安徽省县级涂阴肺结核患者诊断质量抽样调查结果及影响因素分析

目的 了解县级结核病定点医院涂阴肺结核患者诊断现况及影响因素。方法 根据地域分布,采用方便抽样方法,分别抽取安徽省皖南、皖中和皖北各2个县级结核病定点医院(潜山市、望江县、霍邱县、舒城县、太和县和临泉县)。组建省级复核小组,现场复核6个县级结核病定点医院2019年4—5月份登记报告的涂阴肺结核患者病案资料、胸部CT和实验室检查结果等,评价诊断结果一致性,分析影响诊断一致性的因素。计数资料组间比较采用χ²检验,以P<0.05为差异有统计学意义。结果 现场复核患者280例,诊断一致237例,一致率84.64%。81例(28.93%)患者开展了分子生物学检测。单因素分析显示,痰标本质量合格、初治、胸膜有病变、PPD试验阳性、γ-干扰素释放试验阳性及经涂阴诊断小组讨论的患者诊断一致率分别为92.31%(72/78)、87.40%(215/246)、93.10%(81/87)、91.46%(75/82)、100.00%(46/46)、93.59%(73/78),明显高于痰标本质量不合格81.68%(165/202)]、复治64.70%(22/34)]、胸膜无病变80.83%(156/193)]、PPD试验阴性70.83%(17/24)]、γ-干扰素释放试验阴性81.82%(9/11)]及未经涂阴诊断小组讨论81.19%(164/202)]的患者,差异均有统计学意义(χ²值分别为4.887、11.834、6.951、6.685、9.987、6.658,P值均<0.05)。多因素逐步logistic回归分析显示,痰标本不合格(OR=2.944,95%CI:1.130~7.672,P=0.027)、复治(OR=2.465,95%CI:0.916~6.633,P=0.074)、无胸膜病变(OR=2.255,95%CI:0.924~5.499,P=0.074)、未经诊断小组讨论(OR=2.244,95%CI:0.795~6.336,P=0.127)是影响诊断结果一致性的危险因素。结论 县级涂阴肺结核诊断与省级复核结果一致性不高,痰标本质量、初复治、胸膜病变、PPD试验、诊断小组讨论是影响诊断结果一致性的主要因素。患者分子生物学检查比例较低。

Analysis of diagnostic quality sampling survey results and influencing factors of smear negative pulmonary tuberculosis patients in hospitals at county level in Anhui province

Objective To understand the diagnosis status and influencing factors of smear negative pulmonary tuberculosis (PTB) in tuberculosis-designated hospitals at county level. Methods Convenient sampling method was used to select tuberculosis-designated hospitals at county level in Anhui province. A total of 6 counties (Qianshan city, Wangjiang county, Huoqiu county, Shucheng county, Taihe county and Linquan county) were selected (two counties in southern Anhui, central Anhui and northern Anhui respectively). Medical records, thoracic computed tomographic imaging and results of laboratory test of all smear negative PTB patients in the designated hospitals reported between 01 April and 31 May 2019 were retrospectively reviewed by an independent review board consisting of experts from provincial hospital. The consistency of diagnosis results was evaluated and the factors affecting the consistency of diagnosis were analyzed. Chi-square test was used to compare the categorical data, P<0.05 for the difference was statistically significant. Results A total of 280 patients were reviewed and the diagnoses of 237 cases (84.64%) were consistent with original diagnosis. Eight-one cases (28.93%) received biomolecular test. Univariate analysis showed that the diagnostic consistency rates of patients with qualified sputum specimens (92.31%, 72/78), initial treatment (87.40%, 215/246), pleural lesions (93.10%, 81/87), positive PPD (91.46%, 75/82), positive γ-interferon release test (100.00%, 46/46), and with local smear negative diagnosis team discussion (93.59%, 73/78) were significant high than those of the patients with unqualified sputum specimens (81.68%, 165/202), retreatment (64.70%, 22/34), without pleural lesions (80.83%, 156/193), negative PPD (70.83%, 17/24), negative γ-interferon release test (81.82%, 9/11) and without the smear negative diagnosis team discussion (81.19%,164/202), and χ² values were 4.887, 11.834, 6.951, 6.685, 9.987 and 6.658 respectively, and P values were all less than 0.05. Multivariate stepwise logistic regression analysis showed that the qualified sputum specimen (vs. unqualified, OR=2.944, 95%CI: 1.130-7.672, P=0.027), initial treatment (vs. retreatment, OR=2.465, 95%CI: 0.916-6.633, P=0.074), with pleural lesions (vs. without pleural lesions, OR=2.255, 95%CI: 0.924-5.499, P=0.074), PPD negative (vs. positive, OR=0.189, 95%CI: 0.052-0.692, P=0.012), with local diagnostic team discussion (without discussion, OR=2.244, 95%CI: 0.795-6.336, P=0.127) were the factors for the diagnosis consistency. Conclusion Diagnostic consistency for smear negative PTB between hospitals at county-level and provincial independent review board is not high, and the quality of sputum specimens, initial treatment, pleural lesions, PPD test result and local diagnostic team discussion are the main factors affecting the consistency of diagnosis results. The proportion of patients with molecular biological examination is low.