Cunningham W E, Hays R D, Ettl M K, Dixon W J, Liu R C, Beck C K, Shapiro M F
Department of Medicine, School of Medicine, University of California, Los Angeles, USA.
Med Care. 1998 Mar;36(3):295-306. doi: 10.1097/00005650-199803000-00007.
This study examined the prospective effect of reported access to medical care on health-related quality-of-life outcomes in patients with symptomatic human immunodeficiency virus (HIV) disease.
A cohort study was designed with interviews at baseline, follow-up interviews at 3 months after baseline, mortality follow-up through 6 months after baseline, and medical record reviews for selected baseline clinical data. Participants were HIV-infected patients who were receiving ambulatory and/or hospital care at one county-run municipal and one Veterans Administration hospital in metropolitan Los Angeles and were interviewed about access to medical care (using a reliable 9-item scale assessing affordability, availability, and convenience of medical care). Access to care reported by this sample was compared with that of 2,471 patients with other chronic diseases from the Medical Outcomes Study. The main outcome measures were composite scores for physical and mental health-related quality of life 3 months after baseline, derived from a validated 56-item instrument, scored from 0 to 100, and controlling for baseline health-related quality of life.
Overall reported access to medical care in this sample was significantly poorer than that for patients with other chronic diseases (means scores were 63 and 73, respectively). The sample was categorized into tertiles of initial physical and mental health-related quality of life and into groups with initial high versus low access to care. Among those in the middle tertile of physical health-related quality of life at baseline, those with high access improved in physical health scores by 10.2 points relative to those with low access. Those in the low and middle tertiles of initial mental health improved in mental health to a significantly greater extent for those with high versus low access. There were nonsignificant trends toward similar effects for most other subgroups. The effects of access on health-related quality-of-life outcomes were generally robust in multivariate regression analyses that included CD4, hemoglobin, albumin, insurance status, and sociodemographic characteristics.
Access to care at baseline predicted better physical and mental health outcomes at 3 months for those in the middle tertile of physical health and for those in the bottom and middle tertiles of mental health at baseline. Increasing access to care for poor public hospital patients with HIV infection may help to improve health-related quality-of-life outcomes among selected persons with advanced disease.
本研究探讨了报告的医疗服务可及性对有症状的人类免疫缺陷病毒（HIV）疾病患者健康相关生活质量结局的前瞻性影响。
设计了一项队列研究，在基线时进行访谈，在基线后3个月进行随访访谈，在基线后6个月进行死亡率随访，并对选定的基线临床数据进行病历审查。参与者为在洛杉矶大都会区的一家县办市立医院和一家退伍军人管理局医院接受门诊和/或住院治疗的HIV感染患者，并接受了关于医疗服务可及性的访谈（使用一个可靠的包含9个条目的量表评估医疗服务的可负担性、可获得性和便利性）。将该样本报告的医疗服务可及性与来自医疗结局研究的2471名其他慢性病患者的可及性进行比较。主要结局指标是基线后3个月时身体和心理健康相关生活质量的综合得分，该得分来自一个经过验证的包含56个条目的工具，得分范围为0至100，并对基线时的健康相关生活质量进行了控制。
总体而言，该样本报告的医疗服务可及性明显低于其他慢性病患者（平均得分分别为63和73）。将样本按初始身体和心理健康相关生活质量的三分位数以及初始医疗服务可及性高与低的组进行分类。在基线时身体健康相关生活质量处于中间三分位数的人群中，医疗服务可及性高的人群相对于可及性低的人群，身体健康得分提高了10.2分。在初始心理健康处于低和中间三分位数的人群中，医疗服务可及性高的人群在心理健康方面的改善程度明显大于可及性低的人群。大多数其他亚组也有类似效果的非显著趋势。在包括CD4、血红蛋白、白蛋白、保险状况和社会人口统计学特征的多变量回归分析中，医疗服务可及性对健康相关生活质量结局的影响通常较为稳健。
基线时的医疗服务可及性预示着基线时身体健康处于中间三分位数以及心理健康处于低和中间三分位数的人群在3个月时身体和心理健康结局更好。增加对贫困公立医院HIV感染患者的医疗服务可及性可能有助于改善部分晚期疾病患者的健康相关生活质量结局。
