Piette John D, Wagner Todd H, Potter Michael B, Schillinger Dean
Center for Practice Management and Outcomes Research, VA Ann Arbor Health Care System, Ann Arbor, Michigan 48113-0170, USA.
Med Care. 2004 Feb;42(2):102-9. doi: 10.1097/01.mlr.0000108742.26446.17.
Chronically ill patients often experience difficulty paying for their medications and, as a result, use less than prescribed.
The objectives of this study were to determine the relationship between patients with diabetes' health insurance coverage and cost-related medication underuse, the association between cost-related underuse and health outcomes, and the role of comorbidity in this process.
We used a patient survey with linkage to insurance information and hemoglobin A1C (A1C) test results.
We studied 766 adults with diabetes recruited from 3 Veterans Affairs (VA), 1 county, and 1 university healthcare system.
Main outcomes consisted of self-reported medication underuse as a result of cost, A1C levels, symptom burden, and Medical Outcomes Study 12-Item Short-Form physical and mental functioning scores.
Fewer VA patients reported cost-related medication underuse (9%) than patients with private insurance (18%), Medicare (25%), Medicaid (31%), or no health insurance (40%; P <0.0001). Underuse was substantially more common among patients with multiple comorbid chronic illnesses, except those who used VA care. The risk of cost-related underuse for patients with 3+ comorbidities was 2.8 times as high among privately insured patients as VA patients (95% confidence interval, 1.2-6.5), and 4.3 to 8.3 times as high among patients with Medicare, Medicaid, or no insurance. Individuals reporting cost-related medication underuse had A1C levels that were substantially higher than other patients (P <0.0001), more symptoms, and poorer physical and mental functioning (all P <0.05).
Many patients with diabetes use less of their medication than prescribed because of the cost, and those reporting cost-related adherence problems have poorer health. Cost-related adherence problems are especially common among patients with diabetes with comorbid diseases, although the VA's drug coverage may protect patients from this increased risk.
慢性病患者常常在支付药物费用方面存在困难，因此药物使用量低于医嘱用量。
本研究的目的是确定糖尿病患者的医疗保险覆盖情况与费用相关的药物使用不足之间的关系、费用相关的使用不足与健康结局之间的关联，以及共病在此过程中的作用。
我们采用了一项患者调查，并将其与保险信息及糖化血红蛋白（A1C）检测结果相联系。
我们研究了从3个退伍军人事务部（VA）、1个县和1个大学医疗系统招募的766名成年糖尿病患者。
主要结局包括因费用导致的自我报告的药物使用不足、A1C水平、症状负担以及医疗结局研究简明健康调查12项生理和心理功能评分。
报告因费用导致药物使用不足的VA患者（9%）少于有私人保险的患者（18%）、医疗保险患者（25%）、医疗补助患者（31%）或无医疗保险的患者（40%；P<0.0001）。除了使用VA医疗服务的患者外，药物使用不足在患有多种慢性共病的患者中更为常见。在有3种及以上共病的患者中，有私人保险的患者费用相关使用不足的风险是VA患者的2.8倍（95%置信区间，1.2 - 6.5），在医疗保险、医疗补助或无保险的患者中则高4.3至8.3倍。报告因费用导致药物使用不足的个体的A1C水平显著高于其他患者（P<0.0001），症状更多，生理和心理功能更差（均P<0.05）。
许多糖尿病患者因费用问题药物使用量低于医嘱用量，且那些报告有费用相关依从性问题的患者健康状况较差。费用相关的依从性问题在患有共病的糖尿病患者中尤为常见，不过VA的药物覆盖范围可能使患者免受这种风险增加的影响。
