Why are clinicians reluctant to treat smear-negative tuberculosis? An inquiry about treatment thresholds in Rwanda
Why are clinicians reluctant to treat smear-negative tuberculosis? An inquiry about treatment thresholds in Rwanda
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DOI：
10.1177/0272989x06297104
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发表时间：
2007-01-01
影响因子：
3.6
通讯作者：
Van den Ende, Jef
中科院分区：
文献类型：
--
作者：
Basinga, Paulin;Moreira, Juan;Van den Ende, Jef
目的.结核病的诊断在临床医生和公共卫生官员之间仍然存在争议。公共卫生官员害怕治疗太多的病人;临床医生担心真正的病人会得不到治疗。我们想知道，对治疗阈值的分析是否有助于使治疗涂阴病例的直觉决定更具证据基础。方法. 18名临床医生和10名公共卫生专家被要求直观地估计他们对结核病的治疗阈值和这个阈值的关键决定因素：由于疾病和治疗以及后者的风险和成本导致的死亡率和发病率的幅度和主观权重。根据这些因素，作者计算出治疗阈值，并将其与受访者的直观阈值进行比较。根据文献资料计算处方阈值，忽略成本和主观因素。结果总体直观治疗阈值的中位数为52.5%，计算值为11.9%，处方值为2.7%。对于2个因素，公共卫生官员提供的值显着低于临床医生：治疗费用（中位数= 20美元v.300美元; U = 2.5; P = 0.0002）;生命成本（中位数= 500美元v.5000美元; U = 17.5; P = 0.009）。结论这些结果表明，临床医生和公共卫生官员估计错误的阈值，即使使用自己的主观估计的影响因素。如果忽略治疗费用和对引起的伤害的主观权重，则阈值可能会非常低。在阈值原则方面进行良好的培训，并提供正确评估数据的工具，可能有助于发展中国家在结核病方面做出更好的决策。
Purpose. The diagnosis of tuberculosis remains controversial between clinicians and public health officers. Public health officials fear to treat too many patients; clinicians fear that truly diseased will be denied treatment. We wondered whether an analysis of the treatment threshold could help making the often intuitive decision to treat smear-negative cases more evidence based. Methods. Eighteen clinicians and 10 public health specialists were asked for an intuitive estimate of their treatment threshold for tuberculosis and of key determinant factors for this threshold: the magnitude and subjective weight of mortality and morbidity due to both the disease and the treatment and risk and cost of the latter. With these factors, the authors calculated treatment thresholds and compared them to the intuitive thresholds of the interviewees. A prescriptive threshold was calculated based on literature data, omitting cost and subjective factors. Results. The median overall intuitive treatment threshold was 52.5%, the calculated 11.9%, and the prescriptive 2.7%. For 2 factors, public health officers provided significantly lower values than clinicians: cost Of treatment (median = $20 v. $300; U = 2.5; P = 0,0002); cost of life (median = $500 v. $5000; U = 17.5; P = 0.009). Conclusion. These results suggest that clinicians and public health officers estimate wrongly the threshold even when using their own subjective estimate of influencing factors. Omitting treatment cost and subjective weight of provoked harm can result in a very low threshold. Sound training in threshold principles and providing tools to correctly assess data might help in making better decisions in tuberculosis in developing countries.