摘要
研究背景
耐多药结核病是指至少同时对异烟肼和利福平耐药的结核病。其治疗需要采用价格昂贵的二线抗结核药物,治疗的费用高、周期长、治愈率低、死亡率高、传染性强,具有极大的社会危害性。最近几年,耐多药结核病的发病率持续升高,引起了全社会的广泛关注,如何防控耐多药结核病已经成为目前全社会研究的热点。我国的耐多药结核病疫情非常严重,2007年世界卫生组织列出的“全球27个高耐药结核病负担国家”名单中,我国排名第二,大约占世界耐药结核病总负担的22%。2012年世界卫生组织在日内瓦发布的《2012年全球结核病控制报告》中指出,中国和印度的耐多药结核病患者数量最多,耐多药结核病持续威胁着人类健康。
国外通过医防合作控制耐多药结核病取得了显著的效果。2010年我国通过科技重大专项对研究地市的耐多药结核病防控实施了医防合作模式干预,并计划将其进行全国范围内的推广,因此对干预情况进行评价,发现其优势以及不足并进行完善有其必然性与紧迫性。
然而利用常规干预前后的对比评价存在一定问题：一方面由于干预前,耐多药结核病患者的诊断主要依靠临床经验,没有进行实验室检查确诊,因此,使用患者的情况进行前后对比不够严谨；同时,在干预前没有开展医防合作,因此,干预前后对比是从无到有的变化,对指导实践的意义有限。另一方面,干预后耐多药结核病患者的确诊也需要一个过程,同时,根据世界各国的研究经验预计,患者的数量不会很多,因此,本研究无法使用大样本多因素的方法进行控制,也无法应用复杂的统计学方法进行分析。
结合以上问题,本研究拟进行多阶段的评价来观察其进展情况,以达到对耐多药结核病医防合作不断改进与完善的目的。本研究属于课题总体进程中的一部分,反映本阶段的问题。后续的研究与再评价是必要的。
通过研究综述发现,以往的文献多为回顾性的干预前后指标对比评价研究,而且指标数量较少,不成系统,评价结果尚显局限。因此,本研究设计从供方与需方两个角度建立评价指标体系,然后进行干预初期和干预中期的对比分析,评价其进展情况,为我国耐多药结核病医防合作模式的进一步优化以及进行全国范围内的推广提供政策建议。
研究目的
本研究的总体目标是：通过理论研究和实证分析建立适合我国国情的耐多药结核病医防合作模式评价指标体系,并从供方与需方两个角度对干预初期到干预中期的进展情况进行评价,根据研究结果展开讨论并为将来全国范围内的推广提供科学依据。
具体研究目的是：通过科学方法构建适合我国国情的耐多药结核病医防合作模式评价指标体系；通过实证研究,从供方与需方角度评价现行的医防合作模式；提出完善我国耐多药结核病医防合作的政策建议。
研究方法
研究资料来源于“十一五”以及“十二五”国家科技重大专项课题“结核病发病模式研究”干预初期和干预中期的两次调查数据。包括患者面对面调查、机构调查、病案资料调查与关键人物访谈等。
本研究综合考虑全国各省耐多药结核病的基线调查数据、结核病控制的水平、地理分布、经济条件等,选择河南省、黑龙江省、浙江省、天津市、重庆市作为研究现场。在干预初期与干预中期,课题组分别在每个研究现场调查了市、县级两级与耐多药结核病医防合作相关的知情人共40名。干预初期的调查对象为每个研究地区2010年3月1日至2011年2月29日之间留取痰标本,并确诊的患者共119例,其中接受治疗的患者59例,联系到的能够参加现场调查的患者38例。干预中期的调查对象为每个研究地区2011年3月1日至2012年2月29日之间留取痰标本,并确诊的患者共235例,其中接受治疗的患者107例,联系到的能够参加现场调查的患者63例。
本研究结合干预方案,采用文献研究法、专家小组讨论法等广泛收集我国耐多药结核病医防合作的指标,依据SMART原则进行评价指标的初步筛选;用德尔菲法(delphi method)进行专家咨询确定评价指标体系；利用模糊层次分析法确定评价指标的权重,建立科学系统的评价指标体系。主要从供方与需方两个角度对干预初期到干预中期医防合作的进展情况进行评价。
本课题从研究设计阶段、调查准备阶段、现场调查阶段、数据录入与分析阶段以及伦理学方面都进行了严格的质量控制。因此,本研究资料来源真实可靠,分析方法科学合理。
本研究采取定量分析与定性分析相结合的方法。定量分析包括描述性统计分析,主要指标包括率、均值、中位数、卡方检验、非参数检验等。定性分析采用归纳描述性分析方法,按照不同主题对访谈资料进行分类,然后归纳整理,依据主要观点进行提炼。结合两次干预后调查的结果,借鉴差异法原理,主要比较指标在干预初期与干预中期的进展情况,根据其结果进行原因分析,最后根据研究结论提出政策建议。
研究结果
(1)研究地区以及耐多药结核病患者基本情况
五个研究地区人口数最多的为河南省9429万,最少的为天津市1176万。人均GDP最多的为天津市5.40万,最少的为重庆市1.80万。基线调查的时间从1999年到最近的2005年,五个研究现场的总耐多药率河南最高为12.9%,重庆最低为4.60%。黑龙江省大庆市、河南省濮阳市、浙江省衢州市是全球基金项目市,天津市由于地方财政收入较高,因此,耐多药结核病的诊治主要是依靠地方专项进行支持,重庆市不是全球基金项目市,地方财政收入较低,因此,耐多药结核病的诊治主要是依靠医保来维持。
