基于“三位一体”管理体系与传染病全程管理平台的耐药结核病患者主动服务模式应用效果研究

doi:10.19871/j.cnki.xfcrbzz.2026.01.013

新发传染病电子杂志 ›› 2026, Vol. 11 ›› Issue (1): 81-86.doi: 10.19871/j.cnki.xfcrbzz.2026.01.013

基于“三位一体”管理体系与传染病全程管理平台的耐药结核病患者主动服务模式应用效果研究

梁月新¹, 李丽媛², 吕柳英³, 曾艳珍², 张艺², 吴妹², 韦周慧⁴, 刘爱梅⁵, 覃凤喜⁵, 兰宇⁶

1.广西壮族自治区胸科医院科教科,广西柳州 545005;
2.广西壮族自治区胸科医院结核科四病区,广西柳州 545005;
3.广西壮族自治区胸科医院公共卫生科,广西柳州 545005;
4.广西壮族自治区胸科医院结核科二病区,广西柳州 545005;
5.广西壮族自治区胸科医院院办,广西柳州 545005;
6.广西壮族自治区胸科医院信息科,广西柳州 545005

收稿日期:2025-05-18 出版日期:2026-02-28 发布日期:2026-03-16
通讯作者: 梁月新,Email：619311932@qq.com
基金资助:
1.广西壮族自治区科技厅重大专项项目（桂科AA22096027）; 2.广西医疗卫生适宜技术开发与推广应用项目（S2022041）; 3.广西壮族自治区卫生健康委自筹经费科研课题（Z-B20240388）; 4.广西壮族自治区中医药管理局自筹经费科研课题（GXZYB20240287）

Study on the application effect of the active service model for drug-resistant tuberculosis patients based on "trinity-based management system" and the whole-process infectious disease management platform

Liang Yuexin¹, Li Liyuan², Lyu Liuying³, Zeng Yanzhen², Zhang Yi², Wu Mei², Wei Zhouhui⁴, Liu Aimei⁵, Qin Fengxi⁵, Lan Yu⁶

1. Department of Science and Education, Chest Hospital of Guangxi Zhuang Autonomous Region, Guangxi Liuzhou 545005, China;
2. The Fourth Ward of Tuberculosis Department, Chest Hospital of Guangxi Zhuang Autonomous Region, Guangxi Liuzhou 545005, China;
3. Public Health Department, Chest Hospital of Guangxi Zhuang Autonomous Region, Guangxi Liuzhou 545005, China;
4. The Second Ward of Tuberculosis Department, Chest Hospital of Guangxi Zhuang Autonomous Region, Guangxi Liuzhou 545005, China;
5. Administrative Office, Chest Hospital of Guangxi Zhuang Autonomous Region, Guangxi Liuzhou 545005, China;
6. Information Department, Guangxi Chest Hospital, Guangxi Liuzhou 545005, China

Received:2025-05-18 Online:2026-02-28 Published:2026-03-16

摘要/Abstract

摘要： 目的验证基于“三位一体”管理体系与传染病全程管理平台的耐药结核病（drug-resistant tuberculosis,DR-TB）患者主动服务模式的应用效果,为提升DR-TB管理质量提供实践依据。方法采用非随机对照设计,选取广西壮族自治区胸科医院2022年1月至2024年6月收治的130例新发DR-TB患者作为研究对象。2022年1–12月收治的50例新发DR-TB患者为对照组（常规护理）,2023年1月至2024年6月收治的80例新发DR-TB患者为试验组（常规护理+主动服务模式）。主动服务模式依托“平台+短信/微信+人工”实现多主体协同管理,同步制定DR-TB患者督导服药与随访管理流程图,明确全流程节点,规范督导与随访管理。比较两组核心知识知晓率、治疗依从性等指标差异,治疗12月末临床结局指标采用符合方案集（per-protocol set,PPS）进行统计分析。结果最终124例完成研究（试验组76例、对照组48例）。干预1周、出院前1~2d,试验组核心知识知晓率（96.1%、100.0%）及得分[（83.2±4.9）分、（91.8±3.1）分]显著高于对照组[75.0%、81.2%;（69.5±6.0）分、（79.2±4.3）分]（均P<0.001）。PPS分析显示,治疗12月末试验组按时服药率（75.0%）、按时复诊率（81.6%）等指标显著高于对照组（分别为47.9%、58.3%）,失访率（15.8%）等不良结局显著低于对照组（31.2%）（均P<0.05）;耐多药亚组分析显示,试验组痰菌阴转率（88.0%）显著高于对照组（37.5%）,治疗中断率（8.0%）显著低于对照组（37.5%）（均P<0.01）。结论本研究基于“三位一体”管理体系与传染病全程管理平台提出的“平台+短信/微信+人工”DR-TB患者主动服务模式,通过规范督导服药与精准随访流程,可显著改善DR-TB患者的综合管理效果,有效降低失访、治疗中断等不良结局风险,适配基层DR-TB管理场景,具有临床推广价值。

