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Schmidt S, Jacobs MA, Kim J, Hall DE, Stitzenberg KB, Kao LS, Brimhall BB, Wang CP, Manuel LS, Su HD, Silverstein JC, Shireman PK. Presentation Acuity and Surgical Outcomes for Patients With Health Insurance Living in Highly Deprived Neighborhoods. JAMA Surg 2024; 159:411-419. [PMID: 38324306 PMCID: PMC10851138 DOI: 10.1001/jamasurg.2023.7468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 10/14/2023] [Indexed: 02/08/2024]
Abstract
Importance Insurance coverage expansion has been proposed as a solution to improving health disparities, but insurance expansion alone may be insufficient to alleviate care access barriers. Objective To assess the association of Area Deprivation Index (ADI) with postsurgical textbook outcomes (TO) and presentation acuity for individuals with private insurance or Medicare. Design, Setting, and Participants This cohort study used data from the National Surgical Quality Improvement Program (2013-2019) merged with electronic health record data from 3 academic health care systems. Data were analyzed from June 2022 to August 2023. Exposure Living in a neighborhood with an ADI greater than 85. Main Outcomes and Measures TO, defined as absence of unplanned reoperations, Clavien-Dindo grade 4 complications, mortality, emergency department visits/observation stays, and readmissions, and presentation acuity, defined as having preoperative acute serious conditions (PASC) and urgent or emergent cases. Results Among a cohort of 29 924 patients, the mean (SD) age was 60.6 (15.6) years; 16 424 (54.9%) were female, and 13 500 (45.1) were male. A total of 14 306 patients had private insurance and 15 618 had Medicare. Patients in highly deprived neighborhoods (5536 patients [18.5%]), with an ADI greater than 85, had lower/worse odds of TO in both the private insurance group (adjusted odds ratio [aOR], 0.87; 95% CI, 0.76-0.99; P = .04) and Medicare group (aOR, 0.90; 95% CI, 0.82-1.00; P = .04) and higher odds of PASC and urgent or emergent cases. The association of ADIs greater than 85 with TO lost significance after adjusting for PASC and urgent/emergent cases. Differences in the probability of TO between the lowest-risk (ADI ≤85, no PASC, and elective surgery) and highest-risk (ADI >85, PASC, and urgent/emergent surgery) scenarios stratified by frailty were highest for very frail patients (Risk Analysis Index ≥40) with differences of 40.2% and 43.1% for those with private insurance and Medicare, respectively. Conclusions and Relevance This study found that patients living in highly deprived neighborhoods had lower/worse odds of TO and higher presentation acuity despite having private insurance or Medicare. These findings suggest that insurance coverage expansion alone is insufficient to overcome health care disparities, possibly due to persistent barriers to preventive care and other complex causes of health inequities.
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Affiliation(s)
- Susanne Schmidt
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio
| | - Michael A. Jacobs
- Department of Surgery, University of Texas Health San Antonio, San Antonio
| | - Jeongsoo Kim
- Department of Surgery, University of Texas Health San Antonio, San Antonio
| | - Daniel E. Hall
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Lillian S. Kao
- Department of Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston
| | - Bradley B. Brimhall
- Department of Pathology and Laboratory Medicine, University of Texas Health San Antonio, San Antonio
- University Health, San Antonio, Texas
| | - Chen-Pin Wang
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio
| | - Laura S. Manuel
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio
- UT Health Physicians Business Intelligence and Data Analytics, University of Texas Health San Antonio, San Antonio
| | - Hoah-Der Su
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jonathan C. Silverstein
- Department of Biomedical Informatics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Paula K. Shireman
- Department of Surgery, University of Texas Health San Antonio, San Antonio
- University Health, San Antonio, Texas
- Department of Primary Care and Rural Medicine, School of Medicine, Texas A&M University, Bryan
- Department of Medical Physiology, School of Medicine, Texas A&M University, Bryan
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Wang K, Law CK, Zhao J, Hui AYK, Yip BHK, Yeoh EK, Chung RYN. Measuring health-related social deprivation in small areas: development of an index and examination of its association with cancer mortality. Int J Equity Health 2021; 20:216. [PMID: 34579732 PMCID: PMC8474923 DOI: 10.1186/s12939-021-01545-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 09/05/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The small-area deprivation indices are varied across countries due to different social context and data availability. Due to lack of chronic disease-related social deprivation index (SDI) in Hong Kong, China, this study aimed to develop a new SDI and examine its association with cancer mortality. METHODS A total of 14 socio-economic variables of 154 large Tertiary Planning Unit groups (LTPUGs) in Hong Kong were obtained from 2016 population by-census. LTPUG-specific all-cause and chronic condition-related mortality and chronic condition inpatient episodes were calculated as health outcomes. Association of socio-economic variables with health outcomes was estimated for variable selection. Candidates for SDI were constructed with selected socio-economic variables and tested for criterion validity using health outcomes. Ecological association between the selected SDI and cancer mortality were examined using zero-inflated negative binomial regression. RESULTS A chronic disease-related SDI constructed by six area-level socio-economic variables was selected based on its criterion validity with health outcomes in Hong Kong. It was found that social deprivation was associated with higher cancer mortality during 2011-2016 (most deprived areas: incidence relative risk [IRR] = 1.40, 95% confidence interval [CI]: 1.27-1.55; second most deprived areas: IRR = 1.34, 95%CI: 1.21-1.48; least deprived areas as reference), and the cancer mortality gap became larger in more recent years. Excess cancer death related to social deprivation was found to have increased through 2011-2016. CONCLUSIONS Our newly developed SDI is a valid and routinely available measurement of social deprivation in small areas and is useful in resource allocation and policy-making for public health purpose in communities. There is a potential large improvement in cancer mortality by offering relevant policies and interventions to reduce health-related deprivation. Further studies can be done to design strategies to reduce the expanding health inequalities between more and less deprived areas.
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Affiliation(s)
- Kailu Wang
- JC School of Public Health and Primary Care, Faculty of Medicine
, The Chinese University of Hong Kong, Shatin, NT, Hong Kong SAR, China
- Centre for Health Systems and Policy Research, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, NT, Hong Kong SAR, China
| | - Chi-Kin Law
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, NSW Australia
| | - Jiaying Zhao
- School of Demography, The Australian National University, Canberra, Australia
| | - Alvin Yik-Kiu Hui
- JC School of Public Health and Primary Care, Faculty of Medicine
, The Chinese University of Hong Kong, Shatin, NT, Hong Kong SAR, China
| | - Benjamin Hon-Kei Yip
- JC School of Public Health and Primary Care, Faculty of Medicine
, The Chinese University of Hong Kong, Shatin, NT, Hong Kong SAR, China
| | - Eng Kiong Yeoh
- JC School of Public Health and Primary Care, Faculty of Medicine
, The Chinese University of Hong Kong, Shatin, NT, Hong Kong SAR, China
- Centre for Health Systems and Policy Research, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, NT, Hong Kong SAR, China
- CUHK Institute of Health Equity, The Chinese University of Hong Kong, Shatin, NT, Hong Kong SAR, China
| | - Roger Yat-Nork Chung
- JC School of Public Health and Primary Care, Faculty of Medicine
, The Chinese University of Hong Kong, Shatin, NT, Hong Kong SAR, China
- Centre for Health Systems and Policy Research, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, NT, Hong Kong SAR, China
- CUHK Institute of Health Equity, The Chinese University of Hong Kong, Shatin, NT, Hong Kong SAR, China
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Alves A, Civet A, Laurent A, Parc Y, Penna C, Msika S, Hirsch M, Pocard M. Social deprivation aggravates post-operative morbidity in carcinologic colorectal surgery: Results of the COINCIDE multicenter study. J Visc Surg 2020; 158:211-219. [PMID: 32747307 DOI: 10.1016/j.jviscsurg.2020.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
AIM OF THE STUDY Evaluate the impact of social deprivation on morbidity and mortality in surgery for colorectal cancer. METHODS The COINCIDE prospective cohort included nearly 2,000 consecutive patients operated on for colorectal cancer at the Assistance Publique-Hospitals of Paris (AP-HP) from 2008 to 2010. The data on these patients were crossed with the PMSI administrative database. The European Social Deprivation Index (EDI) was calculated for each patient and classified into five quintiles (quintiles 4 and 5 being the most disadvantaged patients). Thirty-day post-operative morbidity was determined according to the Dindo-Clavien classification, with a Had®Hoc re-analysis of each file. Statistical analysis was performed using the proprietary Q-finder® algorithm. RESULTS One thousand two hundred and fifty nine curative colorectal resections were analyzed. Mortality was 2.7% and severe morbidity (Dindo-Clavien≥3) occurred in 16.4%. Mortality was not statistically significantly increased among the most disadvantaged who made up almost two thirds of the population (64.2%). Patients in quintiles 4 and 5 had a statistically significant increase in severe morbidity. The relative risk remained 1.5 even after adjustment for the known risk factors found in the analysis: age>70 years, ASA score, urgency, and laparotomy. CONCLUSIONS The EDI represents an independent risk factor for severe morbidity after carcinologic colorectal resection. This study suggests that the determinants of health are multidimensional and do not depend solely on the quality and performance of the care system. The inclusion of this index in our surgical databases is therefore necessary, as is its use in health policy for the distribution of resources.
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Affiliation(s)
- A Alves
- Service de chirurgie digestive CHU Caen, registre des tumeurs digestive du calvados, Inserm U1086 ANTICIPE, 14000 Caen, France
| | - A Civet
- Quinten-France, 8, rue Vernier, 75017 Paris, France
| | - A Laurent
- AP-HP, groupe hospitalier Henri-Mondor, service de chirurgie digestive et hépatobiliaire, 94000 Créteil, France
| | - Y Parc
- AP-HP, service de chirurgie generale et digestive, hôpital Saint-Antoine, Sorbonne Université, 184 rue du Faubourg Saint-Antoine, 75012 Paris, France
| | - C Penna
- AP-HP, service de chirurgie digestive, hôpital Bicètre, Le Kremlin-Bicètre, France, Université Paris Sud, Orsay, 94270 Le Kremlin-Bicètre, France
| | - S Msika
- AP-HP, service de chirurgie digestive, oeso-gastrique et bariatrique. CHU Bichat, HUPNVS Université Paris Diderot, PRES Sorbonne Paris Cité, 46, rue Henri Huchard, 75018 Paris, France
| | - M Hirsch
- AP-HP, Avenue Victoria, 75004 Paris, France
| | - M Pocard
- AP-HP, service de chirurgie digestive et cancérologique, hôpital Lariboisière, université de Paris, Unité Inserm U1275 CAP Paris-Tech, Carcinose péritoine Paris technologiques, 2, rue Ambroise-Paré, 75010 Paris, France.
