Evaluation Of Multi-drug Resistant Tuberculosis Medical Service After Comprehensive Intervention

Background Multidrug-resistant TB (MDR-TB) is caused by bacteria that are resistant to at least isoniazid and rifampicin, the most effective anti-TB drugs. China is one of the22high tuberculosis burden countries, as well as the member of the27high MDR-TB burden countries. China is facing great challenge on MDR-TB control because of low case finding, diagnosis and treatment delay, poor treatment adherence, high economical burden and other problems. Chinese national TB control center and Bill and Melinda Gates Foundation is piloting a comprehensive intervention in four cities to improve the effects of MDR-TB control. The main contents of the intervention include:using Genetest to fast the MDR-TB patient detection; strengthening the cooperation between designated hospital and TB control department to improve the treatment; using standard treatment protocol to improve the treatment results. The intervention for improving medical service is very important.ObjectiveThe study will evaluate the multi-drug resistant tuberculosis medical services after comprehensive intervention. There will be three parts:case finding, treatment and management and economic burden of disease. The study will also explore the influential factors. There will be some advice to improve the MDR-TB control. MethodsThe study selected Kaifeng of Henan province, Lianyungang of Shandong province, Yongchuan District of Chongqing City and Hohhot of Inner Mongolia as the project cites based on the MDR-TB baseline survey data, tuberculosis control levels and socio-economic conditions.The routine records for suspect MDR-TB patients screening and MDR-TB patients treatment and management was collected and cleared up in the one year running of the program. The case finding, treatment and management will evaluate based on these data. The basic information and hospitalization of MDR-TB patients who treated in standard package was collected using structure questionnaires. These data will be used to evaluate the economic burden of disease. Also, we interviewed the key figure of the TB control departments and the municipal spcialist hospitals, the country doctors who managed patients.Quantitative data, such as the routine monitoring data were managed in Excel, using SPSS18.0for descriptive statistics and statistical inference. The transcripts of interviews data will translate into Word format, using Nvivo7software to analysis.Results1. Case finding of multidrug-resistant tuberculosis patients The screening rate in the four sites was83.98%, the rate in Kaifeng, Lianyungang, Yongchuan District were all more than90.00%. The detection rate with rapid test was6.22%, but in Hohhot the rate was only of2.95%. MDR-TB patients who came from CDC were discovered in7days, time for sputum transport, rapid test and information fed-back is2,5and0; the discovery time for MDR-TB patients coming from hospital is6.2. Management of multidrug-resistant tuberculosis patients In generally,70.78%multi-drug resistant tuberculosis patients detected by fast diagnosis participated in our project. The MDR-TB patients had a higher participate rate(76.16%) than rifampicin resistant tuberculosis patients(62.50%). The patients who had annual family income between5000-10000yuan were more likely to participate in the project.The treatment delay for172MDR-TB patients was5days.49.42%of them started their treatment in4days. Health system delay and patients delay were0days and7days.The treatment adherence declined from0.934to0.787in six months. Most patients (14) dropped out the treatment in the first two months, the default number will increase gradually after short time drop when treatment goes to the fifth month.32.26%(10/31) of the patients who dropped out the project because of side effect; and19.35%(6/31) patients died in six months treatment;9.68%(3/31) of the patients dropped out due to the economic difficulty.3. The economic burden of diseaseThe hospitalization expense after using the standard sevice package were3819.49Yuan/time and97.84Yuan/day/time, account for52.51%and44.23%of the hospitalization expense before the intervention. The drug component declined from59.93%to26.59%, at the same time, the examinations component increased from8.44%to25.62%. The register type, hospital beds and hospital days were the influence factors.The total cost of the whole treatment course was23,430.82Yuan, while the direct medical costs was15,166.68Yuan, the direct non-medical expenses was6056.00Yuan, and the indirect cost of437.00Yuan. The total cost of the whole treatment course account for65.58%of2years household income.84.90%of MDR-TB patients had a catastrophic medical expenses due to treatment of tuberculosis. According to the compensation plan, the whole course of the total cost was7659.14Yuan after compensation, reduced by67.31%. The direct medical costs was1560.08Yuan, reduced by89.71%. If there were no project compensation in follow-up and injection period, the whole course of the total cost would be7659.14Yuan, reduced by54.08%; while the direct medical costs was3360.08Yuan, reduced by77.85%. According to the compensation plan,65.75%of MDR-TB patients had a catastrophic medical expenses due to treatment of tuberculosis, reduced by18%. If there were no project compensation in follow-up and injection period,82.19%of MDR-TB patients had a catastrophic medical expenses due to treatment of tuberculosis.Conclusion and suggestionsThe comprehensive intervention strengthened the medical service of MDT-TB, especially in case finding, treatment and economic burden. However, we also faced some other difficulties in the project, such as that the patients still did not get good treatment adherence.Following are some suggestions:1. The case finding strategy that screening all the smear positive TB patients with rapid test can be replicated elsewhere.2. Standardized treatment and individualized treatment plan could be used in combination. Ensure the quality of fixed-point drug supply and reduce the occurrence of adverse reactions. Strengthen the training of the supervisor to discover and deal with adverse reactions timely.3. Improve the cooperation between the designated hospitals and CDC. Smoothly and timely communication between the partners need to be guaranteed.4. The sustainable finance mechanism need to be established. When the project finished in the sites, the finance mechanism, compensate pattern should continue to perform.