美国密歇根大学安娜堡分校 John Z. Ayanian团队近期取得重要工作进展，他们研究分析了医疗保险优先计划和传统医疗保险对急性心肌梗死患者30天死亡率的影响差异。相关研究成果2022年12月6日在线发表于《美国医学会杂志》上。

据介绍，Medicare Advantage health plans（联邦医疗保险优先计划）2018年覆盖了37%的受益人，2022年覆盖率增至48%。医疗保险优先计划是否为出现特定临床症状的患者提供类似护理，目前尚不清楚。

研究人员比较了2009年至2018年间，出现急性心肌梗死（MI）的患者在医疗保险优先计划和传统医疗保险两种情况下，30天的死亡率和治疗效果。

回顾性队列研究，包括2009-2018年在间在美国医院就诊的557309名ST段抬高型心肌梗死（STEMI）参与者和1670193名非ST段抬高型心肌梗死（NSTEMI）参与者（最终随访日期，2019年12月31日）。

登记医疗保险优先计划的患者和传统医疗保险患者进行比较。

主要结果是校正后的30天死亡率。次要结果包括根据年龄和性别校正的手术使用率（导管插入手术、血管再造）、出院后的药物处方和依从性，以及卫生系统绩效的衡量标准（重症监护室[ICU]入院和30天再住院）。

该研究共包括2227502名参与者，2018年的平均年龄从76.9岁（医疗保险优先计划STEMI）到79.3岁（传统医疗保险 NSTEMI）不等，医疗保险优先计划和传统医疗保险中女性患者的比例相似（41.4% vs 41.9%，2018年）。

2009年，与传统医疗保险相比，医疗保险优先计划的登记与调整后30天死亡率显著降低相关(STEMI为19.1% vs 20.6%;差异为-1.5个百分点[95%置信区间，-2.2至-0.7]，NSTEMI为12.0% vs 12.5%;差异为- 0.5个百分点[95%置信区间，-0.9%至-0.1%])。到2018年，所有组的死亡率都有所下降，在STEMI的医疗保险优先计划组（17.7%）和传统医疗保险组（17.8%）之间不再存在静态显著差异（差异为0.0个百分点[95%置信区间，−0.7至0.6]）。在NSTEMI的医疗保险优先计划组（10.9%）和传统医疗保险组（11.1%）之间（差异为−0.2个百分点[95%置信区间，−0.4至0.1]）。到2018年，医疗保险优先计划和传统医疗保险之间的标准化90天血管再生率没有统计学上的显著差异。指南推荐的药物处方率在医疗保险优先计划患者（91.7%）显著高于接受他汀类药物处方的传统医疗保险患者（89.0%）（差异为2.7个百分点[95%置信区间，1.2至4.2]，对于2018年STEMI）。

医疗保险优先计划患者与传统医疗保险患者相比，入住ICU的可能性显著降低（2018年STEMI，患者为50.3% vs 51.2%，差异为−0.9个百分点[95%置信区间，−1.8至0.0]），并且更可能出院回家，而不是送到急性后治疗中心（2018年STEMI，71.5% vs 70.2%；差异为1.3个百分点[95%置信区间，0.5至2.1]）。校正后的30天再入院率在医疗保险优先计划组中始终低于传统医疗保险组（2009年STEMI，13.8% vs 15.2%；差异为−1.3个百分点[95%置信区间，−2.0至−0.6]; 2018年STEMI，11.2% vs 11.9%；差异为0.6个百分点[95%置信区间，−1.5至0.0]）。

研究结果表明，在患有MI的联邦医疗保险受益人中，与传统联邦医疗保险相比，参加联邦医疗保险优先计划在2009年与适度降低的30天死亡率显著相关，到2018年，这一差异不再具有统计学意义。这些发现，连同其他结果一起考虑，可以深入了解医疗保险类型在治疗和结果方面的差异。

附：英文原文

Title: Association of Medicare Advantage vs Traditional Medicare With 30-Day Mortality Among Patients With Acute Myocardial Infarction

Author: Bruce E. Landon, Timothy S. Anderson, Vilsa E. Curto, Peter Cram, Christina Fu, Gabe Weinreb, Alan M. Zaslavsky, John Z. Ayanian

Issue&Volume: 2022/12/06

Abstract: Importance  Medicare Advantage health plans covered 37% of beneficiaries in 2018, and coverage increased to 48% in 2022. Whether Medicare Advantage plans provide similar care for patients presenting with specific clinical conditions is unknown.