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Lal N, Singh HK, Majeed A, Pawa N. The impact of socioeconomic deprivation on the uptake of colorectal cancer screening in London. J Med Screen 2020; 28:114-121. [PMID: 32295488 DOI: 10.1177/0969141320916206] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Screening programmes based on the faecal occult blood test (FOBT) can reduce mortality from colorectal cancer (CRC). However, a significant variation exists in uptake of the test within the UK. Disproportionate uptake risks increasing inequity during staging at diagnosis and survival from CRC. This study aims to evaluate the impact of socioeconomic deprivation on the uptake of CRC screening (FOBT) in London. METHODS A retrospective review of the "Vanguard RM Informatics" database was performed to identify eligible individuals for CRC screening across all general practices across London over 30 months (2014-2017). The postcodes of the general practices were used to obtain the deprivation data via the "Indices of Deprivation" database. A Spearman's rho correlation was performed to quantify the impact of the deprivation variables on FOBT uptake. RESULTS Overall, 697,402 individuals were eligible for screening across 1359 London general practices, within 5 Clinical Commissioning Groups (CCGs); 48.4% (range: 13%-74%) participated in CRC screening with the lowest participation rates in North West (46%) and North East (47%) London CCGs. All indices of deprivation had a significant correlation with the uptake of FOBT (p < 0.01). CONCLUSION This is the largest study across London to date demonstrating a significant positive correlation between deprivation indices and FOBT uptake, highlighting areas of particular risk. Further studies are imperative to quantify the impact of deprivation on CRC morbidity and mortality, together with focused strategies to reduce socioeconomic inequalities in screening in these high risk areas.
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Affiliation(s)
- Nikhil Lal
- Sheffield Teaching Hospital NHS Foundation Trust, Sheffield, UK
| | - Harpreet Ksi Singh
- Colorectal Surgical Department, West Middlesex University Hospital, Chelsea and Westminster NHS Foundation Trust, Isleworth, UK
| | - Azeem Majeed
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Nikhil Pawa
- Colorectal Surgical Department, West Middlesex University Hospital, Chelsea and Westminster NHS Foundation Trust, Isleworth, UK
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5
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Impact of socioeconomic deprivation on short-term outcomes and long-term overall survival after colorectal resection for cancer. Int J Colorectal Dis 2019; 34:2101-2109. [PMID: 31713715 DOI: 10.1007/s00384-019-03431-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/10/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE The aim of this study was to assess the effects of socioeconomic deprivation on short-term outcomes and long-term overall survival following major resection of colorectal cancer (CRC) at a tertiary hospital in England. METHOD This was an observational cohort study of patients undergoing resection for colorectal cancer from January 2010 to December 2017. Deprivation was classified into quintiles using the English Indices of Multiple Deprivation 2010. Primary outcome was overall complications (Clavien-Dindo grades 1 to 5). Secondary outcomes were the major complications (Clavien-Dindo 3 to 5), length of hospital stay and overall survival. Outcomes were compared between most affluent group and most deprived group. Multivariate regression models were used to establish the relationship taking into account confounding variables. RESULTS One thousand eight hundred thirty-five patients were included. Overall and major complication rates were 44.9% and 11.5% respectively in the most affluent, and 54.6% and 15.6% in the most deprived group. Most deprived group was associated with higher overall complications (odds ratio 1.48, 95% CI 1.13-1.95, p = 0.005), higher major complications (odds ratio 1.49, 1.01-2.23, p = 0.048) and longer hospital stay (adjusted ratio 1.15, 1.06-1.25, p < 0.001) when compared with most affluent group. Median follow period was 41 months (interquartile range 20-64.5). Most deprived group had poor overall survival compared with most affluent, but it was not significant at the 5% level (hazard ratio 1.27, 0.99-1.62, p = 0.055). CONCLUSION Deprivation was associated with higher postoperative complications and longer hospital stay following major resection for CRC. Its relationship with survival was not statistically significant.
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Donkers H, Bekkers R, Massuger L, Galaal K. Socioeconomic deprivation and survival in endometrial cancer: The effect of BMI. Gynecol Oncol 2019; 156:178-184. [PMID: 31759773 DOI: 10.1016/j.ygyno.2019.10.030] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 10/27/2019] [Accepted: 10/28/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVES METHODS: This is a retrospective study of surgically managed endometrial cancer patients in the Royal Cornwall Hospital Truro between January 2006 and August 2017. Patient characteristics, overall survival, recurrence free survival and intra- and postoperative outcomes were evaluated across socioeconomic deprivation groups in which socioeconomic deprivation was measured with the English Indices of Multiple Deprivation (IMD). RESULTS In total, we identified 831 women, of which 690 were included. The median age was 66 years with a median BMI of 31 and the majority of tumours were endometrioid tumours (80.1%). For type 1 (endometrioid) tumours, better survival was seen in the least deprived patients, however this was not significant in a multivariate analysis and only age, stage and BMI remained significant. For type 2 (all other) tumours, no association between survival and socioeconomic deprivation was found and only stage was significant. However, more affluent patients had significantly higher recurrence rates. In addition, we did not find evidence of an association between intra- or post-operative complication rates and socioeconomic deprivation. CONCLUSION Socioeconomic deprivation is associated with survival in endometrial cancer patients, however after adjusting for confounders this association does not remain. Only age, stage and BMI are independent prognostic factors for survival. In addition, there is no evidence of association between socioeconomic deprivation and peri-operative outcomes in endometrial cancer patients.
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Affiliation(s)
- H Donkers
- Royal Cornwall Hospital NHS Trust, Truro, Cornwall, United Kingdom
| | - R Bekkers
- Radboud UMC, Nijmegen, the Netherlands; Catharina Hospital, Eindhoven, the Netherlands
| | | | - K Galaal
- Royal Cornwall Hospital NHS Trust, Truro, Cornwall, United Kingdom; University of Exeter, Exeter, United Kingdom.
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Degett TH, Christensen J, Thomsen LA, Iversen LH, Gögenur I, Dalton SO. Nationwide cohort study of the impact of education, income and social isolation on survival after acute colorectal cancer surgery. BJS Open 2019; 4:133-144. [PMID: 32011820 PMCID: PMC6996631 DOI: 10.1002/bjs5.50218] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 07/16/2019] [Indexed: 12/16/2022] Open
Abstract
Background Acute colorectal cancer surgery has been associated with a high postoperative mortality. The primary aim of this study was to examine the association between socioeconomic position and the likelihood of undergoing acute versus elective colorectal cancer surgery. A secondary aim was to determine 1‐year survival among patients treated with acute surgery. Methods All patients who had undergone a surgical procedure according to the Danish Colorectal Cancer Group (DCCG.dk) database, or who were registered with stent or diverting stoma in the National Patient Register from 2007 to 2015, were reviewed. Socioeconomic position was determined by highest attained educational level, income, urbanicity and cohabitation status, obtained from administrative registries. Co‐variables included age, sex, year of surgery, Charlson Co‐morbidity Index score, smoking status, alcohol consumption, BMI, stage and tumour localization. Logistic regression analysis was performed to determine the likelihood of acute colorectal cancer surgery, and Kaplan–Meier and Cox proportional hazards regression methods were used for analysis of 1‐year overall survival. Results In total, 35 661 patients were included; 5310 (14·9 per cent) had acute surgery. Short and medium education in patients younger than 65 years (odds ratio (OR) 1·58, 95 per cent c.i. 1·32 to 1·91, and OR 1·34, 1·15 to 1·55 respectively), low income (OR 1·12, 1·01 to 1·24) and living alone (OR 1·35, 1·26 to 1·46) were associated with acute surgery. Overall, 40·7 per cent of patients died within 1 year of surgery. Short education (hazard ratio (HR) 1·18, 95 per cent c.i. 1·03 to 1·36), low income (HR 1·16, 1·01 to 1·34) and living alone (HR 1·25, 1·13 to 1·38) were associated with reduced 1‐year survival after acute surgery. Conclusion Low socioeconomic position was associated with an increased likelihood of undergoing acute colorectal cancer surgery, and with reduced 1‐year overall survival after acute surgery.
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Affiliation(s)
- T H Degett
- Danish Cancer Society Research Center, Copenhagen, Denmark.,Center for Surgical Science, Zealand University Hospital, Køge, Denmark
| | - J Christensen
- Danish Cancer Society Research Center, Copenhagen, Denmark
| | - L A Thomsen
- Danish Cancer Society Research Center, Copenhagen, Denmark
| | - L H Iversen
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark.,Danish Colorectal Cancer Group, Denmark
| | - I Gögenur
- Center for Surgical Science, Zealand University Hospital, Køge, Denmark.,Danish Colorectal Cancer Group, Denmark
| | - S O Dalton
- Danish Cancer Society Research Center, Copenhagen, Denmark.,Department of Clinical Oncology and Palliative Care, Zealand University Hospital, Naestved, Denmark
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Influence of social deprivation and remoteness on the likelihood of sphincter amputation for rectal cancer: a high-resolution population-based study. Int J Colorectal Dis 2019; 34:927-931. [PMID: 30877364 DOI: 10.1007/s00384-019-03272-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/28/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Medical care in rectal cancer is subject to social inequality. According to the last French guidelines, a 1-cm distal margin below the lower pole of the rectal tumor is now considered sufficient. This extends the limits of the current sphincter preservation gold standard. Like for other innovative technics, the dissemination of such technics is often subject to social and geographical inequalities. The objective was to analyze whether sphincter preservation in rectal cancer is subject to social or geographical inequality. METHODS The odds of sphincter preservation was modeled by logistic regression among the 1453 patients in the Calvados digestive cancer registry between 1 January 1997 and 31 December 2015 by examining some of the variables that could influence it: social inequalities and geographical remoteness, sex, age, and stage. RESULTS A total of 69.4% of the population received sphincter preservation. Patients in the more deprived quintiles had a significantly higher probability of having sphincter amputation (odds ratio (OR) = 1.469 (1.046-2.064)). This result was no longer significant after adjustment on stage and travel time. There was a dose-effect pattern of geographical remoteness on likelihood of sphincter preservation with a progressive increase in OR between patients living the nearest and the furthest from the reference center (p-trend = 0.0178). CONCLUSION This study shows that the probability of receiving sphincter preservation is influenced by the social environment and strongly influenced by remoteness. Although management guidelines have had a huge impact on the rates of sphincter preservation, they have not reduced the influence of the social and geographical environment on sphincter preservation.
