鼻鼽中医临床路径实施的临床疗效与可行性评价研究
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摘要
目的
变应性鼻炎(allergic rhinitis, AR)在耳鼻咽喉科是一种常见病,中医学属于鼻鼽范畴。中医治疗本病从理论到治疗方法日益丰富,在临床取得了令人满意的效果。广州中医药大学第一附属医院为规范化治疗,提高疗效和医疗品质,降低病人的医疗费用,制订了鼻鼽中医临床路径。本课题在多家医院尝试性实施鼻鼽中医临床路径方案,对其临床疗效、实施效果和可行性进行评价,旨在揭示中医药治疗本病的主要特色和关键优势所在,进一步推动中医药临床疗效评价的客观化和规范化研究提供临床证据。
方法
本研究通过非同期收集的非路径组(分为西药组和脱敏组),与在广州中医药大学第一附属医院等7家医院实施临床路径的路径组的进行比较。主要从临床疗效、医疗费用、实施情况、地区因素、变异因素、患者满意度等几个方面对其可行性进行评价。
结果
1.路径组治疗前后的症状积分有显著降低(P<0.01),且停药一个月后,症状积分较治疗前(P<0.01)和治疗结束时均有减低(P>0.05),西药组停药一个月后积分有升高(P<0.01),且高于路径组的积分(P<0.01),路径组疗效明显优于西药组(P<0.01)；路径组结束时和停药1个月时有效率,与脱敏组1个月疗效、3个月疗效、1年疗效相比,路径组结束时和停药1个月时有效率明显优于脱敏组各时段的积分(P<0.01)。
2.路径组和西药组总费用显著低于脱敏组,有统计学意义。在路径组内,中药治疗费明显高于中医特色医疗费,有统计学意义。路径组中药费+中医特色医疗费、西药组治疗费明显低于脱敏组治疗费,有统计学意义。路径组、西药组的检查费明显低于脱敏组,有统计学意义。
3.北京患者证型的统计显示,其中脾气虚弱证最多,其次是肺气虚寒证20例,肺经伏热证,最少是肾阳不足证。最多和最少的证型有差异,北京地区与总样本的中医证型构成存在一定差异。发现脾气虚弱证、肺气虚寒证、肺经伏热证三证明显有习惯饮食偏好。其中,肺气虚寒证者中有吸烟习惯者最多,脾气虚弱证者中对冷食抗拒者最多,肺经伏热证者中辛辣食品习惯者最多,其次是饮酒。
4.路径组中100%使用了中药汤剂或中成药和滴鼻剂,使用1种中医特色方法的占38.8%,使用2种中医特色方法的占48.1%,使用3种9.4%,使用中医特色疗法的占95.3%,应用较多的依次是针刺法、贴敷、灸法。通过中医临床路径的实施,中医特色疗法的使用得到了推广和规范的使用。
5.在临床路径实施中,变异情况统计结果显示,与本路径实施有关的仅4例,其中2名因不耐受口服中药退出路径,2名无法坚持中医特色疗法中途退出路径。
6.患者基本上对治疗费用、治疗疗程、诊疗服务都很满意,患者反馈建议缩短来院次数。
结论
1.本研究证明鼻鼽中医临床路径的实施除了能改善典型症状外,还能改善患者的体质,远期疗效明显优于西药治疗,降低不良反应,费用合理,有性价比高,患者接受度高,体现了中医整体辩证论治的优势特色和“治未病”的思想。
2.实施本路径时应考虑地域因素,调节饮食结构,减少辛辣、烟酒的摄入。因此本路径应结合当地特点完善实施。
3.通过中医临床路径的实施,中医特色疗法的使用得到了推广和规范化使用。
This research is to evaluate the TCM (Traditional Chinese Medicine)clinical pathway of allergic rhinitis.It is consist of clinical effect, result and feasibility. With this research we can offer more clinical proof that can make TCM curative effect objectively and standardization. Research method, result, conlusion
Research method:
Patients are observerd in7hospitals including the First Affiiated Hospital of Guangzhou University of TCM and so on. All patients are divided to clinical pathway group and non-clinical pathway group. The non-clinical pathway group is also divded into western medicine group and desensitization group.The factors are consited of curative effect, medical cost, executive information and variation agents.We especially put more emphasis on clinical pathway group in Beijing about TCM pattern of syndrome and favor. With these data we also evaluate the regional disparity effect on clinical pathway.
Result
1Clinical curative effect
After treatment with clinical pathway or non-clinical pathway, the main symptoms and secondary symptoms disappeare largely (P<0.05or P<0.01). After one month with no treatmen, the accumulated points of clinical pathway group still decrease but it make no sense (P>0.05) when contrast with the accumulated points after treatment. The accumulated points of non-clinical pathway group increased greatly (P<0.01) when contrast with the accumulated points after treatment and clinical pathway group. So the curative effect of clinical pathway group is better than that of non-clinical pathway group(P<0.01). And the result is same even after1month,3monthes and1year when contrast with the desensitization group(P<0.01).
