公私医疗合作策略在结核病防治与控制中的机制与效果的循证研究
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摘要
研究背景
结核病是全球公共卫生的巨大挑战之一。为加强结核病的治疗和控制,世界卫生组(WHO)提出公立与私立医疗机构合作策略(简称公私医疗合作),旨在动员所有医疗服务提供者共同开展以“直面督导下的短程化疗”(DOTS)为基础的结核病综合防治工作。我国在结核病防控的工作实践中,探索形成一套多元化的医疗卫生机构与结核病防治专业机构(结防所或疾控中心结防科)之间密切合作的结核病联合防控策略,简称医防合作策略。国际上对于结核病防控的公私医疗合作的特点和所取成效已开展一定研究,而国内也针对医防合作在结核病患者的发现、转诊和治疗方面的效果进行分析,但目前对于公私医疗合作策略及医防合作策略的机制总结、模式探讨以及实施效果综合分析评价研究还鲜见报道。
研究目的
全面系统地回顾全球范围内开展的结核病防控的公私医疗合作项目,总结公私医疗合作机制,描述其运作特点及参与合作机构之间的职能与分工,并对其结核病防控效果进行综合评价；深入探讨中国结核病医防合作策略的形成、发展、主要模式及其特点；探索重庆地区结核病医防合作模式的发展情况、优势及存在主要问题,掌握结核病患者归口诊治和管理现状,为针对性地解决医防合作过程中的具体问题及改善结核病患者的诊疗服务提供科学依据。
研究方法
1.采用系统评价的方法,对全球结核病防控公私医疗合作项目的机制与效果进行总结与评价。
全面检索14个电子数据库、2个灰色文献数据库以及6个相关网站截止2012年4月已发表的文献。纳入描述和评价已实施的结核病公私医疗合作项目原始研究。由两名研究员分别独立进行文献筛选、研究分类及数据提取,并交叉核对,讨论达成共识。采用定性描述与合并方法对纳入研究的信息和结果进行归纳,以总结公私医疗合作策略的运作机制并综合评价合作项目实施效果。
2.运用文献回顾、政策文件收集和专家咨询的方法,对我国结核病防控的医防合作策略及合作模式进行总结探讨。
回顾与我国结核病医防合作相关的文献资料,收集整理相关政策法规文件,并咨询结核病防治机构的领导及国际国内相关领域的专家,以总结我国结核病医防合作策略的建立与发展情况,并对主要医防合作模式的特点、优势和局限进行全面总结分析。
3.采用机构调查、政策文件收集、问卷调查与定性访谈相结合的方法,对重庆地区主要的结核病医防合作模式的特点、优势、困难障碍及实施效果进行调查研究和比较分析。
(1)机构调查与政策文件收集：采用机构调查表对参与合作的结防机构和定点医院情况进行调查,查阅机构档案资料并获取相关政策法规文件。调查数据经提取和归纳后,对两种医防合作模式下结核病患者主动就诊、转诊和追踪情况差异进行描述性统计分析。
(2)定量调查：在研究地点选取2012年6月～12月之间确诊的494名新发结核病患者作为研究对象,采用自编调查问卷进行定量调查,了解患者基本信息就诊及转诊情况,调查结果双录入EpiData3.1数据库,并用SPSS17.0软件进行统计分析。
(3)定性访谈：目的性地在调查机构抽取10名领导干部及门诊医生,使用半结构式访谈提纲,对其进行关键人物访谈,了解医防合作模式发展过程、运作特点、工作中的主要优势与困难等信息。使用MAXQDA11软件管理定性资料,并采用主题框架分析法进行定性分析。
研究结果
1.系统评价结果
纳入分析的69篇原始研究,可被归纳为43个在15个国家开展的公私医疗合作项目。根据不同合作项目中参与机构的职责与分工,可将公私医疗合作策略的运作机制归纳为支持机制(包括经济、物资和人员支持)、合同机制(包括正式与非正式合同)以及工作组机制(工作指导委员会)。绝大多数研究肯定了公私医疗合作在DOTS实施、病例发现、治疗结局、患者管理、服务可及性与公平性、相关花费、技术能力、接受程度与合作水平方面具有积极促进作用。
2.中国结核病医防合作策略研究结果
我国探索形成适宜国情的多元化结核病防治的医防合作策略,其合作模式主要分为结防机构模式、定点医院模式、专科医院模式及基层卫生服务网络模式四种,其中以结防机构模式和定点医院模式为主。医防合作策略在全国结核病防治实践工作中发挥了重要作用,但也存在诊治和转诊工作不规范、截留患者、医务人员有限、技术力量和管理能力不足等局限性。
3.重庆地区结核病医防合作模式研究结果
目前重庆各区县开展的结核病防治医防合作主要属于结防机构模式和定点医院模式。结防机构模式可确保患者诊治和管理的系统性和连贯性；定点医院模式在诊疗条件和临床能力上具有明显优势。比较发现,结防所模式下患者转诊到位率较高,首诊更倾向选择指定结防机构；定点医院模式能在一定程度上促进结核病患者发现和追踪水平。两种模式下患者的治疗成功率和涂阳患者治愈率均在90%以上,结防所模式略高于定点医院模式。两种医防合作模式在结核病防治工作中都能发挥了重要作用,但仍然存在自身局限,主要体现在经费投入不足及其引起基础设施、设备条件、人才引进、人员培训、医生工资待遇、患者医疗保障等方的问题,以及综合医院管理协调和业务监督困难,医务人员院感风险高,患者依从性不高等。
结论
无论是全球公私医疗合作策略还是我国医防合作策略,存在不同的合作机制或模式。鉴于各自特点和优势,不同合作机制及模式在结核病防治实践的不同方面发挥作用。对于目前结核病防治实践中普遍存在的困难和障碍,可以从制定政策法规、改善机构工作和研发新型诊疗措施三个层面着手,加大经费投入、明确机构职责、建立监管体制、搭建信息平台、提高福利待遇、改善医疗保障、争取项目经费、促进协调联系、加强培训教育、改进工作方法,进一步促使全球公私医疗合作策略及我国医防合作策略在结核病防控工作中取得巨大成效。
Background
Tuberculosis remains a major challenge to global public health. In order to accelerate Tuberculosis (TB) care and control, the WHO proposed Public-Private Mix (PPM) strategy, which aimed at involving all the TB entities and practitioners to overall implement comprehensive control based on the Directly Observed Treatment Short Course (DOTS) strategy. In China, a diversified collaboration strategy, involving medical institutions (hospital) and professional TB control sectors (TB dispensary or TB Unit under the CDC), for TB care control has been formed during practical work, that is, the hospital-dispensary collaboration. There have been some international studies on the characteristics and effectiveness of PPM, and national researches on patients detection, referral and treatment outcomes. However, studies on summary of collaboration mechanism and model, or systematic evaluation for partnership effectiveness were rarely seen.
