- 學位論文
中部四縣市實施都治計畫之成效初探
Effectiveness of TB DOTS program in central Taiwan
摘要
結核病（Tuberculosis，簡稱TB）目前仍然是引起人類疾病以及死亡的主要傳染病，1993年起世界衛生組織與國際抗癆暨肺病聯盟開始推廣都治計畫，簡稱DOTS。DOTS是世界衛生組織強力向各國推薦的結核病防治策略，也是世界銀行評估為成本效益最高的健康投資。都治計畫目的經由嚴密的直接觀察目視法，確保病人服下每一劑抗結核藥物直到治療成功。並希望藉此發現75%痰塗片陽性結核病患，且完成其中85%的病患治癒目標。 結核病的發生率和死亡率均為台灣法定傳染病的第一位，台灣從1997年起在山地鄉實施都治計畫，於2001年配合結核病防治年推廣實施，於2006年四月開始全台灣的都治計畫，正式聘顧專案關懷員，希望所有的痰抹片陽性與培養陽性的病患皆能在關懷員的觀察下服用藥物，達成世界衛生組織都治計畫之目標。本研究比較都治計畫之前後一年治療效果、醫療經費耗用及成本效果及效益，研究對象相關資料拮取自衛生署疾病管制局結核病通報登記資料庫，都治前一年區間為2005/4/1-2006/3/31，都治後一年區間為2006/4/1-2007/3/31之通報個案，研究對象共計5679人，並以身份證歸戶方式連結衛生署死因資料檔及中區健保局醫療申報費用。 本研究結果顯示，都治計畫實施前後一年間，肺結核病患之年齡仍趨於老化、並以男性居多。在治療效果上，都治計畫實施後一年累計用藥完治率（97%）比都治計畫前一年累計用藥完治率（92.3%）略為提升；死亡率部分，都治計畫實施後一年因TB總死亡率（20.4%），明顯低於都治計畫前一年四縣市因TB之總死亡率（22.4%），顯示中部四縣市因實施都治計畫可降低整體TB總死亡率；另外在驗痰三月陰轉合格率表現上，都治後一年個案（91.0%）整體優於都治前一年（84.2%）；而在後一年參加都治計畫的所有個案中，都治正規在三月痰陰轉率上達95.0%。整體而言，推動都治計畫在中部四縣市是具有效果及成本效益，四縣市努力成果上，則以彰化縣成效最佳，值得其他三個縣市參考學習。 本研究建議，中央政策部分應以健保支付制度，促使醫療院所加強初次通報驗痰措施及抗結核病藥物稽核措施；疾病管制局應與縣市都治團隊積極查核都治品質，並增加65歲以上老人篩檢、落實結核病死因診斷稽核、並建立正確結核病用藥指引及醫護公衛人員訓練；地方衛生單位及醫療院所部份，都治團隊應以透過關懷員每日訪視個案資訊，建立病患為中心溝通協調管道模式，加強結核病衛生教育措施，主動發現早期診斷病例，並提高病患服藥順從性，此外，醫護人員並應主動參與結核病相關訓練及病歷審查會吸取新知，給予病患整體完善照護品質。 依據世界衛生組織訂定之策略，積極推展都治計畫是對抗結核病之最佳方法，持續有效的將其介入結核病防治是有必要的，建議未來應長期執行此策略，藉由落實推動都治工作，採取更積極主動的介入，突破防治工作的瓶頸保障民眾健康。
並列摘要
Tuberculosis (abbreviated to TB) is one of important global health hazards. Since 1993, World Health Organization (WHO) and International Union Against Tuberculosis and Lung Disease (IUATLD) have been conducting an all-out global wide campaign of integrated care for TB patients called Directly Observed Treatment Short-course (DOTS). DOTS was found to be most effective by WHO after trials in many countries with high prevalence of TB, and now it is highly recommended by WHO to all countries as a profound TB control strategy. World Bank has also made an assessment of DOTS and hails it a health investment of the highest cost benefit. DOTS is to take advantage of the watchful eyes of a trustworthy bystander to closely observe the process, ascertain that the patient would take each and every dose of prescribed TB medications, and thus make sure the patient would get cured. It is hoped to be able to spot and identify 75% of all smear positive TB patients and cure 85% among them. For many years, both incidence and mortality rates of TB have stayed number ones among those of all notifiable communicable diseases in Taiwan. Taiwan health authority finally followed the WHO recommendation and launched a DOTS trial program in certain mountainous rural areas in 1997, and phased into a gradual expansion in 2001 in accordance with the execution of then TB Control Year campaign. In April 2006 after the last batch of counties and cities of Taiwan joined in, a brand new nationwide “DOTS program” was born, in which special case carers were officially hired, and hopefully we would reach the DOTS goals set by WHO in the foreseeable future. The purpose of this study was to find out the DOTS program’s cost-effectiveness in two consecutive years, i.e. one year (2005/4/1-2006/3/31) immediately prior to the launch of the new DOTS program, and the one (2006/4/1-2007/3/31) that followed, through the expenditures for the implementation of the DOTS program, indices of therapeutic effectiveness in the two years, and at various stages of its implementation and a cost-benefit analysis of the treatments involved. The figures used in this study were mainly obtained from a Taiwan CDC database for registration of TB case notifications. The individual notified cases studied took place either in. There were 5679 notified TB cases studied. Meanwhile, we also got access to a Department of Health database of death causes and the relevant medical expenditure records from Central