两次参与调查患者的男女比例为2.37：1,年龄分布在25岁到73岁之间,平均年龄45岁,以35、45、55、65以分界点将患者年龄划分为5段,各年龄阶段的比例分别为31.7%、17.8%、17.8%、19.8%、11.9%。文化程度中,初中文化所占的比重最大,为37.6%。经济情况中,低保或贫困户的比例为16.8%。在职业特征中,待业或失业所占的比重最大,为41.6%。参加医保的情况中,新农合所占的比重最大,为66.3%,未参加任何医保的患者排名第二位,为11.9%。户籍特征中,本地户口的比重为84.2%,外地户口所占的比重为15.8%。
(2)政策环境与组织管理
总体而言,干预中期耐多药结核病医防合作的政策环境以及组织管理情况较干预初期有了很大程度的进展,五个研究地市均已经全部制定耐多药结核病医防合作相关政策,建立了医防合作领导小组,通过例会和电话来进行沟通,尽管沟通频次不尽相同,但能够满足医防合作需要。同样,仍然存在有待改进与完善的地方,特别是筹资机制揭示出很多问题。
作为权重系数最大的指标筹资,筹资来源与筹资模式未发生变化；主要的改善是重庆市医保报销比例、额度以及药品纳入医保目录的比例都出现了大幅度提升,其他四个研究地市医保政策均未有进展。
(3)医防合作体系与服务能力
实验室配置方面,干预初期到干预中期没有变化。市级疾控中心实验室配置最为完善,痰涂片、痰培养以及药敏试验均能够开展：县级结防机构均能进行痰涂片,但河南省濮阳市与黑龙江省大庆市在两次评价时均不能进行痰培养,其余三个研究地区县级结防机构均可进行痰培养。感染控制方面,市级定点医院与市级疾控中心进展明显,初期评价时患者与医务人员的防护都不够完善,到中期时都比较到位；定点医院进行了病房改造,增强了感染控制能力；县级结防机构在感染控制方面相对薄弱而且没有进展。总体人力资源的配置干预中期较干预初期更为完备,存在的问题是,干预中期,仍有部分疾控中心的实验室只有1人。不同时期不同机构的培训覆盖率中,以初期评价定点医院相关医生培训覆盖率29.9%为最低；干预中期定点医院与疾控中心医生培训覆盖率都较干预初期有所增加；疾控中心与定点医院两个机构进行对比,干预初期疾控中心医生培训覆盖率高于定点医院,到干预中期两者相同。
在服务能力方面,主要从痰培养及时性、药敏试验及时性、耐药结果反馈及时性、治疗及时性、出院后转诊及时性等方面进行评价,这几方面是医防合作指标体系中的核心指标,是“合作”能力的最主要体现,结果显示干预中期较干预初期均有很大进展。
(4)患者服务利用情况
干预初期与干预中期导致患者未能接受治疗的原因前五位相同,分别为死亡流动人口、对治疗不信任、经济困难以及失去联系。区别在于干预初期位于第三位的为对治疗不信任,而到干预中期这一原因位于第五位；干预初期位于第五位的为与患者失去联系,到干预中期这一原因位于第三位。
患者发现与诊断情况包括涂阳痰标本痰培养率、痰标本涂阳培阴率、培养阳性菌种鉴定率、培养阳性患者药敏试验率、可疑者筛查率以及患者平均诊断时间等,在干预中期均较干预初期有明显改善,但仍然存在涂阳培阴率超出标准的现象。
患者治疗满6个月与疗程结束情况属于核心指标。但由于初期评价距离医防合作模式开始实施时间相对较短,治疗满6个月的患者只有2名,没有完成疗程的患者。两次评价显示,中期评价时接受治疗患者住院治疗的比例为56.1%,高于初期评价时的23.7%。中期评价时,6月末痰涂片阴转的患者比例为63.0%,6月末痰培养阴转的患者比例为55.0%,疗程结束时患者治愈率为41.0%。
患者管理情况包括患者追踪到位情况、前6个月内接受DOT患者比例、6个月内规则服药患者比例、治疗6个月丢失患者比例、治疗管理落实情况等,总体有了很大的进展；仍未达到全部患者均追踪到位与落实治疗管理。
干预初期未能计算患者疾病经济负担情况;干预中期,医疗总费用均数为41005.81元,患者自付费用均数为7387.84元,自付比例为18%；38例患者中17人发生了灾难性卫生支出,其比例为44.7%。
(5)满意度情况
干预中期定点医院工作人员对医防合作满意程度较干预初期有所提高;疾控中心工作人员对医防合作满意程度干预初期与干预中期相同：两次调查均显示,疾控中心工作人员满意度均高于定点医院工作人员。
耐多药结核病患者对自付比例满意程度由初期评价的55.3%提高到中期评价的76.2%。两次评价耐多药结核病患者对疾控中心以及定点医院服务的满意度没有变化,且都大于80%。
结论与政策建议
(1)耐多药结核病防控需要全社会共同参与,因此提高全民防控意识刻不容缓。同时,构建优质社会支持网络对增加患者战胜疾病信心并促进患者早日康复有至关重要的作用。
