以患者为中心的耐多药/利福平耐药结核病患者关怀服务实施效果分析

doi:10.3969/j.issn.1000-6621.2021.06.015

摘要/Abstract

摘要：

目的评价以患者为中心的耐多药/利福平耐药结核病(MDR/RR-TB)患者关怀服务的实施效果。方法以西安市胸科医院确诊的MDR/RR-TB患者作为研究对象。其中,2019年6—12月西安市胸科医院新确诊的所有MDR/RR-TB患者(182例)均采用患者关怀服务模式,纳入观察组进行分析。同时,回顾性分析2018年6—12月确诊的所有MDR/RR-TB患者(159例),作为对照组。对照组患者在住院期间给予常规的依从性评估、健康教育、心理支持及出院后电话回访;观察组患者在常规措施基础上,提供个体化的关怀服务,包括住院期间一对一咨询、社区转介和出院后的复诊提醒、随访咨询,以及小组活动、同伴支持等措施。比较两组患者纳入治疗率、随访12个月失访率和复诊率的差异。结果观察组患者的纳入治疗率、12个月复诊率分别为92.9%(169/182)和92.6%(1308/1413),均明显高于对照组患者[分别为84.9%(135/159)和78.3%(930/1188)],差异均有统计学意义(χ²=5.547,P=0.019;χ²=109.689,P<0.01)。观察组随访12个月失访率为7.0%(11/157),明显低于对照组的32.3%(43/133),差异有统计学意义(χ²=30.474,P<0.01)。观察组和对照组分别有10例(10/11)和27例(62.8%,27/43)的失访发生在随访的前6个月。结论以患者为中心的关怀服务有助于提高患者的纳入治疗率和治疗依从性,降低随访12个月失访率。

关键词: 结核,抗多种药物性, 患者关怀, 护理实践模式, 对比研究

Abstract:

Objective To analyze the implementation effectiveness of patient-centered comprehensive supportive care service for multidrug-resistant/rifampicin-resistant tuberculosis (MDR/RR-TB) patients. Methods The MDR/RR-TB patients diagnosed in Xi ’an Chest Hospital were selected as the subjects. Among them, all newly diagnosed MDR/RR-TB patients from June to December 2019 (182 cases), who received the patient-care services, were enrolled as the intervention group for analysis. Meanwhile, all newly diagnosed MDR/RR-TB patients from June to December 2018 (159 cases) were enrolled as the control group. Patients in the control group were given regular compliance assessment, health education and psychological support during hospitalization and follow-up by telephone after discharge. On the basis of routine measures, patients in the intervention group were provided with individualized care services, including one-on-one consultation and community referral during hospitalization, and subsequent visit reminders, follow-up consultation, group activities and peer support, etc., after discharge. The differences of the treatment rate, the rate of loss to follow-up (LTFU) at the 12th month, and the rate of subsequent visits were compared between the two groups. Results The treatment rate and the 12-month follow-up rate of patients in the intervention group were 92.9% (169/182) and 92.6% (1308/1413) respectively, which were significantly higher than those in the control group (84.9% (135/159) and 78.3% (930/1188) respectively), and the differences were statistically significant (χ²=5.547, P=0.019; χ²=109.689, P<0.01). The LTFU rate at the 12th month of the control group was 7.0% (11/157), which was significantly lower than the control group (32.3%, 43/133). The difference was statistically significant (χ²=30.474, P<0.01). Ten cases (10/11) of the intervention group and 27 cases (62.8%, 27/43) of the control group were LTFU in the first 6 months. Conclusion Patient-centered supportive care services could help to improve the treatment rate and treatment adherence of the MDR/RR-TB patients, and reduce the rate of LTFU at the 12th month.

Key words: Tuberculosis,multidrug-resistant, Patient care, Nursing practice model, Comparative study

赵阿利, 袁荣, 罗卉, 何小谋, 党丽云. 以患者为中心的耐多药/利福平耐药结核病患者关怀服务实施效果分析[J]. 中国防痨杂志, 2021, 43(6): 606-611. doi: 10.3969/j.issn.1000-6621.2021.06.015

ZHAO A-li, YUAN Rong, LUO Hui, HE Xiao-mou, DANG Li-yun. Analysis of the effects of patient-centered comprehensive supportive care service for MDR/RR-TB patients[J]. Chinese Journal of Antituberculosis, 2021, 43(6): 606-611. doi: 10.3969/j.issn.1000-6621.2021.06.015

