臺灣結核病照護政策之成效評估：以2008-2011全國免費抗結核二線藥管理控制為例

Abstract

研究目的 2006年衛生署疾病管制局委託衛生署胸腔病院執行「免費抗結核二線藥物管理及寄送計畫」，旨在以DOTS五大面向中「穩定供應有品質的藥品」進行結核防治策略介入。計畫已行之有年，政府耗費大量人力、物力及資金，卻未知計畫與國內結核病治療成效是否有關連性，因此以本研究進行驗證計畫執行成效。 方法 為求政策執行背景一致，收集2008年至2011年之計畫申請資料，將歷年案例分為MDR-TB組、一般抗藥非MDR-TB組及藥物副作用組，並登入結核病通報系統查詢治療結果。預期在全國免費抗結核二線藥物做為策略介入後，以描述性統計分析觀察四年內申請案例、性別及年齡等人口學變項比例，再以卡方檢定及羅吉斯回歸進行統計分析。 結果 經卡方檢定後得知年齡(P<0.0001)、性別(P=0.0003)及申請用藥原因(P=0.0009)等達到統計顯著；而申請用藥年度(P=0.26)及申請用藥區域(P=0.32)、有無跨縣市(P=0.23)等變項統計未達顯著。 再以羅吉斯回歸(logistic regression)分析後可知年齡、性別及用藥原因達統計顯著。年齡部分以65歲以上群組做為參考組，20歲以下完治率是5.27倍，21歲至34歲完治率是13.6倍，35歲至49歲完治率是3.78倍，50歲至64歲完治率是2.44倍，各分組整體完治率均優於65歲以上群組。 而性別部分以男性作為參考組時，女性完治率是1.48倍。申請用藥原因部分以藥物副作用組作為參考組，一般抗藥非MDR組的完治率是1.53倍，MDR完治率是0.96倍，一般抗藥非MDR組治療成效最佳。 結論 經由統計分析後得知，國內免費抗結二線藥的管理控制策略對於結核病防治是有所助益的。但仍然需注意的是，WHO多次呼籲DOTS策略應全面施行才容易達到成效，我國政府單位多年來投入大量人力物力與資金，本次研究中仍發現有部分案例只申請免費用藥而未加入DOTS，形同結核防治死角。因此如何徹底落實DOTS，讓DOTS全面覆蓋我國所有結核病人，才是未來防治的一大挑戰。

Research purpose In 2006, Taiwan Center for Disease Control commissioned Chest hospital, department of health to implement one of the TB control strategies: free second-line anti-tuberculosis drugs management and sending plan. The plan connects one of DOTS elements, uninterrupted supply of quality-assured drugs, which uses free drugs to be an intervention in Taiwan TB control policy. It has been executed in many years, the Government consumed lots of personnel, material and funds, but the relative between this plan and domestic TB treatment is still unknown. In this study, we will investigate the effectiveness of the plan. Method For the sake of consisting with the background of police implementation, data is collected from 2008 to 2011. In this study, cases are divided into three groups: MDR-TB, drug-resistant but not MDR-TB, and side-effects, and then logged in TB notification system to confirm all case information. When sending free second-line drugs as an anti-TB strategy intervention, descriptive statistical analysis and statistical software SAS 9.2 are used to observe demographic variables. In the last, chi-square test and logistic regression statistical analysis would be used to evaluate effectiveness. Result By the chi-square test, age (P <0.0001), gender (P = 0.0003) and apply medication reasons (P = 0.0009) are statistical significance; application medication annual (P = 0.26) and the application of medication area (P = 0.32), and whether the city and the county (P = 0.23) are not statistically significant. Then, logistic regression analysis revealed that age, sex and apply medication reasons of statistical significance when outcome is treatment complete. In age part, more than 65 years group as the reference, the odds ratio of below 20 years is 5.27(OR=5.27, 95%CI 0.69-40.43), 21years to 34years is 13.6(OR=13.6, 95%CI 4.26-43.36) ,35 years to 49 years is 3.78(OR=3.78, 95%CI 2.5-5.72), 50 years to 64years is 2.44(OR=2.44, 95%CI 1.88-3.18).The whole treatment complete is better than above 65 years group. In sex part, male as the reference group, treatment complete rate of female is 1.48(OR=1.48, 95%CI 1.17-1.87). In apply medication reasons part, side-effects as the reference, the odds ratio of MDR-TB is 0.96(OR=0.96, 95%CI 0.56-1.64); drug-resistant but not MDR is 1.53 (OR=1.53, 95%CI 1.16-2.01). The drug-resistant but not MDR group is better than others. Conclusions According to statistical analysis, it shows that the free second-line anti-tuberculosis drugs strategy is effective for TB control. WHO repeatedly appeals the DOTS strategy must be fully implemented to make achieve effectiveness. However, some cases only apply for free medication without adding DOTS in this study. Therefore, how to fully implement DOTS and DOTS comprehensive coverage of all TB patients in Taiwan, is a big challenge for future prevention.