計畫編號：DOH92-DC-1109

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1 DOH92-DC-1038 * *

2 , % CDC2001 1~12 18 logistic regression analysis - I

3 II

4 Abstract Tuberculosis is one of the important health issues in the world, and is the notifiable disease in Taiwan. Tuberculosis cases have been registered and followed up by center of disease control (CDC) each year. The effects of prevention for tuberculosis were satisfied. However, the death rate of 5.81 per hundred thousand population was still higher than the control standard rate defined by WHO that the tuberculosis death rate is less than 2 people per hundred thousand population. There were 14,486 confirmed diagnosis TB cases and the default rate was 5.16% in Incomplete treatment is the important factor that increases the difficulty of tuberculosis s prevention and treatment. This study would like to investigate the relative factors of failed treatment for TB patients. The database was derived from CDC nationwide dataset of TB patients that registered in CDC from January to December in This study would like to examine whether the patients were successfully treated after 18 months of registration and whether the patient had interrupted treatment more than two months during the treatment period. Proportional random sampling was applied to select TB patients. Structured questionnaire were used to interview TB patients by phone. Descriptive statistics described the patients characteristics and the related variables according to treatment status. Logistic regression analysis was conducted to analyze the associated factors that influenced the treatment outcome of TB patients. The results showed that the factors associated with interrupted treatments including lacking family support such as divorce or separation, taking medicine irregularly, having great impacts on life, being unfamiliar with the way of taking medicine, and feeling heavy burden of medical expenditure. The main problems for patients after taking medicine were drug s side effect and uncomfortable. Thus, the key factor causing to have interrupted treatments was highly related to III

81 per hundred thousand population was still higher than the control standard rate defined by WHO that the tuberculosis death rate is less than 2 people per hundred thousand population.

5 patients compliance behaviors. In addition, the factors associated with successful treatment were male, middle level education, and lower family income. Patients with these characteristics would have lower cure rates. When patients took medicine irregularly, had interrupted treatment, or lacked the awareness of TB, it would increase to have failed treatments. Based on the results, the study provides some recommendations to CDC decision makers as follows: (1) advocate the concept of going to the fixed hospitals/clinics for TB treatments; (2) encourage pharmaceutical factory to invent new TB medicine with lower side effect or shorter treatment course; (3) recommend the Bureau of National Health Insurance to modify the payment system for TB treatment; (4) reconfirm the TB dataset correctly. There are some recommendations to physicians as follows: (1) enhance the awareness of TB and treatment course to TB patients; (2) improve the communication with patients families and enhance family s support; (3) implement case management program for TB patients. The recommendations to public health nurses are the following: (1) increase the visits and give more concerns to TB patients; (2) enhance TB patients compliance. Key word: Tuberculosis, Interrupted treatment, Failed rate, Cure rate IV

When patients took medicine irregularly, had interrupted treatment, or lacked the awareness of TB, it would increase to have failed treatments.

6 V

7 VI

.. 47 3-7... 48 3-7... 49 3-8... 50 3-9... 51 3-9.

8 0.65% 0.06% 1.29% 0.11% ( 2001) WHO (Directly Observed Therapy, DOT)

9 mycobacterium tuberculosis INHRMPpyrazinamide(PZA, Z) ethambutol(emb, E) 0 0 (2HRZ/4HR) INH (>4%) EMB(2HRZE/4HRE) 90% 95% American Thoracic Society, 1986 AIDS HIV PZAHER 9 INH ERZ ER RMP HEZ 9-12 HE

10 American Thoracic Society, 1986; British Thoracic Society, 1990 (monotherapy) 1991 HRZ HR ( fixed - dose tablet) WHO (Directly Observed Therapy, DOT) WHO 2003 MDR-TB Pedro, 2002 MDR-TB 3

11 ( ) % %94.1% TB Center 4

12 16% 84% , % , % 12 ( 2003)