(2)继续保持已建立完备的耐多药结核病医防合作领导组织与及时、快速的协调机制。同时,在今后的发展中,积极探索多样化激励与考核机制,同时可以考虑将其动态化,根据医防合作发展现状不断进行适当调整。
(3)重视解决耐多药结核病医防合作筹资来源。
①更多的调动当地经费投入到耐药结核病医防合作之中,纳入当地的年度财政预算并且形成常规化经费投入,以保证当地耐多药结核病防控工作顺利进行。
②继续完善耐多药结核病相关医保政策。医保政策由于其可持续性强,若能相应向耐多药结核病倾斜,其保障力度非常大。
③探索建立针对耐多药结核病患者的医疗救助制度。
(4)医防合作各个组成要素中,市级疾控中心参与医防合作能力最强,干预中期较干预初期也有明显进展,应继续提高市级疾控系统参与耐多药结核病医防合作的能力。
(5)应充分认识到定点医院在医防合作中的不可或缺性,以及目前存在的由于补偿不到位导致的定点医院参与医防合作积极性不高等问题。适当加大补偿力度,并探索对定点医院承担耐多药结核病防控等公共卫生职能的长效补偿机制。
(6)加大对基层结防机构的重视程度与投入力度,提高其配置水平,提高其参与医防合作的能力。基层结防机构医务人员要继续加强对就诊患者的耐多药结核病知识宣教,打消其顾虑,从而提高防护意识。
(7)加大对耐多药结核病患者教育,端正其治疗态度,增强其治愈信心,提高其依从性。积极探索多种形式的耐多药结核病患者补偿机制,在现有医疗保险基础上,建立针对耐多药结核病患者的特殊医疗救助机制。同时,本研究中由于流动人口而导致患者无法进行治疗以及患者治疗管理依从性差等问题非常突出。因此,需加大对流动人口的关注。建立流动人口跨地区追踪机制。
Background
Multi-drug resistant tuberculosis has come to refer to cases in which the tuberculosis strain is resistant at least to isoniazid and rifampicin. It spreads through the respiratory tract, so once infected, the crowd becomes the primary multi-drug resistant tuberculosis patients. Multi-drug resistant tuberculosis needs to adopt expensive second-line anti-tuberculosis drugs for long cycle treatment.Because of the the high cost,low cure rate and high mortality, multi-drug resistant tuberculosis has great danger to society. In recent years, the incidence of tuberculosis especially the incidence of multidrug-resistant tuberculosis is on the rise, thus it attracted widespread attention. How to control multidrug-resistant tuberculosis becomes the hot spots in the study of whole society. The epidemic of multidrug-resistant tuberculosis in China is very serious. In2007the World Health Organization lists "27highly drug-resistant tuberculosis burden countries in the world", China ranked the second,and it bears about22%of the world's total burden of multidrug-resistant tuberculosis. In2012, the World Health Organization global tuberculosis control report released in Geneva notes that China and India have the largest number of multidrug-resistant tuberculosis patients, and multidrug-resistant tuberculosis will continue threat to human health.
