The Effects of Individual and Neighborhood Socioeconomic Status on Dialysis-related Medical Care in Hemodialysis Patients

Autor: Chia-Tien Chang, 張嘉恬
Rok vydání: 2014
Druh dokumentu: 學位論文 ; thesis
Popis: 102
Background: Tackling health inequalities is a key concern of public health policy makers. The effect of socioeconomic status (SES) on health care quality has been observed in many studies. Therefore, eliminating the discrepancy of health care between socioeconomic status has become an important policy in many countries. In the past decades, whether the patients were referred to nephrology earlier and the probability of receiving arteriovenous fistulas (AVF) are the main influences on the effect of hemodialysis. The major purpose of Taiwan's National Health Insurance (NHI) is to reduce financial barriers to care. It is worth ascertaining if individual and neighborhood socioeconomic inequalities exist in early nephrology referral and the probability of receiving AVF for hemodialysis patients. Methods: This population-based retrospective cohort study examined the incidence of new hemodialysis patients in 2009 as identified from the Taiwan National Health Insurance database and relevant secondary data. Early referral was defined as patients meeting with a nephrologist more than 90 days before initial hemodialysis, and the type of vascular access (AVF vs. arteriovenous grafts (AVG)) creation was defined as patients' first vascular access creation within one year before and after HD initiation. Stepwise binomial logistic regression models were performed to examine the effect of individual socioeconomic status (premium-based monthly salary (NT$), level of education, and employment status) and neighborhood SES (“average family income and expenditure per household” and “educational attainment of population aged 15 and over - junior college and above”) on early nephrology referral and the probability of receiving AVF after controlling for demographic characteristics, co-morbid conditions, and characteristic of major health care organizations before referral. Results: A total of 7,687 consecutive adult incident hemodialysis patients were identified, and 70.9% of them were referred early. In subgroups, the early referral rate was 69.0% among patients aged between 18 and 64 years and 72.4% among patients aged 65 years and older. Unemployment patients and those with lower premium-based monthly salary had significantly lower early referral rate after controlling for other factors (OR=0.85, 95%CI=0.74-0.98; OR=0.86, 95%CI=0.75-0.98). A total of 6,303 incident hemodialysis patients received AVF or AVG, and 83.0% of them used AVF. In subgroups, the probability of receiving AVF was 88.6% among patients aged between 18 and 64 years and 77.9% among patients aged 65 years and older. After controlling for other factors, the patients with lower premium-based monthly salary had lower probability of receiving AVF (OR=0.81, 95%CI=0.67-0.99). Compared with patients graduated from college, patients graduated from elementary school (OR=0.54, 95%CI=0.38-0.76), junior high school (OR=0.64, 95%CI=0.44-0.94), and senior high school (OR=0.65, 95%CI=0.44-0.96) had lower probability of receiving AVF. No significant association was found between neighborhood SES and referral pattern and the type of vascular access creation. Conclusions: Individual socioeconomic inequalities exist in early nephrology referral and the type of vascular access creation for hemodialysis patients despite universal health coverage. We suggested that how to enhance health literacy should be paid more attention, in order to eliminate the discrepancy of patients with chronic kidney disease between socioeconomic status.
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