新发涂阳肺结核患者就诊和诊断延误的影响因素研究

中国防痨杂志 ›› 2012, Vol. 34 ›› Issue (12): 790-794.

新发涂阳肺结核患者就诊和诊断延误的影响因素研究

王倪周林白丽琼许卫国何金戈成诗明

102206 北京，中国疾病预防控制中心结核病预防控制中心患者关怀部 (王倪、周林)，主任办公室（成诗明)；湖南省结核病防治所结核病控制科（白丽琼）；江苏省疾病预防控制中心慢性传染病防制科（许卫国）；四川省疾病预防控制中心结防所（何金戈）

收稿日期:2012-10-20 出版日期:2012-12-10 发布日期:2013-03-09
通信作者: 成诗明 E-mail:smcheng@chinatb.org
基金资助:
中国全球基金结核病项目实施性研究(08-009)

Factors associated with patients’ delay and diagnosis delay for patients with smear positive pulmonary tuberculosis

WANG Ni，ZHOU Lin，BAI Li-qiong，XU Wei-guo，HE Jin-ge，CHENG Shi-ming

Department of Care for Patients, National Center for Tuberculosis Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing 102206, China

Received:2012-10-20 Online:2012-12-10 Published:2013-03-09
Contact: CHENG Shi-ming E-mail:smcheng@chinatb.org

摘要/Abstract

摘要： 目的分析新发涂阳肺结核患者就诊和诊断延误的影响因素，为制定减少延误发生的干预措施提供科学依据。方法采取典型调查的方法，在东、中、西部各选择1个县作为研究现场，采用编制的《新发涂阳肺结核患者诊疗过程调查表》对研究现场结核病防治（简称“结防”）机构2010年5—9月登记发现的329例初治涂阳肺结核患者全部进行了面对面的问卷调查，获得有效个案调查表329份。使用t检验比较就诊延误、诊断延误等不同指标间差异有无统计学意义，使用Cox比例风险回归模型分析影响患者就诊延误的因素，使用非参数检验比较不同医疗机构患者的发现和转诊延误。结果患者就诊延误15d(0~594d)，诊断延误10d(0~429d)，就诊延误与诊断延误的差异无统计学意义(t=1.596, P=0.111)。与自费相比较，有其他医疗保险（除外新农合）的患者就诊延误更短（β=0.701，Waldχ²=6.223，P=0.013，RR=2.015），有发热症状的患者更易就诊（β=0.430，Waldχ²=11.556，P=0.001，RR=1.537），而有咳嗽症状（β=-0.711，Waldχ²=9.314，P=0.002，RR=0.491）或咯痰症状（β=-0.429，Waldχ²=8.549，P=0.003，RR=0.651）的患者就诊延误更长。不同医疗机构发现结核病可疑者的能力差异有统计学意义（χ²=115.134，P=0.000），其中药店的延误时间最长（26d，四分位间距66.5d），县级及以上医院(0d，四分位间距0d)、乡镇卫生院(0d，四分位间距6d)和结防机构(0d，四分位间距0d)延误时间最短；不同医疗机构转诊结核病可疑者的能力上差异有统计学意义（χ²=55.476，P=0.000），其中结防机构延误时间最短（0d，四分位间距1d），个体诊所延误时间最长（9d，四分位间距19.5d）。结论新发涂阳肺结核患者的延误包括患者和医疗机构两方面的因素，其中缺乏对结核病可疑症状的相关知识或对症状不重视是导致患者延误的主要因素，而基层医疗机构结核病可疑者的发现和转诊延误是导致医疗机构延误的主要因素。

关键词:

