title: Combined effect of individual and neighbourhood socioeconomic status on mortality of rheumatoid arthritis patients under universal health care coverage system.
abstract: BACKGROUND
  The National Health Insurance program in Taiwan is a public insurance system for the entire population of Taiwan initiated since March 1995. However, the association of socioeconomic status (SES) and prognosis of rheumatoid arthritis (RA) patients under this program has not been identified.
  
  
  OBJECTIVE
  Using the National Health Insurance Research Database in Taiwan, we aimed to examine the combined effect of individual and neighbourhood SES on the mortality rates of RA patients under a universal health care coverage system.
  
  
  METHODS
  A study population included patients with RA from 2004 to 2008. The primary end point was the 5-year overall mortality rate. Individual SES was categorized into low, moderate and high levels based on the income-related insurance payment amount. Neighbourhood SES was defined by household income and neighbourhoods were grouped as an 'advantaged' area or a 'disadvantaged' area. The Cox proportional hazards regression model was used to compare outcomes between different SES categories. A two-sided P value < 0.05 was considered statistically significant.
  
  
  RESULTS
  Medical data of 23900 RA patients from 2004 to 2008 were reviewed. Analysis of the combined effect of individual SES and neighbourhood SES revealed that 5-year mortality rates were worse among RA patients with a low individual SES compared to those with a high SES (P < 0.001). In the Cox proportional hazards regression model, RA patients with low individual SES in disadvantaged neighbourhoods incurred the highest risk of mortality (Hazard ratio = 1.64; 95% confidence interval, 1.26-2.13, P < 0.001).
  
  
  CONCLUSIONS
  RA patients with a low SES have a higher overall mortality rate than those with a higher SES, even with a universal health care system. It is crucial that more public policy and health care efforts be put into alleviating the health disadvantages, besides providing treatment payment coverage.
authors.affiliation: Department of Internal Medicine, Cardinal Tien Hospital, School of Medicine, Fu-Jen Catholic University, New Taipei City.
authors.forename: Cheng-Hsin
authors.initials: CH
authors.lastname: Chen
authors.affiliation: Division of Allergy, Immunology, and Rheumatology, Department of Internal Medicine, Buddhist Dalin Tzu Chi General Hospital, Chiayi, School of Medicine, Tzu Chi University, Hualian, Department of Life Science and Institute of Molecular Biology, National Chung Cheung University, Chiayi.
authors.forename: Kuang-Yung
authors.initials: KY
authors.lastname: Huang
authors.affiliation: Department of Internal Medicine, Cardinal Tien Hospital, School of Medicine, Fu-Jen Catholic University, New Taipei City.
authors.forename: Jen-Yu
authors.initials: JY
authors.lastname: Wang
authors.affiliation: Department of Life Science and Institute of Molecular Biology, National Chung Cheung University, Chiayi.
authors.forename: Hsien-Bin
authors.initials: HB
authors.lastname: Huang
authors.affiliation: Community Medicine Research Center and Institute of Public Health, National Yang-Ming University, Taipei.
authors.forename: Pesus
authors.initials: P
authors.lastname: Chou
authors.affiliation: School of Medicine, Tzu Chi University, Hualian, Department of Life Science and Institute of Molecular Biology, National Chung Cheung University, Chiayi, Community Medicine Research Center and Institute of Public Health, National Yang-Ming University, Taipei, Department of Otolaryngology, Department of Education and Center for Clinical Epidemiology and Biostatistics, Buddhist Dalin Tzu Chi General Hospital, Chiayi, Taiwan, Republic of China. hematcd@hotmail.com.
authors.forename: Ching-Chih
authors.initials: CC
authors.lastname: Lee
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001172:Arthritis, Rheumatoid / Q000191:economics / Q000401:mortality*; D015331:Cohort Studies; D005260:Female; D054624:Health Status Disparities; D006801:Humans; D008297:Male; D008875:Middle Aged; D009313:National Health Programs; D011204:Poverty Areas; D011379:Prognosis; D016016:Proportional Hazards Models; D012111:Residence Characteristics; D012189:Retrospective Studies; D012923:Social Class; D013624:Taiwan / Q000453:epidemiology; D055815:Young Adult
keywords: Health care system; mortality; national health insurance; public policy; rheumatoid arthritis; socioeconomic status.