Trachtenberg Aaron J, Dik Natalia, Chateau Dan, Katz Alan
Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada.
Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
Ann Fam Med. 2014 Sep-Oct;12(5):402-7. doi: 10.1370/afm.1683.
Individuals of lower socioeconomic status have higher rates of hospitalization due to ambulatory care-sensitive conditions, particularly chronic obstructive pulmonary disease and asthma. We examined whether differences in patient demographics, ambulatory care use, or physician characteristics could explain this disparity in avoidable hospitalizations.
Using administrative data from the city of Winnipeg, Manitoba, Canada, we identified all adults aged 18 to 70 years with chronic obstructive pulmonary disease or asthma, grouped together as obstructive airway disease. We divided patients into census-derived income quintiles using average household income. We performed a series of multivariate logistic regression analyses to determine how the association of socioeconomic status with the risk of obstructive airway disease-related hospitalizations changed after controlling for blocks of covariates related to patient demographics (socioeconomic status, age, sex, and comorbidity), ambulatory care use (continuity influenza vaccination and specialist referral), and characteristics of the patient's usual physician (eg, payment mechanism, sex, years in practice).
We included 34,741 patients with obstructive airway disease, 729 (2.1%) of whom were hospitalized with a related diagnosis during a 2-year period. Patients having a lower income were more likely to be hospitalized than peers having the highest income, and this effect of socioeconomic status remained virtually unchanged after controlling for every other variable studied. In a fully adjusted model, patients in the lowest income quintile had approximately 3 times the odds of hospitalization relative to counterparts in the highest income quintile (odds ratio = 2.93; 95% confidence limits: 2.19, 3.93).
In the setting of universal health care, the income-based disparity in hospitalizations for respiratory ambulatory care-sensitive conditions cannot be explained by factors directly related to the use of ambulatory services that can be measured using administrative data. Our findings suggest that we look beyond the health care system at the broader social determinants of health to reduce the number of avoidable hospitalizations among the poor.
社会经济地位较低的个体因门诊护理敏感型疾病（尤其是慢性阻塞性肺疾病和哮喘）而住院的比例较高。我们研究了患者人口统计学特征、门诊护理利用情况或医生特征方面的差异是否能够解释这种可避免住院方面的差异。
利用来自加拿大曼尼托巴省温尼伯市的行政数据，我们识别出所有年龄在18至70岁之间患有慢性阻塞性肺疾病或哮喘的成年人，将其归为阻塞性气道疾病组。我们使用家庭平均收入将患者分为根据人口普查得出的收入五分位数组。我们进行了一系列多变量逻辑回归分析，以确定在控制了与患者人口统计学特征（社会经济地位、年龄、性别和合并症）、门诊护理利用情况（连续流感疫苗接种和专科转诊）以及患者的常规医生特征（例如，支付机制、性别、从业年限）相关的协变量组后，社会经济地位与阻塞性气道疾病相关住院风险之间的关联如何变化。
我们纳入了34741例阻塞性气道疾病患者，其中729例（2.1%）在两年期间因相关诊断而住院。收入较低的患者比收入最高的同龄人更有可能住院，并且在控制了所研究的其他所有变量后，社会经济地位的这种影响几乎没有变化。在一个完全调整的模型中，收入最低五分位数组的患者相对于收入最高五分位数组的患者住院几率约为3倍（优势比 = 2.93；95%置信区间：2.19，3.93）。
在全民医疗保健的背景下，基于收入的呼吸道门诊护理敏感型疾病住院差异无法通过与门诊服务利用直接相关且可利用行政数据测量的因素来解释。我们的研究结果表明，我们应超越医疗保健系统，关注更广泛的健康社会决定因素，以减少贫困人群中可避免的住院人数。
