Impact of private funding on access to elective hospital treatment in the regions of England and Wales. National records survey

Socio-demographic factors and their impact on the number of resections for patients with recurrent glioblastoma

Glioblastoma multiforme (GBM) is the most aggressive malignant brain tumour. Having a second or subsequent operation at recurrence may be a positive prognostic factor for survival. Recent studies suggest that socio-demographic variables may influence survival, raising the question whether surgical care differs based on these variables. We examined the relationship between selected socio-demographic variables and the number of repeat operations undergone by patients with recurrent GBM. Data from all patients diagnosed with GBM between 2001 and 2011 was obtained from a clinical database maintained across two institutions (one public, one private). The clinical and socio-demographic factors for patients who received one operation were compared to those who had two or more operations, using chi-squared analyses to determine statistical differences between groups. Socioeconomic status was measured using the Index of Relative Socioeconomic Advantage and Disadvantage scores. Of 553 patients, 449 (81%) had one operation and 104 (19%) had ≥2 operations. Patients who had ≥2 operations were significantly younger (median 55 years versus 64 years, p<0.001), less likely to have multifocal (p=0.043) or bilateral (p=0.037) disease and more likely to have initial macroscopic resection (p=0.006), than those who had only one operation. Socioeconomic status did not significantly differ between the groups (p=0.31). Similarly, there was no significant difference between the number of operations in patients from regional versus city residence and public versus private hospital. This is reassuring as it suggests similar surgical management options are available for patients regardless of socio-demographic background.

Few insurance-based differences in upper extremity elective surgery rates after healthcare reform

BACKGROUND

Before the US Patient Protection and Affordable Care Act of 2010, there were documented insurance-based disparities in access to orthopaedic surgeons and care of orthopaedic conditions. While Massachusetts passed healthcare reform in 2007 with many similar provisions, it is unknown whether the disparities were present during the period of the law's enactment.

QUESTIONS/PURPOSES

We asked whether differences in rates of surgery between patients with novel government-subsidized healthcare plans and other forms of insurance, and between uninsured and insured patients, were similar after institution of the Massachusetts reform laws.

METHODS

We identified 7577 patients diagnosed with upper extremity injuries between January 1, 2007 and October 1, 2010. From an institutional administrative database, we extracted demographics, insurance status, and plan of care. Insurance categories included government-subsidized healthcare plan (Commonwealth Care), private insurance, workers compensation, military-related (TriCare), Medicare, Medicaid (MassHealth), non-Commonwealth Care, and other insured and uninsured. After adjusting for age, gender, and diagnosis, we compared the proportions of patients who underwent elective surgery.

RESULTS

Of 7577 patients, 1685 (22%) underwent elective upper extremity surgery. The adjusted rates of surgery were similar across most insurance categories, with higher rates in the workers compensation and TriCare categories compared with Commonwealth Care. Uninsured patients were as likely to undergo surgery as insured patients.

CONCLUSION

In a population with near-universal health insurance, a government-run health insurance exchange, and novel, government-subsidized, managed care plans, we found few insurance-based differences in rates of elective upper extremity orthopaedic surgery in a cohort of patients after healthcare reform.

Policy strategies to reduce waits for elective care: a synthesis of international evidence

This synthesis seeks to assess and explain the effectiveness of policy interventions to reduce elective wait times or lists. PubMed, EMBASE, EconLit, and grey literature were systematically searched for relevant studies and reviews. Strategies with the strongest evidence base include paying for activity, buying capacity locally and setting targets with strong incentives. There is also evidence for improving the use of existing capacity. Limiting demand through rationing can reduce waits, but is ethically problematic. Short-term injections of funding, cross-border treatment schemes, unenforced targets and promotion of private health insurance had the weakest evidence. Available evidence favours options that act fairly directly on supply, demand or local organizations' behaviour, over indirect strategies that depend on a 'domino effect'. Further research is needed to determine how to achieve major, system-wide improvements in the use of capacity.

Effects of socioeconomic and geographic variations on survival for adult glioma in England and Wales

BACKGROUND

To investigate the effects of SES and geographic variations on survival for adult patients with glioma, we analyzed data from 30489 patients from the Cancer Registry in England and Wales.

METHODS

Median survival and CSRs for 8 variables (age, sex, morphology, World Health Organization [WHO] grade, tumor site, SES, geographic regions, and periods of diagnosis) are calculated using the Kaplan-Meier method. Distributions among different variables are compared using chi(2) test. Cox regressions are performed for estimating HRs to death.

RESULTS

The median survival and the 1-, 5-, and 10-year CSR in this population are 0.42 years, 29.1%, 12.0%, and 7.7%, respectively. There is a gradient in SES from the south to the north (chi(2) test, P < .001) and a gradual increment in higher SES from the early to the recent period (chi(2) test, P < .001). Mono- and multivariate analyses reveal that all the 8 variables influenced the survival (P < .05). Age (HR, 1.04 per year from 15 years, P < .001), WHO grade (1.21 per grade from grade I, P < .001), and morphology (HR from 1.23 to 1.89, compared with ependymoma, P < .05) are the most influential factors. However, there are also independent effects from SES (HR, 1.03 per quintile of deprivation, P < .001) and geographic regions (HR, 1.10 for outside southern England; P < .001) on the survival.

CONCLUSIONS

Although age and tumor characteristics (morphology, WHO grade, tumor site) are well-known prognostic factors, SES and geographic variations also play a slight but significant role, and for more cost-effective allocation of health resources, alleviation on these 2 modifiable factors should be considered.