Objectives
To systematically identify global PPM programmes, summarize the partnership mechanisms, narrate the characteristics, roles and responsibilities of involved sectors, and assess their effectiveness of TB control; to study the development, models and characteristics of the hospital-dispensary TB collaboration in China; to study the development, advantages and barriers of models for hospital-dispensary TB collaboration in Chongqing, investigate the present situation of centralized diagnosis, treatment and management for patients, in order to provide scientific evidence for solving the problems during collaboration process and promoting the health service for TB patients.
Methods
1. Systematic review was performed to summarize the mechanism and assess the effectiveness of PPM programmes.
Publications until April2012were identified by a search in14electronic databases, two gray literature databases and six relevant websites. Original studies of description and evaluation for PPM programmes were included. Two researchers independently screened, sorted and extracted the data, disagreements were discussed and reach consensus. Qualitative approach was adopted to summarize and synthesize data, to draw the collaborative mechanisms and effectiveness of PPM prgrammes.
2. Literature review, document collection and experts consultation were performed to study the hospital-dispensary TB collaboration and its collaboration models.
We reviewed literatures and materials of hospital-dispensary TB collaboration in China, collected documents of related policy and law, and consulted national and international professionals, to summarized the establishment and development of hospital-dispensary TB collaboration, then overall summarize and analyze characteristics, advantages and limitations of main collaboration models.
3. Facility-based survey, document collection, questionnaire investigation and qualitative interview were conducted to compare and analyze the characteristics, advantages, limitations and effectiveness between two TB collaboration models in Chongqing.
Facility-based survey and document collection:we obtained data from involved sectors using sector survey forms, looked up policy and law from sector documents. Data was extracted and categorized, then descriptively statistic analysis was performed to detect variations of patients visits, diagnosis and trace between two models
Quantitative investigation:we investigated494newly diagnosed TB patients through self-designed questionnaire from June to December2012, to collect their basic information, visits and referral situation. The data were double entered using EpiData3.1and analyzed by SPSS17.0
Qualitative interview:ten leaders and outpatient physicians were organized by purposive sample. Key informant interviews were performed using semi-structured topic guides to understand the development, operation, characteristics, advantages and barriers during work. Data was managed by MAXQDA11software and analyze using framework approach.
