RU2611398C1 - Method of increasing the efficiency of treatment of patients with tuberculosis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to phthisiology, and can be used to improve the efficiency of treatment of patients with tuberculosis. Method includes the determination of the degree of patient’s medication adherence through his questioning, which is performed at the beginning of the main course of treatment. Stens are determined and after its determination diagnose the factors affecting the level of adherence, and then the prediction of medication adherence is determined: if total score is from 35 points and more, 1–2 stens mark the unsatisfactory medication adherence, if it is 16–34 points, 3–5 stens mark satisfactory medication adherence, if it is 4–15 points, 6–8 stens mark good medication adherence, if it is up to 3 points, 9–10 stens mark medication adherence. In case of unfavorable prognosis at 1–5 stens prescribe cycloferon immunomodulator and methods of psychotherapy, as well as the chemotherapy regimen correction is carried out by changing the method of administration of etiotropic drugs, and at a satisfactory medication adherence etiotropic drugs are administered parenterally, and at unsatisfactory medication adherence etiotropic drugs are administered parenterally and inhalationly.

EFFECT: use of invention improves efficiency of treatment of patients with tuberculosis by determining the degree of patient’s medication adherence for further treatment correction.

1 cl, 2 ex

Description

The invention relates to medicine, namely to TB, and can be used to increase the effectiveness of the treatment of a patient with tuberculosis.

Compliance with the principle of domestic medicine to treat a patient, and not a disease, reflects the objectively existing relationship between the psycho-emotional status of the patient and his disease. In the era of chemotherapy in the treatment of tuberculosis patients, the main attention is paid to medical methods, while personal and individual psychoemotional factors are taken into account to a lesser extent in the construction of a treatment and rehabilitation strategy. In single studies, a relationship has been established between the state of the psycho-emotional sphere of a patient with tuberculosis and the course of the disease [Streltsov V.A., Baranova V.G., Stolbun Yu.V. The need to assess the psychological status of patients with pulmonary tuberculosis // Tuberculosis and lung disease. 2011. - No. 5. - S. 176-177; Filippova T.P. Pathogenetically directed correction of the body's adaptive reactions in the treatment of newly diagnosed patients with secondary forms of pulmonary tuberculosis. Abstract. dis. doctor. - M. - 2008.28 p.]. Meanwhile, specific antibiotic therapy is not always the key to success in the treatment of tuberculosis patients [Shilova M.V. The organization of tuberculosis care in Russia and ways of modernizing the organizational and methodological management of dispensary observation of tuberculosis patients in modern epidemic and socio-economic conditions // Tuberculosis and lung diseases. - 2011. - No. 5. - S. 236-237]. The low effectiveness of the treatment is difficult to explain only by the formation of drug resistance of the pathogen or improper therapy. In this case, a violation of the treatment regimen due to their lack of adherence has a significant effect. The true causes of low adherence remain unrecognized and often refute modern therapeutic techniques. In particular, the psychological motives of patients refusing treatment remain unclear.

Adherence to treatment or the degree of correspondence between patient behavior and recommendations is often considered in modern medicine as a compliance problem (from the English. Patient compliance) and is one of the basic principles of treatment at present. Many patients with tuberculosis do not always comply with incomprehensible recommendations for a long time, which leads to a disruption in treatment regimens, and thereby to a decrease in its effectiveness [Bogorodskaya EM, Smerdin SV, Sterlikov SA Organizational aspects of the treatment of tuberculosis patients in modern socio-economic conditions. - M .: New Terra. - 2011. - 216 p.]. The formation of adherence to treatment is influenced by factors related to the psychological characteristics of the patient’s personality, the clinical picture of the disease (form, duration of the complication, relapse of the disease), the nature of relations with relatives and friends, the results of treatment, the level of competence of medical personnel and the organization of medical care. It is known that with increasing commitment, the effectiveness of treatment of patients increases by 30-40% [S. Kravchenko The problem of increasing patient compliance in phthisiology, 01/20/11. URL: www.spellsystems.ru].

In this regard, the introduction of chemotherapy regimen correction methods into the phthisiatric practice, taking into account the patient’s adherence to treatment with the aim of increasing cooperation with medical personnel, which ultimately strengthens treatment control and increases the effectiveness of rehabilitation, is relevant.

Known methods for determining compliance, such as the riboflavin marker method, when riboflavin was added to the test drug and placebo and express control of its content in the urine was performed, and thus, the administration of prescribed drugs was monitored [Krupitsky EM, Bortsov A.V. Application of the principles of evidence-based medicine in conducting clinical trials in narcology // Review of a psychiatrist. and honey. psychol. 2005; 2 (1)]. In patients with schizophrenia, a DAI (Disease Attitude Inventory) treatment scale was used [Hogan T et al. A self-report scale predictive of drug compliance in schizophrenics: reliability and discriminative validity // Psychol. Med. - 1983. - No. 13. - P. 177-183].

