Department of Population Health Sciences, UW-Madison, Madison, USA.
Departments of Medicine and of Medical Microbiology and Immunology, School of Medicine and Public Health, UW-Madison, Madison, USA.
BMC Infect Dis. 2020 Nov 11;20(1):831. doi: 10.1186/s12879-020-05539-w.
The discovery of antibiotics in the mid-twentieth century marked a major transition in tuberculosis (TB) treatment and control. There are few studies describing the duration of TB disease and its treatment from the pre-chemotherapy era and little data on how these treatments changed in response to the development of effective antibiotics. The goal of this research is to understand how inpatient treatment for high incidence populations, the First Nations peoples of Saskatchewan, Canada, changed in response to increasing availability of antibiotics effective against TB. We expected that as treatment regimens transitioned from convalescence-only to triple antibiotic therapy, the length of inpatient treatment would shorten.
Analyses were performed on records of sanatoria admissions and discharges occurring between 1933 and 1959 in Saskatchewan, Canada. Year of antibiotic discovery was taken as a proxy for treatment regimen: no chemotherapy (pre-1944), mono-therapy (Streptomycin, 1944-1946), dual-therapy (Streptomycin and PAS, 1946-1952), and triple-therapy (Streptomycin, PAS, and INH 1952-). A pooled linear regression of log-transformed length of first admission as predicted by year of admission was modeled to assess the relationship between admission length and year of admission, corrected for clinical and demographic variables.
First admission length increased 19% in the triple-therapy era as compared to the pre-chemotherapy era, from 316 days (10.4 months) to 377 days (12.4 months). After the discovery of INH (1952), we find statistically significant increases in the proportion of successfully completed therapies (0.55 versus 0.60, p = 0.035), but also in patients who left hospital against medical advice (0.19 versus 0.29, p < 0.0001), indicating that as hospitalizations lengthened, more patients chose to discharge without the sanction of their physician. The readmission rate increased from 10 to 50% of all admissions while the province-level TB-specific death rate fell from 63.1 per 10,000 in 1933 to 4.7 per 10,000 in 1958.
Counterintuitively, we find that the length of first admissions increased with the discovery of TB-treating antibiotics. Increasing admission volume and readmission rate indicate an intensification of inpatient TB treatment during this era. These analyses provide a novel estimate of the effect of changing treatment policy on sanatorium admissions in this population.
20 世纪中叶抗生素的发现标志着结核病（TB）治疗和控制的重大转变。很少有研究描述化疗前时代结核病的持续时间及其治疗，也几乎没有关于这些治疗如何随着有效抗生素的发展而变化的数据。本研究的目的是了解加拿大萨斯喀彻温省发病率高的原住民第一民族人群的住院治疗如何随着对 TB 有效的抗生素的可获得性增加而发生变化。我们预计，随着治疗方案从仅疗养期转变为三联抗生素治疗，住院治疗的时间将会缩短。
对加拿大萨斯喀彻温省 1933 年至 1959 年期间疗养院入院和出院记录进行了分析。抗生素发现的年份被视为治疗方案的代表：无化疗（1944 年前）、单药治疗（链霉素，1944-1946 年）、二联治疗（链霉素和 PAS，1946-1952 年）和三联治疗（链霉素、PAS 和 INH，1952-1959 年）。采用线性回归模型对住院时间的对数进行建模，以评估住院时间与入院年份之间的关系，并校正临床和人口统计学变量。
与化疗前时代相比，三联治疗时代的首次住院时间增加了 19%，从 316 天（10.4 个月）增加到 377 天（12.4 个月）。在发现异烟肼（1952 年）后，我们发现成功完成治疗的比例有统计学意义的增加（0.55 对 0.60，p=0.035），但也有更多的患者未经医生同意出院（0.19 对 0.29，p<0.0001），这表明随着住院时间的延长，更多的患者选择在没有医生批准的情况下出院。再入院率从所有入院患者的 10%增加到 50%，而省级结核病特定死亡率从 1933 年的每 10000 人 63.1 人下降到 1958 年的每 10000 人 4.7 人。
反直觉的是，我们发现随着治疗结核病的抗生素的发现，首次住院时间增加了。入院量和再入院率的增加表明，在这一时期，住院结核病治疗的强度有所增加。这些分析为这一人群中治疗政策变化对疗养院入院的影响提供了一个新的估计。
