Alter David A, Iron Karey, Austin Peter C, Naylor C David
Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
JAMA. 2004 Mar 3;291(9):1100-7. doi: 10.1001/jama.291.9.1100.
Some have argued that Canada's uniquely restrictive approach to private health insurance keeps the socioeconomic elite inside the public system so that their demands and influence elevate the standard of service for all Canadian citizens. The extent to which this theory is a valid representation of Canadian health care is unknown.
To explore how patients with acute myocardial infarction from different socioeconomic backgrounds perceive their care in Canada's universal health care system and to correlate patients' backgrounds and perceptions with actual care received.
DESIGN, SETTING, AND PATIENTS: Prospective observational cohort study with follow-up telephone interviews of 2256 patients 30 days following acute myocardial infarction discharged from 53 hospitals across Ontario, Canada, between December 1999 and June 2002.
Postdischarge use of cardiac specialty services; satisfaction with care; willingness to pay directly for faster service or more choice; and mortality according to income and education, adjusted for age, sex, ethnicity, clinical factors, onsite angiography capacity at the admitting hospital, and rural-urban residence.
Compared with patients in lower socioeconomic strata, more affluent or better educated patients were more likely to undergo coronary angiography (67.8% vs 52.8%; P<.001), receive cardiac rehabilitation (43.9% vs 25.6%; P<.001), or be followed up by a cardiologist (56.7% vs 47.8%; P<.001). Socioeconomic differences in cardiac care persisted after adjustment for confounders. Despite receiving more specialized services, patients with higher socioeconomic status were more likely to be dissatisfied with their access to specialty care (adjusted RR, 2.02; 95% confidence interval, 1.20-3.32) and to favor out-of-pocket payments for quicker access to a wider selection of treatment options (30% vs 15% for patients with household incomes of Can 60 000 dollars or higher vs less than Can 30 000 dollars, respectively; P<.001). After adjusting for baseline characteristics, socioeconomic status was not significantly associated with mortality at 1 year following hospitalization for myocardial infarction.
Compared with those with lower incomes or less education, upper middle-class Canadians gain preferential access to services within the publicly funded health care system yet remain more likely to favor supplemental coverage or direct purchase of services.
一些人认为，加拿大对私人医疗保险采取的独特限制措施使社会经济精英留在公共医疗体系内，这样他们的需求和影响力提高了所有加拿大公民的服务标准。该理论在多大程度上准确反映了加拿大的医疗保健情况尚不清楚。
探讨来自不同社会经济背景的急性心肌梗死患者如何看待加拿大全民医疗保健系统中的医疗服务，并将患者的背景和看法与实际接受的医疗服务相关联。
设计、地点和患者：前瞻性观察队列研究，对1999年12月至2002年6月期间从加拿大安大略省53家医院出院的2256例急性心肌梗死患者在出院30天后进行电话随访。
出院后心脏专科服务的使用情况；对医疗服务的满意度；愿意直接付费以获得更快服务或更多选择；以及根据收入和教育程度调整后的死亡率，调整因素包括年龄、性别、种族、临床因素、收治医院的现场血管造影能力以及城乡居住情况。
与社会经济地位较低的患者相比，更富裕或受教育程度更高的患者更有可能接受冠状动脉造影（67.8%对52.8%；P<0.001）、接受心脏康复治疗（43.9%对25.6%；P<0.001）或由心脏病专家进行随访（56.7%对47.8%；P<0.001）。在对混杂因素进行调整后，心脏护理方面的社会经济差异仍然存在。尽管接受了更多的专科服务，但社会经济地位较高的患者更有可能对获得专科护理不满意（调整后的相对危险度为2.02；95%置信区间为1.20 - 3.32），并且更倾向于自掏腰包以更快地获得更多治疗选择（家庭收入6万加元或更高的患者为30%，而家庭收入低于3万加元的患者为15%；P<0.001）。在对基线特征进行调整后，社会经济地位与心肌梗死住院1年后的死亡率无显著关联。
与收入较低或受教育程度较低的人相比，加拿大中上层阶级在公共资助的医疗保健系统中更容易获得优先服务，但他们仍然更倾向于补充保险或直接购买服务。