结核, 肺/诊断, 误诊, 转诊和会诊

Abstract: Objective To analyze the factors associated with patients’ delay and diagnosis delay for patients with smear positive pulmonary tuberculosis in order to provide evidence base for the formulation of relevant TB control and prevention strategies. Methods The typical survey methods were adopted and 3 counties were selected from the eastern, middle and western provinces each. New smear positive TB patients registered during May 2010 to September 2010 were administered face-to-face self-designed questionnaire survey, 329 effective questionnaires were collected. t test was used for comparing the difference between patients’ delay and diagnosis delay, Cox proportional hazards regression model was used for analyzing the factors associated with health seeking delay, and rank sum test was used for comparing the diagnosis delay between different facilities. Results Health seeking delay was 15 d(0－594 d) and diagnosis delay was 10 d(0－429 d), there is no statistically significant difference between these two indicators(t=1596, P=0.111). Patients who had medical insurance(except for the new rural cooperative medical care) （β=0.701，Waldχ²=6.223，P=0.013，RR=2.015） or suffering from fever（β=0.430，Waldχ²=11.556，P=0.001，RR=1.537） are more likely to go hospitals quickly, but patients with symptom of cough（β=-0.711，Waldχ²=9.314，P=0.002，RR=0.491） or sputum（β=-0.429，Waldχ²=8.549，P=0.003，RR=0.651） are more likely to have a longer delay. For TB case detection, the delays vary caused by different medical institutions（χ²=115.134，P=0.000）,shortest in county hospital or above (0 d, Q 0 d), township hospital (0 d, Q 6 d) and TB facilities (0 d, Q 0 d), longest in pharmacy (26 d, Q 66.5 d). And there are difference between medical institutions on TB patients’ referral（χ²=55.476，P=0.000）, shortest in TB facilities (0 d, Q 1 d), longest in individual private clinics (9 d, Q 19.5 d). Conclusion The factors of delay for patients with smear positive pulmonary tuberculosis will be considered from patients and medical institution. The main factors related to patients were lack of the knowledge of TB suspected symptoms or attaching no importance on it. Delay in TB suspects’ detection and referral in primary care facilities are the main factors affecting medical institutions delay.

Key words: Tuberculosis,pulmonary/diagnosis, Diagnostic errors, Referral and consultation

王倪周林白丽琼许卫国何金戈成诗明. 新发涂阳肺结核患者就诊和诊断延误的影响因素研究[J]. 中国防痨杂志, 2012, 34(12): 790-794.

WANG Ni，ZHOU Lin，BAI Li-qiong，XU Wei-guo，HE Jin-ge，CHENG Shi-ming. Factors associated with patients’ delay and diagnosis delay for patients with smear positive pulmonary tuberculosis[J]. Chinese Journal of Antituberculosis, 2012, 34(12): 790-794.

参考文献

［1］World Health Organization. Global tuberculosis control. WHO report 2000. Geneva: WHO, 2000.

［2］Lin X, Chongsuvivatwong V, Lin L, et al. Dose-response relationship between treatment delay of smear-positive tuberculosis patients and intra-household transmission. Trans R Soc Trop Med Hyp, 2008, 102(8): 797-804.

［3］Byrd RP Jr, Mehta JB, Roy TM. Delay in diagnosis among hospitalized patients with active tuberculosis-predictors and outcomes. Am J Respir Crit Care Med, 2003, 167(2): 278.

［4］中华人民共和国卫生部疾病预防控制局, 中华人民共和国卫生部医政司, 中国疾病预防控制中心. 中国结核病防治规划实施工作指南(2008年版). 北京：中国协和医科大学出版社, 2009：34-35.

［5］成诗明，王倪，周林，等. 新发涂阳肺结核患者各类延误水平相关指标的探讨. 中国防痨杂志, 2011, 33(10): 633-636.

［6］侯双翼, 肖爱清, 李国明, 等. 新发涂阳肺结核病诊断延迟分析. 中国防痨杂志, 2001, 23(4): 225-227.

［7］Yan F, Thomson R, Tang S, et al. Multiple perspectives on diagnosis delay for tuberculosis from key stakeholders in poor rural China: Case study in four provinces. Health Policy, 2007, 82(2): 186-199.

［8］全国第五次结核病流行病学抽样调查技术指导组，全国第五次结核病流行病学抽样调查办公室. 全国第五次结核病流行病学抽样调查报告. 中国防痨杂志，2012，34（8）：485-508.