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Marks KM, West NP, Morris E, Quirke P. Clinicopathological, genomic and immunological factors in colorectal cancer prognosis. Br J Surg 2018; 105:e99-e109. [PMID: 29341159 DOI: 10.1002/bjs.10756] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 10/02/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Numerous factors affect the prognosis of colorectal cancer (CRC), many of which have long been identified, such as patient demographics and the multidisciplinary team. In more recent years, molecular and immunological biomarkers have been shown to have a significant influence on patient outcomes. Whilst some of these biomarkers still require ongoing validation, if proven to be worthwhile they may change our understanding and future management of CRC. The aim of this review was to identify the key prognosticators of CRC, including new molecular and immunological biomarkers, and outline how these might fit into the whole wider context for patients. METHODS Relevant references were identified through keyword searches of PubMed and Embase Ovid SP databases. RESULTS In recent years there have been numerous studies outlining molecular markers of prognosis in CRC. In particular, the Immunoscore® has been shown to hold strong prognostic value. Other molecular biomarkers are useful in guiding treatment decisions, such as mutation testing of genes in the epidermal growth factor receptor pathway. However, epidemiological studies continue to show that patient demographics are fundamental in predicting outcomes. CONCLUSION Current strategies for managing CRC are strongly dependent on clinicopathological staging, although molecular testing is increasingly being implemented into routine clinical practice. As immunological biomarkers are further validated, their testing may also become routine. To obtain clinically useful information from new biomarkers, it is important to implement them into a model that includes all underlying fundamental factors, as this will enable the best possible outcomes and deliver true precision medicine.
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Affiliation(s)
- K M Marks
- Section of Pathology and Tumour Biology, Leeds Institute of Cancer and Pathology, School of Medicine, University of Leeds, Leeds, UK
| | - N P West
- Section of Pathology and Tumour Biology, Leeds Institute of Cancer and Pathology, School of Medicine, University of Leeds, Leeds, UK
| | - E Morris
- Section of Epidemiology and Biostatistics, Leeds Institute of Cancer and Pathology, School of Medicine, University of Leeds, Leeds, UK
| | - P Quirke
- Section of Pathology and Tumour Biology, Leeds Institute of Cancer and Pathology, School of Medicine, University of Leeds, Leeds, UK
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Khalid U, Zaidi A, Cheang A, Horvath S, Szabo L, Ilham MA, Stephens MR. 'Educational' Deprivation is Associated with PD Peritonitis. Perit Dial Int 2018; 38:251-256. [PMID: 29674408 DOI: 10.3747/pdi.2017.00098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 01/02/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Socioeconomic deprivation is an important factor in determining poor health and is associated with a higher prevalence of many chronic diseases, including renal failure, and often poorer outcomes for patients with such conditions. The aim of this study was to investigate the effect of deprivation on peritonitis episodes following peritoneal dialysis (PD)-catheter insertion. METHODS The Welsh Index of Multiple Deprivation (WIMD) was used to assess the influence of socioeconomic deprivation on outcomes following 233 consecutive first PD-catheter insertions from a single institution in the United Kingdom, performed between 2010 and 2015. The primary outcome measure was the presence of peritonitis episodes. RESULTS Peritoneal dialysis catheters were inserted in 243 patients, of which data were available for 233. Fifty-four patients experienced at least 1 episode of peritonitis. Overall, more patients in the most deprived group (vs least deprived) experienced peritonitis, although this was not statistically significant. When analyzing the severity of the peritonitis, within the 'Education' domain of the WIMD, significantly more patients from the most deprived group (compared with the least deprived group) experienced '2 or more peritonitis' episodes (p = 0.04) and were hospitalized for antibiotics (p = 0.02). CONCLUSION This study has shown that patients who live in more 'educationally' deprived areas are more likely to have multiple episodes of peritonitis requiring hospital admission following PD-catheter insertions.
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Affiliation(s)
- Usman Khalid
- Dialysis Access Service, Cardiff & Vale University Health Board, Department of Nephrology & Transplant Surgery, University Hospital of Wales, Heath Park, Cardiff, United Kingdom
| | - Aeliya Zaidi
- Dialysis Access Service, Cardiff & Vale University Health Board, Department of Nephrology & Transplant Surgery, University Hospital of Wales, Heath Park, Cardiff, United Kingdom
| | - Adrian Cheang
- Dialysis Access Service, Cardiff & Vale University Health Board, Department of Nephrology & Transplant Surgery, University Hospital of Wales, Heath Park, Cardiff, United Kingdom
| | - Szabolcs Horvath
- Dialysis Access Service, Cardiff & Vale University Health Board, Department of Nephrology & Transplant Surgery, University Hospital of Wales, Heath Park, Cardiff, United Kingdom
| | - Laszlo Szabo
- Dialysis Access Service, Cardiff & Vale University Health Board, Department of Nephrology & Transplant Surgery, University Hospital of Wales, Heath Park, Cardiff, United Kingdom
| | - Mohamed A Ilham
- Dialysis Access Service, Cardiff & Vale University Health Board, Department of Nephrology & Transplant Surgery, University Hospital of Wales, Heath Park, Cardiff, United Kingdom
| | - Michael R Stephens
- Dialysis Access Service, Cardiff & Vale University Health Board, Department of Nephrology & Transplant Surgery, University Hospital of Wales, Heath Park, Cardiff, United Kingdom
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11
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Systematic review of the influence of socioeconomic deprivation on mortality after colorectal surgery. Br J Surg 2018; 105:959-970. [DOI: 10.1002/bjs.10848] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 01/25/2018] [Accepted: 02/02/2018] [Indexed: 01/12/2023]
Abstract
Abstract
Background
Socioeconomic deprivation is a potentially important factor influencing surgical outcomes. This systematic review aimed to summarize the evidence for any association between socioeconomic group and mortality after colorectal surgery, and to report the definitions of deprivation used and the approaches taken to adjust for co-morbidity in this patient population.
Methods
MEDLINE, Embase, the Cochrane Library and Web of Science were searched for studies up to November 2016 on adult patients undergoing major colorectal surgery, which reported on mortality according to socioeconomic group. Risk of bias and study quality were assessed by extracting data relating to study size, and variations in inclusion and exclusion criteria. Quality was assessed using a modification of a previously described assessment tool.
Results
The literature search identified 59 studies published between 1993 and 2016, reporting on 2 698 403 patients from eight countries. Overall findings showed evidence for higher mortality in more deprived socioeconomic groups, both in the perioperative period and in the longer term. Studies differed in how they defined socioeconomic groups, but the most common approach was to use one of a selection of multifactorial indices based on small geographical areas. There was no consistent approach to adjusting for co-morbidity but, where this was considered, the Charlson Co-morbidity Index was most frequently used.
Conclusion
This systematic review suggests that socioeconomic deprivation influences mortality after colorectal surgery.
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Kim MK, Won DD, Park SM, Kim T, Kim SR, Oh ST, Sohn SK, Kang MY, Lee IK. Effect of Adjuvant Chemotherapy on Stage II Colon Cancer: Analysis of Korean National Data. Cancer Res Treat 2017; 50:1149-1163. [PMID: 29216709 PMCID: PMC6192938 DOI: 10.4143/crt.2017.194] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 12/05/2017] [Indexed: 12/27/2022] Open
Abstract
Purpose Debates exist regarding the effectiveness of adjuvant chemotherapy for stage II colon cancer. This study aimed to investigate the current status of adjuvant chemotherapy and its impact on survival for Korean stage II colon cancer patients by analyzing the National Quality Assessment data. Materials and Methods A total of 7,880 patientswho underwent curative resection for stage II colon adenocarcinoma between January 2011 andDecember 2014 in Koreawere selected randomly as evaluation subjects for the quality assessment. The factors that influenced overall survival were identified. The high-risk group was defined as having at least one of the following: perforation/obstruction, lymph node harvest less than 12, lymphovascular/perineural invasion, positive resection margin, poor differentiation, or pathologic T4 stage. Results The median follow-up period was 38 months (range, 1 to 63 months). Chemotherapy was a favorable prognostic factor for either the high- (hazard ratio [HR], 0.76; 95% confidence interval [CI], 0.38 to 0.59; p < 0.001) or low-risk group (HR, 0.74; 95% CI, 0.61 to 0.89; p=0.002) in multivariate analysis. This was also the case in patients over 70 years of age. The hazard ratio was significantly increased as the number of involved risk factors was increased in patients who didn’t receive chemotherapy. Adding oxaliplatin showed no difference in survival (HR, 1.36; 95% CI, 0.91 to 2.03; p=0.132). Conclusion Adjuvant chemotherapy can be recommended for stage II colon cancer patients, but the addition of oxaliplatin to the regimen must be selective.
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Affiliation(s)
- Min Ki Kim
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Daeyoun David Won
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sun Min Park
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Taejung Kim
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung Ryong Kim
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seong Taek Oh
- Department of Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
| | | | - Mi Yeon Kang
- Health Insurance Review & Assessment Service, Wonju, Korea
| | - In Kyu Lee
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Askari A, Nachiappan S, Currie A, Bottle A, Abercrombie J, Athanasiou T, Faiz O. Who requires emergency surgery for colorectal cancer and can national screening programmes reduce this need? Int J Surg 2017; 42:60-68. [PMID: 28456708 DOI: 10.1016/j.ijsu.2017.04.050] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 04/16/2017] [Accepted: 04/22/2017] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Patients undergoing emergency colorectal cancer (CRC) surgery are at higher risk of poor outcome than those managed electively. The aim of this national study is to identify groups at high risk of undergoing unplanned CRC surgery and assess short and long-term outcome in this cohort subsequent morbidity and mortality as well as quantify their long-term survival. The aim of this national study is to identify groups at high risk of undergoing unplanned CRC surgery and assess short and long-term outcome, subsequent morbidity and mortality as well as quantify their long-term survival. METHODS The Hospital Episode Statistics (HES) database between the years of 1997-2012 was used to identify all patients that had undergone surgery for colorectal cancer. Multivariable logistic regression analysis and cox regression analyses were undertaken to identify patient factors predictive of undergoing emergency and quantify their long-term survival. RESULTS A total of 286,591 patients underwent resection for CRC between April 1997 and April 2012, of which 24.3% (69,718 patients) were admitted as emergencies and underwent emergency surgery. Independent predictors of undergoing emergency surgery were female gender (OR 1.23, CI: 1.21-1.25, p < 0.001), older age (>79 years old OR 1.55, CI: 1.50-1.60, p < 0.001), social deprivation (most deprived quintile, OR 1.64, CI: 1.50-1.80, p < 0.001) and Black African/Caribbean ethnicity (OR 1.36, CI: 1.21-1.66, p < 0.001). All cause 30- and 90-day mortality within the emergency group was significantly higher than that for the electively managed patients group (13.3% versus compared with 3.4% at 30-days) as was 90-day (20.0% versus compared with 5.8% at 90-days). Amongst patients eligible for bowel screening there was an approximate 40% significant reduction in the proportion of patients requiring emergency surgery before and after its introduction in 2006 (23.4%-14.9%, p < 0.001). This reduction in emergency surgery included both proximal and distal cancer resections. CONCLUSION Older, socially deprived and ethnic minority patients with colorectal cancer are more likely to present as emergencies requiring CRC surgery. Public health initiatives, such as bowel cancer screening, appear to have concomitantly reduced emergency and increased elective surgical rates within the eligible cohort. This is likely to have a beneficial impact on population survival. Strategies aimed at preventing emergency presentation by identifying patients at specific risk could improve survival outcome for colorectal cancer surgery in England.