图/表 3

表1

表2

两组患者的干预措施

时机	对照组			观察组
时机	形式	内容	实施人	形式	内容	实施人
住院期间	健康教育	疾病相关知识;规范治疗的重要性;药物不良反应的类型和应对;出院前告知患者出院后用药方法和复诊流程	医生、护士	健康教育	与“对照组”相同	医生、护士
	健康教育	疾病相关知识;规范治疗的重要性;药物不良反应的类型和应对;出院前告知患者出院后用药方法和复诊流程	医生、护士	一对一咨询	(1)诊断前咨询:向患者告知耐药结核病的基本知识、早发现早诊断的意义、诊断方法、各类检测方法的时长及费用、痰标本采集方法、感染控制措施等。(2)纳入治疗咨询:确诊MDR/RR-TB后,告知患者诊断结果、治疗方法、医保政策、早期治疗的重要性,鼓励密切接触者早期筛查。了解患者既往史、经济状况、社会支持等,初步评估患者的治疗意愿及障碍,并在制定患者治疗方案时为医生提供建议。(3)治疗前咨询:初步确定治疗方案后,再次确认患者的治疗意愿,并评估患者的心理、营养和社会支持情况,了解患者的治疗依从性潜在风险,指导患者做好治疗前准备。(4)依从性咨询:启动治疗后,与患者讨论影响规律服药的因素,制定个体化的服药计划;教会患者提高治疗依从性的方法和技能;指导患者识别并正确应对药物不良反应;督导患者正确服药,不可随意自行停药。(5)出院前咨询:出院前1d,了解患者出院前的准备情况、出院后社会支持、工作或生活状况,评估依从性潜在风险;与患者讨论出院后服药计划及下一阶段的治疗目标;利用积极的治疗经历强化患者的治疗信心,预约下次复诊时间	咨询员
	依从性评估	了解既往史、经济状况,评估患者的治疗依从性,制定用药方案	医生
	心理支持	通过健康教育改善患者的认知	医生、护士
				社区转介	出院前3d,通过疾病预防控制中心联系当地社区卫生服务人员,告知其患者在院的治疗情况、居家治疗关怀重点,落实患者出院药物注射问题并建立患者与社区人员之间的联系	咨询员、疾病预防控制机构、社区
出院后	电话随访	出院后第1、3、12个月电话回访用药和药物不良反应的情况,督促患者定期复诊和规律用药	护士	复诊提醒	患者出院后,每月提前1周电话联系患者预约复诊时间	咨询员
出院后	电话随访	出院后第1、3、12个月电话回访用药和药物不良反应的情况,督促患者定期复诊和规律用药	护士	随访咨询	来院复诊时,评估患者居家治疗计划的执行情况和依从性不良风险的应对情况,了解患者近期药物不良反应及处理,告知上一次痰检结果并协助患者完成复诊项目,对患者上一阶段良好依从性给予肯定并与患者共同制定下一阶段的治疗目标,预约下次复诊时间;对于电话联系中断或者不能及时来医院复诊的患者,联系当地疾病预防控制中心跟进患者近期治疗情况	咨询员、社区
治疗全程		-	-	小组活动	每月组织2~3次,经过商讨确定主题和流程,组织有特定需求的患者(8~12例)对疾病、治疗、药物不良反应监测与处理、营养支持及歧视应对等主题进行讨论,并邀请同伴参与主题相关内容的经验分享,以达到患者之间相互倾诉、学习的目的	医生、护士、咨询员
				同伴支持	由经过培训的同伴提供线上(QQ、微信)答疑和情绪疏导,线下生活帮扶、同伴咨询、同伴直视下服药督导或视频服药督导及小组活动分享	同伴员