The prototype is a way to increase the effectiveness of treatment, depending on the level and methods of information and educational work among patients with tuberculosis [Pyanzova T.V. The effect of information and educational work with newly diagnosed patients with tuberculosis on the effectiveness of treatment // Tuberculosis and pulmonary diseases. - 2009. - No. 10. - S. 32-36]. The psychological status was examined using the standardized personality research method (SMOL) [Zaitsev VP, 1981], which is a modification of the Minnesota multi-aspect personality questionnaire (MMP1) [Sobchik LN, 2001] and the average profile was determined according to Welch, then using a special system we determined the level of overcoming the disease in patients with newly diagnosed pulmonary tuberculosis. Depending on the level of potential, individuals with high and low adherence to treatment were identified even before the start of chemotherapy and in order to increase the effectiveness of treatment, an information-educational impact system was used.

The disadvantage of this method is that, firstly, the known method is technically complex, contains complex questions, the answers to which require a sufficiently high level of intelligence, which is absent in most disadvantaged, socially maladaptive patients with tuberculosis.

Secondly, the method is recommended and tested only for patients with newly diagnosed pulmonary tuberculosis.

Thirdly, the known method provides for the application to increase the effectiveness of treatment by increasing adherence to only the information-educational impact system.

The technical result of the invention is to increase the effectiveness of treatment of patients with tuberculosis by determining the degree of adherence to treatment with the aim of further correction of treatment.

The technical result is achieved by determining the degree of adherence of the patient to the treatment, by questioning it, which is carried out at the beginning of the main course of treatment, by determining the wall, predicting the state of adherence and, if the prognosis is poor, adjusting the chemotherapy regimen by changing the methods of administering etiotropic drugs with mainly parenteral and inhalation method, the appointment of the immunomodulator Cycloferon and methods of psychotherapeutic effects.

At the beginning of the main chemotherapy course, the degree of adherence to treatment is determined by using a test questionnaire of 80 questions, scoring for positive answers from the indicated 35 and negative answers from 30 of the indicated questions, transferring the amount of “raw” points to the walls, followed by predicting the patient’s adherence . In case of an unfavorable prognosis, the chemotherapy regimen is corrected by changing the methods of administering etiotropic drugs with the appointment of the predominantly parenteral and inhalation methods in order to strengthen the control of treatment and increase patient motivation, the appointment of the Cycloferon immunomodulator and methods of psychotherapeutic intervention.

Initially, a survey is conducted on the developed questionnaire (Appendix 1), which is designed in such a way as to identify not only objective factors that interfere with treatment, for example, side effects of drugs, or unstable professional contact with medical staff, but also evaluate subjective factors that interfere with treatment such as stress, frustration, stigmatization, suggestibility, addiction to alcohol. The questionnaire contains 80 questions, intended for self-completion by patients with their voluntary consent to testing. At the beginning of the questionnaire, in a brief introduction, the patient is introduced into the survey situation and his interest in communication is stimulated. Questions are simple and accessible in meaning and filling technique. By the middle of the survey, along with increased attention and interest of respondents, the complexity and severity of the questions increases, psychological techniques that activate the patient's attention are used.

The language of the questionnaire is free from frequent cliches, newspaper cliches, stereotypical turns, is close to colloquial speech of patients with tuberculosis, takes into account the predominance of socially maladaptive persons and operates with situations that are quite close and understandable to respondents. During the questionnaire, the respondent does not solve complex tasks that take up a lot of his time, therefore the number of questions is limited to 80, and the answers to them require no more than 20-25 minutes.

When evaluating the results of the survey, the sincerity, or reliability of the answers of the respondents, their installation for cooperation with medical personnel is initially analyzed. 15 questions on the questionnaire constitute a scale of patient sincerity, and if 10 or more points are scored on this scale, the results are not taken into account and separate training sessions are held with the patient. In other cases, the degree of adherence to treatment is further determined, which includes 35 questions of the questionnaire with positive and 30 questions with negative answers, which make up the "raw" points for which the walls are highlighted. With an amount of 35 or more points - 1 and 2 walls, an unsatisfactory adherence to treatment is noted; tendency to frequent violations of the hospital regimen, lack of treatment effect, frequent relapses and exacerbations. With the sum of 16-34 points - 3-5 walls, a satisfactory adherence to treatment is noted; in extreme situations, moderate violations of the hospital regime, poor therapy results, rare relapses and exacerbations. With a sum of 4-15 points - 6-8 walls, a good adherence to treatment is determined; single short-term violations of the hospital regime in extreme situations, low probability of relapse and exacerbations are possible. With a sum of up to 3 points - 9-10 walls, there is a high commitment to treatment; low probability of violations of the hospital regime, high treatment efficiency.

