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Shah R, Chan KKW. The impact of socioeconomic status on stage at presentation, receipt of diagnostic imaging, receipt of treatment and overall survival in colorectal cancer patients. Int J Cancer 2021; 149:1031-1043. [PMID: 33950515 DOI: 10.1002/ijc.33622] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 04/11/2021] [Accepted: 04/26/2021] [Indexed: 11/12/2022]
Abstract
Socioeconomic factors influence patterns of care in colorectal cancer. Our study investigates the impact of socioeconomic status (SES) on stage at presentation, receipt of diagnostic imaging, receipt of treatment and overall survival (OS) in a universal healthcare system. The Ontario Cancer Registry (OCR) was accessed to identify a cohort of patients diagnosed with colorectal adenocarcinoma from 2007 to 2016 in Ontario, Canada. SES was measured using median neighborhood income divided into quintiles (Q1-Q5; Q1 = lowest income). Logistic regression analyses were used to evaluate stage, imaging and treatment. Cox proportional hazards models were used to evaluate OS. All endpoints were adjusted for demographics and comorbidities with OS models also adjusting for stage, imaging and treatment. In total, 39 802 colon and 13 164 rectal patients were identified. Lower SES was associated with advanced stage at presentation in both cohorts (Q1 vs Q5: Colon odds ratio [OR] = 1.08, P = .046, rectal OR = 1.25, P < .0001). Lower SES colon patients were less likely to receive adjuvant oxaliplatin (Q1 vs Q5: OR = 0.78, P < .001) and all palliative chemotherapies studied including oxaliplatin (Q1 vs Q5: OR = 0.60, P < 0.0001), irinotecan (Q1 vs Q5: OR = 0.65, P < .0001), bevacizumab (Q1 vs Q5: OR = 0.70, P < .001), cetuximab (Q1 vs Q5: OR = 0.40, P = .0053) and panitumumab (Q1 vs Q5: OR = 0.54, P = .0036). In rectal patients, lower SES was associated with decreased receipt of rectal cancer resection for stages I-III (Q1 vs Q5: OR = 0.78, P < .001), adjuvant oxaliplatin (Q1 vs Q5: OR = 0.72, P = .0020) and palliative chemotherapies including oxaliplatin (Q1 vs Q5: OR = 0.59, P < .001), irinotecan (Q1 vs Q5: OR = 0.53, P < .001) and bevacizumab (Q1 vs Q5: OR = 0.71, P = .046). All survival models identified poorer OS for lower SES patients (total colorectal; Q1 vs Q5: Hazard ratio [HR] = 1.25, P < .0001). These findings suggest disparities persist even within universal healthcare.
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Affiliation(s)
- Rajan Shah
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kelvin K W Chan
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Canadian Centre for Applied Research in Cancer Control, Toronto, Ontario, Canada
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2
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Ramos KJ, Sykes J, Stanojevic S, Ma X, Ostrenga JS, Fink A, Quon BS, Marshall BC, Faro A, Petren K, Elbert A, Goss CH, Stephenson AL. Survival and Lung Transplant Outcomes for Individuals With Advanced Cystic Fibrosis Lung Disease Living in the United States and Canada: An Analysis of National Registries. Chest 2021; 160:843-853. [PMID: 33878343 DOI: 10.1016/j.chest.2021.04.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 04/02/2021] [Accepted: 04/02/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Understanding how health outcomes differ for patients with advanced cystic fibrosis (CF) lung disease living in the United States compared with Canada has health policy implications. RESEARCH QUESTION What are rates of lung transplant (LTx) and rates of death without LTx in the United States and Canada among individuals with FEV1 < 40% predicted? STUDY DESIGN AND METHODS This was a retrospective population-based cohort study, 2005 to 2016, using the US CF Foundation, United Network for Organ Sharing, and Canadian CF registries. Individuals with CF and at least two FEV1 measurements < 40% predicted within a 5-year period, age ≥ 6 years, without prior LTx were included. Multivariable competing risk regression for time to death without LTx (LTx as a competing risk) and time to LTx (death as a competing risk) was performed. RESULTS There were 5,899 patients (53% male) and 905 patients (54% male) with CF with FEV1 < 40% predicted living in the United States and Canada, respectively. Multivariable competing risk regression models identified an increased risk of death without LTx (hazard ratio [HR], 1.79; 95% CI, 1.52-2.1) and decreased LTx (HR, 0.66; 95% CI, 0.58-0.74) among individuals in the United States compared with Canada. More pronounced differences were seen in the patients in the United States with Medicaid/Medicare insurance compared with Canadians (multivariable HR for death without LTx, 2.24 [95% CI, 1.89-2.64]; multivariable HR for LTx, 0.54 [95% CI, 0.47-0.61]). Patients of nonwhite race were also disadvantaged (multivariable HR for death without LTx, 1.56 [95% CI, 1.32-1.84]; multivariable HR for LTx, 0.47 [95% CI, 0.36-0.62]). INTERPRETATION There are lower rates of LTx and an increased risk of death without LTx for US patients with CF with FEV1 < 40% predicted compared with Canadian patients. Findings are more striking among US patients with CF with Medicaid/Medicare health insurance, and nonwhite patients in both countries, raising concerns about underuse of LTx among vulnerable populations.