2Medical cost
The medical cost of clinical pathway group and western medicine group is greatly lower than the desensitization group(P<0.05)and so it is with the cost of examination.In clinical pathway group the cost of Chinese crude drug is higher than feature heath care cost (P<0.01).
2The pattern of syndrome
In our study we find out that most patients are belonged to deficiency-weakness of spleen-QI, then insufficieny of lung-QI, latent pyrexia of lung meridian. The least is the pattern of insufficiency of kidney yang. There is variance between the pattern of deficiency-weakness of spleen-QI and the pattern of insufficiency of kidney-yang. The pattern composition in Beijing is different with all the sample. Food hobby is clearly related with deficiency-weakness of spleen-QI, insufficieny of lung-QI and latent pyrexia of lung meridian.
Most patients of deficiency-weakness of spleen-QI like smoking. Patients with eficiency-weakness of spleen-QI did not like cold drinks and snacks. Patients of latent pyrexia of lung meridian like spicy food better than wine
4The TCM clinical pathway effect
All the patients in TCM clinical pathway of allergic rhinitis are treated with Chinese crude drug or Chinese formulated drugs, nasal drops. The percentage of patients treated wih one acupuncture is38.8%, two acupuncture treatment48.1%and three acupuncture treatment9.4%. The summary of acupuncture treatment is95.3%. It is composed of needling, spreading and moxibustion. When clinical pathway is applied to patients, feature treatments are used more widely and standardizedly.
5The sign off of patients
Only4patients in clinical pathway group give up.Two patients can not take oral Chinese medicine. The other two can not go on because of feature treatments
6The curative effect
All the patients are satisfied with the manage expense, time of therapy and the diagnose and treatment service. They also expect they can see the doctor less time.
Conclusion
1The TCM clinical pathway of allergic rhinitis can not only cure typical symptom but also can improve patients substances. That is the reason why patients can still feel good even when they terminate treatment.
2The cost of clinical pathway group is lower than desensitization group. With the same cost, the curative effect of clinical pathway group is better than western medicine group.
3The region factor should be considered in clinical pathway. In Beijing we should suggest patients with less spicy food, no drinking and no smoking.
4When clinical pathway is applied to patients.feature treatments are used more widely and standardizedly.
5When clinical pathway is applied into practice, we should optimize based on patients requirements. Then we can use less cost and less time to help patients.
变应性鼻炎(allergic rhinitis, AR)在耳鼻咽喉科是一种常见病,中医学属于鼻鼽范畴。中医治疗本病从理论到治疗方法日益丰富,在临床取得了令人满意的效果。广州中医药大学第一附属医院为规范化治疗,提高疗效和医疗品质,降低病人的医疗费用,制订了鼻鼽中医临床路径。本课题在多家医院尝试性实施鼻鼽中医临床路径方案,对其临床疗效、实施效果和可行性进行评价,旨在揭示中医药治疗本病的主要特色和关键优势所在,进一步推动中医药临床疗效评价的客观化和规范化研究提供临床证据。
方法
本研究通过非同期收集的非路径组(分为西药组和脱敏组),与在广州中医药大学第一附属医院等7家医院实施临床路径的路径组的进行比较。主要从临床疗效、医疗费用、实施情况、地区因素、变异因素、患者满意度等几个方面对其可行性进行评价。
结果
1.路径组治疗前后的症状积分有显著降低(P<0.01),且停药一个月后,症状积分较治疗前(P<0.01)和治疗结束时均有减低(P>0.05),西药组停药一个月后积分有升高(P<0.01),且高于路径组的积分(P<0.01),路径组疗效明显优于西药组(P<0.01)；路径组结束时和停药1个月时有效率,与脱敏组1个月疗效、3个月疗效、1年疗效相比,路径组结束时和停药1个月时有效率明显优于脱敏组各时段的积分(P<0.01)。
2.路径组和西药组总费用显著低于脱敏组,有统计学意义。在路径组内,中药治疗费明显高于中医特色医疗费,有统计学意义。路径组中药费+中医特色医疗费、西药组治疗费明显低于脱敏组治疗费,有统计学意义。路径组、西药组的检查费明显低于脱敏组,有统计学意义。
3.北京患者证型的统计显示,其中脾气虚弱证最多,其次是肺气虚寒证20例,肺经伏热证,最少是肾阳不足证。最多和最少的证型有差异,北京地区与总样本的中医证型构成存在一定差异。发现脾气虚弱证、肺气虚寒证、肺经伏热证三证明显有习惯饮食偏好。其中,肺气虚寒证者中有吸烟习惯者最多,脾气虚弱证者中对冷食抗拒者最多,肺经伏热证者中辛辣食品习惯者最多,其次是饮酒。
4.路径组中100%使用了中药汤剂或中成药和滴鼻剂,使用1种中医特色方法的占38.8%,使用2种中医特色方法的占48.1%,使用3种9.4%,使用中医特色疗法的占95.3%,应用较多的依次是针刺法、贴敷、灸法。通过中医临床路径的实施,中医特色疗法的使用得到了推广和规范的使用。
5.在临床路径实施中,变异情况统计结果显示,与本路径实施有关的仅4例,其中2名因不耐受口服中药退出路径,2名无法坚持中医特色疗法中途退出路径。
6.患者基本上对治疗费用、治疗疗程、诊疗服务都很满意,患者反馈建议缩短来院次数。
结论
1.本研究证明鼻鼽中医临床路径的实施除了能改善典型症状外,还能改善患者的体质,远期疗效明显优于西药治疗,降低不良反应,费用合理,有性价比高,患者接受度高,体现了中医整体辩证论治的优势特色和“治未病”的思想。
2.实施本路径时应考虑地域因素,调节饮食结构,减少辛辣、烟酒的摄入。因此本路径应结合当地特点完善实施。
3.通过中医临床路径的实施,中医特色疗法的使用得到了推广和规范化使用。
This research is to evaluate the TCM (Traditional Chinese Medicine)clinical pathway of allergic rhinitis.It is consist of clinical effect, result and feasibility. With this research we can offer more clinical proof that can make TCM curative effect objectively and standardization. Research method, result, conlusion