13 1, % 1, Karall, 1985Moridky et al., Orem, 1985 Addington,

14 Centers for Disease Control, Westaway, 1989Dunn et al., 1990 Lee et al., Daryl & Ralph, Campbell et al., Isoniazid Campbell et al., 1970 GOTGPTBilirubin CreatinineCBCPlatelet countpza Uric Acid EMB 1997 Mangtani % 12% Bhatti et al.,

15 Hudelson Centers for Disease Control, 1992 Directly Observed Therapy, DOT WHO HRZ HR ( fixed - dose tablet) 1996 WHO ,113 1,500 (Brewer et al., 1998) (Josephine, 8

fixed - dose tablet) 1996 WHO 1999 1,113

16 1994) fee for services disease management (Todd & Nash, 1996) Armstrong1996 Ellrodt (DRG) case management

17 11,

18 5 6 11

19 1 CDC2001 1~12 9, ,162 7,

20 3 1 content validity retest method Cronbach s α 10 Cronbach s α

21 WHO logistic regression analysis 14

22 1 / 15

23 2 / 16

24 a χ 2 χ 2 n=530 n=10,582 p-value n=320 n=1,133 p-value a a 17

25 % % 73.18% 13.65% 58.35% 61.53% 8.71% 50.19% 38.44% % 98.12% 6.82% 92.71% 5.06% % 39.53% 28.35% 3.76% % % % 19.69% 16.56% 7.41% 18

26 % 4.71% (27.5) 16.99% 39.41% 20.12% 52.82% 46.23% 28.68% 22.26% % 32.24% 34.31% 26.28% 18.25% 64.23% % 12% 7.76% 4.71%

27 % 33.18% 10.12% 58.47% % 10.71% 85.65% 14.35% 62.00% 6.94% 62.59% 9.18% 44.94% 18.35% 52.00% 17.29% 64.47% 34.12% 67.18% 28.82% % 2.12%

28 74.35% 74.05% 46.84% 2.56% 81.53% P< % 64.86% (21.88%) (8.30%) 3-2 P< % 29.73%30.63% 16.24%18.00% 3.11% 43.24%

29 P< % 8.93% 23.42% 8.80% % 3-4 P< % 1.49% P< % 15.09% 7.50% 59.06% 3-6 P< %30.00% 11.51%13.40% 22

30 4.91% 26.56% 37.19% % 10.75% 70.63%46.56% 60.75% 18.11% 28.44%25.94% 12.26%12.08% 3-8 P< %81.32% 66.25%74.38% 82.64% 79.69%

31 /

33 / Lee, /

35 % 4.51% 14.36% 9.84% /

37 % 13.40%

38 % % % WHO,

39 % 12% 3 32

41 ~

42 1. Addington WW. Patient compliance. Chest 1979; 76(6): American Thoracic Society. Treatment of tuberculosis and tuberculosis infection in adults and children. Am Rev Respir Dis 1986; 134: Armstrong EP, Langley PC. Disease management programs. American Journal of Health-System Pharmacy 1996; 53(1): Bhatti N, Law MR, Morris JK, Halliday R, Moore-Gillon J. Increasing incidence of tuberculosis in England and Walesa study of the likely causes. British Medical Journal 1995; 310: Brewer TF, Heymann SJ, Ettling M. An effectiveness and cost analysis of presumptive treatment for Mycobacterium tuberculosis. American journal of infection control 1998; 26(3): British Thoracic Society. Chemotherapy and management of tuberculosis in the United Kingdom: recommendations of the Joint Tuberculosis Committee of the British Thoracic Society. Thorax 1990; 45: Campbell AH, Guilfoyle P. Pulmonary tuberculosis, isoniazid and cancer. Brit J Dis Chest 1970; 64: Centers for Disease Control. National action plan to combat multi-drug resistant tuberculosis. Division of Tuberculosis Elimilation. CDC 1992; 19(1): Daryl M, Ralph H. Improving patient compliance. Medical Clinics of North American 1977; 61(4): Dunn SM, Beeney LJ, Hoskins PL, Turtle JR. Knowledge and attitude change as predictors of metabolic improvement in diabetes education. Social Science Medicine 1990; 31(10): Ellrodt M, Gray V, Cook J et al. Evidence-Based Disease Management. Journal of the American Medical Association 1997; 278(20):