Objective  To compare 30-day mortality and treatment for Medicare Advantage and traditional Medicare patients presenting with acute myocardial infarction (MI) from 2009 to 2018.

Design, Setting, and Participants  Retrospective cohort study that included 557309 participants with ST-segment elevation [acute] MI (STEMI) and 1670193 with non–ST-segment elevation [acute] MI (NSTEMI) presenting to US hospitals from 2009-2018 (date of final follow up, December 31, 2019).

Exposures  Enrollment in Medicare Advantage vs traditional Medicare.

Main Outcomes and Measures  The primary outcome was adjusted 30-day mortality. Secondary outcomes included age- and sex-adjusted rates of procedure use (catheterization, revascularization), postdischarge medication prescriptions and adherence, and measures of health system performance (intensive care unit [ICU] admission and 30-day readmissions).

Results  The study included a total of 2227502 participants, and the mean age in 2018 ranged from 76.9 years (Medicare Advantage STEMI) to 79.3 years (traditional Medicare NSTEMI), with similar proportions of female patients in Medicare Advantage and traditional Medicare (41.4% vs 41.9% for STEMI in 2018). Enrollment in Medicare Advantage vs traditional Medicare was associated with significantly lower adjusted 30-day mortality rates in 2009 (19.1% vs 20.6% for STEMI; difference, 1.5 percentage points [95% CI, 2.2 to 0.7] and 12.0% vs 12.5% for NSTEMI; difference, 0.5 percentage points [95% CI, 0.9% to 0.1%]). By 2018, mortality had declined in all groups, and there were no longer statically significant differences between Medicare Advantage (17.7%) and traditional Medicare (17.8%) for STEMI (difference, 0.0 percentage points [95% CI, 0.7 to 0.6]) or between Medicare Advantage (10.9%) and traditional Medicare (11.1%) for NSTEMI (difference, 0.2 percentage points [95% CI, 0.4 to 0.1]). By 2018, there was no statistically significant difference in standardized 90-day revascularization rates between Medicare Advantage and traditional Medicare. Rates of guideline-recommended medication prescriptions were significantly higher in Medicare Advantage (91.7%) vs traditional Medicare patients (89.0%) who received a statin prescription (difference, 2.7 percentage points [95% CI, 1.2 to 4.2] for 2018 STEMI). Medicare Advantage patients were significantly less likely to be admitted to an ICU than traditional Medicare patients (for 2018 STEMI, 50.3% vs 51.2%; difference, 0.9 percentage points [95% CI, 1.8 to 0.0]) and significantly more likely to be discharged to home rather than to a postacute facility (for 2018 STEMI, 71.5% vs 70.2%; difference, 1.3 percentage points [95% CI, 0.5 to 2.1]). Adjusted 30-day readmission rates were consistently lower in Medicare Advantage than in traditional Medicare (for 2009 STEMI, 13.8% vs 15.2%; difference, 1.3 percentage points [95% CI, 2.0 to 0.6]; and for 2018 STEMI, 11.2% vs 11.9%; difference, 0.6 percentage points [95% CI, 1.5 to 0.0]).

Conclusions and Relevance  Among Medicare beneficiaries with acute MI, enrollment in Medicare Advantage, compared with traditional Medicare, was significantly associated with modestly lower rates of 30-day mortality in 2009, and the difference was no longer statistically significant by 2018. These findings, considered with other outcomes, may provide insight into differences in treatment and outcomes by Medicare insurance type.

DOI: 10.1001/jama.2022.20982

Source: https://jamanetwork.com/journals/jama/article-abstract/2799152