The Application of Multidisciplinary Cooperative Complete Management Mode in the Management of Multi-Drug Resistant Tuberculosis Patients


 Objective: This study aims to explore the effect of multi-disciplinary cooperative complete management mode in the treatment of multi-drug resistant tuberculosis (MDR-TB).Methods: 280 patients were randomly classified into the observation group (n = 140) and the control group (n = 140). The control group was applied with the routine management mode, while the observation group was applied with the multi-disciplinary cooperative complete management one. The treatment compliance, life quality, treatment completion rate as well as the patient satisfaction in the two groups were observed.Results: The treatment compliance of the observation group was better than that of the control group (P༜0.05). The life quality of the observation group was higher than those of the control group (P༜0.05). The treatment completion rate of the observation group was higher than that of the control group (P༜0.05). The patient satisfaction of the observation group was better than that of the control group (P༜0.05).Conclusion: The application of multi-disciplinary cooperative management mode to MDR-TB patients can enhance their treatment compliance, life quality, treatment completion rate and satisfaction degree.


Introduction
MDR-TB (multi-drug resistant tuberculosis) in China is still stuck in a tough situation due to the lack of uni ed and standardized management for MDR-TB patients in clinical practice, poor treatment compliance, irregular use of medicine, loss to follow-up, treatment refusal and so on1-4. Patients' poor treatment compliance is a major hazardous factor which makes mycobacterium tuberculosis develop resistance to many drugs5. Many patients refuse to doctor's home visits for fear of revealing their privacy, and they nd it is troublesome and burdensome to take medicines under direct supervision, which leads to the implementation obstacle of taking medicine under supervision6. Therefore, more positive management interventions need to be carried out in order to enhance the medication compliance of patients and their awareness rate of relevant knowledge7. Aiming to improve the medicine-taken patients' treatment compliance, achieve an early detection of the adverse drug reactions, enhance patients' life quality, change the unhealthy emotions of caregivers and patients, promote patient satisfaction and reduce the transmission of mycobacterium tuberculosis, our hospital has adopted multi-disciplinary cooperative complete management mode in the treatment of MDR-TB and has obtained a favorable effect. Here is our report.
1 Materials And Methods

General information
This study chose 280 cases of MDR-TB in Zhejiang Integrated Traditional and Western Medicine Hospital between January 2016 to March 2017 and their TB sputum examination was con rmed as (+) on admission. Besides, rifampicin and isoniazid were tested both ineffective to them. Additionally, they suffered from severe hepatic and kidney dysfunction, cardio-cerebrovascular disease and cognitive impairment. Our study was authorized by Hospital Ethics Committee, and agreed by all patients and their dependent.
The above patients were divided into the control group (n = 140) and the observation group (n = 140) by means of random number table. In the control group, there are 82 males and 58 females, ranging from 25 to 65 years old and the average age is (36.12 ± 3.25) years old. In terms of their education level, 83 cases graduated from primary or middle high school, 45 cases were from senior high school and 12 cases have associate and undergraduate or higher degrees. In the observation group, there are 83 males and 57 females, ranging from 26 to 70 years old and the average age is (38.18 ± 3.27) years old. In terms of their education level, 74 cases graduated from primary or middle high school, 51 cases were from senior high school and 15 cases have associate and undergraduate or higher degrees. The general information comparison of the two groups included gender, age, nationality, occupation, education level (P > 0.05). All detailed information is listed in Table 1.

