按种族、族裔和教育程度划分的心血管疾病与糖尿病控制差异：1999年至2006年美国的趋势及医疗保险覆盖范围的影响

Differences in control of cardiovascular disease and diabetes by race, ethnicity, and education: U.S. trends from 1999 to 2006 and effects of medicare coverage.

作者信息

McWilliams J Michael, Meara Ellen, Zaslavsky Alan M, Ayanian John Z

机构信息

Harvard Medical School, Department of Health Care Policy, 180 Longwood Avenue, Boston, MA 02115, USA.

出版信息

Ann Intern Med. 2009 Apr 21;150(8):505-15. doi: 10.7326/0003-4819-150-8-200904210-00005.

DOI:10.7326/0003-4819-150-8-200904210-00005

PMID:19380852

Abstract

BACKGROUND

Efforts to improve the care of cardiovascular disease and diabetes or expand insurance coverage for adults with these conditions may reduce differences in clinical outcomes.

OBJECTIVE

To assess recent national trends in disease control, trends in sociodemographic differences in control, and changes in sociodemographic differences after age 65 years associated with near-universal Medicare coverage.

DESIGN

Observational and quasi-experimental analyses of repeated cross-sectional data.

SETTING

National Health and Nutrition Examination Survey, 1999 to 2006.

PARTICIPANTS

Adults age 40 to 85 years with relevant clinical conditions.

MEASUREMENTS

Blood pressure control (<140/90 mm Hg) and mean systolic blood pressure among adults with hypertension (n = 4521); glycemic control (hemoglobin A(1c) levels <7.0%) and mean hemoglobin A(1c) levels among those with diabetes (n = 1733); and total cholesterol level control (<5.2 mmol/L [<200 mg/dL]) and mean total cholesterol levels among those with coronary heart disease, stroke, or diabetes (n = 2928). Temporal trends in these measures were compared by race, ethnicity, and education, and sociodemographic differences were compared above and below eligibility for Medicare at age 65 years.

RESULTS

Disease control improved significantly between 1999 and 2006 for all 6 measures (P < 0.001). These trends did not differ by race or ethnicity or by education (P > or = 0.185 for group-time interactions), except that white-Hispanic differences in glycemic control widened (P = 0.042). Black-white differences in systolic blood pressure were smaller among adults age 65 to 85 years than among adults age 40 to 64 years (reduction in difference, 4.2 mm Hg; P = 0.009). Black-white differences in hemoglobin A(1c) levels were also smaller after age 65 years (reduction in difference, 0.7%; P = 0.005), as were Hispanic-white differences (reduction in difference, 0.7%; P = 0.007) and differences between less and more educated adults (reduction in difference, 0.5%; P = 0.033).

LIMITATION

Data were cross-sectional, and estimates may have been biased by coincidental events at age 65 years, such as retirement, that may affect disease control.

CONCLUSION

Control of blood pressure and glucose and cholesterol levels has improved since 1999 for adults with cardiovascular disease and diabetes, but racial, ethnic, or socioeconomic differences have not narrowed significantly. Medicare coverage after age 65 years is associated with reductions in these differences.

PRIMARY FUNDING SOURCE

The Commonwealth Fund.

摘要

背景

改善心血管疾病和糖尿病护理的努力，或扩大患有这些疾病的成年人的保险覆盖范围，可能会减少临床结果的差异。

目的

评估近期全国疾病控制趋势、控制方面的社会人口统计学差异趋势，以及65岁以后与近乎全民医保覆盖相关的社会人口统计学差异变化。

设计

对重复横断面数据的观察性和准实验性分析。

设置

1999年至2006年的国家健康与营养检查调查。

参与者

年龄在40至85岁之间患有相关临床疾病的成年人。

测量指标

高血压成年人（n = 4521）的血压控制（<140/90 mmHg）和平均收缩压；糖尿病患者（n = 1733）的血糖控制（糖化血红蛋白A1c水平<7.0%）和平均糖化血红蛋白A1c水平；冠心病、中风或糖尿病患者（n = 2928）的总胆固醇水平控制（<5.2 mmol/L [<200 mg/dL]）和平均总胆固醇水平。按种族、族裔和教育程度比较这些指标的时间趋势，并比较65岁时医保资格上下的社会人口统计学差异。

结果

1999年至2006年期间，所有6项指标的疾病控制均显著改善（P < 0.001）。这些趋势在种族、族裔或教育程度方面没有差异（组-时间交互作用的P >或= 0.185），但西班牙裔白人间的血糖控制差异扩大（P = 0.042）。65至85岁成年人的收缩压黑-白差异小于40至64岁成年人（差异减少4.2 mmHg；P = 0.009）。65岁以后，糖化血红蛋白A1c水平的黑-白差异也较小（差异减少0.7%；P = 0.005），西班牙裔-白人间的差异也是如此（差异减少0.7%；P = 0.007），受教育程度较低和较高的成年人之间的差异也是如此（差异减少0.5%；P = 0.033）。