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Affiliation(s)
- Alan Askari
- Surgical Epidemiology, Trials and Outcome Centre (SETOC), St Mark's Hospital & Academic Institute, Harrow, Middlesex, HA1 3UJ, United Kingdom.
| | - Subramanian Nachiappan
- Surgical Epidemiology, Trials and Outcome Centre (SETOC), St Mark's Hospital & Academic Institute, Harrow, Middlesex, HA1 3UJ, United Kingdom
| | - Andrew Currie
- Surgical Epidemiology, Trials and Outcome Centre (SETOC), St Mark's Hospital & Academic Institute, Harrow, Middlesex, HA1 3UJ, United Kingdom
| | - Alex Bottle
- Faculty of Medicine, School of Public Health, Dr Foster Unit, Imperial College London, United Kingdom
| | | | - Thanos Athanasiou
- Faculty of Medicine, Department of Surgery & Cancer, St Mary's Hospital, Praed Street, London, W21NY, United Kingdom
| | - Omar Faiz
- Surgical Epidemiology, Trials and Outcome Centre (SETOC), St Mark's Hospital & Academic Institute, Harrow, Middlesex, HA1 3UJ, United Kingdom; Department of Surgery, Imperial College, St Mary's Hospital, Praed Street, London, W21NY, United Kingdom
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Askari A, Nachiappan S, Currie A, Latchford A, Stebbing J, Bottle A, Athanasiou T, Faiz O. The relationship between ethnicity, social deprivation and late presentation of colorectal cancer. Cancer Epidemiol 2017; 47:88-93. [PMID: 28167416 DOI: 10.1016/j.canep.2017.01.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 01/14/2017] [Accepted: 01/16/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Tumour staging at time of presentation is an important factor in determining survival in colorectal cancer. The aim of this paper is to investigate the relationship between ethnicity and deprivation in late (Stage IV) presentation of colorectal cancer. METHODS Data from the Thames Cancer Registry comprising 77,057 colorectal cancer patients between the years 2000 and 2012 were analysed. RESULTS A total of 17,348 patients were identified with complete data, of which 53.9% were male. Patients from a Black Afro/Caribbean background were diagnosed with CRC at a much younger age than the White British group (median age 67 compared with 72, p<0.001). In multiple regression, ethnicity, deprivation and age were positive predictors of presenting with advanced tumour stage at time of diagnosis. Black patients were more likely to present with Stage IV tumours than white patients (OR 1.37, 95% CI 1.18-1.59, p<0.001). Social deprivation was also a predictor of Stage IV cancer presentation, with the most deprived group (Quintile 5) 1.26 times more likely to be diagnosed with Stage IV cancer compared with the most affluent group (CI 1.13-1.40, p<0.001). Sub-group analyses demonstrated that Black & Affluent patients were still at greater risk of Stage IV CRC than their White & Affluent counterparts (OR 1.24, 95% CI 1.11-1.45, p=0.023). Patients with rectal cancer were less likely to present with Stage IV CRC (OR 0.66, 95% CI 0.61-0.71, p<0.001). CONCLUSION Racial and age related disparities exist in tumour presentation in the United Kingdom. Patients from black and socially deprived backgrounds as well as the elderly are more likely to present with advanced tumours at time of diagnosis.
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Affiliation(s)
- Alan Askari
- Surgical Epidemiology, Trials and Outcome Centre (SETOC), St Mark's Hospital & Academic Institute, Harrow, Middlesex, HA1 3UJ, United Kingdom.
| | - Subramanian Nachiappan
- Surgical Epidemiology, Trials and Outcome Centre (SETOC), St Mark's Hospital & Academic Institute, Harrow, Middlesex, HA1 3UJ, United Kingdom.
| | - Andrew Currie
- Surgical Epidemiology, Trials and Outcome Centre (SETOC), St Mark's Hospital & Academic Institute, Harrow, Middlesex, HA1 3UJ, United Kingdom
| | - Andrew Latchford
- Department of Gastroenterology, St Mark's Hospital, Harrow, Middlesex, HA1 3UJ, United Kingdom; Imperial College London, United Kingdom.
| | - Justin Stebbing
- Department of Surgery and Cancer, Imperial College, United Kingdom.
| | - Alex Bottle
- Faculty of Medicine, School of Public Health, Dr Foster Unit, Imperial College London, United Kingdom.
| | | | - Omar Faiz
- Surgical Epidemiology, Trials and Outcome Centre (SETOC), St Mark's Hospital & Academic Institute, Harrow, Middlesex, HA1 3UJ, United Kingdom; Department of Surgery and Cancer, Imperial College, United Kingdom.
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Raine R, Atkin W, von Wagner C, Duffy S, Kralj-Hans I, Hackshaw A, Counsell N, Moss S, McGregor L, Palmer C, Smith SG, Thomas M, Howe R, Vart G, Band R, Halloran SP, Snowball J, Stubbs N, Handley G, Logan R, Rainbow S, Obichere A, Smith S, Morris S, Solmi F, Wardle J. Testing innovative strategies to reduce the social gradient in the uptake of bowel cancer screening: a programme of four qualitatively enhanced randomised controlled trials. PROGRAMME GRANTS FOR APPLIED RESEARCH 2017. [DOI: 10.3310/pgfar05080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BackgroundBowel cancer screening reduces cancer-specific mortality. There is a socioeconomic gradient in the uptake of the English NHS Bowel Cancer Screening Programme (BCSP), which may lead to inequalities in cancer outcomes.ObjectiveTo reduce socioeconomic inequalities in uptake of the NHS BCSP’s guaiac faecal occult blood test (gFOBt) without compromising uptake in any socioeconomic group.DesignWorkstream 1 explored psychosocial determinants of non-uptake of gFOBt in focus groups and interviews. Workstream 2 developed and tested four theoretically based interventions: (1) ‘gist’ information, (2) a ‘narrative’ leaflet, (3) ‘general practice endorsement’ (GPE) and (4) an ‘enhanced reminder’ (ER). Workstream 3 comprised four national cluster randomised controlled trials (RCTs) of the cost-effectiveness of each intervention.MethodsInterventions were co-designed with user panels, user tested using interviews and focus groups, and piloted with postal questionnaires. RCTs compared ‘usual care’ (existing NHS BCSP invitations) with usual care plus each intervention. The four trials tested: (1) ‘gist’ leaflet (n = 163,525), (2) ‘narrative’ leaflet (n = 150,417), (3) GPE on the invitation letter (n = 265,434) and (4) ER (n = 168,480). Randomisation was based on day of mailing of the screening invitation. The Index of Multiple Deprivation (IMD) score associated with each individual’s home address was used as the marker of socioeconomic circumstances (SECs). Change in the socioeconomic gradient in uptake (interaction between treatment group and IMD quintile) was the primary outcome. Screening uptake was defined as the return of a gFOBt kit within 18 weeks of the invitation that led to a ‘definitive’ test result of either ‘normal’ (i.e. no further investigation required) or ‘abnormal’ (i.e. requiring referral for further testing). Difference in overall uptake was the secondary outcome.ResultsThe gist and narrative trials showed no effect on the SECs gradient or overall uptake (57.6% and 56.7%, respectively, compared with 57.3% and 58.5%, respectively, for usual care; allp-values > 0.05). GPE showed no effect on the gradient (p = 0.5) but increased overall uptake [58.2% vs. 57.5% in usual care, odds ratio (OR) = 1.07, 95% confidence interval (CI) 1.04 to 1.10;p < 0.0001]. ER showed a significant interaction with SECs (p = 0.005), with a stronger effect in the most deprived IMD quintile (14.1% vs. 13.3% in usual care, OR = 1.11, 95% CI 1.04 to 1.20;p = 0.003) than the least deprived (34.7% vs. 34.9% in usual care OR = 1.00, 95% CI 0.94 to 1.06;p = 0.98), and higher overall uptake (25.8% vs. 25.1% in usual care, OR = 1.07, 95% CI 1.03 to 1.11;p = 0.001). All interventions were inexpensive to provide.LimitationsIn line with NHS policy, the gist and narrative leaflets supplemented rather than replaced existing NHS BCSP information. This may have undermined their effect.ConclusionsEnhanced reminder reduced the gradient and modestly increased overall uptake, whereas GPE increased overall uptake but did not reduce the gradient. Therefore, given their effectiveness and very low cost, the findings suggest that implementation of both by the NHS BCSP would be beneficial. The gist and narrative results highlight the challenge of achieving equitable delivery of the screening offer when all communication is written; the format is universal and informed decision-making mandates extensive medical information.Future workSocioculturally tailored research to promote communication about screening with family and friends should be developed and evaluated.Trial registrationCurrent Controlled Trials ISRCTN74121020.FundingThis project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 5, No. 8. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Rosalind Raine
- Department of Applied Health Research, University College London, London, UK
| | - Wendy Atkin
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Christian von Wagner
- Department of Epidemiology and Public Health, University College London, London, UK
| | - Stephen Duffy
- Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - Ines Kralj-Hans
- Department of Biostatistics, King’s Clinical Trials Unit, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Allan Hackshaw
- University College London Cancer Trials Centre, London, UK
| | | | - Sue Moss
- Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - Lesley McGregor
- Department of Epidemiology and Public Health, University College London, London, UK
| | - Cecily Palmer
- Department of Applied Health Research, University College London, London, UK
| | - Samuel G Smith
- Department of Epidemiology and Public Health, University College London, London, UK
| | - Mary Thomas
- Department of Applied Health Research, University College London, London, UK
| | - Rosemary Howe
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Gemma Vart
- Department of Epidemiology and Public Health, University College London, London, UK
| | - Roger Band
- Patient and Public Involvement Representative, Evesham, UK
| | - Stephen P Halloran
- NHS Bowel Cancer Screening Programme Southern Hub, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Julia Snowball
- NHS Bowel Cancer Screening Programme Southern Hub, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Neil Stubbs
- NHS Bowel Cancer Screening Programme Southern Hub, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Graham Handley
- NHS Bowel Cancer Screening Programme North East Hub, Gateshead Health NHS Foundation Trust, Queen Elizabeth Hospital, Gateshead, UK
| | - Richard Logan
- NHS Bowel Cancer Screening Programme Eastern Hub, Nottingham University Hospitals, Nottingham, UK
| | - Sandra Rainbow
- NHS Bowel Cancer Screening Programme London Hub, Northwick Park and St Marks Hospitals NHS Trust, Harrow, UK
| | - Austin Obichere
- North Central London Bowel Cancer Screening Centre, University College London Hospitals NHS Foundation Trust, London, UK
| | - Stephen Smith
- NHS Bowel Cancer Screening Programme Midlands and North West Hub, University Hospitals Coventry and Warwickshire NHS Trust, Hospital of St Cross, Rugby, UK
| | - Stephen Morris
- Department of Applied Health Research, University College London, London, UK
| | - Francesca Solmi
- Department of Applied Health Research, University College London, London, UK
| | - Jane Wardle
- Department of Epidemiology and Public Health, University College London, London, UK
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16
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Dale CD, McLoone P, Sloan B, Kinsella J, Morrison D, Puxty K, Quasim T. Critical care provision after colorectal cancer surgery. BMC Anesthesiol 2016; 16:94. [PMID: 27733119 PMCID: PMC5059906 DOI: 10.1186/s12871-016-0243-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 08/04/2016] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Colorectal cancer (CRC) is the 2nd largest cause of cancer related mortality in the UK with 40 000 new patients being diagnosed each year. Complications of CRC surgery can occur in the perioperative period that leads to the requirement of organ support. The aim of this study was to identify pre-operative risk factors that increased the likelihood of this occurring. METHODS This is a retrospective observational study of all 6441 patients who underwent colorectal cancer surgery within the West of Scotland Region between 2005 and 2011. Logistic regression was employed to determine factors associated with receiving postoperative organ support. RESULTS A total of 610 (9 %) patients received organ support. Multivariate analysis identified age ≥65, male gender, emergency surgery, social deprivation, heart failure and type II diabetes as being independently associated with organ support postoperatively. After adjusting for demographic and clinical factors, patients with metastatic disease appeared less likely to receive organ support (p = 0.012). CONCLUSIONS Nearly one in ten patients undergoing CRC surgery receive organ support in the post operative period. We identified several risk factors which increase the likelihood of receiving organ support post operatively. This is relevant when consenting patients about the risks of CRC surgery.
