Gusmano Michael K, Weisz Daniel, Rodwin Victor G, Lang Jonas, Qian Meng, Bocquier Aurelie, Moysan Veronique, Verger Pierre
The Hastings Center, United States.
International Longevity Center-USA, Columbia University, United States.
Health Policy. 2014 Jan;114(1):31-40. doi: 10.1016/j.healthpol.2013.07.011. Epub 2013 Aug 5.
This paper compares access to primary and specialty care in three metropolitan regions of France: Ile de France (IDF), Nord-Pas-de-Calais (NPC) and Provence-Alpes-Côte d'Azur (PACA); and identifies the factors that contribute to disparities in access to care within and among these regions.
To assess access to primary care, we compare variation among residence-based, age-adjusted hospital discharge rates for ambulatory care sensitive conditions (ASC). To assess access on one dimension of specialty care, we compare residence-based, age-adjusted hospital discharge rates for revascularization - bypass surgery and angioplasty - among patients diagnosed with ischemic heart disease (IHD). In addition, for each region we rely on a multilevel generalized linear mixed effect model to identify a range of individual and area-level factors that affect the discharge rates for ASC and revascularization.
In comparison with other large metropolitan regions, in France, access to primary care is greater in Paris and its surrounding region (IDF) than in NPC but worse than in PACA. With regard to revascularization, after controlling for the burden of IHD, use of services is highest in PACA followed by IDF and NPC. In all three regions, disparities in access are much greater for revascularization than for ASC. Residents of low-income areas and those who are treated in public hospitals have poorer access to primary care and revascularizations. In addition, the odds of hospitalization for ASC and revascularization are higher for men. Finally, people who are treated in public hospitals, have poorer access to primary care and revascularization services than those who are admitted for ASC and revascularization services in private hospitals.
Within each region, we find significant income disparities among geographic areas in access to primary care as well as revascularization. Even within a national health insurance system that minimizes the financial barriers to health care and has one of the highest rates of spending on health care in Europe, the challenge of minimizing these disparities remains.
本文比较了法国三个大都市地区（法兰西岛大区（IDF）、北部加来海峡大区（NPC）和普罗旺斯-阿尔卑斯-蓝色海岸大区（PACA））获得初级和专科医疗服务的情况；并确定导致这些地区内部和之间医疗服务可及性差异的因素。
为评估初级医疗服务的可及性，我们比较了基于居住地、年龄调整后的门诊医疗敏感疾病（ASC）的医院出院率差异。为评估专科医疗服务一个维度的可及性，我们比较了基于居住地、年龄调整后的缺血性心脏病（IHD）患者血管重建术（搭桥手术和血管成形术）的医院出院率。此外，对于每个地区，我们使用多层次广义线性混合效应模型来确定一系列影响ASC和血管重建术出院率的个体和地区层面因素。
与法国其他大都市地区相比，巴黎及其周边地区（IDF）获得初级医疗服务的机会比NPC多，但比PACA差。关于血管重建术，在控制IHD负担后，PACA地区的服务使用率最高，其次是IDF和NPC。在所有三个地区，血管重建术的可及性差异比ASC大得多。低收入地区居民和在公立医院接受治疗的人获得初级医疗服务和血管重建术的机会较差。此外，男性因ASC和血管重建术住院的几率更高。最后，在公立医院接受治疗的人比在私立医院因ASC和血管重建术入院的人获得初级医疗服务和血管重建术的机会更差。
在每个地区内，我们发现地理区域之间在获得初级医疗服务和血管重建术方面存在显著的收入差异。即使在一个将医疗保健的经济障碍降至最低且医疗保健支出率在欧洲名列前茅的国家医疗保险系统中，将这些差异降至最低的挑战依然存在。
