Chen Chien-Chou, Chiang Chen-Yuan, Pan Sung-Ching, Wang Jann-Yuan, Lin Hsien-Ho
Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei, Taiwan.
Department of Lung Health and NCDs, International Union Against Tuberculosis and Lung Disease, Paris, France.
BMC Infect Dis. 2015 Nov 2;15:491. doi: 10.1186/s12879-015-1228-x.
Taiwan has integrated the previous vertical tuberculosis (TB) control system into the general health care system. With the phase out of the specialized TB care system and the declining TB incidence, it is likely that clinical workers become less familiar with the presentation of TB, resulting in delay in TB diagnosis and treatment.
We used the detailed information of health care visits in the Taiwan National Health Insurance database to analyze the temporal pattern of the health system delay (HSD) among 3,117 patients with TB between 2003 and 2010.
The median HSD was 29 days (interquartile range 5-73 days), and the median delay increased from 26 days in 2003 to 33.5 days in 2008, thereafter slightly decreased to 32 days in 2010. Patient factors associated with a longer HSD included: aged 45-64 and ≧65 years (as compared to aged <30 years); females (as compared to males); an initial visit as an outpatient (as compared to an inpatient). Provider factors were an initial visit to a provider not specialized in TB (as compared to a TB-related provider), to a primary care clinic or to a medical center (as compared to a district hospital), and in Central region, Northern region, KaoPing region, Southern region and Taipei region (as compared to in Eastern region). Longer distances from the point of initial visit to that of treatment were associated with longer HSD. Patients who switched among different levels or different types of medical care services during their illness exhibited the longest HSD.
In countries where the TB care systems are being restructured from a vertical to a horizontal system, it is critical to monitor HSD and be aware of its increase. The potential increase in the HSD from 2003 to 2008 observed in this study is concerning and the decline of HSD after 2008 might be attributed to the launch of contact investigation. Our results call for actions to improve the efficiency of TB diagnosis in the health care system and to increase the awareness of TB among physicians and the general public.
台湾已将先前的垂直结核病防治系统纳入一般医疗保健系统。随着专门结核病防治系统的逐步淘汰以及结核病发病率的下降，临床工作者可能对结核病的表现变得不那么熟悉，从而导致结核病诊断和治疗的延迟。
我们利用台湾全民健康保险数据库中详细的医疗就诊信息，分析了2003年至2010年间3117例结核病患者中卫生系统延误（HSD）的时间模式。
HSD的中位数为29天（四分位间距为5 - 73天），中位数延误从2003年的26天增加到2008年的33.5天，此后在2010年略有下降至32天。与较长HSD相关的患者因素包括：年龄在45 - 64岁及≥65岁（与年龄<30岁相比）；女性（与男性相比）；初次就诊为门诊患者（与住院患者相比）。提供者因素包括初次就诊于非结核病专科提供者（与结核病相关提供者相比）、基层医疗诊所或医学中心（与地区医院相比），以及在中部地区、北部地区、高屏地区、南部地区和台北地区（与东部地区相比）。从初次就诊点到治疗点的距离越远，HSD越长。在患病期间在不同级别或不同类型医疗服务之间转换的患者表现出最长的HSD。
在结核病防治系统从垂直系统向横向系统重组的国家，监测HSD并意识到其增加至关重要。本研究中观察到的2003年至2008年HSD的潜在增加令人担忧，2008年后HSD的下降可能归因于接触者调查的开展。我们的结果呼吁采取行动提高医疗保健系统中结核病诊断的效率，并提高医生和公众对结核病的认识。
