Safdar Nauman, Hinderaker Sven Gudmund, Baloch Noor Ahmed, Enarson Donald A, Khan Muhammad Amir, Morkve Odd
Association for Social Development, Islamabad, Pakistan.
BMC Res Notes. 2010 Nov 30;3:324. doi: 10.1186/1756-0500-3-324.
The adherence to policies of National TB Control Programme (NTP) to manage a case of tuberculosis (TB) is a fundamental step to have a successful programme in any country. Childhood TB services faces an unmet challenge of case management due to difficulty with diagnosis and relatively new policies. For control of childhood TB in Pakistan, NTP developed and piloted its guidelines in 2006-2007. The objective of this study was to compare the documented case management practices of pediatricians and its impact on the outcome before and after introducing NTP policy guidelines.
An audit of case management practices of a historical cohort study was done in children below 15 years who were put on anti-tuberculosis treatment at all nine public hospitals in three districts in province of Punjab. The study period was two years pre-intervention (2004-05) and two years post-intervention (2006-07) after implementation of new NTP policy guidelines for childhood TB. There were 920 childhood TB cases registered during four years, 189 in pre-intervention period and 731 in post-intervention period. The practices changed significantly in post-intervention period for use of tuberculin skin test (63% of pulmonary cases, 19% of extrapulmonary cases and 67% for site unknown), and for the use of chest x-ray (69% of pulmonary cases, 16% of extrapulmonary cases and 74% for site unknown). Diagnostic scores were recorded for only a minority of cases (18%). The proportion of correct drugs pre- and post-intervention remained same. There were unknown treatment outcomes in 38 out of 141 cases (27%) in pre-intervention and in 483 out of 551 cases (87%) post-intervention, all among the 692 cases without documented treatment supporter.
The study has shown that pediatricians have started following parts of the national policy guidelines for management of childhood TB. The documented use of diagnostic tools is increased but record keeping of case management practices remained inadequate. This seems to increase case finding substantially but the treatment outcomes were poor mainly due to unknown outcomes. Development and implementation of standardized operational tools and regular monitoring system may improve the services.
在任何国家，遵循国家结核病控制规划（NTP）的政策来管理结核病（TB）病例，是使该规划取得成功的基本步骤。由于诊断困难以及政策相对较新，儿童结核病服务面临病例管理方面尚未得到满足的挑战。为了在巴基斯坦控制儿童结核病，NTP在2006 - 2007年制定并试行其指南。本研究的目的是比较引入NTP政策指南前后儿科医生记录的病例管理实践及其对结果的影响。
对旁遮普省三个地区所有九家公立医院中接受抗结核治疗的15岁以下儿童进行了一项历史性队列研究的病例管理实践审计。研究期间为新的儿童结核病NTP政策指南实施前两年（2004 - 2005年）和实施后两年（2006 - 2007年）。四年间共登记了920例儿童结核病病例，干预前189例，干预后731例。干预后，结核菌素皮肤试验的使用情况（肺部病例为63%，肺外病例为19%，部位不明病例为67%）以及胸部X光的使用情况（肺部病例为69%，肺外病例为16%，部位不明病例为74%）有显著变化。仅少数病例（18%）记录了诊断评分。干预前后正确用药的比例保持不变。干预前141例中有38例（27%）治疗结果不明，干预后551例中有483例（87%）治疗结果不明，所有这些均在692例无记录治疗支持者的病例中。
该研究表明，儿科医生已开始遵循儿童结核病管理国家政策指南的部分内容。诊断工具的记录使用有所增加，但病例管理实践的记录保存仍然不足。这似乎大幅增加了病例发现，但治疗结果不佳，主要原因是结果不明。开发和实施标准化操作工具及定期监测系统可能会改善服务。