The next stage is the diagnosis of factors: stress, frustration, suggestibility, addiction to alcohol, socio-psychological status, adverse reactions to treatment, the lack of treatment effect, not established relationship with honey. staff and economic distress. To determine these factors, 10 scales of questions with positive or negative answers are highlighted.

In the process of questioning and subsequent conversations, a “scenario” is realized, which is a kind of psychophysiological training of the patient. It is known that, according to the law of apperception, subjects' understanding of issues occurs indirectly, by passing them through the prism of personal experience that causes individual responses and their differential differences, the influence of the sociocultural factor and socio-psychological characteristics of the patient are taken into account. Thus, the patient’s attitude to himself and his treatment can change, which affects the degree of his adherence.

At the final stage, the prognosis of treatment adherence to the walls is determined. In case of an unfavorable prognosis (walls 1-5), the chemotherapy regimen is corrected by changing the methods of administering etiotropic drugs with the appointment of a predominantly parenteral and inhalation method in order to strengthen the control of treatment and increase patient motivation, the appointment of Cycloferon immunomodulator and methods of psychotherapeutic effects.

Examples of clinical use.

Example 1. A man of 24 years old, a student, was admitted to the clinic with the first detected infiltrative tuberculosis in the lower lobe of the left lung in the decay phase, MBT +. After establishing a diagnosis and prescribing treatment, an assessment was made of the degree of adherence to treatment according to the proposed methodology, which turned out to be within 20 points - 5 walls. Satisfactory adherence was established and moderate conditions of a hospital regimen and poor therapy results were predicted in extreme situations. Further analysis of the questionnaire showed that factors such as frustration and easy suggestibility influence the decrease in adherence to treatment: 5 and 6 points, respectively. For the purpose of psychological and medical correction, discussions were held, sedatives were prescribed, injection of the main anti-TB drugs: isoniazid and rifampicin and a course of immunomodulating therapy with cycloferon. A repeated assessment of the degree of adherence to treatment after 6 weeks showed results within 9 points - 7 walls and a favorable prognosis was established with possible single and short-term violations of the hospital regime in extreme situations and a low probability of relapse and exacerbations. Adverse factors of patient adherence to treatment were found on the scales of frustration and socio-economic status. In the conversations it was found out that the student is afraid of being “expelled” and will lose a year, which will adversely affect the economic situation of his family. A conversation with parents made it possible to reduce the effects of these adverse factors. By the end of the intensive phase of treatment, the decay cavity had healed and bacterial excretion stopped. The patient was discharged to continue treatment on an outpatient basis. Sanatorium treatment was postponed to the summer period.

Example 2. A man, 45 years old, was admitted to the hospital with a diagnosis of Disseminated pulmonary tuberculosis, phase of infiltration and decay, MBT +. Previously, he was repeatedly treated for tuberculosis, however, due to addiction to alcohol, he interrupted chemotherapy courses. Upon admission, an assessment of the degree of adherence to treatment was carried out according to the developed technique (37 points - 2 walls). An unfavorable prognosis has been established. The analysis of the questionnaire showed that such factors as frustration and addiction to alcohol influence the decrease in adherence: 7 and 8 points, respectively. In order to increase the effectiveness of treatment in regimen 2B, rifampicin was injected, a course of debridement bronchoscopy with endobronchial administration of isoniazid and capreomycin was administered, a course of immunomodulating therapy with cycloferon was conducted, and psychotherapeutic discussions were conducted with the participation of a psychologist and narcologist. A reassessment of treatment adherence after 6 weeks showed results: the sum of the “raw” points of 13-6 walls and the prognosis changed. During the examination, there is a positive dynamics in the form of partial resorption of foci and a decrease in the component of infiltration, a decrease in the size of the decay cavity. The patient was discharged with a positive result 6 months after the cessation of bacterial excretion and scarring of the cavity.

Thus, the diagnosis of the degree and prognosis of adherence to treatment will allow timely prescribing of the necessary corrective medication and psychotherapy, reduce the duration of treatment and increase its effectiveness. This will reduce the time of scarring of small caverns, and hence the duration of patients in the hospital, prevent the formation of cavernous forms of pulmonary tuberculosis and improve the epidemiological situation in the region.

Annex 1

Scale adherence rating

80 points of the questionnaire are grouped into ten scales: stress, frustration, stigmatization, suggestibility, addiction to alcohol, socio-psychological status, adverse reactions to treatment, lack of treatment effect, relationships with medical staff, economic distress. The performance of each scale varies between 0 and 10, where 0 represents high compliance on this scale. All scales form two indicators: subjective and objective factors affecting compliance.