43 12. Hudelson P. Gender differentials in tuberculosis the role of socio-economic and cultural factors. Tubercle and Lung Disease 1996; 77: Joint International Union Against Tuberculosis/World Health Organization Study GroupTuberculosis control. Technical Report Series 671. Geneve WHO Josephine G. Controlling Resurgent TuberculosisPublic Health Agencies, Public Policy, and Law. Journal of Health Politic, Policy and Law 1994; 19(1): Karall LP. A treatment for diabetes in Joslin s Diabetes Manual. 12 TH ed. Philadelphia: FleaLea Company 1985; Lee LT, Chen CJ, Tsai SF, Suo J, Chen CY. Morbidity and mortality trends of pulmonary tuberculosis in Taiwan. Journal of Formosan Medicine Association 1992; 91(9): Mangtani P, Jolley DJ, Watson JM, Rodrigues LC. Socioeconomic deprivation and notification rates for tuberculosis in London during British Medical Journal 1995; 310: Moridky DE, Malotte CK, Choi P. A patient education program to improve adherence rates with antituberculosis drug regimens. Health Education Quarterly 1990; 17: Orem DE. Nursing: Concept of practice. St Lousis: McGraw-Hill Pedro GS, Katherine F, Jaime P et al. Feasibility and cost-effectiveness of standardised second-line drug treatment for chronic tuberculosis patients: a national cohort study in Peru. The Lancet 2002; 359: Todd WE, Nash D. Disease Management: A System Approach to Improving Patient Outcomes. Chicago: American Hospital Publishing Inc Westaway MS. Knowledge, beliefs and feeling about tuberculosis. Health Education Research 1989; 4(2):

44 23. Global Tuberculosis control-surveillance, Planning, Fiancing.WHO report (1)

45 199817(4)

46 3-2 χ 2 n=850 % n=739 % n=111 % P-value ~ ~ ~ < / / / / // /// / a /

47 3-2 b χ 2 n=850 % n=739 % n=111 % P-value ( ) ( ) c Fisher's exact a. b. n=489; n=109c

48 3-3 χ 2 n=850 % n=739 % n=111 % P-value < < < < < ( )

49 3-3 n=850 % n=739 % n=111 % c ( ) ( ) a. b. c. d. e. f. 42

50 3-4 χ 2 n=850 % n=739 % n=111 % P-value < < < <

51 3-5 χ 2 n=850 % n=739 % n=111 % P-value < < <

52 3-5 χ 2 n=850 % n=739 % n=111 % P-value < < ( ) Fisher's exact 45

53 3-6 χ n=850 % n=530 % n=320 % < ~ ~ ~ / <0.01 / / / // /// / a P-value /

54 3-6 χ 2 n=850 % n=530 % n=320 % P-value b <0.01 ( ) ( ) c Fisher's exact a. b. n=489c. 47

55 3-7 χ 2 n=850 % n=530 % n=320 % P-value < < < < < ( )

56 3-7 n=850 % n=530 % n=320 % e ( ) f ( ) a. b. c... f. g. 49

57 3-8 χ 2 n=850 % n=530 % n=320 % P-value < < < < <

58 3-9 χ 2 n=850 % n=530 % n=320 % P-value < <

59 3-9 2 χ n=850 % n=530 % n=320 % P-value ( ) Fisher's exact 52

60 3-10 OR P / < < <

61 3-10 OR P < (n=111) (n=739) 54

62 3-11 OR P / / / // /// / ( ) <0.01 ( ) < <

63 3-11 OR P < < < < < (n=530) (n=320) 56

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防疫學苑系列 009

防疫學苑系列 009 第七章肺外結核結核病依據病灶部份可分為肺結核和肺外結核肺結核的病灶侵犯肺實質肺實質以外的病灶統稱為肺外結核肺外結核較難診斷, 一方面是較少見 ( 在台灣, 肺結核與肺外結核的比例是 9:1), 另一方面是疾病部位較難評估,