Saunders Milda R, Ricardo Ana Catherine, Chen Jinsong, Chin Marshall H, Lash James P
University of Chicago Medicine, 5841 S. Maryland, MC 5000, Chicago, IL, 60637, USA.
University of Illinois at Chicago, 820 Wood St, MC 793, Chicago, IL, 60612, USA.
BMC Nephrol. 2016 Mar 9;17:27. doi: 10.1186/s12882-016-0239-1.
In the general population, the association between uninsurance and mortality is well established. We sought to evaluate the association of health insurance status with mortality among working-age participants with albuminuria in the Third National Health and Nutrition Examination Survey, 1988-1994 (NHANES III).
We used data from non-elderly adult participants (18-64) of NHANES III (1988-1994), a nationally representative study of the US civilian, noninstitutionalized population, who provided information on insurance and who had albuminuria, defined as a urine albumin-to-creatinine ratio [UACR] ≥ 30 mg/g and their subsequent mortality to December 31, 2006. Cox proportional hazards models were used to determine associations between insurance status and all-cause mortality and cardiovascular mortality in patients with CKD while adjusting in a stepwise fashion for sociodemographic factors, co-morbidities, and co-morbidity severity/control covariates.
In our sample of individuals with albuminuria (n = 903), mean estimated glomerular filtration rate (eGFR) was 101.6 ml/min/1.73 m(2) with 4.7 % with an eGFR <60. Approximately 15 % of the sample was uninsured, 18 % had public insurance and 67 % had private insurance. Compared to individuals with private insurance, those with public insurance or no insurance were significantly more likely to be a racial or ethnic minority, to have income <200 % below the federal poverty level, to have less than high school education; and they were less likely to be married and to report good or excellent health, all p < 0.05. Being uninsured or having public insurance was associated with increased all-cause mortality in the fully adjusted model (HR 2.97 and 3.65, respectively, p < 0.05). There was no significant relationship between insurance status and cardiovascular mortality.
In a nationally representative sample of individuals with albuminuria, uninsurance and public insurance were associated with increased mortality compared to the private insurance even after controlling for sociodemographic, health status, and health care variables. Improving access to care and the quality of care received may potentially reduce mortality in individuals with evidence of early CKD.
在普通人群中，未参保与死亡率之间的关联已得到充分证实。我们试图在1988 - 1994年第三次全国健康与营养检查调查（NHANES III）中，评估工作年龄的蛋白尿患者的健康保险状况与死亡率之间的关联。
我们使用了NHANES III（1988 - 1994年）中18 - 64岁非老年成年参与者的数据，这是一项对美国平民、非机构化人群具有全国代表性的研究，这些参与者提供了保险信息且患有蛋白尿，蛋白尿定义为尿白蛋白与肌酐比值[UACR]≥30mg/g，并记录了他们至2006年12月31日的后续死亡率。采用Cox比例风险模型来确定保险状况与慢性肾脏病患者全因死亡率和心血管死亡率之间的关联，同时逐步调整社会人口统计学因素、合并症以及合并症严重程度/控制协变量。
在我们蛋白尿患者样本（n = 903）中，平均估计肾小球滤过率（eGFR）为101.6ml/min/1.73m²，其中4.7%的患者eGFR < 60。样本中约15%未参保，18%有公共保险，67%有私人保险。与有私人保险的个体相比，有公共保险或未参保的个体更有可能是少数种族或族裔，收入低于联邦贫困线200%，高中以下学历；他们结婚的可能性较小，且报告健康状况良好或极佳的可能性也较小，所有p < 0.05。在完全调整模型中，未参保或有公共保险与全因死亡率增加相关（风险比分别为2.97和3.65，p < 0.05）。保险状况与心血管死亡率之间无显著关系。
在具有全国代表性的蛋白尿个体样本中，即使在控制了社会人口统计学、健康状况和医疗保健变量后，与私人保险相比，未参保和公共保险仍与死亡率增加相关。改善医疗服务可及性和所接受医疗服务的质量可能会降低早期慢性肾脏病患者的死亡率。
