论文部分内容阅读
目的了解北京市中心城区医疗机构乙型肝炎诊治的实际能力,分析存在的问题并提出建议。方法采用现况调查与非参与观察法相结合的方法,于2009年12月借助5名实际肝病志愿者,在北京市中心城区抽取3家三级医院、2家二级医院、2家一级医院进行诊疗体验,分析这些医疗机构与医务人员对乙型肝炎的实际诊治能力。结果 (1)三级、二级、一级医院整体诊疗人员和设备比较完善,基础条件较好。均有专科或全科医师出诊,能进行肝功能、乙型肝炎和丙型肝炎等病毒性肝炎血清免疫学和腹部超声检查。(2)存在的问题:①门诊医师诊断能力:三级医院过于依赖仪器检查而物理查体少,门诊诊断不够具体;二级中医医院查体缺乏西医体征,中医和西医医院恰当诊断率和恰当处理率都偏低;三级医院与一、二级医院医师询问乙型肝炎患者现病史的合格率比较,差异无统计学意义(χ2=0.05,P>0.05);三级医院与一、二级医院医师对乙型肝炎患者恰当诊断、恰当处理的合格率比较,差异均有统计学意义(χ2值分别为7.70及5.04,P<0.05)。一级医院均没有肝病专科医师,从病史采集、体检到诊断基本不能完成,不具备对血吸虫肝病等少见肝病诊断与鉴别诊断的能力;②超声诊断:作为肝胆常用检查的手段基本能够普及,但检测指标普遍不够细化,导致结论笼统;③肝功能检查:各级医院基本能够普及检查,各家测定值差别不大;个别一级医院检查项目过于简单,参考价值有限;④HBV血清学标志五项检查:基本能够普及,但所用试剂不统一,个别检查结果有误。HBVDNA定量等检查需要依靠专科医院或个别三级医院来检测,二级、一级医院开出的申请单不足。结论北京市中心城区虽基本具备较强的乙型肝炎诊治能力,但诊疗过程中普遍存在询问病史简单、查体不仔细、门诊诊断欠准确、鉴别诊断不足等问题,需要加强专科知识培训。超声以及肝功能、病毒学等实验室检查,存在检测项目开展数量不足、同一指标因试剂不同导致检测结果存在差异无法互认等问题,需要进一步规范化和标准化。本研究结果为“十一五”国家传染病示范区课题的实施提供了参考信息。
Objective To understand the actual diagnosis and treatment of hepatitis B in medical institutions in downtown Beijing, analyze the existing problems and make recommendations. Methods Using the combination of current situation survey and non-participation observation method, in December 2009, with the help of five actual liver disease volunteers, three tertiary hospitals, two secondary hospitals and two primary hospitals were selected in downtown Beijing Carry out the diagnosis and treatment experience and analyze the actual diagnosis and treatment ability of these medical institutions and medical staffs on hepatitis B. Results (1) The level 3, level 2 and level 1 hospitals had better diagnosis and treatment staffs and better equipment, with better basic conditions. All have specialist or general practitioners visit, can carry out liver function, Hepatitis B and Hepatitis C and other viral hepatitis serum immunology and abdominal ultrasound. (2) Existing problems: (1) Diagnostic ability of outpatient physicians: Third-level hospitals rely too much on physical examinations and physical examinations are inadequate; out-patient diagnosis is not specific enough; Second-level Chinese medical examinations lack signs of Western medicine; proper diagnosis and appropriateness of Chinese and Western hospitals The treatment rate is low; level three hospitals and primary and secondary hospital physicians asked hepatitis B patients with the history of the passing rate, the difference was not statistically significant (χ2 = 0.05, P> 0.05); tertiary hospitals and one, two The level hospital doctors correctly diagnosed patients with hepatitis B, the appropriate rate of qualified treatment, the differences were statistically significant (χ2 values were 7.70 and 5.04, P <0.05). First-class hospitals are no liver specialist, collected from the medical history, the basic diagnosis can not be completed, do not have the ability to diagnosis and differential diagnosis of rare liver diseases such as schistosomiasis liver disease; ② ultrasound diagnosis: as a general liver and gallbladder inspection methods can be universal, but The detection of indicators generally not enough detail, leading to general conclusion; ③ liver function tests: basically universal access to all levels of hospital examination, the measured value is not much difference; individual first-class hospital examination project is too simple, limited reference value; ④ HBV serology marker five Check items: the basic can be universal, but the reagents used are not uniform, the results of individual checks are incorrect. HBVDNA quantitative examination need to rely on specialist hospitals or individual tertiary hospitals to detect, two, a hospital out of the application form is not enough. Conclusions Although the central urban area in Beijing basically has strong ability of diagnosis and treatment of hepatitis B, it is necessary to strengthen the training of specialty knowledge in the process of diagnosis and treatment, such as simple examination of history, inaccurate examination, out-patient diagnosis, and lack of differential diagnosis. Ultrasound and liver function, virology and other laboratory tests, there is the lack of testing projects carried out, the same indicator due to different reagents lead to differences in test results can not be recognized and other issues, the need for further standardization and standardization. The results of this study provide reference information for the implementation of the “Eleventh Five-Year” national infectious disease demonstration project.