Dale Katie D, Tay Ee Laine, Trauer James M, Trevan Peter G, Denholm Justin T
Victorian Tuberculosis Program, The Peter Doherty Institute for Infection and Immunity, Victoria, Australia.
Department of Health and Human Services, Victoria, Australia.
BMC Infect Dis. 2017 May 3;17(1):324. doi: 10.1186/s12879-017-2421-x.
Private healthcare providers are important to tuberculosis (TB) management globally, although internationally there are reports of suboptimal management and disparities in treatment commencement in the private sector. We compared the management of TB patients receiving private versus public healthcare in Victoria, an industrialised setting with low tuberculosis (TB) incidence.
Retrospective cohort study: 2002-2015. Private healthcare provision was included as an independent variable in several multivariate logistic and Cox proportional hazard regression models that assessed a range of outcome variables, encompassing treatment commencement delays, management and treatment outcomes.
Of 5106 patients, 275 (5.4%) exclusively saw private providers, and 4714 (92.32%) public. Private care was associated with a shorter delay to presentation (HR 1.36, p = 0.065, 95% CI 1.02-2.00). Private patients were less likely to have genotypic testing (OR 0.66, p = 0.009, 95% CI 0.48-0.90), those with pulmonary involvement were less likely to have a sputum smear (OR 0.52, p = 0.011, 95% CI 0.31-0.86) and provided samples were less likely to be positive (OR 0.54, p = 0.070, 95% CI 0.27-1.05). Private patients with extrapulmonary TB were less likely to have a smear sample (OR 0.7, 95% CI 0.48-0.90, p = 0.009) and radiological abnormalities (OR 0.71, p = 0.070, 95% CI 0.27-1.05). Treatment commencement delays from presentation were comparable for cases with pulmonary involvement and extrapulmonary TB, although public extrapulmonary TB patients received radiological examinations slightly earlier than private patients (HR 0.79, p = 0.043, 95% CI 0.63-0.99) and public patients with pulmonary involvement from high burden settings commenced treatment following an abnormal CXR more promptly than their private counterparts (HR 0.41, p = 0.011, 95% CI 0.21-0.81). Private patients were more likely to receive <4 first-line medications (OR 2.17, p = 0.001, 95% CI 1.36-3.46), but treatment outcomes were comparable between sectors.
The differences we identified are likely to reflect differing case-mix as well as clinician practice. Sputum smear status was an important covariable in our analysis; with its addition we found no significant disparity in the health-system delay to treatment commencement between sectors. Our study highlights the importance of TB programs engaging with private providers, enabling comprehensive data collection that is necessary for thorough and true comparison of TB management and optimisation of care.
尽管国际上有报告称私营部门的结核病管理存在欠佳情况以及治疗开始方面的差异，但私营医疗服务提供者对全球结核病管理至关重要。我们比较了在结核病发病率较低的工业化地区维多利亚，接受私营医疗与公共医疗的结核病患者的管理情况。
回顾性队列研究：2002年至2015年。在多个多变量逻辑回归和Cox比例风险回归模型中，将私营医疗服务作为一个自变量纳入，这些模型评估了一系列结果变量，包括治疗开始延迟、管理和治疗结果。
在5106名患者中，275名（5.4%）仅看私营医疗服务提供者，4714名（92.32%）看公共医疗服务提供者。私营医疗与就诊延迟较短相关（风险比1.36，p = 0.065，95%置信区间1.02 - 2.00）。私营患者进行基因检测的可能性较小（比值比0.66，p = 0.009，95%置信区间0.48 - 0.90），有肺部受累的患者进行痰涂片检查的可能性较小（比值比0.52，p = 0.011，95%置信区间0.31 - 0.86），送检样本呈阳性的可能性较小（比值比0.54，p = 0.070，95%置信区间0.27 - 1.05）。肺外结核病的私营患者进行涂片检查的可能性较小（比值比0.7，95%置信区间0.48 - 0.90，p = 0.009），出现放射学异常的可能性较小（比值比0.71，p = 0.070，95%置信区间0.27 - 1.05）。对于有肺部受累和肺外结核病的病例，从就诊到开始治疗的延迟相当，尽管肺外结核病的公共患者接受放射学检查比私营患者略早（风险比0.79，p = 0.043，95%置信区间0.63 - 0.99），且来自高负担地区有肺部受累的公共患者在胸部X线异常后比私营患者更迅速地开始治疗（风险比0.41，p = 0.011，95%置信区间0.21 - 0.81）。私营患者更有可能接受少于4种一线药物治疗（比值比2.17，p = 0.001，95%置信区间1.36 - 3.46），但不同部门之间的治疗结果相当。
我们发现的差异可能反映了病例组合以及临床医生实践的不同。痰涂片状况是我们分析中的一个重要协变量；加入该变量后，我们发现不同部门在卫生系统导致治疗开始延迟方面没有显著差异。我们的研究强调了结核病项目与私营医疗服务提供者合作的重要性，以便能够全面收集数据，这对于全面、真实地比较结核病管理和优化护理是必要的。