Methods
The control group adopted routine management mode: health propaganda and education, medication management and infection control management were provided during hospitalization. Telephone followup was given after patients were discharged, and community hospital was responsible for the rest of affairs.
The observation group followed the multi-disciplinary cooperative complete management mode: the hospital management team was responsible for during and after the whole process of hospitalization until the completion of the treatment. Speci c operation: (1) A multi-disciplinary cooperative complete management group consists of 2 doctors, 1 duty nurse, 1 specialized nurse of integrated traditional Chinese and western medicine, 1 clinical pharmacist and 1 psychological consultant. Other major caregivers were also invited to the group.
(2) The admission criteria and job responsibilities for each member were made as follow: Doctors: Attending tuberculosis doctors or with higher professional titles who had experience of the treatment and management of MDR-TB patients and who had ever received relevant training were required. Doctors' speci c responsibilities include screening the patients who accorded with the admission criteria, communicating with the patients to obtain their agreement, making the patients' treatment plans and addressing the adverse situations during the process of treatment. Duty nurse: Duty nurses were bedside nurses who were in charge of patients' daily life during their hospitalization. They were responsible for the investigation of TB-related knowledge and infection control knowledge when patients and primary caregivers were admitted to hospital and discharged from hospital. According to the results of the investigation and the knowledge that remained unknown to patients and caregivers, individual and systematic propaganda and education plan were correspondingly made, including adverse drug reaction monitoring, infection control, daily life activities and so on. They also supervised the patients' medicinetaken in person during hospitalization, observed the adverse drug reactions and assisted patients' infection control. In addition, they were involved in the WeChat group for discharged patients and supervised patients to take medicine by video calls every day, informed patients to do reexamination on time through monthly telephone follow-up, observed and dealt with preliminarily patients' adverse reactions and reported to the doctors in charge, offered guidance to discharged patients for infection control during home-base treatment and organized peer support activities. Specialized Nurse of integrated traditional Chinese and western medicine: These nurses were required to implement appropriate Chinese medicine operation technique in line with patients' different symptoms during hospitalization and carried out individual healthy propaganda and education of Chinese medicine. For example, patients with lung yin de ciency syndrome were given auricular-plaster and point-application therapies in order to nourish yin and moisten lung, while sticking therapy was given to improve the common tuberculosis symptoms, such as night sweats and fever. Besides, moxibustion and point massage were applied to address gastric anorexia and gastrointestinal reaction caused by tuberculosis drugs. Discharged patients were provided with knowledge of traditional Chinese medicine and personalized guidance. Clinical pharmacist: The clinical pharmacists had received professional training by our hospital and were mainly responsible for solving the questions and doubts related to the drug e cacy and adverse drug reactions. Psychological consultant: Consultants with a certi cate of psychological consultant and were required to support patients and their chief caregivers psychologically. Patient's primary caregivers: Primary caregivers were taught by duty nurses about the knowledge of medicine precautions, adverse drug reaction symptoms and home infection control. These contents were continuously reinforced during patient's hospitalization and would be tested before discharge. They also supervised patients' daily activities at home after patients were discharged, communicated with nurses or doctors about patients' physical conditions and assisted patients with home infection control.
(3) The basic disease information of patients was obtained and personal information le was established, including name, gender, education, family members, tuberculosis-related knowledge, treatment schemes, treatment course and so on.

Treatment compliance
The treatment compliance was observed between the two groups. Patients in the groups who could take anti-tuberculosis medicine properly and regularly according to the treatment scheme, actively cooperate with the treatment, reexamine regularly on blood routine, hepatic and renal function, CT images of lungs and sputum examination were considered to have good treatment compliance. On the contrary, patients in the groups who failed to do those mentioned above were regarded as having poor treatment compliance.

Evaluation of life quality
Medical Outcomes Study Short-form 36 (MOS SF-36) created by American Medical Institute was adopted to evaluate patients' life quality. The form includes 8 dimensions and 36 items: physiological roles, physiological functions, health conditions, body pain, social functions, vitality, emotional functions, mental health. The total score is ranging from 0 to 100, the higher score shows a better life quality 8 .

Treatment completion rate
Patients' treatment completion rate was observed in terms of whether patients had nished the whole treatment processes or ended the treatment due to adverse drug reactions, treatment failure, lost to follow-up and other aspects (such as returning to their local place for treatment).

Patient satisfaction
The investigation table of satisfaction degree designed by our hospital was adopted to evaluate the mode from ve aspects: very satis ed, satis ed, barely satis ed, okay, not satis ed.

Statistical method
All data were processed by SPSS 22.0 software. The measurement data and enumeration data were analyzed by using t-test and x 2 -test. P < 0.05 was considered statistically signi cant.

Comparison of treatment compliance
Treatment compliance was 87.1% in the observation group and 60.0% in the control group, the differences being statistically signi cant between the two groups (P < 0.001). See Table 2.

Comparison of the improvement of life quality
The score of patients' life quality after treatment in the observation group was (91.03 ± 16.58), while the control group was (72.36 ± 13.08). The life quality in two groups was signi cantly higher than before, and the score of the observation group was signi cantly higher than that of the control group (P < 0.05). See Table 3.

Comparison of treatment completion rate
The treatment completion rate was 95% in the observation group and 72.1% in the control group, the differences being statistically signi cant between the two groups (P < 0.0001). See Table 4.

Comparison of patient satisfaction
Patient satisfaction rate was 97.1% in the observation group and 77.1% in the control group, the differences being statistically signi cant between the two groups (P < 0.05). See Table 5.