关键词: 三位一体管理体系, 传染病全程管理平台, 耐药结核病, 主动服务模式, 治疗依从性, 痰菌阴转率

Abstract: Objective To verify the application effect of the active service model for drug-resistant tuberculosis (DR-TB) patients based on the trinity management system and the full-course management platform for infectious diseases,and to provide practical basis for improving the quality of DR-TB management. Method A non-randomized controlled trial design was adopted, and a total of 130 newly diagnosed DR-TB patients admitted to Chest Hospital of Guangxi Zhuang Autonomous Region from January 2022 to June 2024 were enrolled as study subjects. Among them, 50 newly diagnosed DR-TB patients admitted from January to December 2022 served as the control group, receiving routine nursing care; 80 newly diagnosed DR-TB patients admitted from January 2023 to June 2024 served as the intervention group, receiving routine nursing care plus the active service model.The active service model relies on“platform +SMS/WeChat+manual work”to achieve multi-subject collaborative management. A flowchart for supervised medication and follow-up management of DR-TB patients was formulated simultaneously,clarifying all process nodes and standardizing supervision and follow-up operations.Differences in core knowledge awareness rate, treatment adherence, and other indicators between the two groups were compared.At the end of the 12th month, the clinical outcome indicators were statistically analyzed based on the Per-Protocol Set (PPS). Result 124 patients completed the study (76 in the intervention group and 48 in the control group). At 1 week after intervention and 1-2 days before discharge, the awareness rate of core knowledge (96.1%,100.0%) and scores (83.2±4.9), (91.8±3.1) in the intervention group were significantly higher than those in the control group [75.0%,81.2%; (69.5±6.0), (79.2±4.3)], with all P<0.001. PPS analysis showed that at the end of 12 months, indicators such as the rate of on-time medication intake (75.0%) and on-time follow-up visits (81.6%) in the intervention group were significantly higher than those in the control group (47.9%,58.3%), while adverse outcomes including the loss to follow-up rate (15.8%) were significantly lower than those in the control group (31.2%), with all P<0.05.In the multidrug-resistant subgroup, the sputum mycobacterial conversion rate in the intervention group (88.0%) was significantly higher than that in the control group (37.5%), and the treatment interruption rate (8.0%) was significantly lower than that in the control group (37.5%), with all P<0.01. Conclusion Based on the trinity management system and the whole-process infectious disease management platform, the active service model for DR-TB patients can significantly improve the comprehensive management outcomes of DR-TB patients and effectively reduce the risks of adverse outcomes such as loss to follow-up and treatment interruption through standardized medication supervision and targeted follow-up processes.It is suitable for the DR-TB management

Key words: Trinity-based management system, Whole-process infectious disease management platform, Drug-resistant tuberculosis, Active service model, Treatment adherence, Sputum mycobacterial conversion rate

中图分类号:

梁月新, 李丽媛, 吕柳英, 曾艳珍, 张艺, 吴妹, 韦周慧, 刘爱梅, 覃凤喜, 兰宇. 基于“三位一体”管理体系与传染病全程管理平台的耐药结核病患者主动服务模式应用效果研究[J]. 新发传染病电子杂志, 2026, 11(1): 81-86.

Liang Yuexin, Li Liyuan, Lyu Liuying, Zeng Yanzhen, Zhang Yi, Wu Mei, Wei Zhouhui, Liu Aimei, Qin Fengxi, Lan Yu. Study on the application effect of the active service model for drug-resistant tuberculosis patients based on "trinity-based management system" and the whole-process infectious disease management platform[J]. Electronic Journal of Emerging Infectious Diseases, 2026, 11(1): 81-86.

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基于“三位一体”管理体系与传染病全程管理平台的耐药结核病患者主动服务模式应用效果研究

Study on the application effect of the active service model for drug-resistant tuberculosis patients based on "trinity-based management system" and the whole-process infectious disease management platform

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