Treatment differences by health insurance among outpatients with coronary artery disease: insights from the national cardiovascular data registry.
Treatment differences by health insurance among outpatients with coronary artery disease: insights from the national cardiovascular data registry.
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DOI：
10.1016/j.jacc.2012.11.058
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发表时间：
2013-03-12
影响因子：
24
通讯作者：
Chan, Paul S.
中科院分区：
文献类型：
--
作者：
Smolderen, Kim G.;Spertus, John A.;Tang, Fengming;Oetgen, William;Borden, William B.;Ting, Henry H.;Chan, Paul S.
比较不同保险状态下与药物治疗相关的冠状动脉疾病（CAD）护理的5项护理质量指标的治疗率。在NCDR的PINNACLE登记研究中，我们从30个美国诊所中确定了60，814名CAD门诊患者。以实习地点为随机效应的分层修正泊松回归模型被用来研究健康保险（无保险、公共或私人健康保险）与5项CAD质量指标之间的关联。在60，814名患者中，5716名（9.4%）患者没有保险，11，962名（19.7%）患者有公共保险，而43，136名（70.9%）患者有私人保险。排除后，未投保的CAD患者接受β受体阻滞剂、ACE-I/ARB和降脂治疗的可能性分别比私人保险患者低9%、12%和6%，而公共保险患者接受ACE-I/ARB治疗的可能性低9%。在调整了提供护理的网站后，保险状态的大多数差异都有所减弱。例如，未投保的左心室功能不全和CAD患者接受ACE-I/ARB治疗的可能性较低（未校正RR= 0. 88; 95% CI 0. 84 - 0. 93），在调整部位后，这种差异被消除（校正RR= 0. 95; 95% CI 0. 88 - 1. 03; P= 0. 18）。在这项国家门诊心脏登记中，未投保的患者不太可能接受基于证据的CAD药物治疗。这些差异是由提供护理的网站解释的。努力减少心脏门诊患者之间的保险状态的治疗差异，可能还需要重点提高高比例的未投保患者的网站的循证治疗率。
To compare treatment rates by insurance status for 5 quality-of-care indicators for coronary artery disease (CAD) care related to medication treatment. Within the NCDR's PINNACLE Registry, we identified 60,814 outpatients with CAD from 30 U.S. practices. Hierarchical modified Poisson regression models with practice site as a random effect were used to study the association between health insurance (no insurance, public or private health insurance) and 5 CAD quality measures. Of 60,814 patients, 5716 (9.4%) patients were uninsured and 11,962 (19.7%) had public insurance, whereas 43,136 (70.9%) were privately insured. After accounting for exclusions, uninsured patients with CAD were 9%, 12%, and 6% less likely to receive treatment with beta-blocker, ACE-I/ARB, and lipid lowering therapy, respectively, than privately insured patients, whereas patients with public insurance were 9% less likely to be prescribed ACE-I/ARB therapy. Most differences by insurance status were attenuated after adjusting for the site providing care. For example, whereas uninsured patients with left ventricular dysfunction and CAD were less likely to receive ACE-I/ARB therapy (unadjusted RR=0.88; 95% CI 0.84-0.93), this difference was eliminated after adjustment for site (adjusted RR=0.95; 95% CI 0.88-1.03; P=0.18). Within this national outpatient cardiac registry, uninsured patients were less likely to receive evidence-based medications for CAD. These disparities were explained by the site providing care. Efforts to reduce treatment differences by insurance status among cardiac outpatients may additionally need to focus on improving rates of evidence-based treatment at sites with high proportions of uninsured patients.
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