艾滋病患者的保险状况与死亡率。
Insurance status and mortality among patients with AIDS.
机构信息
Department of Epidemiology, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.
Departments of Ophthalmology, The Icahn School of Medicine at Mount Sinai, New York, NY, USA.
出版信息
HIV Med. 2018 Jan;19(1):7-17. doi: 10.1111/hiv.12531. Epub 2017 Jul 11.
OBJECTIVES
The aim of the study was to evaluate risk factors for mortality, including health care insurance status, among patients with AIDS in the era of modern combination antiretroviral therapy (cART).
METHODS
This study was part of the prospective, multicentre, observational Longitudinal Study of the Ocular Complications of AIDS (LSOCA). Patients were classified as having private health care insurance, Medicare, Medicaid, or no insurance. Hazard ratios (HRs) for death were calculated using proportional hazards regression models and staggered entries, anchored to the AIDS diagnosis date.
RESULTS
Among 2363 participants with AIDS, 97% were treated with cART. At enrolment, 31% of participants had private insurance, 29% had Medicare, 24% had Medicaid, and 16% were uninsured. Noninfectious, age-related diseases, such as hypertension, diabetes, and renal disease, were more frequent among persons with Medicare than among those with private insurance. Compared with those who were privately insured, mortality was greater among participants with Medicare [adjusted HR (HR ) 1.35; 95% confidence interval (CI) 1.08-1.67; P = 0.008]. Among participants with a suppressed HIV viral load, compared with those who were privately insured, HR values for mortality were 1.93 (95% CI 1.08-3.44; P = 0.02) for those with Medicare and 2.09 (95% CI 1.02-4.27; P = 0.04) for those with Medicaid. Mortality among initially uninsured participants was not significantly different from that for privately insured participants, but these participants typically obtained ART and insurance during follow-up. Compared with privately insured participants, time-updated HR values for mortality were 1.34 (95% CI 1.05-1.70; P = 0.02) for those with Medicare, 1.34 (95% CI 1.01-1.80; P = 0.05) for those with Medicaid, and 1.35 (95% CI 0.97-1.88; P = 0.05) for those who were uninsured.
CONCLUSIONS
In persons with AIDS, compared with those with private insurance, those with public insurance had increased mortality, possibly as a result of a greater burden of noninfectious, age-related diseases.
目的
本研究旨在评估艾滋病患者在现代联合抗逆转录病毒治疗（cART）时代的死亡率相关因素，包括医疗保险状况。
方法
本研究为前瞻性、多中心、观察性的艾滋病眼部并发症纵向研究（LSOCA）的一部分。患者被分为私人医疗保险、医疗保险、医疗补助或无保险。使用比例风险回归模型和交错条目，以艾滋病诊断日期为锚点，计算死亡的风险比（HR）。
结果
在 2363 名艾滋病患者中，97%接受了 cART 治疗。在入组时，31%的参与者有私人保险，29%有医疗保险，24%有医疗补助，16%没有保险。与私人保险相比，医疗保险患者更常见非传染性、与年龄相关的疾病，如高血压、糖尿病和肾脏疾病。与私人保险患者相比，医疗保险患者的死亡率更高[校正 HR（HR）1.35；95%置信区间（CI）1.08-1.67；P=0.008]。在 HIV 病毒载量得到抑制的患者中，与私人保险患者相比，医疗保险患者的死亡率 HR 值为 1.93（95%CI 1.08-3.44；P=0.02），医疗补助患者的死亡率 HR 值为 2.09（95%CI 1.02-4.27；P=0.04）。最初没有保险的参与者的死亡率与私人保险参与者没有显著差异，但这些参与者通常在随访期间获得了抗逆转录病毒治疗和保险。与私人保险患者相比，医疗保险患者的死亡率 HR 值为 1.34（95%CI 1.05-1.70；P=0.02），医疗补助患者的死亡率 HR 值为 1.34（95%CI 1.01-1.80；P=0.05），无保险患者的死亡率 HR 值为 1.35（95%CI 0.97-1.88；P=0.05）。
结论
在艾滋病患者中，与私人保险相比，公共保险患者的死亡率更高，这可能是由于非传染性、与年龄相关的疾病负担更大所致。
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