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Affiliation(s)
- C D Dale
- Undergraduate Medical School, School of Medicine, University of Glasgow, Glasgow, UK
| | - P McLoone
- West of Scotland Cancer Surveillance Unit, Public Health Research Group, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - B Sloan
- West of Scotland Cancer Surveillance Unit, Public Health Research Group, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - J Kinsella
- Anaesthesia, Critical Care and Pain Medicine, School of Medicine, Glasgow Royal Infirmary, Glasgow, Scotland, UK
| | - D Morrison
- West of Scotland Cancer Surveillance Unit, Public Health Research Group, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - K Puxty
- Anaesthesia, Critical Care and Pain Medicine, School of Medicine, Glasgow Royal Infirmary, Glasgow, Scotland, UK.
| | - T Quasim
- Anaesthesia, Critical Care and Pain Medicine, School of Medicine, Glasgow Royal Infirmary, Glasgow, Scotland, UK
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ELHadi A, Ashford-Wilson S, Brown S, Pal A, Lal R, Aryal K. Effect of Social Deprivation on the Stage and Mode of Presentation of Colorectal Cancer. Ann Coloproctol 2016; 32:128-32. [PMID: 27626022 PMCID: PMC5019964 DOI: 10.3393/ac.2016.32.4.128] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Accepted: 07/23/2016] [Indexed: 01/29/2023] Open
Abstract
Purpose Based in a hospital serving one of the most deprived areas in the United Kingdom (UK), we aimed to investigate, using the Indices of Deprivation 2010, the hypothesis that deprivation affects the stage and mode of presentation of colorectal cancer. Methods All newly diagnosed patients with colorectal cancer presenting to a District General Hospital in the UK between January 2010 and December 2014 were included. Data were collected from the Somerset National Cancer Database. The effect of social deprivation, measured using the Index of Multiple Deprivation Score, on the stage and mode of presentation was evaluated utilizing Microsoft Excel and IBM SPSS ver. 22.0. Results A total of 701 patients (54.5% male; mean age, 76 years) were included; 534 (76.2%) underwent a surgical procedure, and 497 (70.9%) underwent a colorectal resection. Of the patients undergoing a colorectal resection, 86 (17.3%) had an emergency surgical resection. Social deprivation was associated with Duke staging (P = 0.09). The 90-day mortality in patients undergoing emergency surgery was 12.8% compared to 6.8% in patients undergoing elective surgery (P = 0.06). No association was found between deprivation and emergency presentation (P = 0.97). A logistic regression analysis showed no increase in the probability of metastasis amongst deprived patients. Conclusion This study suggests an association between deprivation and the stage of presentation of colorectal cancer. Patients undergoing emergency surgery tend to have a higher 90-day mortality rate, although this was not related to deprivation. This study highlights the need to develop an individual measure to assess social deprivation.
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Affiliation(s)
- Ahmed ELHadi
- Department of General Surgery, James Paget University Hospital, Great Yarmouth, UK
| | - Sarah Ashford-Wilson
- Department of General Surgery, James Paget University Hospital, Great Yarmouth, UK
| | - Stephanie Brown
- Department of General Surgery, James Paget University Hospital, Great Yarmouth, UK
| | - Atanu Pal
- Department of General Surgery, James Paget University Hospital, Great Yarmouth, UK
| | - Roshan Lal
- Department of General Surgery, James Paget University Hospital, Great Yarmouth, UK
| | - Kamal Aryal
- Department of General Surgery, James Paget University Hospital, Great Yarmouth, UK
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Radwan RW, Coyne PE, Jones HG, Evans MD, Davies M, Harris DA, Beynon J. Social deprivation in patients requiring pelvic exenterative surgery. Colorectal Dis 2016; 18:684-7. [PMID: 26773422 DOI: 10.1111/codi.13274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 10/20/2015] [Indexed: 02/08/2023]
Abstract
AIM Pelvic exenteration is an aggressive operation for locally advanced rectal cancer. Social deprivation has been shown to reduce life expectancy and has been linked to a poorer outcome in patients with colorectal cancer. The aim of this study was to analyse the effect of social deprivation scores on the outcome in these complex patients. METHOD A retrospective review of all patients undergoing pelvic exenteration for primary rectal cancer between 2006 and 2014 was performed. Deprivation scores were calculated for all patients using the Welsh Index of Multiple Deprivation. Patients were then grouped into quartiles, from Q1 (most deprived) to Q4 (least deprived). The primary outcome measure was 5-year survival. RESULTS In all, 120 patients were included (65 female) with a median age of 64 (31-90) years. No differences between quartiles were identified for neoadjuvant therapy (P = 0.687) or type of exenteration (P = 0.690). The median length of stay was significantly higher in the most deprived groups (Q1-Q2; P = 0.023). There was a significant difference in survival between the groups, with lowest 5-year survival rates (53%) in the most deprived quartile (Q1) (P = 0.015). CONCLUSION Social deprivation is significantly associated with postoperative length of stay and survival in patients undergoing pelvic exenteration for primary rectal cancer.
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Affiliation(s)
- R W Radwan
- Swansea Pelvic Oncology Group, Abertawe Bro Morgannwg University Local Health Board, Swansea, UK
| | - P E Coyne
- Swansea Pelvic Oncology Group, Abertawe Bro Morgannwg University Local Health Board, Swansea, UK
| | - H G Jones
- Swansea Pelvic Oncology Group, Abertawe Bro Morgannwg University Local Health Board, Swansea, UK
| | - M D Evans
- Swansea Pelvic Oncology Group, Abertawe Bro Morgannwg University Local Health Board, Swansea, UK
| | - M Davies
- Swansea Pelvic Oncology Group, Abertawe Bro Morgannwg University Local Health Board, Swansea, UK
| | - D A Harris
- Swansea Pelvic Oncology Group, Abertawe Bro Morgannwg University Local Health Board, Swansea, UK
| | - J Beynon
- Swansea Pelvic Oncology Group, Abertawe Bro Morgannwg University Local Health Board, Swansea, UK
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19
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Ahmad N, Green P, Scurr J, Torella F. Influence of Social Deprivation on Outcome of Open Arterial Surgery in Tertiary Care: An Observational Study. J INVEST SURG 2016; 29:289-93. [DOI: 10.3109/08941939.2016.1158888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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20
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The influence of socioeconomic deprivation on early outcomes in vascular access surgery. J Vasc Access 2015; 16:480-5. [PMID: 26070094 DOI: 10.5301/jva.5000406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2015] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Socioeconomic deprivation is an important factor in determining poor health and is associated with a higher prevalence of many chronic diseases including diabetes and renal failure, and often poorer outcomes for patients with such conditions. The influence of deprivation on outcomes following vascular access surgery has not previously been reported. METHODS The Welsh Index of Multiple Deprivation was used to assess the influence of socioeconomic deprivation on outcomes following 507 consecutive first upper limb arteriovenous (AV) fistulas from a single institution in the United Kingdom, performed between 2011 and 2014. The primary outcome measures were early failure and maturation into a working fistula. RESULTS Four hundred and five (80%) patients had a patent AV fistula at the 2-week follow-up clinic. Three hundred and fifty-nine (71%) patients developed a functionally mature AV fistula as determined by clinical assessment and a Doppler scan. There were no differences in either early failure rates (p = 0.95) or maturation rates (p = 0.77) between the least and most deprived groups of patients. CONCLUSIONS In conclusion, this study has shown that socioeconomic deprivation does not influence outcomes following vascular access surgery.
