Witthayapipopsakul Woranan, Anupraiwan Orawan, Veerakul Gumpanart, Mills Anne, Gurol-Urganci Ipek, van der Meulen Jan
Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK.
International Health Policy Program Foundation, Nonthaburi, Thailand.
BMJ Public Health. 2025 Aug 17;3(2):e001264. doi: 10.1136/bmjph-2024-001264. eCollection 2025.
Evidence on the impact of diverse healthcare insurance arrangements on healthcare variation is limited in low-income and middle-income countries. In Thailand, the Civil Servant Medical Benefit Scheme (CSMBS), Social Health Insurance (SHI) and Universal Coverage Scheme (UCS) have different provider choice and reimbursement arrangements and cover different populations. We explored to what extent use of revascularisation in patients with ST elevation myocardial infarction (STEMI) varied by insurance scheme.
We used claims data, including all admissions for patients with STEMI between 2015 and 2020. Outcomes were any type of revascularisation, primary percutaneous coronary intervention (PPCI) and mortality. Regression models were used to estimate absolute differences (ADs) by scheme, adjusted for age, sex, comorbidities and admission year.
Of 98 142 patients, 75.7% were covered by UCS, 13.3% by CSMBS and 11.0% by SHI. Overall, 76.3% underwent revascularisation and 53.8% received PPCI. Mortality rates were 13.2% in-hospital and 20.7% at 180 days. Compared with UCS, use of revascularisation was slightly higher with CSMBS and slightly lower with SHI (AD: CSMBS 1.3% (95% CI -0.2 to 2.8), SHI -0.8% (-2.6 to 1.0), p=0.0264) and use of PPCI was slightly higher with CSMBS and SHI (AD: CSMBS 2.4% (-0.3 to 5.2), SHI 5.2% (3.1 to 7.2), p<0.0001)). CSMBS and SHI-insured patients had lower mortality compared with UCS (AD for in-hospital: CSMBS -1.3% (-2.1 to -0.5), SHI -0.9% (-1.8 to -0.1), p<0.0001; AD for 180-day mortality: CSMBS -4.5% (-5.3 to -3.6), SHI -1.9% (-3.0 to -0.8), p<0.0001). Effects of insurance scheme varied by hospital type for all outcomes (p for interaction<0.0001).
Three-quarters of patients with STEMI received coronary revascularisation, suggesting potential undertreatment. We identified relatively small differences in access to revascularisation by insurance scheme which are unlikely to explain the lower mortality with CSMBS and SHI. Claims data can be used to assess the impact of insurance on access to effective treatments.
在低收入和中等收入国家，关于不同医疗保险安排对医疗差异影响的证据有限。在泰国，公务员医疗福利计划（CSMBS）、社会医疗保险（SHI）和全民覆盖计划（UCS）有不同的医疗服务提供者选择和报销安排，覆盖不同人群。我们探讨了ST段抬高型心肌梗死（STEMI）患者的血运重建使用情况因保险计划而异的程度。
我们使用了索赔数据，包括2015年至2020年间STEMI患者的所有住院病例。结局指标为任何类型的血运重建、直接经皮冠状动脉介入治疗（PPCI）和死亡率。采用回归模型按计划估计绝对差异（ADs），并对年龄、性别、合并症和入院年份进行调整。
在98142例患者中，75.7%由UCS覆盖，13.3%由CSMBS覆盖，11.0%由SHI覆盖。总体而言，76.3%的患者接受了血运重建，53.8%的患者接受了PPCI。住院死亡率为13.2%，180天死亡率为20.7%。与UCS相比，CSMBS的血运重建使用率略高，SHI的略低（AD：CSMBS 1.3%（95%CI -0.2至2.8），SHI -0.8%（-2.6至1.0），p = 0.0264），CSMBS和SHI的PPCI使用率略高（AD：CSMBS 2.4%（-0.3至5.2），SHI 5.2%（3.1至7.2），p < 0.0001）。与UCS相比，CSMBS和SHI参保患者的死亡率较低（住院AD：CSMBS -1.3%（-2.1至-0.5），SHI -0.9%（-1.8至-0.1），p < 0.0001；180天死亡率AD：CSMBS -4.5%（-5.3至-3.6），SHI -1.9%（-3.0至-0.8），p < 0.0001）。所有结局指标的保险计划效应因医院类型而异（交互作用p < 0.0001）。
四分之三的STEMI患者接受了冠状动脉血运重建，提示可能存在治疗不足。我们发现不同保险计划在获得血运重建方面的差异相对较小，这不太可能解释CSMBS和SHI死亡率较低的原因。索赔数据可用于评估保险对获得有效治疗的影响。