The emergence of multidrug-resistant tuberculosis mainly due to the unreasonable medication,both from patients of the demand-side and the clinic management of the supply-side.
The cooperative control of designated hospitals and tuberculosis control agencies had achieved remarkable results in many foreign countries.The Ministry of science and technology in China implemented the cooperation in2010, and will plan to make nationwide promotion. Therefore, an evaluation of its progress, discovering their strengths and weaknesses and making improvements is inevitable and urgent.
However there are problems using the conventional contrast evaluation before and after:On one hand, before the intervention, the diagnosis of multidrug-resistant tuberculosis patients mainly didn't rely on laboratory diagnosis but clinical experience. Therefore, the use of the patient's condition before and after comparison is not precise enough. We did not carry out cooperation before the intervention, therefore, there were only with or without changes before and after for the comparison,with limited significance in guiding practice. On the other hand, the diagnosis of multidrug-resistant tuberculosis needs a period of time. Meanwhile, according to the research experience of the world, there will be a small number of patients. Therefore, our study can not use a large sample multivariate methods to control and can not use complex statistical methods for analysis.
Combination of the above issues, we proposed research to evaluate the progress of the multi-stage. Finding its progress, we will achieve the purpose of continuous improvement and perfection. Therefore, our study is part of the overall process of the subject, reflecting the problems of this stage. The follow-up study and re-evaluation is necessary.
The previous literature are mainly retrospective comparation,evaluating on before and after the intervention,using a small number of indicators, so the results of the evaluation is limited. Therefore, the design of our study is to establish the evaluation index system from the supply-side and demand-side, then make comparison between the early and mid-intervention. Evaluating the progress of cooperation,so we can provide policy recommendations on the nationwide promotion.
Aims
The overall objective of the study is to establish a evaluation index system for cooperation through theoretical study and empirical practice, then to evaluate from the supply-side and demand-side between the early and mid-intervention. At last,we discuss the results to provide a scientific basis for nationwide promotion in the future. The specific purpose is to establish a evaluation index system for cooperation through theoretical study and empirical practice; then to perform empirical research so as to evaluate from the supply-side and demand-side between the early and mid-intervention. We will identify problems and analyze the reasons to put forward policy recommendations for the cooperation.
Methods
The data come from the Ministry of Science and Technology issue " tuberculosis incidence mode" twice intervene survey, including patients face-to-face surveys, institution surveys, medical record information surveys and key informant interview. We chose Henan, Heilongjiang, Zhejiang, Tianjin,Chongqing, as the research sites according to the baseline survey data for the provinces of multidrug-resistant tuberculosis, tuberculosis control level, geographical distribution and socio-economic conditions. A total of40insiders were interviewed separately in the early and mid-intervention.119patients were diagnosed between2010-03-01and2011-02-29,and the initial survey included38cases of patients with a total of59patients received treatment.235patients were diagnosed between2011-03-01and2012-02-29,and the second survey included63cases of patients with a total of107patients received treatment.
We widely collected index of multidrug-resistant tuberculosis in China's practice of cooperation,according to intervention plans,literature research methods and the expert group discussion in our study. We preliminary screened the evaluation index based on SMART principles. Delphi method expert consultation is used to identify evaluation index system. Fuzzy analytical hierarchy process is used for determining the weights of index. Then a scientific system of evaluation index system to evaluate the progress of the cooperation from the supply-side and demand-side was established,
we compared the main index in the progress of the early and mid-intervention,according to the combined results of the survey and the principle of differences. we will conclude the proposed policy recommendations based on the results.
