Departamento de Análises Clínicas for Programa de Pós-Graduação em Farmácia da, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil.
Departamento de Clínica Médica, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil.
BMC Public Health. 2018 Apr 25;18(1):554. doi: 10.1186/s12889-018-5468-8.
Tuberculosis (TB) control programs face the challenges of decreasing incidence, mortality rates, and drug resistance while increasing treatment adherence. The Brazilian TB control program recommended the decentralization of patient care as a strategy for combating the disease. This study evaluated the performance of this policy in an area with high default rates, comparing epidemiological and operational indicators between two similar municipalities.
This study analyzed epidemiological and operational indicators on new cases of pulmonary tuberculosis reported in the Brazilian Notifiable Diseases Information System between 2006 and 2015. In addition, to characterize differences between the populations of the two studied municipalities, a prospective cohort study was conducted between 2014 and 2015, in which patients with new cases of culture-confirmed pulmonary tuberculosis were interviewed and monitored until the disease outcome. A descriptive analysis, the chi-square test, and a Poisson regression model were employed to compare TB treatment outcomes and health care indicators between the municipalities.
Two thousand three hundred nine cases were evaluated, of which 207 patients were interviewed. Over the 2006-2015 period, TB incidence per 100,000 population in the municipality with decentralized care was significantly higher (39%, 95% CI 27-49%) in comparison to that of the municipality with centralized care. TB treatment default rate (45%, 95% CI 12-90%) was also higher in the municipality with decentralized care. During the two-year follow-up, significant differences were found between patients in centralized care and those in decentralized care regarding treatment success (84.5 vs. 66.1%), treatment default (10.7 vs. 25.8%), illicit drug use (27.7 vs. 45.9%), and homelessness (3.6 vs. 12.9%). The operational indicators revealed that the proportion of control smear tests, medical imaging, and HIV tests were all significantly higher in the centralized care. However, a significantly higher proportion of patients started treatment in the early stages of the disease in the municipality with decentralized care.
These data showed a low success rate in TB treatment in both municipalities. Decentralization of TB care, alone, did not improve the main epidemiological and operational indicators related to disease control when compared to centralized care. Full implementation of strategies already recommended is needed to improve TB treatment success rates.
结核病（TB）控制项目面临着降低发病率、死亡率和耐药率，同时提高治疗依从性的挑战。巴西结核病控制项目建议将患者护理去中心化，作为对抗该疾病的一种策略。本研究评估了这一政策在高失访率地区的执行情况，比较了两个类似城市的流行病学和运营指标。
本研究分析了 2006 年至 2015 年期间巴西法定传染病信息系统报告的新发病例的流行病学和运营指标。此外，为了描述两个研究城市之间的人群差异，在 2014 年至 2015 年期间进行了一项前瞻性队列研究，对新发病例培养确诊的肺结核患者进行了访谈和监测，直至疾病结局。采用描述性分析、卡方检验和泊松回归模型比较了两个城市的结核病治疗结果和医疗保健指标。
共评估了 2309 例病例，其中 207 例患者接受了访谈。在 2006 年至 2015 年期间，去中心化护理城市的每 100000 人口结核病发病率（39%，95%CI 27-49%）明显高于集中化护理城市。去中心化护理城市的结核病治疗失访率（45%，95%CI 12-90%）也更高。在两年的随访中，集中化护理和去中心化护理的患者在治疗成功率（84.5%比 66.1%）、治疗失访率（10.7%比 25.8%）、非法药物使用（27.7%比 45.9%）和无家可归（3.6%比 12.9%）方面存在显著差异。运营指标显示，集中化护理的控制涂片检查、医学影像学和 HIV 检查的比例均显著更高。然而，在去中心化护理城市中，有更高比例的患者在疾病早期开始治疗。
这两个城市的结核病治疗成功率均较低。与集中化护理相比，单独的结核病护理去中心化并未改善与疾病控制相关的主要流行病学和运营指标。需要全面实施已经推荐的策略，以提高结核病治疗成功率。
