University of Illinois at Chicago, Chicago, IL, USA.
Am Heart J. 2010 Jun;159(6):1026-36. doi: 10.1016/j.ahj.2010.03.013.
Prior studies have documented that patients' health insurance status can impact use of guideline-based care as well as acute outcomes for coronary artery disease. Whether insurance status remains a contemporary influence among centers participating in a national quality improvement initiative is unknown.
We analyzed data from 237,779 admissions with coronary artery disease from 527 hospitals participating in the Get With The Guidelines-Coronary Artery Disease Program from 2000 to 2008. Insurance status was Medicare (48.8%), Private/Health Maintenance Organization (HMO) (34.9%), Medicaid (8.2%), and No Insurance Documented (NID) (8.2%). Quality of care was measured using standard quality indicators covering acute treatment and discharge measures, utilization of invasive procedures, length of stay, and mortality. Relationship between different insurance types was examined using generalized estimating equation logistic regression and propensity-score matching adjusting for demographics, comorbidities and hospital characteristics.
After propensity matching, full compliance with all eligible measures (deficit-free care) relative to Private/HMO was lower for Medicare (P < .0001) and Medicaid (P < .0001) and higher for the NID group (P = .0312). The acute reperfusion times were comparable among the groups. Compared with the Private/HMO group, all three groups had higher generalized estimating equation-adjusted mortality (OR, 1.15; 95% CI, 1.08-1.21; P < .001; OR, 1.18; 95% CI, 1.09-1.29; P < .001 and OR, 1.13; 95% CI, 1.01-1.25; P = .026), for Medicare, Medicaid, and NID, respectively. After propensity matching, mortality for Medicare was similar (P = .1197) and higher for NID (P = .0015) and Medicaid (P = .0015) groups.
These findings suggest that among centers participating in a national quality improvement initiative patient insurance status may be associated with differences in cardiovascular care and outcomes.
先前的研究表明，患者的医疗保险状况可能会影响基于指南的护理的使用以及冠心病的急性结果。在参与全国质量改进计划的中心中，保险状况是否仍然是一个当代影响因素尚不清楚。
我们分析了 2000 年至 2008 年期间，527 家参与 Get With The Guidelines-Coronary Artery Disease 计划的医院的 237779 例冠心病住院患者的数据。保险状况为医疗保险（48.8%）、私人/健康维护组织（HMO）（34.9%）、医疗补助（8.2%）和无保险记录（8.2%）。使用涵盖急性治疗和出院措施、侵入性程序的使用、住院时间和死亡率的标准质量指标来衡量护理质量。使用广义估计方程逻辑回归和倾向评分匹配来检查不同保险类型之间的关系，同时调整人口统计学、合并症和医院特征。
在倾向匹配后，与私人/HMO 相比，医疗保险（P<0.0001）和医疗补助（P<0.0001）的所有合格措施（无缺陷护理）完全合规率较低，而 NID 组较高（P=0.0312）。各组的急性再灌注时间相当。与私人/HMO 组相比，所有三组的广义估计方程调整死亡率均较高（OR，1.15；95%CI，1.08-1.21；P<0.001；OR，1.18；95%CI，1.09-1.29；P<0.001 和 OR，1.13；95%CI，1.01-1.25；P=0.026），分别用于医疗保险、医疗补助和 NID。在倾向匹配后，医疗保险的死亡率相似（P=0.1197），NID（P=0.0015）和医疗补助（P=0.0015）的死亡率较高。
这些发现表明，在参与全国质量改进计划的中心中，患者的保险状况可能与心血管护理和结果的差异有关。
