Kisely Stephen, Smith Mark, Lawrence David, Cox Martha, Campbell Leslie Anne, Maaten Sarah
Department of Psychiatry, Community Health and Epidemiology, Dalhousie University, Halifax, NS.
CMAJ. 2007 Mar 13;176(6):779-84. doi: 10.1503/cmaj.060482.
Although universal health care aims for equity in service delivery, socioeconomic status still affects death rates from ischemic heart disease and stroke as well as access to revascularization procedures. We investigated whether psychiatric status is associated with a similar pattern of increased mortality but reduced access to procedures. We measured the associations between mental illness, death, hospital admissions and specialized or revascularization procedures for circulatory disease (including ischemic heart disease and stroke) for all patients in contact with psychiatric services and primary care across Nova Scotia.
We carried out a population-based record-linkage analysis of related data from 1995 through 2001 using an inception cohort to calculate rate ratios compared with the general public for each outcome (n = 215,889). Data came from Nova Scotia's Mental Health Outpatient Information System, physician billings, hospital discharge abstracts and vital statistics. We estimated patients' income levels from the median incomes of their residential neighbourhoods, as determined in Canada's 1996 census.
The rate ratio for death of psychiatric patients was significantly increased (1.34), even after adjusting for potential confounders, including income and comorbidity (95% confidence interval [CI] 1.29-1.40), which was reflected in the adjusted rate ratio for first admissions (1.70, 95% CI 1.67-1.72). Their chances of receiving a procedure, however, did not match this increased risk. In some cases, psychiatric patients were significantly less likely to undergo specialized or revascularization procedures, especially those who had ever been psychiatric inpatients. In the latter case, adjusted rate ratios for cardiac catheterization, percutaneous transluminal coronary angioplasty and coronary artery bypass grafts were 0.41, 0.22 and 0.34, respectively, in spite of psychiatric inpatients' increased risk of death.
Psychiatric status affects survival with and access to some procedures for circulatory disease, even in a universal health care system that is free at the point of delivery. Understanding how these disparities come about and how to reduce them should be a priority for future research.
尽管全民医疗保健旨在实现服务提供的公平性，但社会经济地位仍然影响缺血性心脏病和中风的死亡率以及获得血管重建手术的机会。我们调查了精神状态是否与类似的死亡率上升但手术机会减少的模式相关。我们测量了新斯科舍省所有接受精神科服务和初级保健的患者中，精神疾病、死亡、住院以及循环系统疾病（包括缺血性心脏病和中风）的专科或血管重建手术之间的关联。
我们使用起始队列对1995年至2001年的相关数据进行了基于人群的记录链接分析，以计算与普通公众相比每种结局的率比（n = 215,889）。数据来自新斯科舍省心理健康门诊信息系统、医生账单、医院出院摘要和人口动态统计数据。我们根据加拿大1996年人口普查确定的患者居住社区的中位数收入来估计患者的收入水平。
即使在调整了包括收入和合并症在内的潜在混杂因素后，精神科患者的死亡率比仍显著升高（1.34）（95%置信区间[CI] 1.29 - 1.40），这在首次住院的调整率比中也有所体现（1.70，95% CI 1.67 - 1.72）。然而，他们接受手术的机会与这种增加的风险并不匹配。在某些情况下，精神科患者接受专科或血管重建手术的可能性显著降低，尤其是那些曾是精神科住院患者的人。在后一种情况下，尽管精神科住院患者死亡风险增加，但心脏导管插入术、经皮腔内冠状动脉成形术和冠状动脉搭桥术的调整率比分别为0.4I、0.22和0.34。
即使在提供时免费的全民医疗保健系统中，精神状态也会影响循环系统疾病患者的生存以及获得某些手术的机会。了解这些差异是如何产生的以及如何减少它们应是未来研究的重点。
