Crystal S, Sambamoorthi U, Merzel C
Institute for Health, Health Care Policy, and Aging Research, Rutgers University, New Brunswick, NJ 08903, USA.
Health Serv Res. 1995 Oct;30(4):593-614.
This study investigates patterns of utilization of zidovudine (ZDV) by gender, race, risk group, and other respondent characteristics following approval of this treatment.
Longitudinal observational data were used on a demographically diverse population participating in New Jersey's Medicaid waiver program for persons with symptomatic HIV disease.
Claims data were merged with administrative data on demographic characteristics, risk group, and functional status. Periods of ZDV utilization were determined by analysis of pharmacy claims.
The proportion of respondents ever using ZDV (treatment incidence) and the proportion of time on ZDV among users (treatment persistence) were analyzed for a cohort enrolling in 1987 and 1988, and for a cohort enrolling in 1989 and 1990, with follow-up of utilization through August 1992. For each cohort, bivariate analyses were used to compare incidence and persistence by patient subgroup; logistic regression was used to investigate the predictors of incidence in a multivariate model; and OLS regression was used to analyze proportion of time on ZDV among those with any ZDV use.
For the 1987-1988 cohort, substantial race, gender, and risk group differences in utilization were observed, even though all participants in this Medicaid population had financial coverage for ZDV treatment. Treatment incidence was significantly lower for blacks than for others in bivariate comparison (45 percent versus 63 percent had any use of ZDV) and in a logistic regression controlling for a variety of demographic and health status indicators (relative risk .46, CI .31 a variety of demographic and health status indicators (relative risk .46, CI .31 to .69). Treatment persistence differences were also substantial in the 1987-1988 cohort: among ZDV users, women, blacks, and injection drug users (IDUs) had significantly less persistence in use, and the gender and risk group differences were significantly in a multivariate model. In the 1989-1990 cohort, however, both incidence and persistence of treatment converged: no significant differences were observed across demographic groups.
Less-advantaged subgroups lagged in access to this new therapy, suggesting the presence of nonfinancial barriers to care. However, these initial differences subsequently converged.
RELEVANCE/IMPACT: Socioeconomic differences have been observed in access to newly introduced treatments for a variety of diseases, reflecting nonfinancial as well as financial barriers to care. Such differences may or may not disappear as use of therapies becomes institutionalized. Monitoring patterns of treatment initiation as well as persistence of treatment over time, using merged data from claims and administrative files, can provide important information on the diffusion of treatments and the extent to which initial disparities are or are not reduced over time.
本研究调查了齐多夫定（ZDV）在获批用于治疗后，按性别、种族、风险群体及其他应答者特征的使用模式。
对参与新泽西州针对有症状HIV疾病患者的医疗补助豁免计划的人口统计学特征多样的人群使用纵向观察数据。
索赔数据与关于人口统计学特征、风险群体及功能状态的行政数据合并。通过分析药房索赔确定ZDV的使用期。
对1987年和1988年入组的队列以及1989年和1990年入组的队列分析了曾使用ZDV的应答者比例（治疗发生率）及使用者中使用ZDV的时间比例（治疗持续率），随访至1992年8月的使用情况。对于每个队列，采用双变量分析按患者亚组比较发生率和持续率；采用逻辑回归在多变量模型中研究发生率的预测因素；采用普通最小二乘法回归分析任何使用过ZDV者中使用ZDV的时间比例。
对于1987 - 1988年队列，尽管该医疗补助人群的所有参与者都有ZDV治疗的经济覆盖，但在使用情况上观察到了显著的种族、性别和风险群体差异。在双变量比较中，黑人的治疗发生率显著低于其他人群（45%使用过ZDV，而其他人群为63%），在控制了各种人口统计学和健康状况指标的逻辑回归中也是如此（相对风险为0.46，置信区间为0.31至0.69）。1987 - 1988年队列中的治疗持续率差异也很大：在ZDV使用者中，女性、黑人及注射吸毒者（IDU）的使用持续率显著较低，且在多变量模型中性别和风险群体差异显著。然而，在1989 - 1990年队列中，治疗的发生率和持续率趋于一致：各人口统计学群体之间未观察到显著差异。
处于劣势的亚组在获得这种新疗法方面滞后，表明存在非财务性的护理障碍。然而，这些最初的差异随后趋于一致。
相关性/影响：在获得多种疾病新引入治疗方法方面已观察到社会经济差异，这反映了护理的非财务性和财务性障碍。随着治疗的使用制度化，这种差异可能会消失，也可能不会。利用索赔和行政档案的合并数据监测治疗起始模式以及随时间的治疗持续情况，可提供有关治疗传播以及初始差距随时间是否缩小的重要信息。
