Disparities in outcomes associated with rural-urban insurance status in China among inpatient women with stroke: a registry-based cohort study
Disparities in outcomes associated with rural-urban insurance status in China among inpatient women with stroke: a registry-based cohort study
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DOI：
10.21037/atm.2019.08.125
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发表时间：
2019-09-01
影响因子：
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通讯作者：
Wang, Yong-Jun
中科院分区：
文献类型：
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作者：
Gu, Hong-Qiu;Yang, Xin;Wang, Yong-Jun
背景资料：尽管一些研究已经证明了中风护理和结局的性别差异，但有限的研究探讨了与保险相关的结局差异，特别是在女性中风患者中。目的是确定城乡健康保险状况是否影响住院缺血性卒中女性患者的卒中治疗、护理过程和1年临床结局。方法：从中国国家脑卒中登记系统II（CNSR II）中提取新型农村合作医疗（NRCMS）和城镇居民/城镇居民基本医疗保险（URBMI/UEBMI）覆盖的女性急性缺血性脑卒中（AIS）患者。采用考克斯模型中的共享脆弱模型或考虑医院聚集效应的广义估计方程评估城乡保险状况和住院期间的护理质量与1年卒中结局（包括全因死亡、1年复发和1年残疾）之间的关系。对CNSR II中219家医院的5，707例女性患者进行了分析。与URBMI/UEBMI覆盖的2，880名女性患者相比，NRCMS覆盖的2，827名女性患者更年轻（65.7岁对68.9岁），不太可能有血管危险因素，中风前对高血压和血脂异常的认识和治疗。与URBMI/UEBMI覆盖的妇女相比，新农村合作医疗覆盖的妇女更可能接受早期抗血栓药物、出院抗血栓药物、降脂药物，但接受抗高血压药物的可能性更小。与URBMI/UEBMI患者相比，新农村合作医疗女性患者的1年全因死亡率和卒中复发率均显著更高[校正风险比（95%置信区间）：1.40（1.06-1.84）和1.38（1.04-1.83），分别计算]。AIS女性患者城乡参保状况在年龄、脑卒中危险因素、知晓和治疗、护理过程、和1年卒中复发率和死亡率。卫生政策制定者需要关注这些差距，并采取适当措施改善农村地区的初级卫生保健服务。
Background: Despite a few studies have demonstrated sex differences in stroke care and outcomes, limited research has explored insurance-related disparities in outcomes, particularly among women stroke patients. The aim was to determine whether rural-urban health insurance status affect the stroke treatment, process of care, and 1-year clinical outcomes for inpatient ischemic stroke in women.Methods: Women patients with acute ischemic stroke (AIS) covered by New Rural Cooperative Medical Scheme (NRCMS) and urban resident/employee-based basic medical insurance scheme (URBMI/UEBMI) were abstracted from the China National Stroke Registry II (CNSR II). Shared frailty model in the Cox model or generalized estimating equation with consideration of the hospital's cluster effect were used to assess the associations between rural-urban insurance status and quality of care during hospitalization and 1-year stroke outcomes including all-cause death, 1-year recurrence, and 1-year disability.Results: A total of 5,707 women patients enrolled from 219 hospitals in CNSR II were analyzed. Compared with 2,880 women patients covered by URBMI/UEBMI, 2,827 women patients covered by NRCMS were younger (65.7 versus 68.9 years), less likely to have vascular risk factors, awareness and treatment of hypertension and dyslipidemia prior to stroke. Women covered by NRCMS were more likely to receive early antithrombotics, discharge antithrombotics, lipid-lowering drugs, but less likely to receive antihypertensive medication than those covered by URBMI/UEBMI. One-year all-cause mortality and stroke recurrence were both significantly higher in women patients with NRCMS than those with URBMI/UEBMI [ adjusted hazard ratio (95% confidence interval): 1.40 (1.06-1.84) and 1.38 (1.04-1.83), separately].Conclusions: AIS women patients with rural-urban insurance status demonstrated remarkable differences in age, stroke risk factors, awareness and treatment, the process of care, and 1-year stroke recurrence and mortality. Healthcare policymakers need to focus their attention on these disparities and take proper steps to improve primary healthcare service in rural areas.