Social conditions and self-management are more powerful determinants of health than access to care
Social conditions and self-management are more powerful determinants of health than access to care
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DOI：
10.7326/0003-4819-129-5-199809010-00011
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发表时间：
1998-09-01
影响因子：
39.2
通讯作者：
Callahan, LF
中科院分区：
文献类型：
--
作者：
Pincus, T;Esther, R;Callahan, LF
专业组织倡导普及医疗保健，将其作为改善人口健康的主要途径。获得医疗服务是至关重要的急性过程中管理的住院医院，大多数医学教育，研究和培训的设置的结果，但似乎是有限的能力，影响门诊治疗的结果，大多数医疗活动的设置。不同社会经济地位的人在健康方面的差距持续存在并不断扩大，这证明获得保健的机会有限。首先，在普遍享有国民医疗服务的伦敦公务员中，工作分类（一种衡量社会经济地位的指标）比胆固醇水平、血压和吸烟结合起来更能预测心血管死亡。第二，1970年至1980年期间，尽管普及了医疗服务，但英国不同社会经济地位的健康差距扩大了（美国也出现了类似的趋势）。第三，在美国，对于许多疾病的发生来说，高中未完成是比生物因素更大的风险因素，这种关联只能部分地用年龄、种族、性别或吸烟状况来解释。第四，在一项提供最佳护理的临床试验中，正规教育水平预测心血管死亡率优于3年内随机分配到活性药物或安慰剂组。医生及其专业协会进一步认识到普及服务的局限性，可能会加强改善人口健康的努力。
Professional organizations advocate universal access to medical care as a primary approach to improving health in the population. Access to medical services is critical to outcomes of acute processes managed in an inpatient hospital, the setting of most medical education, research, and training, but seems to be limited in its capacity to affect outcomes of outpatient care, the setting of most medical activities. Persistent and widening disparities in health according to socioeconomic status provide evidence of limitations of access to care. First, job classification, a measure of socioeconomic status, was a better predictor of cardiovascular death than cholesterol level, blood pressure, and smoking combined in employed London civil servants with universal access to the National Health Service. Second, disparities in health according to socioeconomic status widened between 1970 and 1980 in the United Kingdom despite universal access (similar trends were seen in the United States). Third, in the United States, noncompletion of high school is a greater risk factor than biological factors for development of many diseases, an association that is explained only in part by age, ethnicity, sex, or smoking status. Fourth, level of formal education predicted cardiovascular mortality better than random assignment to active drug or placebo over 3 years in a clinical trial that provides optimal access to care. Increased recognition of limitations of universal access by physicians and their professional societies may enhance efforts to improve the health of the population.