministry of Health of the People’s Republic of China - Bill Gates Foundation Tuberculosis Prevention and Control Project” (the second phase), it was found that the per capita expense of the medical examinations in the basic service package (468.5 (360.0, 620.0) yuan) was significantly higher than those in outsource service package (310.0 (244.0, 644.0) yuan) (Z=-4.77, P<0.01).Conclusion The direct medical economic burden of smear-positive pulmonary tuberculosis patients of some districts in Jiangsu and Sichuan provinces was heavy, with the total out-of-pocket payments of outpatient more than 1000 yuan. The medical examinations and treatment drugs could cause out-of-pocket payments with different ratios. Drug-related adverse reactions had a relatively important impact on the increasing of out-of-pocket payments for pulmonary tuberculosis patients.

Key words: Tuberculosis, pulmonary, Fees, medical, Cost of illness, Cohort studies