| 摘要: | 背景：民國84年開辦全民健康保險，結核病患就醫自由度大幅增加，亦使原慢性病防治局院直接照護個案比例逐年銳減，醫學中心和各級醫療院所取而代之。疾病管制局也陸續推出許多提高結核病通報率的政策，使通報個案數目增加許多。但是，相對的代價就是偽陽性個案數目與改診斷的數目也增加許多。目的：想了解結核病通報個案改診斷率及相關影響因素；結核病通報個案通報至改診斷時間間隔之分布；結核病通報個案診斷醫師醫院與改診斷醫師醫院關係及相關影響因素；結核病通報個案改診斷之原因分析。方法：第一部份以民國91年全年結核病通報個案進行改診斷率與改診斷時間間隔分析。（註：沒有銷案醫師相關資料）第二部份以民國92年1-6月結核病通報個案改診斷者進行報告醫師醫院與改診斷醫師醫院配對關係之分析。（註：有銷案醫師相關資料）第三部份以郵寄問卷詢問民國92年1-6月結核病通報個案改診斷者之管理員，詢問較詳細改診斷原因。結果：民國91年有近三分之一的通報個案改診斷，個案年齡越高改診斷率越高，通報醫院層級越高改診斷率越低，依據X光或臨床診斷的改診斷率約45%。大約一半的改診斷個案，通報到改診斷的時間間隔是兩百天，只有不到五分之一的個案是在兩個月內完成改診斷，有五分之一的改診斷個案是超過一年才改診斷。民國92年1-6月結核病通報個案在七月底改診斷者有近五分之三通報醫師與改診斷醫師是屬於同一家醫院，其中三分之二是同一位醫師改診斷，只有少數個案（6.9%）是較高層級醫院被較低層級醫院更改診斷。根據問卷調查有近五分之二改診斷理由是發現其他更明確診斷，譬如肺癌或肺炎，有近四分之一是不同醫師對胸部X片判斷意見不一。結論：相較於其他國家，台灣結核病通報的改診斷率太高，由通報到改診斷的平均天數太久，大多超過合理改診斷時間。至於有多少比例是因為行政因素、醫師診斷品質因素或是地段管理師因素造成過長改診斷時間，還有待進一步研究驗證。針對高改診斷率的族群，譬如以X光或臨床診斷或診所通報個案，應該要有一些措施來降低改診斷率，以避免偽陽性診斷對病患造成的不良作用。
Background: After the implementation of National Health Insurance in Taiwan, more and more tuberculosis patients were cared by general hospitals instead of by traditional tuberculosis control centers. Many policies increasing the notification rates were launched by Center for Disease Control of Taiwan in late 1990？H？Hs, which increase the number of registration tuberculosis cases. As we can expect, the number of false positive and change in diagnosis after notification were also increased. Objectives: To determine the rate of change in diagnosis after notification and associated factors; to delineate the distribution of time interval between notification and change in diagnosis; to examine the physicians and hospital relationships between notification and change in diagnosis; to explore the reasons of change in diagnosis after notification. Methods: In first part of the analysis, all cases notified during the year 2002 were used to calculate the rate of change in diagnosis and distribution of time interval between notification and change in diagnosis. The information of physician who changed the diagnosis was recorded since January 2003. Therefore, in the second part of this study, the changed diagnosis cases from January 1, 2003 to June 30, 2003 were collected to analyze the physician and hospital relationships between notification and change in diagnosis. In the third part, we mailed questionnaire to case managers of those changed diagnosis cases on the reasons of change in diagnosis. Results: Near one third of registration cases for the year 2002 the diagnosis was changed, the higher the age of the cases the higher the rate of change in diagnosis, the higher the level of notification hospital the lower the rate of change in diagnosis. Near half of those cases in which the diagnosis was based on X-ray or clinical information changed diagnosis. The median time between notification and change in diagnosis was 200 days, less than one fifth of notification cases the diagnosis was changed within two months and about one fifth of cases in which the time interval was over one year. Of those notification cases from January to July, 2003 who changed diagnosis before July 31, 2003, near three fifth cases the notification hospital and change diagnosis hospital were the same and two third of them were the same doctor. Only very few cases (6.9%) in which the diagnoses made by higher level hospitals were changed by lower level hospitals. According to the questionnaire results, the main reason of changes in diagnosis was ？H？Ha more specific diagnosis was found？H？H (37%) followed by ？H？Hdifferent opinions on X-ray reading between doctors？H？H (25%). Conclusions: Compared with other country, the rate of change in diagnosis after registration in Taiwan was too high and the time interval between notification and change diagnosis was too long and most of the time intervals were not acceptable. Studies are needed to further determine the percentage of change in diagnosis due to administration problem, physician diagnosis problem or case manager problem. Measures should be implemented for those high change diagnosis groups, such as those diagnosis based on X-ray or clinical information and those notified from clinics to avoid the unnecessary adverse effects from false positive diagnosis. |