Regional Branch, Bureau of National Health Insurance (NHI) for necessary data using the ID number of the patient involved. Our results indicate that during the specified two years, the age of new TB cases was still getting older, and more males turned out than females, but it seemed the program had but little influence on the therapeutic outcomes. Fore instance, the accumulated treatment success rate one year after the initiation of the new program turned out to be 97%, somewhat improved from the rate (92.3%) in the previous year of the launch of the new program. In the aspect of mortality, the total mortality of the four counties/cities in the central region of Taiwan that died of TB one year after the implementation of the new program was 20.4%, which is clearly lower than that (22.4%) in the previous year. This indicates that the region’s total mortality did drop considerably due to the enforcing of the DOTS program. Aside from that, about the qualifying rate expressed by successfully changing from smear-positive to smear-negative within three months, there were 91.0% of all cases being successful one year after the activation of the new program, which was, as a whole, better than the 84.2% showing just one year before. Also, among all individual cases that have participated in the DOTS program, the successful changing rates were all better when covered by formal DOTS 95.0%,DOTS program .Overall speaking, to promote DOTS intervening measures turned out to be with a certain degree of positive cost effectiveness. Comparing the accomplishments of the four counties/cities of the central region of Taiwan, we found that Changsha County ranked number one and its success made it a model for the other three to learn from. In the conclusion of this study, we recommend that as far as relevant policy of the central government is concerned, they should make use of the NHI payout channel to encourage all health institutions to strengthen their protocol of preliminary notification of TB cases based on smear test result and setting up effectual checking procedure to ascertain that patients take anti-TB drugs as instructed. The role of Taiwan CDC should be working along with local DOTS task forces to closely monitor the quality of the on-going program, adding a new screening program for elderly people over 65 to make the death causes record be more reliable, and establishing a practical guideline on the correct way of TB drug use and a training course for doctors and nurses in general and public health workers in particular. Finally for the local health units and medical institution, the DOTS tats force should record the daily visits of its hired careers to the patients and set up a patient-centered dialogue and accord nation channel pattern, reinforce the health educational measure on TB, actively discover early stage diagnosed cases, and enhance the obedience of the patient to take drug. In addition, for healthcare workers, they should actively participate in training courses related to TB and medical history review meetings in order to gather knowledge of new developments in the field to be able to provide the most complete and the up-to-date quality care to the patient. According to the strategy formulated by WHO, actively promoting DOTS strategy is by far the most effective method in history for fighting against TB. It’s definitely a necessity to relentlessly and virtuously integrate it into our existing TB control program. For the sake of protecting our people’s good health, we recommend that we shall from now on make this tactic a long-term commitment through actively implementing DOTS, make our best efforts to engage in the intervention program, and overcome the bottle necks in this control tasks.