| 【Objective】Through the analysis of the current status of the whole pathway of treatment for multidrug-resistant tuberculosis(MDR-TB)patients in Zhejiang Province and the factors influencing the regression,to understand the prevention and treatment of MDRTB in Zhejiang Province and provide a scientific basis for the prevention and treatment of MDR-TB in Zhejiang Province.【Methods】1.Data collection.Information on patients diagnosed and registered with MDRTB in Zhejiang Province from 2015-2019 was collected through the national TB information management system,including basic demographic information(gender,age,ethnicity,occupation,mobile population,household registration),time of diagnosis and registration,diagnostic area,testing method,program support and treatment classification.Through on-site investigation and collection of information about the consultation records of MDR-TB patients in Ningbo before diagnosis and information about the designated TB hospitals in Ningbo,including all medical institutions involved in the whole process of consultation and treatment,the level of medical institutions,the capacity of diagnosis and treatment of general TB,and the capacity of diagnosis and treatment of drug-resistant TB.2.The information of MDR-TB patients in Zhejiang Province was incorporated into the patient cascade model(PCM)to analyze the current status of the patient pathway,and the number of patients at each stage of the pathway was derived by combining the formula.3.A chi-square test was used to analyze whether the differences in patient characteristics were statistically significant at each post-diagnosis stage in the treatment pathway,and dichotomous logistic regression was used to analyze the factors affecting patient regression at each post-diagnosis stage in the pathway.The differences were considered statistically significant at P<0.05.4.Based on the information of MDR-TB patient visits and medical institutions in Ningbo,the patient pathway analysis(PPA)method was used to analyze the influence of health service provision on patient referral in the treatment pathway before diagnosis.【Results】1.The treatment pathway of MDR-TB patients was divided into seven consecutive stages based on the PCM model: onset of symptoms in the community,diagnosis of common TB,receipt of multidrug-resistant diagnosis,diagnosis of MDR-TB,receipt of MDR-TB treatment,adherence to treatment for 6 months,and successful treatment.The number of patients diagnosed with MDR-TB and subsequent stages in Zhejiang Province was collected from the national TB information management system,and the number of patients in each stage before diagnosis was estimated.The number of patients at each stage in the above treatment pathway was 6757,5952,2051,1846,1363,1137,and 1010,respectively.The number of successfully treated patients was only 14.95%of the number of patients presenting with symptoms in the community,and the patient loss rate was 85.05%.2.Factors affecting patient regression in the pathway phase after diagnosis of MDR-TB patients.(1)At the stage of whether patients received anti-tuberculosis treatment after diagnosis,a total of 1846 patients with multidrug-resistant tuberculosis were included.The age group over 60 years was more reluctant to receive treatment compared to the age group 20 years and younger(OR=0.295,95% CI=0.141-0.617,P=0.001);compared to workers,the service sector,the teachers and students groups were more willing to receive treatment compared to workers(OR = 2.344,95% CI = 1.26-4.357,P = 0.007 for services;OR = 7.843,95% CI = 2.082-29.535,P = 0.002 for teachers and students);patients with Zhejiang province domicile were more willing to receive treatment than patients with foreign domicile(OR = 0.224.95% CI = 0.123-0.41,P <0.001);patients’ willingness to receive treatment increased year by year compared with2015(OR = 2.028,95% CI = 1.463-2.812,P < 0.001 in 2017;OR = 7.057,95% CI =4.599-10.829,P < 0.001 in 2018 2019 OR= 10.824,95% CI=6.223-18.826,P < 0.001);compared with Hangzhou,patients in Ningbo,Wenzhou,and Jinhua were more reluctant to receive treatment,and patients in Lishui,Huzhou,and Shaoxing were more willing to receive treatment(Ningbo OR=0.551,95% CI=0.362-0.839,P = 0.006;Wenzhou OR=0.587,95%CI=0.383-0.901,P=0.015;Jinhua OR=0.514,95%CI=0.333-0.792,P =0.003;Lishui OR=4.034,95%CI=1.388-11.723,P =0.01;Huzhou OR=3.13,95% CI=1.288-7.607,P=0.012;Shaoxing OR=4.508,95% CI=1.816-11.187,P=0.001);patients using traditional drug sensitivity testing methods were less willing to receive treatment than those using molecular rapid testing methods(OR=0.576,95% CI=0.429-0.774,P < 0.001);patients with repeat treatment were more willing to receive treatment than patients with initial treatment(OR = 2.234,95% CI = 1.738-2.872,P < 0.001).(2)A total of 1363 patients with multidrug-resistant tuberculosis were included in the stage of whether patients adhered to treatment for 6 months after receiving antituberculosis treatment.The older patients were less likely to adhere to treatment compared to the age group under 20 years(OR=0.359,95% CI=0.138-0.93,P =0.035 for the age group 41-60 years;60 years age group above OR=0.185,95%CI=0.07-0.488,P =0.001);patients registered in 2016,2018 and 2019 were more adherent compared to2015(2016 OR=2.119,95%CI=1.314-3.418,P =0.002;2018 OR= 2.409,95% CI =1.501-3.865,P < 0.001;2019 OR = 2.496,95% CI = 1.497-4.162,P < 0.001);compared to Hangzhou,patients in the Wenzhou and Taizhou regions were less likely to adhere to treatment(Wenzhou OR = 0.581,95% CI = 0.361-0.936,P = 0.026;OR=0.502,95%CI=0.297-0.85,P =0.01);patients with program support were instead less adherent(OR=0.371,95% CI=0.179-0.772,P =0.008);and patients with repeat treatment were also less adherent compared to patients with primary treatment(OR=0.648,95% CI =0.465-0.901,P = 0.01).(3)In the phase of whether patients could be treated successfully after adherence to treatment,a total of 1137 patients with multidrug-resistant tuberculosis were included,and logistic regression analysis revealed that the factors affecting whether patients could be treated successfully were mainly age and occupation.Patients over 60 years of age were less likely to be treated successfully compared to the age group of 20 years and younger(OR=0.166,95% CI=0.033-0.833,P =0.029);patients in agriculture,livestock,and fisheries and services were more likely to be treated successfully compared to workers(agriculture,livestock,and fisheries OR=1.922,95% CI=1.108-3.335,P =0.02;Service sector OR=4.147,95% CI=1.392-12.36,P =0.011).3.In the treatment pathway of patients before diagnosis,a total of 241 cases of MDR-TB patients in Ningbo from 2015-2019 were included in the on-site survey.PPA analysis of patients’ demand for medical care and accessibility of health services revealed that in terms of accessibility of TB diagnosis,the most frequent medical institution for patients’ first visit after the onset of symptoms was a municipal medical institution,amounting to 40.25%,and 56% of patients failed to go to a designated hospital at the first visit,and the median time taken by patients from the first visit to diagnosis was 14 days,experiencing an average of 2 referrals.【Conclusion】1.Patients with multidrug-resistant tuberculosis in Zhejiang Province were lost at all stages of the treatment pathway to varying degrees,and the overall loss rate was high.2.The impact of various factors on patients at different stages of the treatment pathway after diagnosis varies,mainly age,occupation,household registration,time and place of diagnosis,testing method and treatment classification.3.TB diagnosis coverage,referral time and number of times in the treatment pathway before patient diagnosis were factors that influenced patient transfer,and there were differences between patient needs and consistency of TB diagnosis services. |