The results are presented as scores on each of 10 scales, designed in such a way that a higher score indicates a lower level of compliance. The following indicators are quantified:

1. Stress, inadequate adaptation of patients due to individual type differences, leads to changes in psychophysiological indicators and self-esteem, objectively reflecting their general mental state in the new conditions of the TB hospital, restricts their medical appointments (avoidance of taking drugs, violation of the regime, focus on non-traditional methods of treatment, alcohol abuse), complicates the healing process and worsens health.

2. Frustration occurs in patients in the hospital and manifests itself in a number of emotional processes such as disappointment, anxiety, irritation, despair in the absence of a rapid onset of the positive effect of treatment, and although in a state of frustration they can continue the struggle to get what they want, but if they they don’t know exactly what needs to be done to succeed, frustration can turn into aggression directed inside or outside the body.

3. Stigmatization is the process of distinguishing tuberculosis patients from other individuals on the basis of their epidemiological danger and discrimination against them, violating the usual social ties, friendships and family relationships, which can become a persistent obstacle to the cure of such patients.

4. Suggestibility - increased compliance with the motives that are provoked by household members, “experienced” roommates, ill-wishers, uncritical willingness to obey, a tendency to become infected with other people's moods and adopt habits. Increased suggestibility characterizes patients with a relatively low level of intellectual development and unformed logical thinking, which is part of the criticality structure. Certain conditions, such as illness, stress, lack of time, lack of competence and group pressure, can trigger an increase in individual suggestibility.

5. Addiction to alcohol, a disease, a form of substance abuse, characterized by a painful addiction to alcohol (ethyl alcohol), with mental and physical dependence on it and negative consequences, which can be expressed by mental and physical disorders, as well as violations of social relations of a patient suffering from this disease .

6. Socio-psychological status implies the patient’s personality not only as an individual, but also as a specific socio-psychological type, which is characterized by mentality, social activity, value orientations, positions that determine the line of behavior in a particular socio-psychological environment of a TB hospital, in which external social influences and connections are transformed into internal motives and relationships of the individual.

7. Adverse reactions to treatment, established during the preliminary test and already known at the time of drug release, do not cover all possible manifestations of their toxic effects and, when used, unknown side effects are possible that can have an adverse effect on compliance.

8. The absence of a treatment effect characterizes mood, the presence of depression, anxiety, and a general low indicator of positive emotions. His indicators indicate the presence of depressive, anxious experiences, mental distress.

9. Unfolding relationships with medical staff: when trust ceases to be the basis of the relationship between the doctor and the patient, built on cooperation, which includes support, understanding, respect and sympathy.

10. Economic trouble - this is the low social status of the patient, not allowing to cope with the functions in any of the spheres of life or several at the same time. Adaptive abilities of economically dysfunctional families are significantly reduced; the process of curing the sick proceeds with great difficulties.

Scales are grouped into two indicators: “subjective compliance factors” and “objective compliance factors”:

1. Subjective compliance factors

Component scales:

- stress

- Frustration

- stigmatization

- Suggestibility

- Addiction to alcohol

2. Objective compliance factors

Component scales:

- Socio-psychological status

- Adverse reactions to treatment

- Lack of treatment effect

- Unworthy relationships with medical staff

- Economic trouble

Each positive or negative answer that matches the answer in the table corresponds to 1 point. The prevailing scores indicate subjective or objective factors of low compliance and the direction in which psychological or medical assistance is expected.

Claims (1)

A way to increase the effectiveness of treatment for tuberculosis patients, characterized in that they determine the degree of adherence to the patient by questioning using the questionnaire from Appendix 1, which is carried out at the beginning of the main course of treatment, by determining the wall, and after determining the wall, factors that affect the degree are diagnosed adherence, and then determine the prognosis of adherence to treatment: with an amount of 35 points or more - 1-2 walls indicate an unsatisfactory adherence to treatment, with an amount of 16-34 ba la - 3-5 walls indicate satisfactory adherence to treatment, with a sum of 4-15 points - 6-8 walls determine a good adherence to treatment, with a sum of up to 3 points - 9-10 walls determine a high adherence to treatment, with an unfavorable prognosis 1-5 walls are prescribed the immunomodulator cycloferon and methods of psychotherapeutic influence, and also carry out the correction of the chemotherapy regimen by changing the methods of administration of etiotropic drugs, and with satisfactory adherence to treatment, etiotropic drugs are administered parenterally, and with unsatisfactory adherence to treatment, etiotropic drugs are administered parenterally and by inhalation.