Our study used a combination of quantitative and qualitative analysis method. Quantitative analysis included descriptive statistics analysis, and the key index including rate, mean, median, chi-square test, non-parametric tests. Qualitative analysis by induction method of Descriptive Analysis. We classified the interviews in accordance with the different themes, and then they were collated and analyzed based on the main points.
Results
(1) The situation of study area and patients with multidrug-resistant tuberculosis The largest population of the five research areas is94,290,000in Henan Province, The population of the least number is11,760,000in Tianjin. The per capita GDP was up to54000in Tianjin, and at least18000in Chongqing. The time of the baseline survey from1999to2005.the total multi-drug resistance of up to12.9%in Henan, and as low as4.60%in Chongqing o f the Five study sites. Daqing City in Heilongjiang Province, Puyang City in Henan Province and Quzhou City in Zhejiang Province are the gobal Fund Project Cities. Because of its high local fiscal revenue, the diagnosis and treatment of multidrug-resistant tuberculosis in Tianjin is mainly relying on local special support.Chongqing City is not a gobal Fund Project city, also because of its low local revenues, diagnosis and treatment of multidrug-resistant tuberculosis is mainly rely on Medicare to maintain.
The patients involved in the investigation were with male to female ratio of2.37:1, and the age were from25-year-old to73-year-old with mean age45years. The patients age was divided by35,45,55,65, and the according proportion were31.7%,17.8%,17.8%,19.8%,11.9%. junior middle school education was37.6%as the largest proportion. Subsistence allowances or the proportion of poor households accounted for16.8%., unemployed or unemployment was41.6%as the largest proportion of Occupational characteristics, new rural cooperative was66.3%as the largest proportion of patients participated in Medicare, and patients did not participate in any Medicare ranked second, accounting for11.9%. The local accounted for84.2%, the proportion of the foreign accounted for15.8%.
(2) Policy environment and organizational management Overall, the Policy environment and organizational management had progessed a lot in the second survey. The five cities had all established cooperation leading group with communication through regular meetings and telephone on the early evaluation. But there are still needs to be improved and perfected, especially the financing mechanisms which reveals a lot of problems.
As the largest weight indicators,The financing source was not changed. The main improvement is the proportion of Chongqing Medicare reimbursement amount as well as the proportion of drugs into the health insurance directory. None of the other four cities Medicare policy progressed.
(3) The cooperative system and service capabilities
Only the city of Tianjin and Puyang City, Henan Province developed incentive assessment mechanism on the early evaluation. To the mid-term evaluation, five cities all developed a dynamic substance incentives.
There was no progress in the laboratory configuration. The municipal CDC were the most perfect, and they are able to carry out sputum smear, sputum culture and susceptibility testing. The county tuberculosis prevention agencies can perform sputum smear. The two cities:Puyang City, Henan Province, Daqing City, Heilongjiang Province couldn't not conduct sputum culture. The municipal designated hospitals and municipal CDC progress is obvious for the infection control. The patient and the protection of medical personnel were not perfect in the early,but they are in place to medium-term. The designated hospital made ward transformation, enhancing infection control capabilities. The county tuberculosis prevention agencie's control is relatively weak and there is no progress. The human resource were more complete in the medium-term than the early. The problem is that there are still only one laboratory assistant of some CDC in the interim.29.9%training coverage related to the training of the designated hospital doctors in the initial evaluation is the lowest. Therefore, the initial evaluation, the designated hospitals to participate in the training effect in the early is the poorest overall. Doctors training coverage increased both in the designated hospitals and CDC in the mid-intervention. The CDC doctors training coverage is higher than the designated hospitals in the early, and in the mid-intervention they are the same.
We made comparative evaluation on service capabilities including sputum culture timeliness, timely susceptibility testing, the timeliness betrween drug result of feedback and treatment, timeliness and other aspects of the intervention in the early and mid-intervention. These aspects are both the most important manifestation of the ability of "cooperation" and the core index.
(4) Patient's service utilization
The top five causes of the confirmed patients with multidrug-resistant tuberculosis that failed to receive treatment were death, mobile populations, lost of contact, economic difficulties, as well as distrust of the treatment.
The detection and diagnosis of the patients improved significantly, including negative culture rate of sputum smear positive specimens, coated male sputum samples of sputum culture rate, the positive the strain identification rate of culture susceptibility testing positive patients, the screening rate as well as the average diagnosis time.
