Gu Hong-Qiu, Yang Xin, Rao Zhen-Zhen, Wang Chun-Juan, Zhao Xing-Quan, Wang Yi-Long, Liu Li-Ping, Liu Chelsea, Li Hao, Li Zi-Xiao, Wang Yong-Jun
China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China.
National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China.
Ann Transl Med. 2019 Sep;7(18):426. doi: 10.21037/atm.2019.08.125.
Despite a few studies have demonstrated sex differences in stroke care and outcomes, limited research has explored insurance-related disparities in outcomes, particularly among women stroke patients. The aim was to determine whether rural-urban health insurance status affect the stroke treatment, process of care, and 1-year clinical outcomes for inpatient ischemic stroke in women.
Women patients with acute ischemic stroke (AIS) covered by New Rural Cooperative Medical Scheme (NRCMS) and urban resident/employee-based basic medical insurance scheme (URBMI/UEBMI) were abstracted from the China National Stroke Registry II (CNSR II). Shared frailty model in the Cox model or generalized estimating equation with consideration of the hospital's cluster effect were used to assess the associations between rural-urban insurance status and quality of care during hospitalization and 1-year stroke outcomes including all-cause death, 1-year recurrence, and 1-year disability.
A total of 5,707 women patients enrolled from 219 hospitals in CNSR II were analyzed. Compared with 2,880 women patients covered by URBMI/UEBMI, 2,827 women patients covered by NRCMS were younger (65.7 versus 68.9 years), less likely to have vascular risk factors, awareness and treatment of hypertension and dyslipidemia prior to stroke. Women covered by NRCMS were more likely to receive early antithrombotics, discharge antithrombotics, lipid-lowering drugs, but less likely to receive antihypertensive medication than those covered by URBMI/UEBMI. One-year all-cause mortality and stroke recurrence were both significantly higher in women patients with NRCMS than those with URBMI/UEBMI [adjusted hazard ratio (95% confidence interval): 1.40 (1.06-1.84) and 1.38 (1.04-1.83), separately].
AIS women patients with rural-urban insurance status demonstrated remarkable differences in age, stroke risk factors, awareness and treatment, the process of care, and 1-year stroke recurrence and mortality. Healthcare policymakers need to focus their attention on these disparities and take proper steps to improve primary healthcare service in rural areas.
尽管有一些研究表明中风护理和预后存在性别差异，但针对预后方面与保险相关的差异，尤其是女性中风患者中的此类差异，开展的研究有限。本研究旨在确定城乡医疗保险状况是否会影响女性住院缺血性中风的治疗、护理过程及1年临床预后。
从中国国家卒中登记二期（CNSR II）中提取参加新型农村合作医疗制度（NRCMS）以及基于城市居民/职工的基本医疗保险制度（URBMI/UEBMI）的急性缺血性中风（AIS）女性患者。使用Cox模型中的共享脆弱模型或考虑医院聚类效应的广义估计方程，评估城乡保险状况与住院期间护理质量以及包括全因死亡、1年复发和1年残疾在内的1年中风预后之间的关联。
对来自CNSR II中219家医院的5707名女性患者进行了分析。与2880名参加URBMI/UEBMI的女性患者相比，2827名参加NRCMS的女性患者更年轻（65.7岁对68.9岁），中风前有血管危险因素、高血压和血脂异常的知晓率及治疗率更低。与参加URBMI/UEBMI的女性相比，参加NRCMS的女性更有可能接受早期抗栓治疗、出院时抗栓治疗、降脂药物治疗，但接受抗高血压药物治疗的可能性较小。参加NRCMS的女性患者1年全因死亡率和中风复发率均显著高于参加URBMI/UEBMI的女性患者[调整后风险比（95%置信区间）：分别为1.40（1.06 - 1.84）和1.38（1.04 - 1.83）]。
具有城乡保险状况的AIS女性患者在年龄、中风危险因素、知晓率和治疗情况、护理过程以及1年中风复发率和死亡率方面存在显著差异。医疗保健政策制定者需要关注这些差异，并采取适当措施改善农村地区的初级医疗服务。
