Pincus T, Esther R, DeWalt D A, Callahan L F
Vanderbilt University School of Medicine, Nashville, Tennessee 37232, USA.
Ann Intern Med. 1998 Sep 1;129(5):406-11. doi: 10.7326/0003-4819-129-5-199809010-00011.
Professional organizations advocate universal access to medical care as a primary approach to improving health in the population. Access to medical services is critical to outcomes of acute processes managed in an inpatient hospital, the setting of most medical education, research, and training, but seems to be limited in its capacity to affect outcomes of outpatient care, the setting of most medical activities. Persistent and widening disparities in health according to socioeconomic status provide evidence of limitations of access to care. First, job classification, a measure of socioeconomic status, was a better predictor of cardiovascular death than cholesterol level, blood pressure, and smoking combined in employed London civil servants with universal access to the National Health Service. Second, disparities in health according to socioeconomic status widened between 1970 and 1980 in the United Kingdom despite universal access (similar trends were seen in the United States). Third, in the United States, noncompletion of high school is a greater risk factor than biological factors for development of many diseases, an association that is explained only in part by age, ethnicity, sex, or smoking status. Fourth, level of formal education predicted cardiovascular mortality better than random assignment to active drug or placebo over 3 years in a clinical trial that provides optimal access to care. Increased recognition of limitations of universal access by physicians and their professional societies may enhance efforts to improve the health of the population.
专业组织倡导普及医疗服务，将其作为改善民众健康的主要途径。获得医疗服务对于在住院医院进行管理的急性病程的治疗结果至关重要，而住院医院是大多数医学教育、研究和培训的场所，但在影响门诊医疗（大多数医疗活动的场所）治疗结果方面，其能力似乎有限。根据社会经济地位持续存在且不断扩大的健康差异，证明了获得医疗服务存在局限性。首先，在可普遍获得国民医疗服务的伦敦在职公务员中，职业分类（一种社会经济地位的衡量指标）比胆固醇水平、血压和吸烟这三项因素综合起来，更能预测心血管疾病死亡情况。其次，尽管英国民众可普遍获得医疗服务，但在1970年至1980年间，根据社会经济地位划分的健康差异仍在扩大（美国也出现了类似趋势）。第三，在美国，未完成高中学业比生物因素更易引发多种疾病，这种关联仅部分可由年龄、种族、性别或吸烟状况来解释。第四，在一项能提供最佳医疗服务的临床试验中，接受正规教育的程度比随机分配接受活性药物或安慰剂治疗三年更能预测心血管疾病死亡率。医生及其专业协会对普及医疗服务局限性的认识不断提高，可能会加大改善民众健康状况的努力。