［9］Lin X, Chongsuvivatwong V, Geater A, et al. The effect of geographical distance on TB patient delays in a mountainous province of China. Int J Tuberc Lung Dis, 2008, 12(3): 288-293.

［10］Lonnroth K, Thuong LM, Linh PD, et al. Delay and discontinuitya survey of TB patient’s search of a diagnosis in a diversified health care system. Int J Tuberc Lung Dis, 1999, 3(11):992-1000.

[1]	刘昕, 王志超. 结核性肛周脓肿延误诊断临床分析(附5例报告)[J]. 中国防痨杂志, 2020, 42(5): 527-528.
[2]	谢龙舟, 张运刚, 向薛名, 赵蓓, 张秀琴, 李红, 岳金才, 朱桂芳, 田甜, 钟吉伟, 钟家勇, 粟仲锐. 一例多发性骨关节结核并发皮肤结核患者的诊治过程分析[J]. 中国防痨杂志, 2019, 41(1): 112-117.
[3]	胡春梅,尹春阳,顾小燕,方刚,张侠. 19例支气管结核患儿的临床特征及误诊情况分析[J]. 中国防痨杂志, 2018, 40(3): 333-335.
[4]	王志刚,丁红. 恶性胸膜间皮瘤误诊为结核性胸膜炎17例原因分析[J]. 中国防痨杂志, 2018, 40(11): 1194-1200.
[5]	朱桂云,李晓霞,康丽菲,陈宁,杨永辉. 肺隐球菌病并发纵隔淋巴结结核误诊一例——病例报告及文献复习[J]. 中国防痨杂志, 2018, 40(11): 1231-1234.
[6]	吴妍，李琦，张宗德. γ-干扰素释放试验对老年肺结核的辅助诊断价值[J]. 中国防痨杂志, 2016, 38(2): 122-128.
[7]	吴妍李琦. 老年肺结核的诊治现状与进展[J]. 中国防痨杂志, 2015, 37(9): 975-978.
[8]	叶琳张齐龙黎星. 误诊为结核性脑膜炎的抗N-甲基-D-天冬氨酸受体脑炎一例[J]. 中国防痨杂志, 2015, 37(9): 999-1000.
[9]	万荣，李明武，赖明红，刘永莉. 结核感染T细胞斑点试验在老年肺结核中的诊断价值[J]. 中国防痨杂志, 2015, 37(4): 348-352.
[10]	李金莉，王峰，彭毅，洪创跃，杨应周. 环介导等温扩增技术检测痰样结核分枝杆菌临床价值评价[J]. 中国防痨杂志, 2015, 37(2): 134-139.
[11]	范琳，王鹏，杨妍，马俊，葛燕萍，卫卫，崔振玲. RNA恒温扩增实时荧光检测技术检测支气管肺泡灌洗液对涂阴肺结核的快速诊断价值[J]. 中国防痨杂志, 2015, 37(2): 140-144.
[12]	陈亮，钟球，刘文，覃杰，梁波涛，高翠南，周琳. 肺结核球误诊为周围型肺癌及两者的CT表现分析[J]. 中国防痨杂志, 2015, 37(2): 178-182.
[13]	廉娟雯. 误诊为肺结核的42例细支气管肺泡癌患者临床分析[J]. 中国防痨杂志, 2014, 36(7): 579-583.
[14]	赵冰，欧喜超，夏辉，李强，逄宇，张治英，董海燕，李俊晨，章建康，池俊英，赵雁林. Xpert Mtb/RIF检测技术在结核病诊断中的应用评价[J]. 中国防痨杂志, 2014, 36(6): 462-466.
[15]	林玲，刘厚明，邓群益，张洁云，张明霞，朱秀云，张国良，邓国防，岳建荣，陈心春，谢虹. γ干扰素释放试验在肺结核和非结核分枝杆菌肺病鉴别诊断中的应用价值[J]. 中国防痨杂志, 2014, 36(6): 477-481.