結核病地段個案管理人員及都治關懷員之個案管理負擔探討

Abstract

結核病（Tuberculosis，TB）為全球造成最多死亡數的第二大傳染病[1]，世界衛生組織（World Health Organization，WHO）建議各國推動直接觀察服藥（Directly Observed Treatment Short-course，DOTS）策略，確保非抗藥性的結核病至少持續服藥6個月的標準治療療程。在台灣，由衛生所護理人員擔任地段個案管理人員，縣市政府另遴聘DOTS關懷員，以病人為中心提供「送藥到手、服藥入口、吞完再走」的服務，以達到治療成功目標。此措施因治療時程長及逐案送藥的服務需要耗費相當人力，因此依台灣的結核病流行情形規劃適當的人力，對防治計畫的推行相當重要。 研究目的 為檢視目前結核病基層防治人力是否符合各地區流行現況的人力需求，本研究計畫瞭解台灣目前管理中的縣市結核病個案分佈，以及基層管理人員（地段個案管理人員及DOTS關懷員）的個案管理量與訪視負擔，並分析縣市人員個案管理量與結核病防治成效（治療成功率及發生率變動）的相關性。 方法 以疾病管制局系統登錄之結核病管理基層人員去識別後的編碼資料為分析對象，主要利用描述性統計計算2012年6月各縣市結核病管理個案數、地段個案管理人員及DOTS關懷員個案管理量，以迴歸分析人員訪視達成率及其影響因子；另並針對各縣市個案管理量與治療成功率及發生率變動之相關性進行檢定。 結果 2012年6月大部分縣市之現有地段個案管理人員數及所有縣市之DOTS關懷員人數均符合人員配置管理原則的最低需求，但其中台北市地段個案管理人員平均個案管理量及單一人員管理負擔明顯偏高。 2011年1月至2012年6月地段個案管理人員之個案訪視達成率與人口密度呈負相關，與老化指數呈正相關。DOTS關懷員的個案關懷率與人口密度呈負相關，與關懷個案數呈正相關，與病人不合作率呈負相關。 檢定結核病地段個案管理人力配置與結核病防治推動成效的關係，未發現縣市地段個案管理人員平均個案管理負擔與結核病治療成功率有明顯相關，亦未發現與結核病發生率或發生率變動有明顯相關。 結論 台灣結核病基層管理人員的個案管理量有縣市差異，各縣市地段個案管理人員平均管理個案數為1.0~35.0人不等，以台北市人員管理負擔最大，且人員數明顯不足；各縣市DOTS關懷員平均個案負擔為1.0~7.6人不等，屬合理範圍。 DOTS關懷員之關懷個案數高者關懷率亦較高，是否與關懷員年資經驗或給付制度有關，未來可另深入分析；地段管理個案數與訪視達成率未達統計顯著相關（P=0.08），但如以10%顯著水準為檢定標準則呈現負相關，仍值得注意。

Background: Tuberculosis (TB) is the second greatest infectious disease that caused the most deaths worldwide. World Health Organization (WHO) recommended the Directly Observed Treatment Short-course (DOTS) strategy to ensure the standard six-month treatment course for drug-sensitive TB disease. In Taiwan, local health center nurses, who serve as TB case managers, and treatment supporters retained by local governments, offer patient-centered service of directly observed treatments. This strategy facilitates success in TB treatments despite the long treatment course and considerable human resources. Therefore, appropriate manpower planning based on Taiwan’s TB epidemic is essential for TB control. Objectives: To clarify whether the current quantities of frontline staffs for TB control meets the needs of the endemic status in Taiwan, this research aims to analyze the geographical distribution of TB cases, case burden (i.e. the caseloads and case visits) on local managers and treatment supporters and their case visit achieving rate, as well as the correlation between caseloads and treatment success rates and incidences of TB. Methods: Study subjects were non-identifiable data of frontline personnel registered in TB case management system of Taiwan Centers for Disease Control. Descriptive statistics were adopted to analyze the caseload in each city and county, the quantities of local TB cases managers and treatment supporters and their case burden in June, 2012, while factors influencing the case visit achieving rates were on the basis of the linear regression analysis. The correlation between caseloads and treatment success rates of 2009 cohort of new TB cases and TB incidence variations from 2005 to 2010 by counties and cities were tested in addition. Results: The quantities of local TB cases managers and treatment supporters were in line with the minimal requirements of distributional principles in most counties and cities in June, 2012. Both individual and average caseloads on each local TB case manager were significantly higher in Taipei City. From January, 2011 to June, 2012, the case visit achieving rate of local TB cases managers was negatively correlated with population density, while was positively correlated with the aging index in the correspondent cities and counties. For DOTS treatment supporters, the higher case direct observation rate was associated with higher caseloads, lower population density and lower patient uncooperative rate. Test results showed no significant correlation between the average caseload of local TB case managers and TB treatment success rate, the TB incidence rate, and the incidence variation. Conclusion: This study demonstrated geographical differences in case burdens of frontline staff for TB control. The average caseload of local TB case managers in each cities and counties ranged from 1.0 to 35.0 in June 2012. The highest case burden and significantly inadequate manpower were found in Taipei City. The average caseload of DOTS treatment supporters had a reasonable, range from 1.0 to 7.6. Analysis revealed positive correlation between case direct observation rate and caseloads of DOTS treatment supporters. Further study may be required to see whether the reason was related to senior experience of treatment supporters or the payment institutions. The association between case visit achieving rate and caseloads of local TB case managers was not statistically significant (P=0.08), nevertheless, the negative correlation was still noteworthy as at 10% significance level.