Danchin Nicolas, Neumann Anke, Tuppin Philippe, De Peretti Christine, Weill Alain, Ricordeau Philippe, Allemand Hubert
Department of Coronary Artery Disease, Hôpital Européen Georges Pompidou, Assistance Publique Hôpitaux de Paris and Université René Descartes 5, 20 rue Leblanc, Paris, France.
Circ Cardiovasc Qual Outcomes. 2011 Nov 1;4(6):619-25. doi: 10.1161/CIRCOUTCOMES.111.961193. Epub 2011 Oct 4.
The type of medical coverage in patients with acute myocardial infarction (AMI) may affect their treatment and outcome.
We used the reimbursement database from the French National Health Insurance to determine the impact of full medical coverage (Couverture Médicale Universelle Complémentaire, CMUC), a free supplemental insurance for low-income earners <60 years of age, on treatment and outcomes of patients with AMI. The population comprised consecutive patients <60 years of age hospitalized for AMI from January to June 2006 in France. Of 4939 patients with AMI aged <60 years, 587 (12%) were on the CMUC. CMUC patients were younger, with more prior cardiovascular and comorbid conditions. CMUC and non-CMUC patients were admitted to the same types of institutions, including academic hospitals and private clinics. The use of cardiac catheterization and coronary interventions was similar (adjusted relative risk, 0.97; 95% confidence interval, 0.91-1.05; P=0.45). In-hospital mortality was also comparable (3.1% versus 2.8%, P=0.69). There was no difference in early use of secondary prevention medications after multivariate adjustment. At 30 months, survival and acute coronary syndrome-free survival were lower in CMUC patients (trend, not significant after adjustment). Long-term adherence to statin therapy was lower in CMUC patients (64% versus 77%; adjusted relative risk, 0.82; 95% confidence interval, 0.73-0.92).
Free full coverage for socially deprived people levels inequalities in the acute and midterm treatment of AMI patients. However, full reimbursement per se is not sufficient to ensure optimal patient adherence to secondary prevention medications and may not be enough to prevent an excess of long-term events.
急性心肌梗死（AMI）患者的医保类型可能会影响其治疗及预后。
我们利用法国国家医疗保险的报销数据库，来确定针对60岁以下低收入者的免费补充保险——全民补充医疗保险（CMUC）对AMI患者治疗及预后的影响。研究人群包括2006年1月至6月在法国因AMI住院的连续60岁以下患者。在4939例60岁以下的AMI患者中，587例（12%）参加了CMUC。CMUC患者更年轻，既往心血管疾病及合并症更多。CMUC患者和非CMUC患者入住相同类型的机构，包括学术医院和私立诊所。心脏导管插入术和冠状动脉介入治疗的使用情况相似（调整相对风险为0.97；95%置信区间为0.91 - 1.05；P = 0.45）。住院死亡率也相当（3.1%对2.8%，P = 0.69）。多变量调整后，二级预防药物的早期使用没有差异。在30个月时，CMUC患者的生存率和无急性冠状动脉综合征生存率较低（调整后趋势不显著）。CMUC患者他汀类药物治疗的长期依从性较低（64%对77%；调整相对风险为0.82；95%置信区间为0.73 - 0.92）。
为社会弱势群体提供免费全额保险可缩小AMI患者急性和中期治疗中的不平等。然而，全额报销本身不足以确保患者对二级预防药物的最佳依从性，可能也不足以预防过多的长期事件。
