医疗保险与2型糖尿病患者代谢控制及自我管理遵循度的相关性

Association between status of medical insurance and self-management compliance, metabolic control in patients with type 2 diabetes mellitus

目的 探讨医疗保险（医保）的有无与我国2型糖尿病（T2DM）患者代谢指标控制、自我管理遵循程度及并发症发生的相关性.方法 采用多中心横断面调查,于2010年在全国范围内选择各省市有代表性的50家医学中心,共纳入T2DM患者5852例,其中有医保者4824例（医保组）,无医保者1028例（自费组）.对其人口统计学资料、用药情况、代谢指标、糖尿病相关花费、自我管理的遵循程度等进行问卷调查.对两组患者的性别、体质指数（BMI）、吸烟、糖尿病病程、年龄、文化程度进行1：2倾向性匹配后,最终有1281例患者纳入分析.采用单因素方差分析及卡方检验比较两组间各指标的差异,Pearson相关分析进行相关性检验.结果（1）医保在该研究人群中的平均覆盖率达82.43%.医保组患者糖化血红蛋白（HbA1c）、空腹血糖（FPG）、餐后2 h血糖（2hPG）、甘油三酯（TG）和总胆固醇（TC）等均显著低于自费组[分别为：HbA1c（8.6±2.4）%比（9.0±2.4）%、FPG（8±3）比（9±4）mmol/L、2hPG（12±5）比（13±5）mmol/L、TG（2.0±1.6）比（2.3±2.1）mmol/L、TC（4.8±1.4）比（5.0±1.5）mmol/L,F=4.229~21.620,均P〈0.05].Pearson相关性分析也显示医保与上述代谢指标之间存在着显著的负相关（相关系数分别为-0.079、-0.129、-0.129、-0.102、-0.057,均P〈0.05）.医保组患者慢性并发症的发生率低于自费组,但差异无统计学意义（均P〉0.05）.（2）医保组糖尿病相关花费显著高于自费组[5000 （3000,10000）比4500（2415,8000）元,P=0.004].医保组患者的自我管理（包括教育、复查、运动、用药、自我监测、医师咨询）遵循度也显著高于自费组（分别为81.26%比71.20%、55.85%比45.67%、37.35%比29.27%、70.84%比58.54%、24.82%比20.37%、26.81%比18.74%;χ2=2.906~18.838,除自我监测P=0.088外,其余P值均小于0.05）.Pearson相关分析结果也显示医保与患者的自我管理遵循度（包括教育、复查、运动、用药、自我监测）存在显著正相关（相关系数分别为0.114、0.096、0.115、0.109、0.077,均P〈0.05）.结论 本研究人群中有17.57%的T2DM患者没有医保支付,医保的缺乏可能会通过减少相应的医疗花费及降低患者自我管理的遵循度而导致代谢指标控制较差.提示必要的医保支持可潜在改善T2DM患者的代谢控制.

Objective To investigate the impact of status of medical insurance on self-management compliance and metabolic control in patients with type 2 diabetes mellitus （T2DM） in China. Methods This was an observational cross-sectional study including 5 852 patients with T2DM across 50 representative centers in China. Among these patients, 4 824 patients were covered by medical insurance （medical insurance group, MI group） whereas 1 028 patients were not （self-payment group, SP group）. The data of demographics,medical history,metabolic parameters,diabetes related costs and self-management obedience were collected by questionnaire survey.A total of 1 281 subjects were included in the analysis which were 1：2 propensity score matched by sex, smoking, body mass index （BMI）, smoking, diabetes duration,education level and age. One-way ANOVA and Chi-squared test were used to test the differences between the two groups. Pearson correlation analysis was applied in correlation test. Results （1）The average coverage of medical insurance was 82.43% in this population. Patients in MI group had lower levels of glycated hemoglobin A1c（HbA1c）,fasting plasma glucose（FPG）,2 hours postprandial plasma glucose（2hPG）, triglycerides（TG）and total cholesterol（TC）than patients in SP group[HbA1c（8.6±2.4）% vs（9.0±2.4）%;FPG （8±3）vs（9±4）mmol/L;2hPG（12±5）vs（13±5）mmol/L;TG（2.0±1.6）vs（2.3±2.1）mmol/L;TC（4.8±1.4）vs （5.0 ± 1.5） mmol/L, F=4.229-21.620, all P〈0.05]. Pearson correlation analysis also revealed a negative correlation between the status of medical insurance and the metabolic parameters previously mentioned（the corresponding correlation indexes were-0.079,-0.129,-0.129,-0.102,-0.057, respectively, all P〈0.05）. The prevalence of chronic complications in SP group were slightly higher than that in MI group but with no statistical significance （all P〉0.05）. Patients in MI group had higher costs related to diabetes [5 000 （3 000,10 000）vs 4 500（2 415,8 000）RMB,P〈0.05]and higher compliance of self-management including diabetes education（81.26% vs 71.20%）,reexamination（55.85% vs 45.67%）,exercise（37.35% vs 29.27%）, drug program （70.84% vs 58.54%）, self-monitoring （24.82% vs 20.37%） and doctor visits （26.81% vs 18.74%） （χ2=2.906-18.838, all P〈0.05 except the self-monitoring, P=0.088）. Pearson correlation analysis revealed that MI had a positive correlation with diabetes self-management obedience （correlation indexes were 0.114,0.096,0.115,0.109,0.077,respectively）.Conclusions There are 17.57% patients with T2DM not covered by medical insurance in this survey.Lacking of medical insurance may be associated with lower medical expenditure and self-management compliance, and consequently may lead to poorer metabolic control. These results suggest that the coverage of medical insurance for T2DM patients might play a potential role in the improvement of metabolic control.