Results
1. Results from systematic review
A total of69studies were included and categorized into43PPM programmes implemented among15countries. The collaborative mechanism could be summarized in three mechanisms as the support mechanism (financial, material and personnel), contract mechanism (formal and informal) and working group mechanism (working group committee) according the roles and responsibilities of involved sectors. Most studies indicated that PPM could improve the effectiveness of TB control programmes in the aspects of DOTS utilization, case detection, treatment outcomes, case management, accessibility and equity, costs, technical capacity, acceptability and cooperation.
2. Results from study on Chinese hospital-dispensary TB collaboration
A diversified collaboration strategy for TB control was developed in China. The main collaborative models include dispensary model, designated hospital model, special hospital model and Primary health service network model. Hospital-dispensary TB collaboration played an important role in TB care and control in China, however, limitations also existed such as informal diagnosis, treatment and referral, limited personnel and technical capacity, poor management and so on.
3. Results from study on collaboration models of hospital-dispensary in Chongqing
Presently the main TB collaboration models in Chongqing were dispensary model and designated hospital model. The dispensary model could ensure the systematicness and coherence of patients diagnosis, treatment and management; the designated hospital model could improve patients detection and tracing. The successful treatment rates and cure rates of TB patients in both the two models reached90%, and the dispensary model was littler higher. Two models could achieve relatively good outcomes but have some limitations, mainly like insufficient financial input, poor infrastructure and medical condition, lack of staff, short in training, low wages and incentives, incomplete health insurance, high infection risk of physicians and poor adherence of patients.
Conclusion
Global public-private mix strategy and Chinese hospital-dispensary collaboration strategy have diverse mechanism and models. Different models could play important roles in TB control practice due to their own advantages. As to cope with difficulties and barriers during the TB control work, we could make improvement from three levels of establish policy and law, promote sector work and develop new measures for treatment and diagnosis, specifically in the aspects of increasing fund input, specifying the responsibility of involved sectors, setting supervision systems, establishing information platform, promoting wages and incentives, improving insurance, applying related funds, reinforcing cooperation, enhancing training and education, modifying working methods, in order to improve PPM and hospital-dispensary collaboration and achieve success in TB care an control.
