Haider Aamir, Mamdani Muhammad, Shaw James C, Alter David A, Shear Neil H
Division of Dermatology, University of Toronto, Toronto, Ontario, Canada.
J Am Acad Dermatol. 2006 Feb;54(2):331-5. doi: 10.1016/j.jaad.2005.03.029.
Canada's universal health care system is designed to ensure equitable access to medical care based on need rather than socioeconomic status, although a number of studies indicate a preferential access and greater use of specialist services for those patients in higher socioeconomic groups.
The primary objective of this study was to determine whether socioeconomic status influences access to specialist care by a dermatologist for the management of acne in Ontario, Canada. A secondary objective was to determine whether the urban-rural dwelling status of patients affects access to specialty care.
We conducted a population-based cohort study using administrative health care databases covering more than 12 million residents of Ontario. Individuals age 12 to 27 years with a new diagnosis of acne by a general practitioner were identified as belonging to 1 of 5 socioeconomic groups based on median annual neighborhood household income. Patients were then observed for 2 years after the index visit to identify visits to a dermatologist. The main outcome measure was visitation to a dermatologist within 2 years of an initial diagnosis of acne.
The study cohort consisted of 295,469 patients given a diagnosis of acne by their primary care physician of which 59,799 (20%) were subsequently referred to a dermatologist. Of those in the lowest income group of less than Can dollars 20,000, 17% were referred to a dermatologist, as compared with 24% in the highest income group of greater than Can dollars 80,000 (P value for trend < .001). Furthermore, patients living in an urban area had a 43% greater likelihood of being referred to a dermatologist (odds ratio 1.43, 95% confidence interval 1.39-1.48) as compared with patients in a rural location.
Limitations of our study include imputing socioeconomic status of patients on the basis of median income at the neighborhood level rather than on the basis of data on individual patients. Furthermore, our use of administrative databases did not allow us to characterize the severity of acne in our population cohort and whether that would affect referral patterns.
Within Canada's universal health care system, those likely to be in lower socioeconomic groups are significantly less likely to visit a dermatologist for specialist consultation.
加拿大的全民医疗保健系统旨在确保根据需求而非社会经济地位公平获得医疗服务，尽管多项研究表明，社会经济地位较高的患者能优先获得并更多地使用专科服务。
本研究的主要目的是确定社会经济地位是否会影响加拿大安大略省痤疮患者获得皮肤科医生专科护理的机会。次要目的是确定患者的城乡居住状况是否会影响获得专科护理的机会。
我们利用涵盖安大略省1200多万居民的行政医疗保健数据库进行了一项基于人群的队列研究。根据社区家庭年收入中位数，将12至27岁被全科医生新诊断为痤疮的个体确定为5个社会经济群体之一。在索引就诊后对患者进行2年观察，以确定其是否就诊于皮肤科医生。主要结局指标是在痤疮初诊后2年内就诊于皮肤科医生。
该研究队列包括295469名被初级保健医生诊断为痤疮的患者，其中59799名（20%）随后被转诊至皮肤科医生处。收入低于20000加元的最低收入组中，17%的患者被转诊至皮肤科医生处，而收入高于80000加元的最高收入组中这一比例为24%（趋势P值<0.001）。此外，与农村地区的患者相比，城市地区的患者被转诊至皮肤科医生处的可能性高43%（优势比1.43，95%置信区间1.39 - 1.48）。
我们研究的局限性包括根据社区层面的收入中位数而非个体患者数据来推断患者的社会经济地位。此外，我们使用行政数据库无法描述我们人群队列中痤疮的严重程度以及这是否会影响转诊模式。
在加拿大的全民医疗保健系统中，社会经济地位较低的人群就诊于皮肤科医生进行专科咨询的可能性显著较低。
