Singleton L, Turner M, Haskal R, Etkind S, Tricarico M, Nardell E
Division of Tuberculosis Prevention and Control, Massachusetts Department of Public Health, Boston 02130, USA.
JAMA. 1997 Sep 10;278(10):838-42.
Patients with tuberculosis (TB) who are nonadherent to therapy or have complicated medical or social problems pose a threat to public health. In some cases, hospitalization may be a necessary component of a comprehensive TB control program.
To describe experience with a new inpatient program for TB control.
Retrospective review.
Eighteen-bed, secure, TB treatment unit in a state public health hospital providing a spectrum of acute and chronic care services.
Patients with known or suspected TB who were unable to be treated as outpatients and were hospitalized from 1990 through 1995.
Voluntary or involuntary hospitalization, with medical, psychosocial, and legal services.
Admissions, treatment completion, and disposition.
A total of 166 patients with a confirmed diagnosis of TB accounted for 214 hospitalizations for TB. The mean age was 42 years, 132 (79.5%) were men, 84 (50.6%) were nonwhite, and 45 (27.1%) were foreign born. At the time of admission, 58 patients (34.5%) were homeless, 116 (69.9%) had a history of abuse of alcohol or other drugs, and 46 (31.7%) were positive for human immunodeficiency virus. The mean length of stay was 119.7 days (median, 70 days; range, 7-656 days), and was higher among homeless patients than nonhomeless patients (168.8 vs 93.4 days). Of 48 patients (28.9%) who were admitted involuntarily, 21 required long-term confinement under court order. Admission indications (not mutually exclusive) changed over 5 years: nonadherence decreased (95% to 34%), medical complexity increased (14% to 77%), short-term isolation increased (19% to 39%), and involuntary admission decreased (54% to 13%). Of 157 patients with positive cultures for Mycobacterium tuberculosis, 36 (23.1%) were resistant to at least 1 drug, including 16 who were multidrug resistant. A total of 123 patients (74.7%) were discharged to an outpatient setting to complete therapy, 40 (24.1%) required inpatient care to complete therapy, and 3 died (1 from TB) before discharge.
A high proportion of patients with TB who failed outpatient therapy completed treatment in a combined medical and psychosocial inpatient unit. During the 5-year study period, involuntary admissions decreased and most patients completed therapy as outpatients. In Massachusetts, this program plays an important role in protecting public health and in providing specialized medical management for patients to complete therapy in a safe and supportive environment.
不坚持治疗或存在复杂医疗或社会问题的结核病患者对公众健康构成威胁。在某些情况下，住院治疗可能是综合结核病控制项目的必要组成部分。
描述一项新的结核病住院控制项目的经验。
回顾性研究。
一家州立公共卫生医院的拥有18张床位的安全结核病治疗单元，提供一系列急性和慢性护理服务。
1990年至1995年期间已知或疑似患有结核病且无法作为门诊患者治疗而住院的患者。
自愿或非自愿住院，并提供医疗、心理社会和法律服务。
入院情况、治疗完成情况和出院情况。
共有166例确诊为结核病的患者因结核病住院214次。平均年龄为42岁，132例（79.5%）为男性，84例（50.6%）为非白人，45例（27.1%）出生于国外。入院时，58例患者（34.5%）无家可归，116例（69.9%）有酗酒或其他药物滥用史，46例（31.7%）人类免疫缺陷病毒检测呈阳性。平均住院时间为119.7天（中位数为70天；范围为7 - 656天），无家可归患者的住院时间高于有家可归患者（168.8天对93.4天）。在48例（28.9%）非自愿入院的患者中，21例需要根据法院命令长期监禁。5年期间入院指征（并非相互排斥）发生了变化：不坚持治疗的情况减少（从95%降至34%），医疗复杂性增加（从14%增至77%），短期隔离增加（从19%增至39%），非自愿入院减少（从54%降至13%）。在157例结核分枝杆菌培养阳性的患者中，36例（23.1%）对至少1种药物耐药，其中16例为多重耐药。共有123例患者（74.7%）出院后到门诊完成治疗，40例（24.1%）需要住院完成治疗，3例在出院前死亡（1例死于结核病）。
门诊治疗失败的高比例结核病患者在综合医疗和心理社会的住院单元完成了治疗。在5年研究期间，非自愿入院减少，大多数患者作为门诊患者完成了治疗。在马萨诸塞州，该项目在保护公众健康以及为患者在安全和支持性环境中完成治疗提供专业医疗管理方面发挥着重要作用。