结核病是全球公共卫生的巨大挑战之一。为加强结核病的治疗和控制,世界卫生组(WHO)提出公立与私立医疗机构合作策略(简称公私医疗合作),旨在动员所有医疗服务提供者共同开展以“直面督导下的短程化疗”(DOTS)为基础的结核病综合防治工作。我国在结核病防控的工作实践中,探索形成一套多元化的医疗卫生机构与结核病防治专业机构(结防所或疾控中心结防科)之间密切合作的结核病联合防控策略,简称医防合作策略。国际上对于结核病防控的公私医疗合作的特点和所取成效已开展一定研究,而国内也针对医防合作在结核病患者的发现、转诊和治疗方面的效果进行分析,但目前对于公私医疗合作策略及医防合作策略的机制总结、模式探讨以及实施效果综合分析评价研究还鲜见报道。
研究目的
全面系统地回顾全球范围内开展的结核病防控的公私医疗合作项目,总结公私医疗合作机制,描述其运作特点及参与合作机构之间的职能与分工,并对其结核病防控效果进行综合评价；深入探讨中国结核病医防合作策略的形成、发展、主要模式及其特点；探索重庆地区结核病医防合作模式的发展情况、优势及存在主要问题,掌握结核病患者归口诊治和管理现状,为针对性地解决医防合作过程中的具体问题及改善结核病患者的诊疗服务提供科学依据。
研究方法
1.采用系统评价的方法,对全球结核病防控公私医疗合作项目的机制与效果进行总结与评价。
全面检索14个电子数据库、2个灰色文献数据库以及6个相关网站截止2012年4月已发表的文献。纳入描述和评价已实施的结核病公私医疗合作项目原始研究。由两名研究员分别独立进行文献筛选、研究分类及数据提取,并交叉核对,讨论达成共识。采用定性描述与合并方法对纳入研究的信息和结果进行归纳,以总结公私医疗合作策略的运作机制并综合评价合作项目实施效果。
2.运用文献回顾、政策文件收集和专家咨询的方法,对我国结核病防控的医防合作策略及合作模式进行总结探讨。
回顾与我国结核病医防合作相关的文献资料,收集整理相关政策法规文件,并咨询结核病防治机构的领导及国际国内相关领域的专家,以总结我国结核病医防合作策略的建立与发展情况,并对主要医防合作模式的特点、优势和局限进行全面总结分析。
3.采用机构调查、政策文件收集、问卷调查与定性访谈相结合的方法,对重庆地区主要的结核病医防合作模式的特点、优势、困难障碍及实施效果进行调查研究和比较分析。
(1)机构调查与政策文件收集：采用机构调查表对参与合作的结防机构和定点医院情况进行调查,查阅机构档案资料并获取相关政策法规文件。调查数据经提取和归纳后,对两种医防合作模式下结核病患者主动就诊、转诊和追踪情况差异进行描述性统计分析。
(2)定量调查：在研究地点选取2012年6月～12月之间确诊的494名新发结核病患者作为研究对象,采用自编调查问卷进行定量调查,了解患者基本信息就诊及转诊情况,调查结果双录入EpiData3.1数据库,并用SPSS17.0软件进行统计分析。
(3)定性访谈：目的性地在调查机构抽取10名领导干部及门诊医生,使用半结构式访谈提纲,对其进行关键人物访谈,了解医防合作模式发展过程、运作特点、工作中的主要优势与困难等信息。使用MAXQDA11软件管理定性资料,并采用主题框架分析法进行定性分析。
研究结果
1.系统评价结果
纳入分析的69篇原始研究,可被归纳为43个在15个国家开展的公私医疗合作项目。根据不同合作项目中参与机构的职责与分工,可将公私医疗合作策略的运作机制归纳为支持机制(包括经济、物资和人员支持)、合同机制(包括正式与非正式合同)以及工作组机制(工作指导委员会)。绝大多数研究肯定了公私医疗合作在DOTS实施、病例发现、治疗结局、患者管理、服务可及性与公平性、相关花费、技术能力、接受程度与合作水平方面具有积极促进作用。
2.中国结核病医防合作策略研究结果
我国探索形成适宜国情的多元化结核病防治的医防合作策略,其合作模式主要分为结防机构模式、定点医院模式、专科医院模式及基层卫生服务网络模式四种,其中以结防机构模式和定点医院模式为主。医防合作策略在全国结核病防治实践工作中发挥了重要作用,但也存在诊治和转诊工作不规范、截留患者、医务人员有限、技术力量和管理能力不足等局限性。
3.重庆地区结核病医防合作模式研究结果
目前重庆各区县开展的结核病防治医防合作主要属于结防机构模式和定点医院模式。结防机构模式可确保患者诊治和管理的系统性和连贯性；定点医院模式在诊疗条件和临床能力上具有明显优势。比较发现,结防所模式下患者转诊到位率较高,首诊更倾向选择指定结防机构；定点医院模式能在一定程度上促进结核病患者发现和追踪水平。两种模式下患者的治疗成功率和涂阳患者治愈率均在90%以上,结防所模式略高于定点医院模式。两种医防合作模式在结核病防治工作中都能发挥了重要作用,但仍然存在自身局限,主要体现在经费投入不足及其引起基础设施、设备条件、人才引进、人员培训、医生工资待遇、患者医疗保障等方的问题,以及综合医院管理协调和业务监督困难,医务人员院感风险高,患者依从性不高等。
结论
无论是全球公私医疗合作策略还是我国医防合作策略,存在不同的合作机制或模式。鉴于各自特点和优势,不同合作机制及模式在结核病防治实践的不同方面发挥作用。对于目前结核病防治实践中普遍存在的困难和障碍,可以从制定政策法规、改善机构工作和研发新型诊疗措施三个层面着手,加大经费投入、明确机构职责、建立监管体制、搭建信息平台、提高福利待遇、改善医疗保障、争取项目经费、促进协调联系、加强培训教育、改进工作方法,进一步促使全球公私医疗合作策略及我国医防合作策略在结核病防控工作中取得巨大成效。
Background
Tuberculosis remains a major challenge to global public health. In order to accelerate Tuberculosis (TB) care and control, the WHO proposed Public-Private Mix (PPM) strategy, which aimed at involving all the TB entities and practitioners to overall implement comprehensive control based on the Directly Observed Treatment Short Course (DOTS) strategy. In China, a diversified collaboration strategy, involving medical institutions (hospital) and professional TB control sectors (TB dispensary or TB Unit under the CDC), for TB care control has been formed during practical work, that is, the hospital-dispensary collaboration. There have been some international studies on the characteristics and effectiveness of PPM, and national researches on patients detection, referral and treatment outcomes. However, studies on summary of collaboration mechanism and model, or systematic evaluation for partnership effectiveness were rarely seen.
