Evaluation On Diagnosis And Treatment Services In5MDR-TB Designated Hospitals

Background:Multidrug-resistant tuberculosis (MDR-TB) is a severe life-threatening chronic infectious disease, which has the following characteristics of treatment including long time, complication, high cost, low cure rate, and higher mortality. The national tuberculosis drug resistance survey in2007-2008shows the MDRTB rate of the smear-positive pulmonary tuberculosis patients was8.32%; that of new S+TB patients and retreated S+TB patients was5.71%and25.64%respectively, all of which are higher than the global average.From January1,2006to August31,2009, a baseline survey was carried out by National Center for Tuberculosis Control and Prevention (NCTB) of China CDC in5designated hospitals. The results shows that there is no clear terms of reference and funding for the hospital with limited laboratory capacity. There’s no standard treatment for MDR-TB patients, and case management after hospitalization is poor. The overall medical cost is high to treat MDR-TB patients. To settle these problems, NCTB, China CDC has been taken a series of intervention measures such as financing, laboratory capacity building, PPM-DOTS in the5designated hospitals since March2010.Interventions have been carried out for more than one year in order to improve the work quality of MDR-TB diagnosis and treatment. It’s necessary to make a comparison study on medical services providing by the designated hospitals before and after interventions.Objective:Through a preliminary evaluation on standard MDR-TB diagnosis and treatment before and after MDR interventions in the designated hospitals, scientific evidences will be recommended to improve the quality of MDR-TB diagnosis and treatment. Methods:To select5MDR designated hospitals as research object to undertake interventions, and to make questionnaire survey and key persons’interviews to make clear MDR-TB medical service in designated hospitals after interventions; To collect MDR-TB hospitalized patients’files and make questionnaire investigation to know the treatment services they received in the designated hospitals after interventions, and make a comparison with the previous baseline survey.Results:1. Comparison of MDR-TB service before and after intervention in the designated hospitals1.1The policy environment, financial inputs and PPM-DOTSBefore interventions, these5hospitals have not yet carried out MDR-TB service. There’s no MDR-TB control policies, measures and financial inputs. After the interventions, they all developed free-service policy and PPM-DOTS policy on MDR-TB diagnosis, treatment and case management. In Tianjin, funding for diagnosis and case management is covered by local major special funds (1,050,000RMB). In Quzhou city Zhejiang Province, Puyang city Henan Province, and Daqing city Heilongjiang Province, funding for MDR-TB diagnosis, treatment and case management is covered by GF (12-27million RMB). In Chongqing Municipality, it’s free for MDR-TB diagnosis, OPD&hospitalization treatment is reimbursed from0to50%by medical insurance. The rest costs are paid by patients themselves. Before intervention implementation, there’s no clear responsibility arrangement between medical institutions and TB control services. After interventions, local governments makes everyone’s responsibility clear in different medical services in terms of MDR-TB diagnosis, treatment and case management, trained related staff and set up coordination mechanism.1.2Diagnosis and treatment capacity and infection controlBefore the interventions, only Tianjin CDC can diagnose MDR-TB patients through the drug susceptibility test (DST). After the interventions, all the5designated hospitals can take DST and diagnosis as per the test results, lab quality control is fully applied and MDR-TB OPD patients’number is increased stepwise.As for infection control, compared with pre-intervention time, self-protection awareness of not only medical doctors but also patients have been improved; medical institution environment and infrastructure have been perfected, it has obviously improved.2. Comparative analysis on MDR-TB diagnosis and treatment among different medical institutions.After the interventions,4,360active pulmonary tuberculosis cases were screened by the5designated hospitals, the sputum culture rate is100%, and drug sensitivity test rate is78.4%.119MDR-TB patients were detected, out of which59cases were treated (49.7%). The main reasons for the rest60untreated cases are:no follow-up visits for floating population (61.5%); died (25.0%); the rate for migrant workers without treatment is33.3%. In cities because of patients’death, the rate of non-receiving treatment is75%. In Chongqing Municipality, due to the low reimbursement ratio, the reject treatment rate is38.9%.2,490smear-positive pulmonary tuberculosis patients were screened, out of which46MDR-TB patients were diagnosed, and detection rate is2%.476retreatment smear positive pulmonary tuberculosis patients were screened, out of it,66MDR-TB patients were diagnosed, and detection rate is15.5%. Screened smear-negative pulmonary tuberculosis patients1,070patients, diagnosed patients with MDR-TB is7cases, multiple drug resistant rate is0.7%.Before the interventions, the standard regimen rate at beginning of treatment is3.7%, which is increased to100%after the interventions. Before the interventions, MDR-TB cases after hospitalization have never been referred to Tuberculosis Institutions; the referral rate reaches100%after the interventions.Before the interventions, the median hospitalization expenditure for a MDR-TB patient is11,752RMB, and the daily average median hospitalization is328.2RMB. After the interventions, it’s reduced to3704.6RMB and195RMB respectively. Before the interventions, self-paid proportion of patients’hospitalization expenditure is49.5%. After interventions, hospital-paid ratio dropped to25.2%. But in Chongqing Municipality, there was one MDR-TB patient paid100%hospitalization by him/herself.Conclusion:After the interventions, it improves multi-financing channels in these5cities, implements MDR-TB case management and sets up MDR-TB free-service policy. MDR-TB diagnosis, treatment and case management is funded by the GF, Major projects and local special funding. It alleviates patients’economical burden. But with the ending of international projects and Major projects, there will still be financial risks for sustainability.After the interventions, laboratory capability has been greatly improved in these5 designated hospitals. Anti-TB drug susceptibility test can be regularly done in these labs. The MDR-TB standardized treatment had been greatly improved, and the referral rate of MDR-TB patients after hospitalization has also been improved dramatically. MDR-TB patients’ hospitalization expenditure reduced substantially, and their self-paid costs are obviously decreased. Their economic burden has also been alleviated apparently. Up to now only half of MDR-TB patients received treatment, it’s necessary to have further discussion on how to make a strategy to improve MDR-TB patients’treatment proportion.After the interventions, in Wanzhou city of Chongqing Municipality the reimbursement proportion for OPD and hospitalization is increased to50%, yet it’s still a heavy burden for MDR-TB patients’. The rate for receiving MDR-TB treatment is only10%, the medical insurance reimbursement proportion needs to be further increased.