老年人多种慢性病共存生存中无社会经济梯度。
Absence of a Socioeconomic Gradient in Older Adults' Survival with Multiple Chronic Conditions.
机构信息
Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, 4th Floor, Toronto, Ontario M5T 3M6, Canada.
Institute for Clinical Evaluative Sciences, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada; Schools of Pharmacy and Public Health & Health Systems, University of Waterloo, 200 University Avenue West, Waterloo, Ontario, N2L 3G1, Canada.
出版信息
EBioMedicine. 2015 Nov 18;2(12):2094-100. doi: 10.1016/j.ebiom.2015.11.018. eCollection 2015 Dec.
BACKGROUND
Individuals of low socioeconomic status experience a disproportionate burden of chronic conditions; however it is unclear whether chronic condition burden affects survival differently across socioeconomic strata.
METHODS
This retrospective cohort study used health administrative data from all residents of Ontario, Canada aged 65 to 105 with at least one of 16 chronic conditions on April 1, 2009 (n = 1,518,939). Chronic condition burden and unadjusted mortality were compared across neighborhood income quintiles. Multivariable Cox proportional hazards models were used to examine the effect of number of chronic conditions on two-year survival across income quintiles.
FINDINGS
Prevalence of five or more chronic conditions was significantly higher among older adults in the poorest neighborhoods (18.2%) than the wealthiest (14.3%) (Standardized difference > 0·1). There was also a socioeconomic gradient in unadjusted mortality over two years: 10.1% of people in the poorest neighborhoods died compared with 7.6% of people in the wealthiest neighborhoods. In adjusted analyses, having more chronic conditions was associated with a statistically significant increase in hazard of death over two years, however the magnitude of this effect was comparable across income quintiles. Individuals in the poorest neighborhoods with four chronic conditions had 2.07 times higher hazard of death (95% CI: 1.97-2.19) than those with one chronic condition, but this was comparable to the hazard associated with four chronic conditions in the wealthiest neighborhoods (HR: 2.29, 95% CI: 2.16-2.43).
INTERPRETATION
Among older adults with universal access to health care, the deleterious effect of increasing chronic condition burden on two-year hazard of death was consistent across neighborhood income quintiles once baseline differences in condition burden were accounted for. This may be partly attributable to equal access to, and utilization of, health care. Alternate explanations for these findings, including study limitations, are also discussed.
背景
社会经济地位较低的个体承受着不成比例的慢性病负担；然而，尚不清楚慢性病负担对不同社会经济阶层的生存影响是否不同。
方法
本回顾性队列研究使用了来自加拿大安大略省所有年龄在 65 至 105 岁之间的居民的健康管理数据，这些居民在 2009 年 4 月 1 日至少患有 16 种慢性疾病中的一种（n=1,518,939）。在社区收入五分位数之间比较了慢性病负担和未经调整的死亡率。使用多变量 Cox 比例风险模型检查了在收入五分位数中，慢性疾病数量对两年生存率的影响。
结果
在最贫困社区（18.2%）的老年人中，患有五种或更多种慢性疾病的比例明显高于最富裕社区（14.3%）（标准化差异>0.1）。在两年内未经调整的死亡率方面，也存在社会经济梯度：最贫困社区中有 10.1%的人死亡，而最富裕社区中有 7.6%的人死亡。在调整后的分析中，患有更多的慢性疾病与两年内死亡的风险显著增加相关，然而，这种影响的幅度在收入五分位数之间是可比的。患有四种慢性疾病的最贫困社区的个体死亡风险是患有一种慢性疾病的个体的 2.07 倍（95%CI：1.97-2.19），但这与最富裕社区中与四种慢性疾病相关的死亡风险（HR：2.29，95%CI：2.16-2.43）相当。
解释
在普遍获得医疗保健的老年人中，一旦考虑到基线条件负担的差异，增加慢性病负担对两年内死亡风险的不利影响在社区收入五分位数之间是一致的。这可能部分归因于对医疗保健的平等获取和利用。还讨论了这些发现的其他解释，包括研究的局限性。
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