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Khalid U, Laftsidis P, Chapman D, Stephens MR, Asderakis A. The influence of socioeconomic deprivation on outcomes in pancreas transplantation. Clin Transplant 2015; 29:409-14. [DOI: 10.1111/ctr.12533] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Usman Khalid
- Cardiff Transplant Unit; Department of Nephrology & Transplant Surgery; University Hospital of Wales; Cardiff UK
| | - Prodromos Laftsidis
- Cardiff Transplant Unit; Department of Nephrology & Transplant Surgery; University Hospital of Wales; Cardiff UK
| | - Dawn Chapman
- Cardiff Transplant Unit; Department of Nephrology & Transplant Surgery; University Hospital of Wales; Cardiff UK
| | - Michael R. Stephens
- Cardiff Transplant Unit; Department of Nephrology & Transplant Surgery; University Hospital of Wales; Cardiff UK
| | - Argiris Asderakis
- Cardiff Transplant Unit; Department of Nephrology & Transplant Surgery; University Hospital of Wales; Cardiff UK
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Wiggans MG, Shahtahmassebi G, Aroori S, Bowles MJ, Stell DA. Socioeconomic status influences the likelihood but not the outcome of liver resection for colorectal liver metastasis. HPB (Oxford) 2015; 17:150-8. [PMID: 24992178 PMCID: PMC4299389 DOI: 10.1111/hpb.12290] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 05/05/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim of this study was to compare the socioeconomic profile of patients undergoing liver resection for colorectal liver metastasis (CLM) in a regional hepatopancreatobiliary unit with that of the local population. A further aim was to determine if degree of deprivation is associated with tumour recurrence after resection. METHODS A retrospective analysis of patients undergoing liver resection for CLM was performed. Geodemographic segmentation was used to divide the population into five categories of socioeconomic status (SES). RESULTS During a 7-year period, 303 patients underwent resection for CLM. The proportion of these patients in the two least deprived categories of SES was greater than that of the local population (50.2% versus 40.2%) and the proportion in the two most deprived categories was lower (18.3% versus 30.1%) (P < 0.001). There was no difference in recurrence rate (P = 0.867) or disease-free survival among categories of SES (P = 0.913). Multivariate analysis demonstrated no association between SES and tumour recurrence (P = 0.700). CONCLUSIONS Liver resection for CLM is performed more commonly among the least socioeconomically deprived population than among the most deprived. However, degree of deprivation was not associated with tumour recurrence after resection.
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Affiliation(s)
- Matthew G Wiggans
- Department of Hepatopancreatobiliary Surgery, Plymouth Hospitals National Health Service (NHS) Trust, Derriford HospitalPlymouth, UK,Department of Medicine, Peninsula College of Medicine and Dentistry, Plymouth UniversityPlymouth, UK,Correspondence, Matthew G. Wiggans, Department of Upper Gastrointestinal Surgery, Derriford Hospital, Derriford Road, Plymouth PL6 8DH, UK. Tel: +44 1752 431486. Fax: +44 845 155 8235. E-mail:
| | - Golnaz Shahtahmassebi
- Department of Physics and Mathematics, School of Science and Technology, Nottingham Trent UniversityNottingham, UK
| | - Somaiah Aroori
- Department of Hepatopancreatobiliary Surgery, Plymouth Hospitals National Health Service (NHS) Trust, Derriford HospitalPlymouth, UK
| | - Matthew J Bowles
- Department of Hepatopancreatobiliary Surgery, Plymouth Hospitals National Health Service (NHS) Trust, Derriford HospitalPlymouth, UK
| | - David A Stell
- Department of Hepatopancreatobiliary Surgery, Plymouth Hospitals National Health Service (NHS) Trust, Derriford HospitalPlymouth, UK,Department of Medicine, Peninsula College of Medicine and Dentistry, Plymouth UniversityPlymouth, UK
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Dik VK, Aarts MJ, Van Grevenstein WMU, Koopman M, Van Oijen MGH, Lemmens VE, Siersema PD. Association between socioeconomic status, surgical treatment and mortality in patients with colorectal cancer. Br J Surg 2014; 101:1173-82. [PMID: 24916417 DOI: 10.1002/bjs.9555] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2014] [Indexed: 12/18/2022]
Abstract
BACKGROUND High socioeconomic status is associated with better survival in colorectal cancer (CRC). This study investigated whether socioeconomic status is associated with differences in surgical treatment and mortality in patients with CRC. METHODS Patients diagnosed with stage I-III CRC between 2005 and 2010 in the Eindhoven Cancer Registry area in the Netherlands were included. Socioeconomic status was determined at a neighbourhood level by combining the mean household income and the mean value of the housing. RESULTS Some 4422 patients with colonic cancer and 2314 with rectal cancer were included. Patients with colonic cancer and high socioeconomic status were operated on with laparotomy (70·7 versus 77·6 per cent; P = 0·017), had laparoscopy converted to laparotomy (15·7 versus 29·5 per cent; P = 0·008) and developed anastomotic leakage or abscess (9·6 versus 12·6 per cent; P = 0·049) less frequently than patients with low socioeconomic status. These differences remained significant after adjustment for patient and tumour characteristics. In rectal cancer, patients with high socioeconomic status were more likely to undergo resection (96·3 versus 93·7 per cent; P = 0·083), but this was not significant in multivariable analysis (odds ratio (OR) 1·44, 95 per cent confidence interval 0·84 to 2·46). The difference in 30-day postoperative mortality in patients with colonic cancer and high and low socioeconomic status (3·6 versus 6·8 per cent; P < 0·001) was not significant after adjusting for age, co-morbidities, emergency surgery, and anastomotic leakage or abscess formation (OR 0·90, 0·51 to 1·57). CONCLUSION Patients with CRC and high socioeconomic status have more favourable surgical treatment characteristics than patients with low socioeconomic status. The lower 30-day postoperative mortality found in patients with colonic cancer and high socioeconomic status is largely explained by patient and surgical factors.
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Affiliation(s)
- V K Dik
- Departments of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht, The Netherlands
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Askari A, Faiz O. Response to "Emergency presentation and socioeconomic status in colon cancer". Eur J Surg Oncol 2014; 40:1163. [PMID: 24854595 DOI: 10.1016/j.ejso.2014.01.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Accepted: 01/30/2014] [Indexed: 10/25/2022] Open
Affiliation(s)
- Alan Askari
- Surgical Epidemiology, Trials and Outcomes Centre (SETOC), St. Mark's Hospital & Academic Institute, London, Middlesex, United Kingdom.
| | - O Faiz
- Surgical Epidemiology, Trials and Outcomes Centre (SETOC), St. Mark's Hospital & Academic Institute, London, Middlesex, United Kingdom
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Bokey L, Chapuis PH, Keshava A, Rickard MJFX, Stewart P, Dent OF. Complications after resection of colorectal cancer in a public hospital and a private hospital. ANZ J Surg 2014; 85:128-34. [PMID: 24852703 DOI: 10.1111/ans.12685] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND To our knowledge, immediate post-operative complication rates after resection of colorectal cancer (CRC) have not been compared between public and private hospitals in the Australian health care system. We compared the frequency of surgical and medical complications between a public tertiary referral hospital and a private hospital. METHODS Data were drawn from a prospective registry of all patients having a resection for CRC between 2000 and 2010 performed by members of the Concord Hospital colorectal surgical unit, either at this hospital or at a single private hospital with which they were affiliated. Complication rates were compared after adjustment for preoperative and perioperative features by logistic regression. RESULTS Among the 16 surgical complications, the only significant difference after adjustment for other features was a higher rate of septicaemia in the public hospital (odds ratio (OR) 2.2, 95% confidence interval (CI) 1.1-4.6). Among the seven medical complications, the only significant differences were a higher risk of cardiac complications in patients with cardiac co-morbidity (OR 1.8, 95% CI 1.1-3.0) and of respiratory complications in patients without respiratory co-morbidity (OR 3.1, 95% CI 2.2-5.9) in the public hospital. CONCLUSION In this study, where the same group of surgeons performed all reported CRC resections in the two hospitals, no independent effect of the type of hospital was found on 15 of 16 surgical complications and 5 of 7 medical complications. Type of hospital had no impact on rates of specific complications apart from septicaemia and cardiorespiratory complications, which were higher in the public hospital.
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Affiliation(s)
- Les Bokey
- Department of Colorectal Surgery, Liverpool Hospital, Sydney, New South Wales, Australia; School of Medicine, University of Western Sydney, Sydney, New South Wales, Australia
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Oliphant R, Nicholson GA, Horgan PG, Molloy RG, McMillan DC, Morrison DS. Deprivation and Colorectal Cancer Surgery: Longer-Term Survival Inequalities are Due to Differential Postoperative Mortality Between Socioeconomic Groups. Ann Surg Oncol 2013; 20:2132-9. [DOI: 10.1245/s10434-013-2959-9] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Indexed: 11/18/2022]
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Lyratzopoulos G, Barbiere J, Rachet B, Baum M, Thompson M, Coleman M. Changes over time in socioeconomic inequalities in breast and rectal cancer survival in England and Wales during a 32-year period (1973–2004): the potential role of health care. Ann Oncol 2011; 22:1661-1666. [DOI: 10.1093/annonc/mdq647] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Faiz O, Haji A, Burns E, Bottle A, Kennedy R, Aylin P. Hospital stay amongst patients undergoing major elective colorectal surgery: predicting prolonged stay and readmissions in NHS hospitals. Colorectal Dis 2011; 13:816-22. [PMID: 20402737 DOI: 10.1111/j.1463-1318.2010.02277.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Reduced hospital stay confers clinical and economic benefits for patients and healthcare providers. This article examines the length of stay and consequent bed resource usage of patients undergoing elective excisional colorectal surgery in English NHS trusts. METHOD All patients undergoing elective colorectal resections for malignancy between 1996 and 2006 in English NHS trusts were included from the Hospital Episode Statistics data set. Unifactorial and multifactorial analyses were performed to identify independent predictors of prolonged stay and 28-day readmission. RESULTS Over the 10-year period, 186,013 patients underwent elective colorectal procedures in 181 NHS trusts. About 2.893 b million bed days were utilized for elective colorectal surgery. Admission stay was shorter following colonic surgery than following rectal surgery (median 11 vs 13 days, P < 0.001). A 2-day decrease in median stay was observed over the 10-year period for both colonic and rectal procedures. Readmissions within 28 days of discharge were higher following rectal excision than following colonic surgery (9.4 vs 7.6%, P < 0.001). Multiple logistic regression analyses revealed the following independent predictors of prolonged hospital stay: distal (vs proximal) bowel resection, benign pathology, open technique, increasing age, comorbidity, social deprivation and low provider volume status. Independent predictors of 28-day readmission included distal bowel resection, benign diagnosis, young age, social deprivation and high provider volume status. CONCLUSION Patients of advanced age, with associated comorbidities, and those living in areas of social deprivation are at increased risk of prolonged stay. Targeted pre-emptive discharge planning and enhanced use of laparoscopic surgery could improve bed resource utilization.
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Affiliation(s)
- O Faiz
- Department of Biosurgery and Surgical Technology, Imperial College London, St Mary's Hospital, London, UK.
