背景與目的：結核病診斷與治療延遲會影響患者治療結果，也會增加結核病傳染的機率與範圍，因此是結核病防治的重要議題。可惜過去研究大多是以小樣本與使用問卷調查，本研究以健保申報資料分析台灣結核病診斷與治療延遲情形與相關影響因素。
材料與方法：本研究以2005年1月1日至12月31日疾病管制局中央傳染病監測資訊網中登錄痰塗片陽性或痰培養陽性確診個案為主要研究對象，進一步連結比對中央健康保險局全區之門、住診就醫申報資料庫，共獲得5,877位結核病患。病患由第一次因結核病相關呼吸道及結核病徵狀碼診斷至醫療院所就醫日期到被接受結核菌痰檢驗診斷的最早日期之時間間隔定義為醫師診斷延遲(Physician delay)天數；第一次因相關診斷就醫日期到開始接受結核藥物治療日期為健康照護系統延遲(Healthcare system delay)天數。
主要發現：在2005年全國共有6,812位痰檢驗陽性之新確診肺結核病患通報登錄於疾病管制局監測系統，其中有5,877人有健保就醫及藥物治療紀錄。男性病患占70%，居住地65%在新興都會區以上，21%病人領有重大傷病證明。平均就醫12.8次才開始接受結核藥物治療、超過半數病患歷經6家以上之醫療機構，才被診斷出痰陽性肺結核並接受治療。醫師診斷延遲天數之中位數為43天(Inter-quartile range, 7-138天)，醫療照護體系延遲天數之中位數為53天(Inter-quartile range, 12-147天)。長時間診斷和治療延遲與性別、年齡、重大傷病及農漁民身分相關。這與國內江振源醫師於2003年之研究相較，顯著延遲時間超長於該研究。
結論：結核病診斷與治療延遲之情形嚴重，醫療機構延遲長於治療延遲。強化醫療機構診斷結核病之品質與能力具有迫切性。醫師必需具有高警覺性，及早驗痰才能及早正確地診斷結核病。衛生署應盡速整合各委託代檢驗談機構之普及性和痰塗片檢驗品質，並依據此調查現況，協助規劃更適切的防治計劃，以切合醫療機構更有效率妥善遵循正確的流程和治療之需求。

Background: The longer interval between the onset of symptoms and initiation of anti-tuberculosis treatment, the more the people been infected by tuberculosis (TB). TB diagnosis can be delayed when patients postpone seeking care after the onset of symptom (patient delay), or when health providers take more time than required to diagnose patients seeking care (healthcare system delay). Most of previous studies were hospital-based or local studies with small number of patients. Objectives: To investigate healthcare delays in diagnosis and treatment of active TB in Taiwan using claims data of National Health Insurance. Method: Sputum smear or culture positive cases reported to the National TB Notification Registry of the year 2005 were included in this study. All the diagnoses of each health care visit before the date of TB diagnosis confirmed were examined for case by case. Healthcare system delay was defined as the interval between the first date of visit with respiratory-related diagnosis (ICD-9-CM codes 460-519, 780, 783,786 and 787) and the date of which the anti-TB medication was prescribed. If the interval between two dates with respiratory-related diagnosis is longer than two month then it was excluded, cause it would be supposed an another episode. Five TB specialists were asked to confirm the screen logic of these controversial cases to determine the healthcare system delay. The healthcare system delay was longer than two months has been defined as longer delay. Results: There were 5,877 active TB cases reported in 2005 with 60,747 outpatient and 4,086 inpatient visits. The median healthcare system delay is 53 days (Inter-quartile range, 12-147天) . Physicians in clinics had long median delay 42days(Inter-quartile range, 7-138天). About half of the cases had health care system delay were loner. We also found that the delay increased with the age and severe disease of the TB cases. Conclusion: Taiwan implemented the Universal National Health Insurance program since 1995 with coverage rate more than 97% of all citizens. Nevertheless, only 35% and 60% of the active TB began anti-TB treatment within one to two months. More efforts are needed to reduce the healthcare system delay in Taiwan.