Discussion
Patients with tuberculosis are required to take medicine on a full-course and regular basis due to the long courses of tuberculosis with the chronic and delayed features. Besides, the problems of discharged patients' treatment compliance emerged, such as missing doses, stopping taking medicine or missing the re-examination appointments. Compared with the non-drug resistant tuberculosis, treatment of drug resistant tuberculosis (especially multi-drug resistant TB, MDR-TB/extensively drug-resistant TB, XDR-TB) requires more drug combinations, which means lower e cacy, long-course therapy and worse tolerance. On average, only 22-26% of the XDR-TB patients in the world successfully completed anti-tuberculosis therapy 9 . At present, drug resistant tuberculosis has become one of the most important public health issues, which has a negative effect on the global containment of tuberculosis by 2035 and the elimination of tuberculosis by 2050 proposed by World Health Organization (WHO). According to the 2017 Global Tuberculosis Report released by WHO, the incident number of tuberculosis in the world reached 10,400,000 in 2016, among which new cases of MDR-TB and rifampicin drug resistant tuberculosis were 600, 000 and new cases of XDR-TB reached 30, 000 10 . However, the current management mode of MDR-TB patients has hit a bottleneck. For example, it is di cult to improve patients' treatment compliance and completion rate. Therefore, it is very urgent to explore a new management mode to better ensure patients' successful treatment, hence reducing public health hazard.
Multi-disciplinary cooperative complete management mode is realized by a team made up of medical staff from different disciplines and professional background, and it demonstrates a new orientation of exploration and development for medical institutions in China. By means of this mode, multi-faceted nursing knowledge propaganda, education and instructions can be provided for patients, which forms a set of systematic, standardized and comprehensive nursing procedures and aims to improve patients' awareness of their diseases, regulate patients' behavior in order to promote their treatment e cacy and enhance patients' treatment compliance and life quality 11 . The mode always puts patients under the limelight in clinical work and plays a highly important role in improving medical quality as well as patients' satisfaction on condition that patients' medical safety is guaranteed 12 . The application of the team's management on patients with chronic diseases has showed that patients' negative sentiments, life quality can be effectively improved 13 , and transfer treatment and continual care can also be improved 14 .
Consequently, we introduced the mode into the management of MDR-TB patients, which turned out that these patients bene ted a lot from the mode: their treatment compliance, completion rate and life quality were considerably promoted.
Multi-disciplinary cooperative complete management mode presents a new care management mode, which has achieved great application effect overseas. However, there are few domestic researches about this mode 15 . Compared with the conventional nursing pattern of tuberculosis, this mode has the following characteristics: Stage: In terms of in-hospital and out-hospital, patients can be ensured to take medicine on a regular basis and complete the designated treatment course on time; Continuity: The whole nursing process is carried out by the management group which is established upon admission.
The seamless connection makes the nursing care service continual and effective and decreases the potential information leakage; Richness: The establishment of personal les, drug use instructions, regular assessment, health education and so on are added based on nursing care in the mode; Diversity of forms: The forms of follow-up include various ways, such as phone calls, home visits and out-patient clinic follow-up. Multi-media, health booklets and bedside education are contained in health education.
Sending texts, telephone enquiry and on-site supervision are applied to supervise patients taking medicine. The researches by Cao Maotao 16 , Luo Shizhen 17 and Zhang Huayan 18 revealed that multidisciplinary cooperative complete management mode can effectively regulate MDR-TB patients' treatment habits, improve patients' health knowledge level and medication compliance in order to further facilitate the improvement of prognosis, which produces a noticeable curative effect and deserves clinical application and expansion.
Multi-disciplinary cooperative complete management mode is a new model in which multi-disciplinary cooperation and complete management mode are effectively integrated together. Many professional medical staff in the team have complementary backgrounds and skills, and they are encouraged to involve in a dynamic process of collaborating and communicating with each other. In this way, multiple guarantee can be ensured and team members can better meet patients' multi-faceted needs in a more effective, professional and comprehensive manner 19 . In this study, the multi-disciplinary mode could avoid the singleness and poor pertinency of the traditional one and effectively combine the merits of both the new mode and the traditional one so as to optimize its advantages. The application of multidisciplinary cooperative complete management mode in the management of MDR-TB patients provides an interactive platform in which doctors and patients, patients and main caregivers can communicate with each other. Professional nursing care was provided throughout the whole process of treatment, and disease-related knowledge which patients failed to grasp after discharge, and the knowledge of infection control, health education and self-regulation were provided in particular for the purpose of helping patients get continuous, seamless and professional treatment and care, which ultimately aimed to control disease, improve the curative effect as well as life quality.
The establishment of the systematic and coherent procedures of multi-disciplinary cooperative complete management mode has resulted in a practical and workable implementation plan and patient-centered approach. The application of multi-disciplinary collaborative intervention in MDR-TB patients is bene cial to patients' recovery and is worthy of clinical promotion and application. Admittedly, the application of the mode in the management of MDR-TB patients is only a preliminary study. As medical staff with multiple professional backgrounds are required in the mode, which is fairly complicated and needs considerable economic investment. Thus, policy-wise top-level design and a wider, deeper and multicenter study are in urgent need.

Founding
Zhejiang TCM Science and Technology Plan Project (Project No.: 2016za157)