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Bharathan B, Welfare M, Borowski DW, Mills SJ, Steen IN, Kelly SB. Impact of deprivation on short- and long-term outcomes after colorectal cancer surgery. Br J Surg 2011; 98:854-65. [DOI: 10.1002/bjs.7427] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2010] [Indexed: 11/09/2022]
Abstract
Abstract
Background
The aim of the study was to determine the association between short- and long-term outcomes and deprivation for patients undergoing operative treatment for colorectal cancer in the Northern Region of England.
Methods
This was a retrospective analytical study based on the Northern Region Colorectal Cancer Audit Group database for the period 1998–2002. The Index of Multiple Deprivation 2004, an area-based measure, was recalibrated and used to quantify deprivation. Patients were ranked based on their postcode of residence and grouped into five categories.
Results
Of 8159 patients in total, 7352 (90·1 per cent) had surgery; 6953 (94·6 per cent) of the 7352 patients underwent tumour resection and 4935 (67·7 per cent) of 7294 had a margin-negative (R0) resection. Deprivation was not associated with age, sex, tumour site, stage or other tumour-related factors. Compared with the most affluent group, the most deprived patients had fewer elective operations (72·9 versus 76·4 per cent; P = 0·014), more adverse co-morbidity (P < 0·001) and fewer curative resections (65·5 versus 71·2 per cent; P < 0·001). In multivariable analysis, deprivation was not an independent predictor of postoperative death (odds ratio (OR) 0·72, 95 per cent confidence interval 0·48 to 1·06; P = 0·101) but it was a predictor of curative resection (OR 1·24, 1·01 to 1·52; P = 0·042), overall survival (HR 0·83, 0·73 to 0·95; P = 0·006) and relative survival (HR 0·74, 0·58 to 0·95; P = 0·023).
Conclusion
Deprivation, both independently and by influencing other surgical predictors, impacts on short- and long-term outcomes of patients with colorectal cancer.
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Affiliation(s)
- B Bharathan
- Department of Surgery, North Tyneside General Hospital, North Shields, UK
- Northern Region Colorectal Cancer Audit Group, Hexham General Hospital, Hexham, UK
| | - M Welfare
- Department of Surgery, North Tyneside General Hospital, North Shields, UK
| | - D W Borowski
- Department of Surgery, North Tyneside General Hospital, North Shields, UK
- Northern Region Colorectal Cancer Audit Group, Hexham General Hospital, Hexham, UK
| | - S J Mills
- Northern Region Colorectal Cancer Audit Group, Hexham General Hospital, Hexham, UK
- Department of Surgery, Wansbeck General Hospital, Ashington, UK
| | - I N Steen
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - S B Kelly
- Department of Surgery, North Tyneside General Hospital, North Shields, UK
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Stephens MR, Evans M, Ilham MA, Marsden A, Asderakis A. The influence of socioeconomic deprivation on outcomes following renal transplantation in the United kingdom. Am J Transplant 2010; 10:1605-12. [PMID: 20199499 DOI: 10.1111/j.1600-6143.2010.03041.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Socio-economic deprivation is an important determinant of poor health and is associated with a higher incidence of end-stage renal disease, higher mortality for dialysis patients and lower chance of being listed for transplantation. The influence of deprivation on outcomes following renal transplantation has not previously been reported in the United Kingdom. The Welsh Index of Multiple Deprivation was used to assess the influence of socio-economic deprivation on outcomes for 621 consecutive renal transplant recipients from a single centre in the United Kingdom transplanted between 1997 and 2005. Outcomes measured were rate of acute rejection and graft survival. Patients from the most deprived areas were significantly more likely to experience an episode of acute rejection requiring treatment (36% vs. 27%, p=0.01) and increasing overall deprivation correlated with increasing rates of rejection (p=0.03). Income deprivation was significantly and independently associated with graft survival (HR 1.484, p=0.046). Among patients who experienced acute rejection 5-year graft survival was 79% for those from the most deprived areas compared with 90% for patients from the least deprived areas (p = 0.018). Overall socio-economic deprivation is associated with higher rate of acute rejection following renal transplantation and income deprivation is a significant and independent predictor of graft survival.
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Aarts MJ, Lemmens VEPP, Louwman MWJ, Kunst AE, Coebergh JWW. Socioeconomic status and changing inequalities in colorectal cancer? A review of the associations with risk, treatment and outcome. Eur J Cancer 2010; 46:2681-95. [PMID: 20570136 DOI: 10.1016/j.ejca.2010.04.026] [Citation(s) in RCA: 162] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2010] [Revised: 04/15/2010] [Accepted: 04/28/2010] [Indexed: 11/15/2022]
Abstract
BACKGROUND Upcoming mass screening for colorectal cancer (CRC) makes a review of recent literature on the association with socioeconomic status (SES) relevant, because of marked and contradictory associations with risk, treatment and outcome. METHODS The Pubmed database using the MeSH terms 'Neoplasms' or 'Colorectal Neoplasms' and 'Socioeconomic Factors' for articles added between 1995 and 1st October 2009 led to 62 articles. RESULTS Low SES groups exhibited a higher incidence compared with high SES groups in the US and Canada (range risk ratio (RR) 1.0-1.5), but mostly lower in Europe (RR 0.3-0.9). Treatment, survival and mortality all showed less favourable results for people with a lower socioeconomic status: Patients with a low SES received less often (neo)adjuvant therapy (RR ranging from 0.4 to 0.99), had worse survival rates (hazard ratio (HR) 1.3-1.8) and exhibited generally the highest mortality rates up to 1.6 for colon cancer in Europe and up to 3.1 for rectal cancer. CONCLUSIONS A quite consistent trend was observed favouring individuals with a high SES compared to those with a low SES that still remains in terms of treatment, survival and thus also mortality. We did not find evidence that the low/high SES gradients for treatment chosen and outcome are decreasing. To meet increasing inequalities in mortality from CRC in Europe for people with a low SES and to make mass screening successful, a high participation rate needs to be realised of low SES people in the soon starting screening program.
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Affiliation(s)
- Mieke J Aarts
- Eindhoven Cancer Registry, Comprehensive Cancer Centre South (IKZ), P.O. Box 231, 5600 AE Eindhoven, The Netherlands.
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Harris AR, Bowley DM, Stannard A, Kurrimboccus S, Geh JI, Karandikar S. Socioeconomic deprivation adversely affects survival of patients with rectal cancer. Br J Surg 2009; 96:763-8. [DOI: 10.1002/bjs.6621] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Abstract
Background
The aim was to examine the influence of socioeconomic deprivation on stage at presentation, perioperative mortality, permanent stoma rates and overall survival in patients with rectal cancer.
Methods
Data on patient demographics, mode and stage of presentation, and short- and longer-term outcomes were extracted from a database of patients with rectal cancer. Comparisons were made after stratification into quintiles of socioeconomic deprivation.
Results
In total 486 patients were identified. Fewer patients from the most deprived group than from the least deprived group underwent resectional surgery (79·2 versus 93 per cent; P = 0·005). Permanent stoma rates among patients who had surgery were 40·8 and 30 per cent respectively (P = 0·110). The overall 5-year survival rate was 32·8 per cent for the most deprived compared with 64·0 per cent for the least deprived patients (P < 0·001). Respective rates for those who underwent resectional surgery were 49·9 and 72 per cent (P = 0·030).
Conclusion
In rectal cancer, socioeconomic deprivation appears to be associated with poorer outcomes and survival. This has important implications for healthcare planning.
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Affiliation(s)
- A R Harris
- Department of General Surgery, Birmingham Heartlands Hospital, Heart of England NHS Foundation Trust, Bordesley Green East, Birmingham B9 5SS, UK
| | - D M Bowley
- Department of General Surgery, Birmingham Heartlands Hospital, Heart of England NHS Foundation Trust, Bordesley Green East, Birmingham B9 5SS, UK
| | - A Stannard
- Department of General Surgery, Birmingham Heartlands Hospital, Heart of England NHS Foundation Trust, Bordesley Green East, Birmingham B9 5SS, UK
| | - S Kurrimboccus
- Department of General Surgery, Birmingham Heartlands Hospital, Heart of England NHS Foundation Trust, Bordesley Green East, Birmingham B9 5SS, UK
| | - J I Geh
- Oncology, Birmingham Heartlands Hospital, Heart of England NHS Foundation Trust, Bordesley Green East, Birmingham B9 5SS, UK
| | - S Karandikar
- Department of General Surgery, Birmingham Heartlands Hospital, Heart of England NHS Foundation Trust, Bordesley Green East, Birmingham B9 5SS, UK
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Tilney H, Lovegrove RE, Smith JJ, Thompson MR, Tekkis PP. The National Bowel Cancer Project: social deprivation is an independent predictor of nonrestorative rectal cancer surgery. Dis Colon Rectum 2009; 52:1046-53. [PMID: 19581845 DOI: 10.1007/dcr.0b013e3181a65f41] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE This study was designed to assess the impact of social deprivation on rates of abdominoperineal excision of the rectum in the United Kingdom. METHODS Data were extracted from the Association of Coloproctology of Great Britain and Ireland Colorectal Cancer Database (2000-2005). Social deprivation was assessed by using the Index of Multiple Deprivation (2004) score. Logistic regression was performed to identify independent predictors of nonrestorative surgery. RESULTS A total of 12,128 patients underwent anterior resection or abdominoperineal excision for Dukes A-C cancer in 101 centers; 2,625 patients (21.6 percent) underwent abdominoperineal excision (median, 20.8 (interquartile range, 16.5-27.9) percent per unit). Abdominoperineal excision rates decreased from 24.3 to 18.2 percent (P < 0.001) and varied between the least and most deprived groups from 18 to 26.4 percent, respectively (P < 0.001). Independent predictors of abdominoperineal excision were: year of surgery (odds ratio = 0.855 per year increase, P < 0.001), female vs. male gender (odds ratio = 0.82, P < 0.001), use of neoadjuvant radiotherapy (odds ratio = 2.4, P < 0.001), and social deprivation (most vs. least deprived: odds ratio = 1.638, P < 0.001). CONCLUSIONS Abdominoperineal excision rates vary considerably between centers. Gender and deprivation status independently predict formation of a permanent stoma. These results have important implications for intercenter comparisons of surgical quality and may suggest inequalities in health care provision.