1. World Health Organization. Global tuberculosis control: surveillance, planning, financing. WHO report 2007. WHO/HTM/TB/2007.376.
2.Chiang CY, Chang CT, Chang RE, Li CT, Huang RM. Patient and health system delays in the diagnosis and treatment of tuberculosis in Southern Taiwan. Int J Tuberc Lung Dis 2005;9(9):1006-12.
3.Small PM and Fujiwara PI. Management of tuberculosis in the United States. N Engl J Med 2001;345(3):189-200.
4.Ward J, Siskind V and Konstantinos A. Patient and health care system delays in Queensland tuberculosis patients, 1985-1998. Int J Tuberc Lung Dis 2001; 5(11): 1021-7.
5.Farah MG, Rygh JH, Steen TW, Selmer R, Heldalet E, Bjuneal G. Patient and health care system delays in the start of tuberculosis treatment in Norway. BMC Infect Dis 2006; 6: 33.
6.Selvam JM, Wares F, Perumal M.et al. Health-seeking behaviour of new smear-positive TB patients under a DOTS programme in Tamil Nadu, India 2003. Int J Tuberc Lung Dis 2007;11(2): 161-7.
7.Yan F, Tang S, Squire SB et al. Multiple perspectives on diagnosis delay for tuberculosis from key stakeholders in poor rural China: Case study in four provinces. Health Policy 2007;82(2):186-99
8.Werf MJ, Chechulin Y, Yegorova OB et al. Health care seeking behaviour for tuberculosis symptoms in Kiev City, Ukraine. Int J Tuberc Lung Dis 2006; 10(4): 390-5.
9.Theobald S, Tolhurst R and Squire SB. Gender, equity: new approaches for effective management of communicable diseases. Trans R Soc Trop Med Hyg 2006; 100(4):. 299-304.
10.Shargie EB, Morkve O and Lindtjorn B. Tuberculosis case-finding through a village outreach programme in a rural setting in southern Ethiopia:community randomized trial. Bull World Health Organ 2006;84(2): 112-9.
11.Rojpibulstit M, Kanjanakiritamrong J, Chongsuvivatwong V. Patient and health system delays in the diagnosis of tuberculosis in Southern Thailand after health care reform. Int J Tuberc Lung Dis 2006;10(4): 422-8.
12.Okur E, Yilmaz A, Saygi A, Selvi A, Sungun F,Ozturk E, Dabak G. Patterns of delays in diagnosis amongst patients with smear-positive pulmonary tuberculosis at a teaching hospital in Turkey. Clin Microbiol Infect 2006;12(1): 90-2.
13.Kasse Y, Jasseh M, Corrah T, Donkor SA, Antonnio M et al. Health seeking behaviour, health system experience and tuberculosis case finding in Gambians with cough. BMC Public Health 2006; 6: 143.
14.Golub JE, Bur S, Cronin WA et al. Delayed tuberculosis diagnosis and tuberculosis transmission. Int J Tuberc Lung Dis 2006;10(1): 24-30.
15.Gagliotti C, Resi D, Moro ML. Delay in the treatment of pulmonary TB in a changing demographic scenario. Int J Tuberc Lung Dis 2006; 10(3): 305-9.
16.Ohmori M, Ozasa K, Mori T, Wada M et al. Trends of delays in tuberculosis case finding in Japan and associated factors. Int J Tuberc Lung Dis 2005; 9(9): 999-1005.
17.Golub JE, Bur S, Cronin WA et al. Patient and health care system delays in pulmonary tuberculosis diagnosis in a low-incidence state. Int J Tuberc Lung Dis 2005; 9(9): 992-8.
18.dos Santos MA, Albuquerque MF, Ximenes RA et al. Risk factors for treatment delay in pulmonary tuberculosis in Recife, Brazil. BMC Public Health 2005; 5(1): 25.
