Page 71 - 2022-19-中国全科医学

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【Abstract】 Background The high prevalence of multimorbidity among middle-aged and older adults has become a
serious issue needing to be addressed by China's healthcare system. The number of chronic diseases is related to health service
utilization and medical costs，but there is still a lack of relevant national surveys in China. Objective To understand the
prevalence and features of multimorbidity and to examine its associations with health service utilization and medical costs among
middle-aged and older Chinese adults. Methods Data were collected from the 2018 wave of China Health and Retirement
Longitudinal Study（CHARLS） during April to October 2021，involving 16 674 Chinese adults（ ≥ 45 years old）.
Multimorbidity was defined as the coexistence of two or more of the self-reported 14 chronic conditions. Health service utilization
was measured using inpatient service utilization in the past year and outpatient service utilization in the past month. Medical costs
were measured using total inpatient cost and out-of-pocket（OOP） cost for inpatient care in the past one year，total outpatient
costs and OOP cost for outpatient care in the past one month. Logistic regression was used to estimate the association between the
number of chronic diseases and health service utilization. Quantile regression was adopted to estimate the association between the
number of chronic diseases and medical costs. Results Of all participants，9 561（57.34%） had multimorbidity. 2 624（15.74%）
had utilized inpatient services in the past year，and 2 588（15.52%） used outpatient services in the past one month. Inpatient
service utilization，outpatient service utilization，total inpatient cost，OOP cost for inpatient care，total outpatient cost，and
OOP cost for outpatient care varied significantly by the number of chronic diseases（P<0.05）. Multivariate Logistic regression
analysis indicated that the number of chronic diseases was associated with inpatient service utilization（P<0.05）. Suffering from 1，
2，3，4 and ≥ 5 chronic diseases was associated with 1.882 times〔95%CI（1.547，2.290）〕，2.939 times〔95%CI（2.429，
3.555）〕，4.231 times〔95%CI（3.490，5.130）〕，5.723 times〔95%CI（4.680，7.000）〕，and 8.671 times〔95%CI
（7.173，10.482）〕 higher rate of inpatient service utilization，respectively. Having 1，2，3，4 and ≥ 5 chronic diseases
was associated with 1.684 times〔95%CI（1.421，1.995）〕，2.481 times〔95%CI（2.101，2.931）〕，3.691 times〔95%CI
（3.115，4.374）〕，3.774 times〔95%CI（3.134，4.544）〕，and 5.577 times〔95%CI（4.698，6.620）〕 higher rate of
outpatient service utilization，respectively. Each increased chronic disease was associated with an increase in both total inpatient
costs and OOP for inpatient care at the upper and middle（50，75 and 90 percentiles） percentile levels，with larger effects on
the upper percentile 〔90th percentile Coeff（95%CI）=1 248.43（219.20，2 277.66） for total hospital costs；90th percentile
Coeff（95%CI）=706.36（266.87，1 145.86） for OOP for inpatient care〕. Each increased chronic disease was also associated
with an increase in both total outpatient costs and OOP for outpatient care，and the effects on the upper percentiles were larger
〔90th percentile Coeff（95%CI）=196.33（31.06，361.61） for total outpatient costs；90th percentile Coeff（95%CI）=128.56
（26.83，230.28） for OOP for outpatient care〕. Conclusion In middle-aged and older Chinese adults，multimorbidity was
highly prevalent，and the increase in the number of coexisted chronic diseases was associated with higher rate of health service
utilization and medical costs. The government should pay more attention on primary care to manage the demand for health services
and medical costs associated with multimorbidity.
【Key words】 Multiple chronic conditions；Facilities and services utilization；Fees，medical；Quantile regression

慢性病是造成全球疾病负担的重要因素 ［1］ ，每年 性调查 ［18，24-25］ ，缺少全国性数据的调查结果。另外，
约有 71% 的死亡可归因于慢性病 ［2］ 。共病，即患有两 既往研究多采用线性回归等传统方法估计共病对医疗费
种或两种以上的慢性病 ［3-5］ 。相比于患单种慢性病，多 用的平均影响 ［9，26］ ，结果偏向反映中心位置的情况，
种慢性病的相互作用会对人群造成更大的健康危害 ［6］ ， 当模型残差不满足正态分布时，不能很好反映分布的非
与诸多不良结局相关 ［5-12］ 。持续升高的共病患病率已 中心位置情况，忽略了共病对高医疗费用人群的影响与
成为各国卫生体系面临的重要问题 ［4，13-14］ 。虽然，目 对低费用人群的影响可能存在很大不同 ［27］ ，而分位数
前中低收入国家（包括我国）的共病患病率大多低于高 回归能弥补这一不足，可以利用数据全部的信息估计共
收入国家 ［15-16］ ，但也正在逐渐接近高收入国家水平 ［14］ 。 病对医疗费用分布不同位置的影响 ［28］ 。因此，基于以
中老年人是慢性病发病和死亡的高危人群 ［2，17］ ，因此 往研究的经验和不足，本研究采用中国健康与养老追踪
有必要了解我国中老年人群共病的患病情况和特征，以 调 查（China Health and Retirement Longitudinal Study，
便为患者提供合适的卫生服务。共病对卫生服务利用和 CHARLS）2018 年的全国代表性数据，调查我国中老年
医疗费用的影响是一个值得研究的话题。多项研究发 人群慢性病共病的患病情况和特征，分析共病对卫生服
现，慢性病患病数量的增加与卫生服务利用、医疗费用 务利用和医疗费用的影响，从而为开展慢性病共病相关
的增加明显相关 ［18-23］ 。然而，我国既往研究多为地区 卫生服务提供依据。