Research method:
Patients are observerd in7hospitals including the First Affiiated Hospital of Guangzhou University of TCM and so on. All patients are divided to clinical pathway group and non-clinical pathway group. The non-clinical pathway group is also divded into western medicine group and desensitization group.The factors are consited of curative effect, medical cost, executive information and variation agents.We especially put more emphasis on clinical pathway group in Beijing about TCM pattern of syndrome and favor. With these data we also evaluate the regional disparity effect on clinical pathway.
Result
1Clinical curative effect
After treatment with clinical pathway or non-clinical pathway, the main symptoms and secondary symptoms disappeare largely (P<0.05or P<0.01). After one month with no treatmen, the accumulated points of clinical pathway group still decrease but it make no sense (P>0.05) when contrast with the accumulated points after treatment. The accumulated points of non-clinical pathway group increased greatly (P<0.01) when contrast with the accumulated points after treatment and clinical pathway group. So the curative effect of clinical pathway group is better than that of non-clinical pathway group(P<0.01). And the result is same even after1month,3monthes and1year when contrast with the desensitization group(P<0.01).
2Medical cost
The medical cost of clinical pathway group and western medicine group is greatly lower than the desensitization group(P<0.05)and so it is with the cost of examination.In clinical pathway group the cost of Chinese crude drug is higher than feature heath care cost (P<0.01).
2The pattern of syndrome
In our study we find out that most patients are belonged to deficiency-weakness of spleen-QI, then insufficieny of lung-QI, latent pyrexia of lung meridian. The least is the pattern of insufficiency of kidney yang. There is variance between the pattern of deficiency-weakness of spleen-QI and the pattern of insufficiency of kidney-yang. The pattern composition in Beijing is different with all the sample. Food hobby is clearly related with deficiency-weakness of spleen-QI, insufficieny of lung-QI and latent pyrexia of lung meridian.
Most patients of deficiency-weakness of spleen-QI like smoking. Patients with eficiency-weakness of spleen-QI did not like cold drinks and snacks. Patients of latent pyrexia of lung meridian like spicy food better than wine
4The TCM clinical pathway effect
All the patients in TCM clinical pathway of allergic rhinitis are treated with Chinese crude drug or Chinese formulated drugs, nasal drops. The percentage of patients treated wih one acupuncture is38.8%, two acupuncture treatment48.1%and three acupuncture treatment9.4%. The summary of acupuncture treatment is95.3%. It is composed of needling, spreading and moxibustion. When clinical pathway is applied to patients, feature treatments are used more widely and standardizedly.
5The sign off of patients
Only4patients in clinical pathway group give up.Two patients can not take oral Chinese medicine. The other two can not go on because of feature treatments
6The curative effect
All the patients are satisfied with the manage expense, time of therapy and the diagnose and treatment service. They also expect they can see the doctor less time.
Conclusion
1The TCM clinical pathway of allergic rhinitis can not only cure typical symptom but also can improve patients substances. That is the reason why patients can still feel good even when they terminate treatment.
2The cost of clinical pathway group is lower than desensitization group. With the same cost, the curative effect of clinical pathway group is better than western medicine group.
3The region factor should be considered in clinical pathway. In Beijing we should suggest patients with less spicy food, no drinking and no smoking.
4When clinical pathway is applied to patients.feature treatments are used more widely and standardizedly.
5When clinical pathway is applied into practice, we should optimize based on patients requirements. Then we can use less cost and less time to help patients.
引文
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