中国癌症患者的医疗保险在临终关怀、支出和死亡地点方面的差异：一项基于人群的回顾性研究。
Disparities in end-of-life care, expenditures, and place of death by health insurance among cancer patients in China: a population-based, retrospective study.
机构信息
Department of Social Medicine and Health Management, School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.
Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA.
出版信息
BMC Public Health. 2020 Sep 4;20(1):1354. doi: 10.1186/s12889-020-09463-1.
BACKGROUND
Disparities in the utilization, expenditures, and quality of care by insurance types have been well documented. Such comparisons have yet to be investigated in end-of-life (EOL) settings in China, where public insurance covers over 95% of the Chinese population. This study examined the associations between health insurance and EOL care in the last six months of life: outpatient visits, emergency department (ED) visits, inpatient services, intensive care unit (ICU) admissions, expenditures, and place of death among the cancer patients.
METHODS
A total of 398 patients diagnosed with cancer who survived more than 6 months after diagnosis and died from July 2015 to June 2017 in urban Yichang, China, were included. Descriptive analysis and multivariate regression models were used to investigate the bivariate and independent associations, respectively, between health insurance with EOL healthcare utilization, expenditures and place of death.
RESULTS
Urban Employee Basic Medical Insurance (UEBMI) beneficiaries visited EDs more frequently than Urban Resident-based Basic Medical Insurance (URBMI) and New Rural Cooperative Medical Scheme (NRCMS) beneficiaries (marginal effects [95% Confidence Interval]: 2.15 [1.81-2.48] and 1.92 [1.59-2.26], respectively). NRCMS and UEBMI beneficiaries had more hospitalizations than URBMI beneficiaries (1.01 [0.38-1.64] and 0.71 [0.20-1.22], respectively). Compared to URBMI beneficiaries, NRCMS beneficiaries and UEBMI beneficiaries had ¥15,722 and ¥43,241 higher expenditures. Similarly, UEBMI beneficiaries were most likely to die in hospitals, followed by NRCMS (UEBMI vs. NRCMS: 0.23 [0.11-0.36]) and URBMI (UEBMI vs. URBMI: 0.67 [0.57-0.78]) beneficiaries.
CONCLUSIONS
The disproportionately lower utilization of EOL care among NRCMS and URBMI beneficiaries, compared to UEBMI beneficiaries, raised concerns regarding quality of EOL care and financial burdens of NRCMS and URBMI beneficiaries. Purposive hospice care intervention might be warranted to address EOL care for these beneficiaries in China.
背景
不同类型的保险在利用、支出和医疗服务质量方面存在差异，这一点已得到充分证明。在中国，公共保险覆盖了超过 95%的人口，在临终（EOL）环境中尚未对这种情况进行比较。本研究考察了医疗保险与癌症患者生命最后 6 个月的 EOL 护理之间的关系：门诊就诊、急诊就诊、住院服务、重症监护病房（ICU）入院、支出和死亡地点。
方法
共纳入 398 名在中国城市宜昌被诊断患有癌症且在诊断后存活超过 6 个月并于 2015 年 7 月至 2017 年 6 月期间死亡的患者。采用描述性分析和多变量回归模型分别调查医疗保险与 EOL 医疗利用、支出和死亡地点之间的双变量和独立关联。
结果
城镇职工基本医疗保险（UEBMI）受益人与城镇居民基本医疗保险（URBMI）和新型农村合作医疗（NRCMS）受益人相比，急诊就诊更为频繁（边际效应[95%置信区间]：2.15[1.81-2.48]和 1.92[1.59-2.26]）。NRCMS 和 UEBMI 受益人的住院次数多于 URBMI 受益人（1.01[0.38-1.64]和 0.71[0.20-1.22]）。与 URBMI 受益人相比，NRCMS 受益人和 UEBMI 受益人支出分别高出¥15722 和¥43241。同样，UEBMI 受益人的医院死亡率最高，其次是 NRCMS（UEBMI 比 NRCMS：0.23[0.11-0.36]）和 URBMI（UEBMI 比 URBMI：0.67[0.57-0.78]）受益人。
结论
与 UEBMI 受益人相比，NRCMS 和 URBMI 受益人的 EOL 护理利用率较低，这令人担忧 EOL 护理的质量和 NRCMS 和 URBMI 受益人的经济负担。在中国，可能需要有针对性的临终关怀干预措施来解决这些受益人的 EOL 护理问题。
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