Treatment of patients is part of the core indicators. However, due to the relatively short implementation time of the cooperation, only two patients'treatment was full six months,and none complete the whole course.56.1%of treated patients hospitalized in the mid-term evaluation, and there is a substantial increase compared to23.7%of the initial. The proportion of patients with sputum smear negative conversion of6months was63.0%, sputum culture negative conversion proportion was55.0%, the cure rate was41.0%at the end of the treatment in the mid-term evaluation.
Patient management overall had great progressed,including patient tracking in place within the first six months, the proportion of patients to accept DOT within6months,the proportion of patients missing in the first6months, the implement of treatment and management. But not all the patients had been track in place.
We are unable to calculate the economic burden of disease in patients initially. The total medical expenses mean was41,005.81yuan, with7387.84yuan of the patient-pocket costing,payingl8%in the interim.17of38patients had catastrophic health expenditure, the ratio was44.7%on the mid-term evaluation.
(5) Satisfaction
The designated hospitals staff satisfaction with the cooperation increased than the early. The CDC staff satisfaction with the cooperation did not change in the early and mid-term intervention. The CDC staff satisfaction are higher than the designated hospital staff in both surveys.
The satisfaction of patients for paying the proportion increased from55.3%in the initial to76.2%of the mid-term. The patients satisfaction with the services of the CDC and designated hospitals is more than80%both in the two surveys.
Conclusions and policy implications
(1) At present, the prevention and control of tuberculosis, especially multidrug-resistant tuberculosis is an important work requires participation of the whole society. So it is urgent to raise the awareness of prevention. We have to spread multidrug-resistant tuberculosis prevention and control knowledge as soon as possible by making it serve as a scientific knowledge into local health education plann.It needs to establish "government leading, multisectoral cooperation, the whole society participation" of regular operatinal mechanism about health education and promotion of multi-drug-resistant tuberculosis. It is good social support network that plays a crucial role in the patients'rehabilitation. When the patient is sick, he had increased dependency on medical services, and also need more understanding, caring and help. Building a good social support network helps patients fight diseases and increase confidence, so they can get well soon.
(2) We have to remain the comprehensive cooperation organization building and timely coordination mechanism established in the early. And we can explore diversified incentive assessment mechanism in the future. A dynamic incentive assessment mechanism can be considered and adjusted based on the development status of the cooperation.
(4) The cooperation funding sources must be addressed as a priority.
①More local fund need to be mobilized to the cooperation, and also be conducted in the yearly routine local budget, so as to ensure the smooth progress of the work of the multi-drug resistant tuberculosis.
②The health insurance policy of multi-drug resistant tuberculosis need to be improved. Because of its sustainability,the health care system will have srong support if inclined to multi-drug resistant tuberculosis.
③The establishment of a medical assistance system need to be explored.
(4) The municipal CDC is the srongest to participate in the cooperation of the various elements, and they significantly progressed in the interim. The limitation is that part of the research and cities had too small number of laboratory personnel. Therefore, we need to increase staffing of the laboratory in order to ensure the effectiveness and speed of the laboratory of cooperation. Meanwhile, the capacity of municipal CDC need to be continually improved in the prevention and control of multi-drug resistant tuberculosis to strengthen cooperation with the designated hospitals.
(5)We should be fully aware that the designated hospitals in the the cooperation is in essential. Due to inadequate compensation, the designated hospitals are not enthusiastic in the cooperation. The compensation need to be increased and the long-term compensation mechanism need to be explored for the public health functions that designated hospitals bear.
(6) Greater emphasis should be made on the basic preventing institutions and investment, increasing their level of configuration and their capacity to participate in the cooperation. Patients'knowledge should continue to strengthen to dispel their concerns and raise their awareness of protection, thus it can make a protective effect for both patients and doctors.
(7) Patients need to be educated to correct the attitude of their treatment, to improve compliance, and to enhance their confidence of its cure. Various forms of compensation mechanisms need to be actively explored. A special compensation measures need to be established on the basis of the existing medical insurance. It is not enough for simple control of local registered permanent resident of multidrug-resistant tuberculosis patients for the increasing floating population. It is very promient in our study that the poor compliance and the incomplete treatment the floating population had. Therefore, more attention need to be given to floating population. Establishment of trans-regional tracking mechanism for patients in floating population is necessary and the track work should be carried out as soon as possible.
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