Department of Health Policy & Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
J Eval Clin Pract. 2020 Dec;26(6):1711-1721. doi: 10.1111/jep.13341. Epub 2020 Jan 28.
RATIONALE, AIMS, AND OBJECTIVES: Clinical studies show equivalent health outcomes from interventional procedures and treatment with medication only for stable angina patients. However, patients may be subject to overuse or access barriers for interventional procedures and may exhibit suboptimal adherence to medications. Our objective is to evaluate whether community-level health literacy is associated with treatment selection and medication adherence patterns.
The sample included Medicare fee-for-service beneficiaries (20% random sample) with stable angina in 2007-2013. We used an area-level health literacy variable because of the lack of an individual measure in claims. We measured the association between (a) area-based health literacy with treatment selection (medication only, percutaneous coronary intervention [PCI], or coronary artery bypass grafting (CABG) surgery) and (b) area-based health literacy with medication adherence. We controlled for other factors including demographics, co-morbidity burden, dual eligibility, and area deprivation index.
We identified 8300 patients of whom 8.7% lived in a low health literacy area. Overall, 56% of patients received medication only, 28% received PCI, and 15% received CABG. Patients in low health literacy areas were less likely to receive CABG (-3.5 percentage points; 95% CI, -6.8 to -0.3) than were patients in high health literacy areas, but the significance was sensitive to specification. Overall, 81.5% and 71.5% of patients were adherent to antianginals and statins, respectively. Living in low health literacy areas was associated with lower adherence to antianginals (-3.3 percentage points; 95% CI, -6.1 to -0.6) but not statins.
Low area-based health literacy was associated with being less likely to receive CABG and lower adherence, but the differences between low and high health literacy areas were small and sensitive to model specification. Individual factors such as dual eligibility status and race/ethnicity had stronger associations with outcomes than had area-based health literacy, suggesting that this area-based measure was inadequate to account for social determinants in this study.
背景、目的和目标：临床研究表明，对于稳定性心绞痛患者，介入治疗和单纯药物治疗的健康结果相当。然而，患者可能会过度使用介入治疗或面临治疗障碍，并且对药物的依从性可能不理想。我们的目的是评估社区层面的健康素养是否与治疗选择和药物依从性模式相关。
该样本包括 2007 年至 2013 年期间有稳定性心绞痛的医疗保险按服务收费受益人的 20%随机抽样。由于索赔中缺乏个人衡量标准，我们使用了基于区域的健康素养变量。我们衡量了（a）基于区域的健康素养与治疗选择（仅药物治疗、经皮冠状动脉介入治疗[PCI]或冠状动脉旁路移植术[CABG]手术）之间的关联，以及（b）基于区域的健康素养与药物依从性之间的关联。我们控制了其他因素，包括人口统计学特征、合并症负担、双重资格和区域贫困指数。
我们确定了 8300 名患者，其中 8.7%的患者居住在低健康素养地区。总体而言，56%的患者接受了仅药物治疗，28%的患者接受了 PCI，15%的患者接受了 CABG。低健康素养地区的患者接受 CABG 的可能性较低（减少 3.5 个百分点；95%CI，-6.8 至-0.3），而高健康素养地区的患者则相反，但这种差异对规范很敏感。总体而言，81.5%和 71.5%的患者分别对抗心绞痛药物和他汀类药物的依从性较高。居住在低健康素养地区与抗心绞痛药物的依从性较低有关（减少 3.3 个百分点；95%CI，-6.1 至-0.6），但与他汀类药物无关。
低基于区域的健康素养与接受 CABG 的可能性较低和较低的药物依从性相关，但低和高健康素养地区之间的差异很小，并且对模型规范敏感。个人因素，如双重资格状况和种族/民族，与结果的关联比基于区域的健康素养更强，这表明在这项研究中，这种基于区域的衡量标准不足以解释社会决定因素。