表2

图1

参考文献 20

[1]	World Health Organization. Global tuberculosis report 2020. Geneva: World Health Organization, 2020.
[2]	Wurie FB, Cooper V, Horne R, et al. Determinants of non-adherence to treatment for tuberculosis in high-income and middle-income settings: a systematic review protocol. BMJ Open, 2018,8(1):e019287. doi: 10.1136/bmjopen-2017-019287. doi: 10.1136/bmjopen-2017-019287 URL
[3]	中国防痨协会. 耐药结核病化学治疗指南(2019年). 北京: 人民卫生出版社, 2019: 1.
[4]	World Health Organization. Multidrug-resistant tuberculosis (MDR-TB) indicators: A minimum set of indicators for the programmatic management of MDR-TB national tuberculosis control programmes. Geneva: World Health Organization, 2010.
[5]	中华人民共和国国家卫生健康委员会办公厅. 国家卫生健康委办公厅关于印发中国结核病预防控制工作技术规范(2020版)的通知. 国卫办疾控函〔2020〕279号. 2020-04-02.
[6]	王黎霞, 成诗明, 周林. 中国结核病患者关怀手册. 北京: 北京大学医学出版社, 2012: 42-45.
[7]	TB CARE I. International standards for tuberculosis care [M/OL]. 3rd ed. The Hague, TB CARE I, 2014: 10. [2020-12-10]. https://www.who.int/tb/publications/ISTC_3rdEd.pdf?ua=1.
[8]	尤媛媛, 张国龙, 陈裕. 120例初治耐多药肺结核患者治疗依从性的影响因素分析. 中国防痨杂志, 2020,42(3):249-254. doi: 10.3969/j.issn.1000-6621.2020.03.013. doi: 10.3969/j.issn.1000-6621.2020.03.013
[9]	Gebreweld FH, Kifle MM, Gebremicheal FE, et al. Factors influencing adherence to tuberculosis treatment in Asmara, Eritrea: a qualitative study. J Health Popul Nutr, 2018,37(1):1. doi: 10.1186/s41043-017-0132-y. doi: 10.1186/s41043-017-0132-y pmid: 29304840
[10]	M’imunya JM, Kredo T, Volmink J. Patient education and counselling for promoting adherence to treatment for tuberculosis. Cochrane Database Syst Rev, 2012, 2012(5): CD006591. doi: 10.1002/14651858.CD006591. doi: 10.1002/14651858.CD006591
[11]	秦志华, 施军卫, 邱青, 等. 195例耐多药肺结核患者治疗依从性及影响因素分析. 结核病与肺部健康杂志, 2016,5(4):283-287. doi: 10.3969/j.issn.2095-3755.2016.04.008. doi: 10.3969/j.issn.2095-3755.2016.04.008
[12]	吴波. 结核病患者治疗管理新技术的应用与进展. 中国防痨杂志, 2019,41(10):1136-1139. doi: 10.3969/j.issn.1000-6621.2019.10.014. doi: 10.3969/j.issn.1000-6621.2019.10.014
[13]	周群博. 云南省耐多药肺结核流行特征及治疗效果影响因素研究. 昆明: 昆明医科大学, 2017.
[14]	Perkins R, Repper J. Where is peer support going? Mental Health and Social Inclusion, 2019,23(2):61-63. doi: 10.1108/MHSI-05-2019-060. doi: 10.1108/MHSI-05-2019-060 URL
[15]	朱丽, 张修磊. 延伸护理对耐多药肺结核患者生命质量和治疗依从性的影响研究. 结核病与肺部健康杂志, 2018,7(1):44-48. doi: 10.3969/j.issn.2095-3755.2018.01.010. doi: 10.3969/j.issn.2095-3755.2018.01.010
[16]	Onazi O, Adejumo AO, Redwood L, et al. Community health care workers in pursuit of TB: Discourses and dilemmas. Soc Sci Med, 2020,246:112756. doi: 10.1016/j.socscimed.2019.112756. doi: 10.1016/j.socscimed.2019.112756 URL
[17]	Sanz Herrero F. The role of community pharmacies in the treatment of tuberculosis. Arch Bronconeumol, 2016,52(8):451-452. doi: 10.1016/j.arbres.2016.01.008. doi: 10.1016/j.arbres.2016.01.008 URL
[18]	Walker IF, Shi O, Hicks JP, et al. Analysis of loss to follow-up in 4099 multidrug-resistant pulmonary tuberculosis patients. Eur Respir J, 2019,54(1):1800353. doi: 10.1183/13993003.00353-2018. doi: 10.1183/13993003.00353-2018 URL
[19]	Hirasen K, Berhanu R, Evans D, et al. High rates of death and loss to follow-up by 12 months of rifampicin resistant TB treatment in South Africa. PLoS One, 2018,13(10):e0205463. doi: 10.1371/journal.pone.0205463. doi: 10.1371/journal.pone.0205463 URL
[20]	周美兰, 陈梓, 王坚杰, 等. 武汉市耐多药肺结核防治项目患者发现和近期治疗效果分析. 中国防痨杂志, 2012,34(5):299-303.

一般特征	对照组(159例)		观察组(182例)		χ²值	P值
一般特征	例数	构成比(%)	例数	构成比(%)	χ²值	P值
性别					0.393	0.553
男性	115	72.3	126	69.2
女性	44	27.7	56	30.8
年龄组(岁)					1.717	0.424
7~18	8	5.0	6	3.3
18~59	133	83.7	148	81.3
60~85	18	11.3	28	15.4
文化程度					1.354	0.508
小学及以下	25	15.7	31	17.0
初中和高中	99	62.3	120	66.0
大专及以上	35	22.0	31	17.0
并发糖尿病					1.451	0.244
是	22	13.8	34	18.7
否	137	86.2	148	81.3
居住地					0.973	0.324
西安市	71	44.7	91	50.0
其他地区	88	55.3	91	50.0
医疗费用支付方式					0.206	0.677
医疗保险	128	80.5	150	82.4
自费	31	19.5	32	17.6