Ramphal-Naley L, Kirkhorn S, Lohman W H, Zelterman D
Department of Occupational Medicine, United Occupational Health of Services of Allina, Eagan, MN 55121, USA.
Am J Infect Control. 1996 Aug;24(4):243-53. doi: 10.1016/s0196-6553(96)90056-5.
Physicians have historically shown poor compliance with tuberculosis (TB) skin testing and treatment after infection. Studies showed that nearly one half of physicians had positive skin test results, but one half to two thirds of physicians with negative tuberculin skin test results did not undergo annual skin testing despite significant exposure to patients with TB. Compliance with chemoprophylaxis after skin test conversion was worse; only 8% to 10% of physicians with a positive tuberculin skin test result received antituberculous therapy. The Centers for Disease Control and Prevention published guidelines on prevention of tuberculosis transmission recommending that all health care workers (including physicians) comply with regular skin testing and get appropriate follow-up care. The Occupational Safety and Health Administration has adopted the guidelines as part of its strategy to prevent occupationally acquired TB. OSHA's requirement provided the opportunity to study the effect on physicians of hospital-wide attempts to apply those guidelines. No previous study has looked at the differences in compliance between physicians in training, full-time staff physicians, and part-time staff (associate physicians). Understanding these differences will enable the hospital's administration to target efforts to improve compliance with TB surveillance and medical therapy after skin test conversion.
Two hundred eighty-four physicians (189 staff physicians, 65 resident physicians, and 30 associate physicians) responded to a questionnaire that asked about demographic and professional characteristics, current status of tuberculin skin test results, and follow-up of physicians with positive skin test results.
We found that 71% of resident and full-time physicians were current in their tuberculin skin test status, whereas 66% of associate physicians were up to date. Thirteen percent of the resident and full-time physicians had positive TB skin test results, compared with 20% of associate physicians. Female physicians had a lower prevalence of positive skin test results than did male physicians. The departments of pathology, surgery, and pediatrics had the highest prevalence of positive test results, followed by radiology, emergency medicine, and obstetrics and gynecology. Family practice and internal medicine were among the departments with the lowest prevalence of positive skin test results. Physicians obtained their skin tests from multiple sources and had their test results interpreted in multiple facilities; hence, the test procedure was not uniform. Compliance with disease prophylaxis was 55% among the resident physicians with positive Mantoux test results, 44% among the full-time staff physicians, and only 17% among the associate physicians. More than half of the physicians with positive Mantoux test results remained untreated.
Physicians have unique issues in complying with TB surveillance that need to be specifically addressed by hospitals in light of guidelines enforceable by the Occupational Safety and Health Administration. Resident physicians were the most compliant with TB surveillance and treatment after infection. Staff and associate staff physicians had poor compliance with treatment. Although this study shows some improvement when compared with prior studies on physician compliance, hospital follow-up and enforcement may be necessary to bring about significant behavioral change among physicians.
历史上，医生对结核菌素皮肤试验及感染后的治疗依从性较差。研究表明，近一半的医生皮肤试验结果呈阳性，但结核菌素皮肤试验结果为阴性的医生中，有一半至三分之二尽管大量接触结核病患者，却未进行年度皮肤试验。皮肤试验结果转为阳性后，化学预防的依从性更差；结核菌素皮肤试验结果呈阳性的医生中，只有8%至10%接受了抗结核治疗。疾病控制与预防中心发布了预防结核病传播的指南，建议所有医护人员（包括医生）定期进行皮肤试验并接受适当的后续护理。职业安全与健康管理局已将这些指南作为其预防职业性结核病战略的一部分。职业安全与健康管理局的要求为研究在全院范围内应用这些指南对医生的影响提供了契机。此前尚无研究探讨住院医师、全职 staff 医生和兼职 staff（助理医生）在依从性方面的差异。了解这些差异将使医院管理层能够有针对性地努力提高对结核菌素皮肤试验结果转为阳性后的结核病监测和药物治疗的依从性。
284名医生（189名 staff 医生、65名住院医生和30名助理医生）回复了一份问卷，问卷询问了人口统计学和专业特征、结核菌素皮肤试验结果的当前状况以及皮肤试验结果呈阳性的医生的后续情况。
我们发现，71%的住院医生和全职医生的结核菌素皮肤试验状态是最新的，而助理医生中这一比例为66%。住院医生和全职医生中有13%的结核菌素皮肤试验结果呈阳性，而助理医生中这一比例为20%。女性医生皮肤试验结果呈阳性的患病率低于男性医生。病理科、外科和儿科的试验结果呈阳性的患病率最高，其次是放射科、急诊科以及妇产科。家庭医学科和内科是试验结果呈阳性的患病率最低的科室之一。医生从多个来源进行皮肤试验，且在多个机构解读试验结果；因此，试验程序并不统一。结核菌素试验结果呈阳性的住院医生中，疾病预防的依从性为55%，全职 staff 医生中为44%，而助理医生中仅为17%。结核菌素试验结果呈阳性的医生中，超过一半仍未接受治疗。
医生在遵守结核病监测方面存在独特问题，医院需要根据职业安全与健康管理局可执行的指南专门加以解决。住院医生在感染后的结核病监测和治疗方面依从性最高。staff 医生和助理 staff 医生在治疗方面依从性较差。尽管与之前关于医生依从性的研究相比，本研究显示出一些改善，但医院的后续跟进和执行可能有必要促使医生的行为发生显著改变。