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Affiliation(s)
- Henry Tilney
- Department of Biosurgery and Surgical Technology, St. Mary's Hospital, Imperial College, London, United Kingdom
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Frederiksen B, Osler M, Harling H, Ladelund S, Jørgensen T. The impact of socioeconomic factors on 30-day mortality following elective colorectal cancer surgery: A nationwide study. Eur J Cancer 2009; 45:1248-1256. [DOI: 10.1016/j.ejca.2008.11.035] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2008] [Revised: 11/18/2008] [Accepted: 11/25/2008] [Indexed: 11/17/2022]
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Beswick S, Affleck P, Elliott F, Gerry E, Boon A, Bale L, Nolan C, Barrett JH, Bertram C, Marsden J, Bishop DT, Newton-Bishop JA. Environmental risk factors for relapse of melanoma. Eur J Cancer 2008; 44:1717-25. [PMID: 18602256 PMCID: PMC2583252 DOI: 10.1016/j.ejca.2008.05.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2008] [Revised: 05/17/2008] [Accepted: 05/19/2008] [Indexed: 11/22/2022]
Abstract
Aim To identify lifestyle factors affecting risk of relapse. Methods A comparison of 131 relapsed melanoma patients with 147 non-relapsers. Results Relapsers were more likely to report financial hardship using a number of different measures including access to holidays and feeling financially insecure (odds ratio (OR) 5.7, 95% confidence interval (CI) (1.5, 21.4)). Relapsers worked longer hours (mean 37 h per week compared with 31, p = 0.02). There was no reported difference in stress associated with recent life events. There was no effect of housing quality, employment factors or body mass index (BMI) on risk of relapse. There was a protective effect of antibiotics in the peri-operative period. Conclusion The study provides preliminary evidence for adverse effects of chronic financial hardship, but not recent stressful events on cancer relapse. As these data were collected in a retrospective case–control study subject to recall bias, the data must now be explored in a prospective study.
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Affiliation(s)
- Samantha Beswick
- Section of Epidemiology and Biostatistics, Leeds Institute of Molecular Medicine, Cancer Research UK Clinical Centre at Leeds, St James’s University Hospital, Leeds LS9 7TF, United Kingdom
| | - Paul Affleck
- Section of Epidemiology and Biostatistics, Leeds Institute of Molecular Medicine, Cancer Research UK Clinical Centre at Leeds, St James’s University Hospital, Leeds LS9 7TF, United Kingdom
| | - Faye Elliott
- Section of Epidemiology and Biostatistics, Leeds Institute of Molecular Medicine, Cancer Research UK Clinical Centre at Leeds, St James’s University Hospital, Leeds LS9 7TF, United Kingdom
| | - Edwina Gerry
- Section of Epidemiology and Biostatistics, Leeds Institute of Molecular Medicine, Cancer Research UK Clinical Centre at Leeds, St James’s University Hospital, Leeds LS9 7TF, United Kingdom
| | - Andy Boon
- Leeds Teaching Hospitals, NHS Trust, United Kingdom
| | - Linda Bale
- Section of Epidemiology and Biostatistics, Leeds Institute of Molecular Medicine, Cancer Research UK Clinical Centre at Leeds, St James’s University Hospital, Leeds LS9 7TF, United Kingdom
| | - Clarissa Nolan
- Section of Epidemiology and Biostatistics, Leeds Institute of Molecular Medicine, Cancer Research UK Clinical Centre at Leeds, St James’s University Hospital, Leeds LS9 7TF, United Kingdom
| | - Jennifer H. Barrett
- Section of Epidemiology and Biostatistics, Leeds Institute of Molecular Medicine, Cancer Research UK Clinical Centre at Leeds, St James’s University Hospital, Leeds LS9 7TF, United Kingdom
| | - Chandra Bertram
- Section of Epidemiology and Biostatistics, Leeds Institute of Molecular Medicine, Cancer Research UK Clinical Centre at Leeds, St James’s University Hospital, Leeds LS9 7TF, United Kingdom
| | - Jerry Marsden
- University Hospital Birmingham, NHS Foundation Trust, United Kingdom
| | - D. Timothy Bishop
- Section of Epidemiology and Biostatistics, Leeds Institute of Molecular Medicine, Cancer Research UK Clinical Centre at Leeds, St James’s University Hospital, Leeds LS9 7TF, United Kingdom
| | - Julia A. Newton-Bishop
- Section of Epidemiology and Biostatistics, Leeds Institute of Molecular Medicine, Cancer Research UK Clinical Centre at Leeds, St James’s University Hospital, Leeds LS9 7TF, United Kingdom
- Corresponding author: Tel.: +44 113 2064668; fax: +44 113 234 0183.
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Abstract
OBJECTIVE To assess rates of abdominoperineal excision of the rectum (APER) for rectal cancer between centers and over time, and to evaluate the influence of patient characteristics, including social deprivation, on APER rate. METHODS Data on patients undergoing APER or anterior resection (AR) in England were extracted from a national administrative database for the years 1996 to 2004. The primary outcome was the proportion of patients presenting with rectal cancer undergoing APER. Hierarchical logistic regression was used to identify independent factors associated with a nonrestorative resection. RESULTS Data on 52,643 patients were analyzed, 13,109(24.9%) of whom underwent APER. The APER rate significantly reduced over the study period from 29.4% to 21.2% (P < 0.001). Operative mortality following AR decreased significantly during the period of study (5.1% to 4.2%, P = 0.002), while that following APER did not (P = 0.075). Male patients were more likely to undergo APER (P < 0.001), whereas those with an emergency presentation more commonly underwent AR (P < 0.001). Independent predictors of increased APER rate were male gender (odds ratio [OR] = 1.239, P < 0.001) and social deprivation (most vs. least deprived; OR = 1.589, P < 0.001), whereas increasing patient age (OR = 0.977, P = 0.027 per 10-year increase), year of study (2003/4 vs. 1996/7; OR = 0.646, P < 0.001) and initial presentation as an emergency (OR = 0.713, P < 0.001) were associated with lower APER rates. After accounting for case-mix, there was significant between-center variability in APER rates. CONCLUSION Socially deprived patients were more likely to undergo abdominoperineal resection. Significant improvements in rates of nonrestorative resection were seen over time but although short-term outcomes following AR have improved, those following APER have not. Permanent stoma rates following rectal cancer surgery may be considered a surrogate marker of surgical quality.
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Weller D, Coleman D, Robertson R, Butler P, Melia J, Campbell C, Parker R, Patnick J, Moss S. The UK colorectal cancer screening pilot: results of the second round of screening in England. Br J Cancer 2007; 97:1601-5. [PMID: 18026197 PMCID: PMC2360273 DOI: 10.1038/sj.bjc.6604089] [Citation(s) in RCA: 145] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
An evaluation of the second round of faecal occult blood (FOB) screening in the English site of the UK Colorectal Cancer Screening Pilot (comprising the Bowel Cancer Screening Pilot based in Rugby, general practices in four Primary Care Trusts, and their associated hospitals) was carried out. A total of 127 746 men and women aged 50–69 and registered in participating general practices were invited to participate. In all, 15.9% were new invitees not included in the previous round. A total of 52.1% of invitees returned a screening kit. Uptake varied with gender, age, and level of deprivation; was lower than in the first round (51.9 vs 58.5% P<0.0001), but was high (81.1%) in those who had participated in the first round with a negative result. Test positivity was 1.77%, significantly higher than in the first round, and the detection rate of neoplasia similar (5.67 per 1000), resulting in a lower positive predictive value. The sensitivity of FOBt in the first round was estimated as 57.7–64.4%. There was a significant impact on workload, particularly on endoscopy services. The cancer detection rate (0.94 per 1000) was lower than in the first round. Effort will be required to minimise inequalities in uptake, and to ensure adequate capacity of endoscopy services.
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Affiliation(s)
- D Weller
- Community Health Sciences - General Practice, University of Edinburgh, 20 West Richmond Street, Edinburgh EH8 9DX, UK.
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Abstract
In the past two decades, the rate of surgery in older people has increased more rapidly than the rate of aging of the population, so both a larger proportion and a greater number of older people are now undergoing surgery. This may partly reflect a cultural change in surgery and anaesthesia with respect to a greater willingness to undertake elective procedures in older people, although there remain areas where they have less access to surgery than do younger patients. For instance, older people are less likely to undergo operative procedures after a cancer diagnosis. Furthermore, in those who do have surgery, resection rate (i.e. curative therapy) is lower than in younger people with equivalent tumour stages, and even more so in older patients with COPD, cardiovascular disease or diabetes. This article explores the complex relationship between age and surgical outcome, provides an evidence-based overview of risk assessment and common postoperative problems in older people, and summarizes good practice points (at times necessarily pragmatic) for clinical management of the older surgical patient. There has been a substantial expansion in the literature examining risks, outcomes and interventions in older surgical patients since the previous review article of this subject published in this journal. Although we do not cover anaesthesia in older people, the review of that topic remains relevant. The American Society of Anaesthesiologists' Classification of Risk which illustrates that risk is disease- rather than age- based, is shown in Table 1. Most publications examine elective rather than emergency surgery in older people (with the exception of hip fracture), and this is reflected in the content of the paper.
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Morris M, Iacopetta B, Platell C. Comparing survival outcomes for patients with colorectal cancer treated in public and private hospitals. Med J Aust 2007; 186:296-300. [PMID: 17371210 DOI: 10.5694/j.1326-5377.2007.tb00904.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2006] [Accepted: 01/03/2007] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To determine whether treatment in a private versus public hospital was an independent predictor of survival outcomes in patients with colorectal cancer. DESIGN Retrospective, population-based study. SETTING Tertiary care hospitals. PARTICIPANTS All patients diagnosed with colorectal cancer in Western Australia between 1993 and 2003. INTERVENTIONS Management in private versus public hospitals. MAIN OUTCOME MEASURES Overall survival and cancer-specific survival rates. RESULTS 5809 patients were treated for colorectal cancer. Of these, 1523 (26%) were managed in private hospitals. The 5-year overall survival rates for private and public hospital patients were 59.4% (95% CI, 56.9%-61.9%) and 48.6% (95% CI, 47.0%-50.2%), respectively. Significant independent predictors of overall survival were: treatment in a private hospital (P = 0.0001; relative risk [RR], 0.764; 95% CI, 0.696-0.839); younger age (P = 0.0001; RR, 1.032; 95% CI, 1.029-1.036); male sex (P = 0.001; RR, 1.148; 95% CI, 1.068-1.234); and cancer stage (eg, Stage II: P = 0.0001; RR, 1.508; 95% CI, 1.316-1.729). CONCLUSIONS Treatment in a private hospital was a significant independent predictor of survival outcomes. Further validation of these results would have a significant bearing on how we approach health care delivery for patients with colorectal cancer.
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Affiliation(s)
- Melinda Morris
- School of Surgery and Pathology, University of Western Australia, Perth, WA
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