| Objective(s):To assess the current status of delay in patients with rifampicin-resistant tuberculosis,describe the degree of delay and influencing factors,study the healthcare seeking behavior of patients with rifampicin-resistant tuberculosis,map out the patient’s healthcare seeking pathway,explore countermeasures for the prevention and treatment of patients with drug-resistant tuberculosis,and propose targeted interventions and recommendations to promote patients’ early treatment and improve adherenceMethods:1.Study on the delayed status of patients with rifampicin-resistant tuberculosis in Yunnan Province: 2189 cases of rifampicin-resistant tuberculosis patients in Yunnan Province from 2016-2021 were retrieved through the Tuberculosis Management Information System,and the general conditions of patients and the time when patients presented with symptoms,visited and confirmed the diagnosis were collected.Epi Data 3.1 was used to establish the database,and SPSS 20.0 was used for statistical analysis.Median(quartile)and composition ratio were used for statistical description;chi-square test and dichotomous logistic regression model were applied to explore the influence of different demographic and treatment characteristics on patient delay.The test level was α=0.05.2.Study on the pathway of patients with rifampicin-resistant tuberculosis:According to the number of previous rifampicin-resistant patients and epidemic situation in each state and city of Yunnan Province,seven eligible states and cities were selected: Kunming,Honghe,Lincang,Dali,Zhaotong,Qujing,and Chuxiong,and a survey was conducted to understand the patients’ pathways(first consultation institution,referral process,confirmation institution,treatment institution,etc.)through a self-administered questionnaire,and Excel was used to clean the data with reference to the pathway model method We used Excel to clean the data and refer to the pathway model method and the patient pathway analysis(PPA)method to depict the detailed pathways of patients’ visits and treatments in the pathway viewable way,and the viewable presentation was mainly based on Sankey diagrams and heat maps to display the pathway analysis of drug-resistant patients.Results:Study on the delayed status of patients with rifampicin-resistant tuberculosis in Yunnan Province:(1)basic patient profile: the final number of patients included in this study was 2189 cases.Patients were predominantly male,with 1585 cases,accounting for 72.41%;age group was predominantly 45 to 55 years old,with median and interquartile spacing of 50(37,60)years;ethnicity was predominantly Han,accounting for 65.50%(1434 cases);occupation was predominantly farmer,with1797 cases(82.09%);treatment type was predominantly retreatment patients,with1254 cases(57.29%);the first diagnosis unit was mainly at the state and municipal level in 1375 cases(62.81%).(2)Discovery delay: the median time interval change trend of patients’ discovery delay was rising and then decreasing.from 2016 to 2018,the median time interval of discovery increased from 50 days to 109 days,an increase of 1.18 times;then declined year by year since 2018,the median time interval of discovery decreased from 109 days to 42 days in 2021,a decrease of61.47%.Logistic regression analysis showed that the test method was drug sensitivity test(OR=5.193,95% CI: 3.750-7.193)and the first diagnostic facility was state municipal(OR=1.449.95% CI: 1.199-1.752)as risk factors for delayed detection in patients with rifampicin-resistant tuberculosis.(3)Treatment delay: 1488 patients were enrolled in treatment and the remaining 701 patients were not enrolled in treatment as of December 31,2021 and remained in treatment delay.The percentage of patients included in treatment came to show an upward trend,from 52.50% in 2017 to 71.20% in 2021,and the rate of patients included in treatment increased by 18.70%.the median time interval of treatment for 1488 drug-resistant patients included in treatment increased from 1 day in 2016 to 11 days in 2021,a 10-fold increase.Logistics regression analysis showed that male patients(OR=1.318,95% CI:1.070-1.624),25-35 years age group(OR=0.676,95% CI: 0.487-0.938),35-45 years age group(OR=0.686,95% CI: 0.493-0.953),45-55 years age group(OR=0.662,95%CI: 0.488-0.900),farmers(OR=1.328,95% CI: 1.029-1.712),and local patients(OR=4.006,95% CI: 3.212-4.996)had a higher probability of treatment delay.2.Study on the pathway of patients with rifampicin-resistant tuberculosis:(1)Basic patient profile: 237 patients were included,with median age and interquartile spacing of 46(36,58)years,predominantly male,predominantly Han,followed by Yi,with household registration type and current address type predominantly in the city of this state,81.86% and 88.61%,respectively,with primary and junior high school as the main education level The majority of the patients were married,the majority were farmers in terms of marital status,the majority were farmers in terms of occupation.(2)Diagnostic pathways: A total of 53 diagnostic pathways were finally summarized,with the largest number of patients diagnosed with rifampicin-resistant TB at county-level medical institutions,132 cases(55.70%);only one pathway(one case)was diagnosed at a county-level non-tuberculosis designated hospital,9 cases(6.82%)had been to village-level medical institutions,22 cases(16.67%)to township-level medical institutions,8 cases(6.06%)had been to state-and municipal-level medical institutions,and 87 cases(65.91%)had been to private institutions or non-designated medical institutions.Rifampicin-resistant TB was diagnosed in 101 cases(43.02%)at the state and municipal level medical institutions,only one patient was diagnosed at the state and municipal level non-tuberculosis designated hospital,4 cases(3.96%)had visited village level medical institutions,10 cases(9.90%)had visited township level medical institutions,54 cases(53.47%)had visited county level medical institutions,25 patients(24.75%)visited non-designated medical institutions;there were 4 pathways with the first diagnosis unit at the provincial level,and a total of 4patients were diagnosed with rifampicin-resistant tuberculosis at the designated hospital for drug-resistant tuberculosis at the provincial level,and the pathways were different for all 4 patients.(3)Treatment pathways: A total of 10 treatment pathways were summarized,among which the pathways and the number of patients who started receiving second-line anti-tuberculosis drug therapy at the state and municipal drug-resistant sentinel hospitals were the highest,with a total of 213 patients(89.87%),of whom 93.90% were diagnosed directly at the state and municipal drug-resistant sentinel hospitals and started receiving regular second-line anti-tuberculosis drug therapy;patients who started receiving second-line anti-tuberculosis drug therapy at the provincial drug-resistant sentinel hospitals Only24 patients(10.13%)were on the path of second-line anti-tuberculosis drug treatment,of which 19 patients(79.17%)were directly diagnosed and started to receive regular second-line anti-tuberculosis drug treatment at the provincial drug-resistant designated hospitals.Conclusion(s):1.Patients with rifampicin-resistant tuberculosis in Yunnan Province had substantially shorter detection delays and shorter treatment delays.2.Patients with drug susceptibility testing and first diagnostic medical institution at the state and city level were more likely to experience delay in detection.3.Males,>65 years,farmers,and local population are risk factors for delayed treatment.4.The diagnosis pathway and treatment pathway of rifampicin-resistant patients in Yunnan Province are simple,most patients can be diagnosed at county-level medical institutions and the vast majority are treated at state-and municipal-level medical institutions to achieve local access to care.5.The accessibility of health services for rifampicin-resistant tuberculosis in Yunnan Province can meet patients’ demand for medical care. |
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