Ross Joseph S, Bradley Elizabeth H, Busch Susan H
Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine, School of Medicine, Yale University, New Haven, Conn 06520-8088, USA.
JAMA. 2006 May 3;295(17):2027-36. doi: 10.1001/jama.295.17.2027.
More than 45 million individuals in the United States lack health insurance, potentially limiting their access to and use of appropriate health care services. Although the uninsured comprise a range of income levels, little attention has been directed at higher-income uninsured adults and their patterns of care.
To examine whether having higher income attenuates the association between being uninsured and using fewer recommended health care services.
DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional analysis of data from the 2002 Behavioral Risk Factor Surveillance System, drawn from a nationally representative sample of households. Participants were community-dwelling adults (n = 194 943; 50% women) aged 18 to 64 years in 2002.
Self-reported use of screening for cervical, breast, and colorectal cancer; serum cholesterol screening and measurement, aspirin use, and tobacco cessation and weight loss counseling for cardiovascular risk reduction; and serum cholesterol and glycosylated hemoglobin measurement, eye and foot examination, and influenza and pneumococcal vaccination for diabetes management.
Among eligible adults, use of cancer prevention services ranged from 51% for colorectal cancer screening to 88% for cervical cancer screening, while use of cardiovascular risk reduction services ranged from 38% for weight loss counseling to 81% for aspirin use, and use of services for diabetes management ranged from 33% for pneumococcal vaccination to 88% for serum glycosylated hemoglobin measurement. In bivariate analyses, health insurance and annual household income were both strongly associated with use of nearly all examined health care services (P values <.01). Using multivariable analysis, increased annual household income did not significantly increase the likelihood of uninsured compared with insured adults receiving recommended health care services for cancer prevention, cardiovascular risk reduction, or diabetes management (P values >.05).
Even among higher-income adults, lack of health care insurance was associated with significantly decreased use of recommended health care services; increased income did not attenuate the difference in use between uninsured and insured adults. Efforts to improve the use of recommended health care services among the uninsured should focus on patient education and expanding insurance eligibility for both lower-income and higher-income adults.
美国有超过4500万人没有医疗保险，这可能会限制他们获得和使用适当医疗服务的机会。尽管未参保人群涵盖了不同收入水平，但很少有人关注高收入未参保成年人及其就医模式。
研究较高收入是否会减弱未参保与较少使用推荐医疗服务之间的关联。
设计、背景和参与者：对2002年行为危险因素监测系统的数据进行横断面分析，数据来自全国具有代表性的家庭样本。参与者为2002年年龄在18至64岁的社区居住成年人（n = 194943；50%为女性）。
自我报告的宫颈癌、乳腺癌和结直肠癌筛查使用情况；血清胆固醇筛查和测量、阿司匹林使用情况，以及为降低心血管风险进行的戒烟和减肥咨询；以及为糖尿病管理进行的血清胆固醇和糖化血红蛋白测量、眼部和足部检查，以及流感和肺炎球菌疫苗接种。
在符合条件的成年人中，癌症预防服务的使用率从结直肠癌筛查的51%到宫颈癌筛查的88%不等，而降低心血管风险服务的使用率从减肥咨询的38%到阿司匹林使用的81%不等，糖尿病管理服务的使用率从肺炎球菌疫苗接种的33%到血清糖化血红蛋白测量的88%不等。在双变量分析中，医疗保险和家庭年收入与几乎所有检查的医疗服务使用情况都密切相关（P值<.01）。使用多变量分析，与参保成年人相比，家庭年收入增加并未显著增加未参保成年人接受癌症预防、降低心血管风险或糖尿病管理推荐医疗服务的可能性（P值>.05）。
即使在高收入成年人中，缺乏医疗保险也与推荐医疗服务的使用显著减少有关；收入增加并未减弱未参保和参保成年人在医疗服务使用上的差异。改善未参保人群对推荐医疗服务使用情况的努力应侧重于患者教育，并扩大低收入和高收入成年人的保险资格。
