Gichuhi Stephen, Kabiru Joy, M'bongo Zindamoyen Alain, Rono Hillary, Ollando Ernest, Wachira Joseph, Munene Rhoda, Onyuma Timothy, Sagoo Mandeep S, Macleod David, Weiss Helen A, Burton Matthew J
International Centre for Eye Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
Department of Ophthalmology, University of Nairobi, P.O Box 19676-00202, Nairobi, Kenya.
BMC Health Serv Res. 2017 Jul 14;17(1):485. doi: 10.1186/s12913-017-2428-4.
In Africa, accessing eye health services is a major challenge. Ocular surface squamous neoplasia (OSSN) is a substantial ocular health problem in Africa related to solar UV light exposure and HIV infection among other risk factors. The disease causes visual loss and even death in advanced cases. This study was conducted to assess referral pathway and treatment delay for patients with OSSN in Kenya.
Adults with conjunctival lesions presenting to four eye centres were asked about their occupations, when they noticed the growth, health facilities visited in seeking care, cost of consultation, surgery, medicines and histopathology and dates at each step. The time-to-presentation was divided into quartiles and correlates analysed using ordinal logistic regression.
We evaluated 158 first-time presenters with OSSN. Most were women (102 [65%]), living with HIV (78/110 tested [71%]), with low to medium income (127 [80%]). Most of the HIV patients (49/78 [63%]) were in antiretroviral care programs. About half (88/158, [56%]) presented directly to the study centres while the rest were referred. Indirect presenters sought care earlier than direct presenters (median 2.0 months vs 5.5 months) and travelled a shorter distance to the first health facility (median 20 km vs 30 km) but had surgery later (median 12.5 months vs 5.5 months). Visits beyond the first health facility for indirect presenters markedly increased delay (median 7.3, 29.0, 37.9, and 32.0 months for 1-4 facilities, respectively). Delay was associated with number of health facilities visited (adjusted ordered OR = 9.12; 95%CI 2.83-29.4, p < 0.001) and being female (adjusted ordered OR = 2.42; 95%CI 1.32-4.44, p = 0.004). At the time of presentation at the study centres for surgery the median tumour diameter in both directly and indirectly presenting patients was 6 mm (p = 0.52) and the histological spectrum of OSSN was similar between the groups (p = 0.87).
Referral delays definitive treatment for OSSN. Women were more likely to experience delay. Despite regular contact with the health system for those with known HIV infection, delays occurred. Early detection and referral of OSSN in the HIV service might reduce delays, but reassuringly delay did not give rise to a larger proportion with more advanced grade of OSSN.
在非洲，获得眼部保健服务是一项重大挑战。眼表鳞状上皮病变（OSSN）是非洲一个严重的眼部健康问题，与太阳紫外线暴露和艾滋病毒感染等其他风险因素有关。该疾病在晚期会导致视力丧失甚至死亡。本研究旨在评估肯尼亚OSSN患者的转诊途径和治疗延迟情况。
询问到四个眼科中心就诊的结膜病变成人患者的职业、发现肿物的时间、寻求治疗时就诊的医疗机构、会诊、手术、药物及组织病理学检查的费用以及每一步骤的日期。将就诊时间分为四分位数，并使用有序逻辑回归分析相关性。
我们评估了158例首次就诊的OSSN患者。大多数为女性（102例[65%]），感染艾滋病毒（78/110例接受检测[71%]），收入低至中等（127例[80%]）。大多数艾滋病毒患者（49/78例[63%]）参加了抗逆转录病毒治疗项目。约一半（88/158例，[56%]）直接到研究中心就诊，其余为转诊患者。间接就诊者比直接就诊者更早寻求治疗（中位时间2.0个月对5.5个月），到首个医疗机构的距离更近（中位距离20公里对30公里），但手术时间更晚（中位时间12.5个月对5.5个月）。间接就诊者在首个医疗机构之外的就诊显著增加了延迟时间（分别就诊1 - 4个医疗机构时，中位延迟时间为7.3、29.0、37.9和32.0个月）。延迟与就诊的医疗机构数量有关（调整后的有序OR = 9.12；95%CI 2.83 - 29.4，p < 0.001）以及女性（调整后的有序OR = 2.42；95%CI 1.32 - 4.44，p = 0.004）。在研究中心进行手术时，直接和间接就诊患者的肿瘤中位直径均为6毫米（p = 0.52），两组间OSSN的组织学谱相似（p = 0.87）。
转诊会延迟OSSN的确定性治疗。女性更易经历延迟。尽管已知感染艾滋病毒的患者与卫生系统有定期接触，但仍会出现延迟。在艾滋病毒服务中早期发现和转诊OSSN可能会减少延迟，但令人放心的是，延迟并未导致OSSN更高级别比例的增加。
