| Backgroud:As the neglect of policy in many areas of the world 20 years ago, tuberculosis(TB) prevention and control system has been damaged or even vanished; due to AIDS epidemic, TB and HIV dual infections increase dramatically; tubercle bacillus drug resistance, particularly the rapid growth and epidemic of multi-drug resistant tubercle bacillus; rapid population growth in developing countries, the epidemic spreads from the high-incidence areas to the low-incidence areas, leading to tuberculosis resurgence all over the world. Tuberculosis has been resurgent since the mid 1980s, as in the United States, representative of the developed countries, the epidemic which gets better control has stopped declining and even picked up, in many developing countries, the epidemic of tuberculosis which undering control has aggravated or again ,out of control. In view of the serious situation of global tuberculosis epidemic, the World Health Organization announced that tuberculosis was in global emergency state in April 1993. TB epidemic also causes serious concern in most countries around the world, many countries has re-revised and improved their national TB control programs. In some countries, including China, TB control has made great progress in recent years. In order to continuously consolidate and improve the hard-won achievements for tuberculosis control, timely detect problems existed in the tuberculosis prevention and control practice, sum up experiences and lessons, and improve the overall implementation of the tuberculosis control program, timely synthetical evaluation for tuberculosis control effects is needed. In other countries, some organizations or countries have engaged in a number of research concerning the synthetical evaluation for TB control results, such as TSRU (The International Tuberculosis Surveillance Research Unit), LTSC (The International Tuberculosis Surveillance Centre) and Japan, significant breakthroughs and contributions in effective evaluation index have been made . However, once put the index into effect, which has been generally accepted by significant value today, there still exists quite a few problems, making it difficult to promote and apply the use of the synthetical evaluation work. At present, few research in this area is carried out by chinese scholars. Moreover, instead of simultaneously carrying out a synthetical and systematic evaluation on TB control project, which is an organic system involved in multiple aspects, most of the evaluations assess the quality of work unilaterally, failing to reflect the overall perspective of TB control effects. Therefore, it can be concluded that up to now, the synthetical evaluation for TB prevention and control effects is still under exploration and need to be improved. Literatures with respect to the synthetical evaluation for TB control effects are rare, to this day, no precedent which is generally accepted and followed indeed can be found, which is a vacancy of synthetical evaluation in the medical field. Nevertheless, it also provides researchers engaged in TB control a new topic which is of broad prospect as well as exploration full of the unknown.Aims:To explore a synthetical evaluation system for TB control effects for the purpose of evaluating tuberculosis control effect in the TB prevention and control institutions at all levels objectively, comprehensively and scientifically and providing evidences for decision maker in policy making and taking measures to make the implementation of tuberculosis control program even better.(1) To establish synthetical evaluation index system for TB control, by which tuberculosis control are evaluated comprehensively and objectively and achievements and problems in the tuberculosis control work are summarized timely.(2) To explore an appropriate mathematical statistics method for synthetical evaluation of the TB control effects, by witch synthetical evaluation of the TB control can be comprehensive, operable, reasonable and acceptable.(3) To combine the synthetical evaluation index system for TB control and SAS procedure, then puting them in the use of synthetical evaluation for the tuberculosis control and testing the applicability, feasibility and operability.Methods:(l)Introduce literature research and brainstorming to establish the item pool for the synthetical evaluation index of TB control effects.(2)Introduce the Delphi method to establish the synthetical evaluation index system for TB control effects.(3) Combine "Technique for Order Preference by Similarity to Ideal Solution" (TOPSIS) with "Rank-Sum Ratio" (RSR) as the mathematical statistics method for synthetically evaluating TB control effects.(4)Program the SAS computer code for the combination of TOPSIS and RSR mathematical statistics method used in synthetical evaluation.(5)Put the synthetical evaluation system for TB control effects into practice, synthetically evaluate the TB control effects among 14 TB agencies in prefecture-level city by making a horizontal comparison in Guangxi in 2005, synthetically evaluate the TB control effects in BaiSe city by making a vertical comparison from 2005 to 2010.RESULTS:1. The establishment of the synthetical evaluation index system for TB control effects(1) The item pool for the synthetical evaluation index system of TB control effectsThrough the introduce of brainstorming to the TB prevention and control professionals and health administrators at the provincial, city and county levels,9 classes 38 evaluation index were collected. Through the widely literature researching with respect to TB control, monitor and evaluation, effect assessment, project implementation and other aspects,10 classes 62 evaluation index were obtained.10 classes 67 evaluation index were ultimately included through both classifying and merging the evaluation index acquired from brainstorming and the literature researching, formed the item pool for the synthetical evaluation index system of TB control effects. The 10 classes of the item pool included:government commitment, case detection, management of patient treatment, tuberculosis laboratory test, tuberculosis information management, anti-TB drug supply and management, health promotion, training, supervision and epidemic.(2) The Delphi consulting results in first round:①Expert active coefficient: a total of 40 consultative questionnaires were sent in this round,40 valid questionnaires were returned, with a recovery rate of 100%, in other word, the exper active coefficient was 100%.②Expert authority extent:the mean authority coefficient of 67 evaluation index ranged from 0.631 to 0.846 among 40 experts in the current round of survey, and the mean authority coefficient of all evaluation index was 0.745.③Concentration extent of expert advice: the importance score of the 67 evaluation index averaged from 1.675 to 4.550 among 40 experts in the current round of consultancy,18 index with a mean importance score>4, full-score rate ranged from 0% to 57.5%,19 index with a full-score rate>20%, including 18 index with a mean importance score>4.