19.Cheng G, Tolhurst R, Li RZ, Meng QY.Tang S. Factors affecting delays in tuberculosis diagnosis in rural China: a case study in four counties in Shandong Province. Trans R Soc Trop Med Hyg 2005; 99(5): 355-62.
20.Rodger A, Jaffar S, Paynter S et al. Delay in the diagnosis of pulmonary tuberculosis, London, 1998-2000:analysis of surveillance data. BMJ 2003; 326(7395): 909-10.
21.Lewis KE, Stephens C, Shahidi MM, Packe G. Delay in starting treatment for tuberculosis in east London. Commun Dis Public Health 2003; 6(2): 133-8.
22.Rajeswari R, Chandrasekaran V, Suhadev M et al. Factors associated with patient and health system delays in the diagnosis of tuberculosis in South India. Int J Tuberc Lung Dis 2002; 6(9): 789-95.
23.Sherman LF, Fujiwara PI, Cook SV, Bazerman LB, Frieden TR. Patient and health care system delays in the diagnosis and treatment of tuberculosis. Int J Tuberc Lung Dis 1999; 3(12): 1088-95.
24.Long NH, Johansson E, Lonnroth K et al. Longer delays in tuberculosis diagnosis among women in Vietnam. Int J Tuberc Lung Dis 1999;3(5): 388-93.
25.Paynter S, Hayward A, Wilkinson P, Lozewicz S, Coker R. Patient and health service delays in initiating treatment for patients with pulmonary tuberculosis: retrospective cohort study. Int J Tuberc Lung Dis 2004; 8(2): 180-5.
26.Liam CK, Tang BG. Delay in the diagnosis and treatment of pulmonary tuberculosis in patients attending a university teaching hospital. Int J Tuberc Lung Dis 1997; 1(4): 326-32.
27.Nardell EA. Needles in haystacks: diagnosing tuberculosis under low prevalence conditions. Tuber Lung Dis 1996; 77(5): 389-90.
28.Xu B, Jiang QW, Xiu Y, Diwan VK. Perceptions and experiences of health care seeking and access to TB care--a qualitative study in rural Jiangsu Province, China. Health Policy 2004; 69(2): 139-49.
29.Johansson E, Long NH, Diwan VK, Winkvist A. Gender and tuberculosis control: perspectives on health seeking behaviour among men and women in Vietnam. Health Policy 2000; 52(1): 33-51.
30.Pascopella L, Kellam S, Ridderhof J et al. Laboratory reporting of tuberculosis test results and patient treatment initiation in California. J Clin Microbiol 2004; 42(9): 4209-13.
31.Godfrey-Faussett P, Kaunda H, Kamanga J et al. Why do patients with a cough delay seeking care at Lusaka urban health centres? A health systems research approach. Int J Tuberc Lung Dis 2002; 6(9): 796-805.
32.Xu B, Jiang QW, Xiu Y et al. Diagnostic delays in access to tuberculosis care in counties with or without the National Tuberculosis Control Programme in rural China. Int J Tuberc Lung Dis 2005; 9(7): 784-90.
中文部分
陸坤泰、江振源、李仁智等編. 結核病診治指引. 行政院衛生署疾病管制局；2004:1-32.
行政院衛生署. 結核病十年減半全民動員計劃. 行政院衛生署2006
索任. 台灣防癆工作回顧. 感染控制雜誌2003; 13（3）: 173-9.
姜義新、李政益, 行政院衛生署疾病管制局所屬X光巡迴檢查車成本效益分析.(研究成果報告) DOH92-DC-2301. 行政院衛生署疾病管制局2003.
行政院衛生署, 全民健康保險統計動向/2005. http://www.doh.gov.tw/statistic/data/全民健康保險統計動向/2005.htm
劉介宇、洪永泰、莊義利等：台灣地區鄉鎮市區發展類型應用於大型健康調查抽樣設計之研究。健康管理學刊 2006；4(1)：1-22