Objectives
To systematically identify global PPM programmes, summarize the partnership mechanisms, narrate the characteristics, roles and responsibilities of involved sectors, and assess their effectiveness of TB control; to study the development, models and characteristics of the hospital-dispensary TB collaboration in China; to study the development, advantages and barriers of models for hospital-dispensary TB collaboration in Chongqing, investigate the present situation of centralized diagnosis, treatment and management for patients, in order to provide scientific evidence for solving the problems during collaboration process and promoting the health service for TB patients.
Methods
1. Systematic review was performed to summarize the mechanism and assess the effectiveness of PPM programmes.
Publications until April2012were identified by a search in14electronic databases, two gray literature databases and six relevant websites. Original studies of description and evaluation for PPM programmes were included. Two researchers independently screened, sorted and extracted the data, disagreements were discussed and reach consensus. Qualitative approach was adopted to summarize and synthesize data, to draw the collaborative mechanisms and effectiveness of PPM prgrammes.
2. Literature review, document collection and experts consultation were performed to study the hospital-dispensary TB collaboration and its collaboration models.
We reviewed literatures and materials of hospital-dispensary TB collaboration in China, collected documents of related policy and law, and consulted national and international professionals, to summarized the establishment and development of hospital-dispensary TB collaboration, then overall summarize and analyze characteristics, advantages and limitations of main collaboration models.
3. Facility-based survey, document collection, questionnaire investigation and qualitative interview were conducted to compare and analyze the characteristics, advantages, limitations and effectiveness between two TB collaboration models in Chongqing.
Facility-based survey and document collection:we obtained data from involved sectors using sector survey forms, looked up policy and law from sector documents. Data was extracted and categorized, then descriptively statistic analysis was performed to detect variations of patients visits, diagnosis and trace between two models
Quantitative investigation:we investigated494newly diagnosed TB patients through self-designed questionnaire from June to December2012, to collect their basic information, visits and referral situation. The data were double entered using EpiData3.1and analyzed by SPSS17.0
Qualitative interview:ten leaders and outpatient physicians were organized by purposive sample. Key informant interviews were performed using semi-structured topic guides to understand the development, operation, characteristics, advantages and barriers during work. Data was managed by MAXQDA11software and analyze using framework approach.
Results
1. Results from systematic review
A total of69studies were included and categorized into43PPM programmes implemented among15countries. The collaborative mechanism could be summarized in three mechanisms as the support mechanism (financial, material and personnel), contract mechanism (formal and informal) and working group mechanism (working group committee) according the roles and responsibilities of involved sectors. Most studies indicated that PPM could improve the effectiveness of TB control programmes in the aspects of DOTS utilization, case detection, treatment outcomes, case management, accessibility and equity, costs, technical capacity, acceptability and cooperation.
2. Results from study on Chinese hospital-dispensary TB collaboration
A diversified collaboration strategy for TB control was developed in China. The main collaborative models include dispensary model, designated hospital model, special hospital model and Primary health service network model. Hospital-dispensary TB collaboration played an important role in TB care and control in China, however, limitations also existed such as informal diagnosis, treatment and referral, limited personnel and technical capacity, poor management and so on.
3. Results from study on collaboration models of hospital-dispensary in Chongqing
Presently the main TB collaboration models in Chongqing were dispensary model and designated hospital model. The dispensary model could ensure the systematicness and coherence of patients diagnosis, treatment and management; the designated hospital model could improve patients detection and tracing. The successful treatment rates and cure rates of TB patients in both the two models reached90%, and the dispensary model was littler higher. Two models could achieve relatively good outcomes but have some limitations, mainly like insufficient financial input, poor infrastructure and medical condition, lack of staff, short in training, low wages and incentives, incomplete health insurance, high infection risk of physicians and poor adherence of patients.
Conclusion
Global public-private mix strategy and Chinese hospital-dispensary collaboration strategy have diverse mechanism and models. Different models could play important roles in TB control practice due to their own advantages. As to cope with difficulties and barriers during the TB control work, we could make improvement from three levels of establish policy and law, promote sector work and develop new measures for treatment and diagnosis, specifically in the aspects of increasing fund input, specifying the responsibility of involved sectors, setting supervision systems, establishing information platform, promoting wages and incentives, improving insurance, applying related funds, reinforcing cooperation, enhancing training and education, modifying working methods, in order to improve PPM and hospital-dispensary collaboration and achieve success in TB care an control.
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