④Coordination extent of expert advice: the overall coordination coefficient of the importance score for the evaluation index was 0.528 among 40 experts in the current round of consultancy, by chi-square test,χ2= 1393.000, P=0.000, so it could be considered that the experts advice reached an accordance, the coefficient of variation of the 67 evaluation index among experts ranged from 0.111 to 0.392.(3) The Delphi consulting results in second round:①Expert active coefficient:a total of 40 consultative questionnaires were sent in this round,39 valid questionnaires were returned, with a recovery rate of 97.5%, in other word,the expert active coefficient was 97.5%.②Expert authority extent:the mean authority coefficient of every evaluation index ranged from 0.800 to 0.863 among 39 experts in the current round of survey, and the mean authority coefficient of all evaluation index was 0.835.③Concentration extent of expert advice:the importance score of the 18 evaluation index averaged from 3.615 to 4.692 among 39 experts in the current round of consultancy, full-score rate ranged from 12.8% to 69.2%,11 index with a full-score rate>20%, including 8 evaluation index with a mean importance score>4.④Coordination extent of expert advice: the overall coordination coefficient of the importance score for the evaluation index was 0.220 among 39 experts in the current round of consultancy, by chi-square test,χ2= 145.840, P=0.000, so it could be considered that the experts advice reached an accordance. The coefficient of variation of the 18 evaluation index among experts ranged from 0.100 to 0.235.(4) Establishment of the synthetical evaluation index system: According to the results from two rounds of Delphi expert consultation, and combined the operational practice in evaluating the TB control effects, researcher decided to select the evaluation index with the importance score>4 in both two rounds of consultation, as well as index that are easy to get access in the TB practical work, to compose the synthetical evaluation index system of TB control effects.These evaluation indexes included:the funding rate that the government committed to place, the staffing rate, the task completion rate of newly found smear- positive pulmonary TB patients, the overall arrival rate, the cure rate, the complete treatment rate of the new smear-negative patients, the passing rate of sputum smear, the completion rate of supervision.2. Combination of the TOPSIS and RSR as the mathematical statistics method for synthetically evaluating TB control effects, and program SAS computer code for the whole calculative process.(1) TOPSIS had no special requirements on the samples, It could took adequate use of the information and obtained quantified,accurate as well as intuitive results, and less information were loss by using raw data directly to operate, resulting in accurate gap reflection among various evaluation project. RSR was applied to sub-file the rank results acquired from TOPSIS, extended TOPSIS and made up for the deficiency of TOPSIS. Meanwhile, TOPSIS also played a complementary role in overcoming RSR's defect, which loss of information might occur due to the non-parametric conversion.(2) Detailed explanatory notes were attached following the vast majority of SAS program statement, making it better readable. In the synthetical evaluation for multi-object and multi-index, there's no need to establish SAS data set, the rank and sub-file results of synthetical evaluation could be achieved in two steps after changing the numbers of evaluative object and index according to the actual situation, and inputting the data with the same trend. 3. The preliminary application research of synthetical evaluation for TB control effects(1)Horizontal comparison: synthetical evaluation for TB control effects among 14 TB agencies of prefecture-level city in Guangxi,2005.The synthetical evaluation results of TB control effects among 14 TB agencies of prefecture-level city in Guangxi,2005, by the order of good to bad, were as follows:Nanning, Guigang, Laibin, Beihai, Qinzhou. Among which Nanning and Guigang were in the"good" grade, Guilin, Chongzuo, Liuzhou, Hezhou, Yulin, Hechi, Wuzhou, Baise and Fangchenggang were in the "middle" grade, Laibin, Beihai and Qinzhou were in the "bad" grade. And the analysis of variance was taken to test whether the differences among each grade were statistically significant, F=91.35, P=0.000, a statistically significant difference in overall was found among the three grades. Pairwise comparisons were made in each grade, and statistically significant difference was observed in any two grades.The TB control effects in the "Good" grade group were better than those in the "middle" grade group, The TB control effects in the "middle" grade group were better than those in the "bad" grade group.(2) Vertical comparison: synthetical evaluation for TB control effects in Baise City from 2005 to 2010.The synthetical evaluation results of TB control effects in Baise City from 2005 to 2010, by the order of good to bad, were as follows: 2010,2009,2008,2007,2006, 2005. Among which 2010 and 2009 were in the "good" grade,2008,2007,2006, 2005 were in the "middle" grade. And the two-sample t test was taken to test whether the differences between the two grades were statistically significant, t= 3.020, P =0.000, a statistically significant difference was obtained between the two grades. The synthetical evaluation of TB control effects in the "Good" grade group was better than those in the "middle" grade group. Conclusions:(1) A more objective and synthetical evaluation index system of TB control effects could be established by applying the Delphi.(2) Combination of TOPSIS and RSR for the synthetical evaluation of TB control effects could not only sort the evaluative object, but also sub-file the sorting results, resulting in improving the efficiency of statistical analysis, and making the synthetical evaluation results of TB control effects even more accuracy, objectivity and practicality.(3)The synthetical evaluation of SAS program sorting and sub-filing has universal, efficient and practical advantages, which can greatly simplify the computing process and improve the calculation accuracy.(4) The availability of the resources and the operational effectiveness of synthetical evaluation for TB control effects, making the effect of synthetical evaluation in TB control feasible in TB prevention and control practical work. In practice, the result of sorting and grading results of synthetical evaluation for TB control effects are consistent with the reality basically and are instructive in the comprehensive and balanced development of tuberculosis control.
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