Kuo Raymond N, Lai Chao-Lun, Yeh Yi-Chun, Lai Mei-Shu
Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei City, Taiwan.
Division of Cardiology, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu City, Taiwan.
PLoS One. 2017 Jun 8;12(6):e0179127. doi: 10.1371/journal.pone.0179127. eCollection 2017.
One of the main objectives behind the expansion of insurance coverage is to eliminate disparities in health and healthcare. However, researchers have not yet fully elucidated the reasons for disparities in the use of high-cost treatments among patients of different occupations. Furthermore, it remains unknown whether discretionary decisions made at the hospital level have an impact on the administration of high-cost interventions in a universal healthcare system. This study investigated the adoption of drug-eluting stents (DES) versus bare metal-stents (BMS) among patients in different occupations and income levels, with the aim of gauging the degree to which the inclination of health providers toward treatment options could affect treatment choices at the patient-level within a universal healthcare system.
We adopted a cross-sectional observational study design using hierarchical modeling in conjunction with the population-based National Health Insurance database of Taiwan. Patients who received either a BMS or a DES between 2007 and 2010 were included in the study.
During the period of study, 42,124 patients received a BMS (65.3%) and 22,376 received DES (34.7%). Patients who were physicians or the family members of physicians were far more likely to receive DES (OR: 3.18, CI: 2.38-4.23) than were patients who were neither physicians nor in other high-status jobs (employers, other medical professions, or public service). Similarly, patients in the top 5% income bracket had a higher probability of receiving a DES (OR: 2.23, CI: 2.06-2.47, p < .001), than were patients in the lowest income bracket. After controlling for patient-level factors, the inclination of hospitals (proportion of DES>50% or between 25% and 50%) was shown to be strongly associated with the selection of DESs (OR: 3.64 CI: 3.24-4.09 and OR: 2.16, CI: 2.01-2.33, respectively).
Even under the universal healthcare system in Taiwan, socioeconomic disparities in the use of high-cost services remain widespread. Differences in the care received by patients of lower socioeconomic status may be due to the discretionary decisions of healthcare providers.
扩大保险覆盖范围背后的主要目标之一是消除健康和医疗保健方面的差距。然而，研究人员尚未充分阐明不同职业患者在使用高成本治疗方法上存在差异的原因。此外，在全民医疗保健系统中，医院层面的自主决策是否会对高成本干预措施的管理产生影响仍不清楚。本研究调查了不同职业和收入水平的患者中药物洗脱支架（DES）与裸金属支架（BMS）的使用情况，旨在衡量在全民医疗保健系统中，医疗服务提供者对治疗方案的倾向在多大程度上会影响患者层面的治疗选择。
我们采用横断面观察性研究设计，结合基于人群的台湾国民健康保险数据库进行分层建模。研究纳入了2007年至2010年间接受BMS或DES治疗的患者。
在研究期间，42124名患者接受了BMS（65.3%），22376名患者接受了DES（34.7%）。医生或医生家属比既不是医生也不在其他高地位职业（雇主、其他医疗职业或公共服务）的患者更有可能接受DES（比值比：3.18，可信区间：2.38 - 4.23）。同样，收入最高的5%人群比收入最低的人群接受DES的概率更高（比值比：2.23，可信区间：2.06 - 2.47，p <.001）。在控制了患者层面的因素后，医院的倾向（DES比例>50%或在25%至50%之间）与DES的选择密切相关（比值比分别为：3.64，可信区间：3.24 - 4.09；以及比值比：2.16，可信区间：2.01 - 2.33）。
即使在台湾的全民医疗保健系统下，高成本服务使用方面的社会经济差距仍然普遍存在。社会经济地位较低的患者所接受的护理差异可能归因于医疗服务提供者的自主决策。
