Factors associated with catastrophic total costs due to tuberculosis under a designated hospital service model: a cross-sectional study in China
Factors associated with catastrophic total costs due to tuberculosis under a designated hospital service model: a cross-sectional study in China
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DOI：
10.1186/s12889-020-09136-z
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发表时间：
2020-06-26
影响因子：
4.5
通讯作者：
Bo, Dingyi
中科院分区：
文献类型：
--
作者：
Yang, Tianchi;Chen, Tong;Bo, Dingyi
背景2009年《执业医师法》颁布后，中国部分区县将当地综合性医院指定为结核病定点管理医院。据我们所知，在这种服务模式下，对结核病患者灾难性支付的研究有限，结论往往不一致。此外，中国尚未发表使用2018年世界卫生组织（世卫组织）更新的结核病灾难性总成本定义的研究。本研究采用世界卫生组织推荐的最新标准，分析指定医院模式下结核病家庭灾难性总成本的发生率，并探讨其影响因素。方法对宁波市所有10家定点医院进行横断面分析。于2018年9月至2018年10月招募经结核分枝杆菌痰培养确诊的符合条件的肺结核病例进行调查。我们使用结核病治疗总费用超过家庭结核病前年收入的20%来评估灾难性总费用。在改变阈值的同时进行敏感性分析。最小绝对收缩和选择算子（LASSO）回归应用于选择变量，并使用多元逻辑回归分析来确定灾难总成本的决定因素。结果共纳入672例患者，中位年龄41岁。调查家庭的灾难性总成本率为37.1%，受MDR影响的家庭的灾难性总成本率为69.6%。医疗费用占总费用的60%以上。住院率为57.7%。无合并症、无严重药物不良反应、利福平敏感结核病患者住院率分别为53.9%、54.9%和55.3%。贫困户患者住院率最高（Q1:54.8%, Q2:61.4%, q2:52.2%, q2:49.5%, q2:69.7%， P=0.011），严重药物不良反应发生率最高（Q1:29.6%, Q2:19.6%, q2:28.0%, q2:33.7%, q2:35.3%， P=0.034）。老年人、最低生活保障、病前或病后失业、经济状况差、在城外就医、住院、缺乏当地基本医疗保险和多药耐药等因素与灾难性成本呈正相关。结论宁波市有相当比例的肺结核患者和家庭面临灾难性经济风险。现有的政策侧重于扩大基本医疗保险和经济保护措施的覆盖范围（例如现金转移，以补偿低收入家庭的直接非医疗费用和收入损失），这可能是不够的。量身定制的方案，减轻不适当的医疗保健和解决公平的医疗服务是值得关注的。
BackgroundCertain districts and counties in China designated local general hospital as the designated hospital for tuberculosis (TB) management after the promulgation of the Law of Practicing Physicians in 2009. To our knowledge, there is limited research on catastrophic payments of TB patients under this service model, often with inconsistent conclusions. In addition, there has been no published studies from China using the updated 2018 World Health Organization (WHO) definition of catastrophic total costs due to TB. This study used the latest criterion recommended by the WHO to analyze the incidence of catastrophic total costs for households affected by TB under the designated hospital model and explore its influencing factors.MethodsA cross-sectional analysis was carried out in all ten designated hospitals in Ningbo, China. Eligible pulmonary TB cases confirmed by sputum culture of Mycobacterium tuberculosis were recruited and surveyed from September 2018 to October 2018. We evaluated catastrophic total costs using total costs for TB treatment exceeding 20% of the household's annual pre-TB income. A sensitivity analysis was performed while varying the thresholds. The least absolute shrinkage and selection operator (LASSO) regression were applied to select variables, and multiple logistic regression analysis were used to identify the determinants of catastrophic total costs.ResultsA total of 672 patients were included, with a median age of 41years old. The rate of catastrophic total costs of surveyed households was 37.1%, and that of households affected by MDR was 69.6%. Medical cost accounted for more than 60% of the total cost. 57.7% cases were hospitalized. The hospitalization rates of patients with no comorbidities, no severe adverse drug reactions, and rifampin-sensitive TB were 53.9, 54.9, and 55.3%, respectively. Patients in the poorest households had the highest hospitalization rates (Q1:54.8%, Q2:61.4%, Q3:52.2%, Q4:49.5%, Q5:69.7%, P=0.011) and the highest incidence of severe adverse drug reactions (Q1:29.6%, Q2:19.6%, Q3:28.0%, Q4:33.7%, Q5:35.3%, P=0.034). Factors such as elderly, minimum living security, unemployed before or after illness, poor economic status, seeking medical care outside the city, hospitalization, absence of local basic medical insurance coverage and MDR were positively associated with catastrophic costs.ConclusionSubstantial proportions of patients and households affected by pulmonary TB faced catastrophic economic risks in Ningbo, China. The existing policies that focus on expanding the coverage of basic medical insurance and economic protection measures (such as cash transfers to compensate low-income households for direct non-medical costs and income loss) might be insufficient. Tailored program that mitigate inappropriate healthcare and address equity of care delivery are worthy of attention.