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Affiliation(s)
- Kathleen J Ramos
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA.
| | - Jenna Sykes
- Division of Respirology, St. Michael's Hospital, Toronto, ON, Canada
| | - Sanja Stanojevic
- Translational Medicine, Hospital for Sick Children, Toronto, ON, Canada
| | - Xiayi Ma
- Division of Respirology, St. Michael's Hospital, Toronto, ON, Canada
| | | | - Aliza Fink
- Cystic Fibrosis Foundation, Bethesda, MD
| | - Bradley S Quon
- Division of Respirology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | | | | | | | | | - Christopher H Goss
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA; Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, WA
| | - Anne L Stephenson
- Division of Respirology, St. Michael's Hospital, Toronto, ON, Canada; Keenan Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
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Diaconu V, Ouellette N, Bourbeau R. Modal lifespan and disparity at older ages by leading causes of death: a Canada-U.S. comparison. JOURNAL OF POPULATION RESEARCH 2020; 37:323-344. [PMID: 33269014 PMCID: PMC7686011 DOI: 10.1007/s12546-020-09247-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The U.S. elderly experience shorter lifespans and greater variability in age at death than their Canadian peers. In order to gain insight on the underlying factors responsible for the Canada-U.S. old-age mortality disparities, we propose a cause-of-death analysis. Accordingly, the objective of this paper is to compare levels and trends in cause-specific modal age at death (M) and standard deviation above the mode (SD(M +)) between Canada and the U.S. since the 1970s. We focus on six broad leading causes of death, namely cerebrovascular diseases, heart diseases, and four types of cancers. Country-specific M and SD(M +) estimates for each leading cause of death are calculated from P-spline smooth age-at-death distributions obtained from detailed population and cause-specific mortality data. Our results reveal similar levels and trends in M and SD(M +) for most causes in the two countries, except for breast cancer (females) and lung cancer (males), where differences are the most noticeable. In both of these instances, modal lifespans are shorter in the U.S. than in Canada and U.S. old-age mortality inequalities are greater. These differences are explained in part by the higher stratification along socioeconomic lines in the U.S. than in Canada regarding the adoption of health risk behaviours and access to medical services.
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Affiliation(s)
- Viorela Diaconu
- Max Planck Institute for Demographic Research, Rostock, Germany
| | - Nadine Ouellette
- Department of Demography, Université de Montréal, Montreal, QC Canada
| | - Robert Bourbeau
- Department of Demography, Université de Montréal, Montreal, QC Canada
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Dubois TB, Simpson SH, Eurich DT. Time to Treatment Intensification in Newly Treated Adult Type 2 Diabetes Patients: Comparison of Canada and the United States. Can J Diabetes 2019; 44:312-316. [PMID: 31831258 DOI: 10.1016/j.jcjd.2019.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 08/30/2019] [Accepted: 09/17/2019] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Our aim in this study was to determine whether differences exist in time to treatment intensification in newly treated type 2 diabetes patients in Canada and the United States (US). METHODS Two separate retrospective cohorts of diabetes patients were used from Canada and the US. Time to treatment intensification (i.e. addition of a second antihyperglycemic agent after initial metformin use) was determined using multivariate Cox proportional hazard models. RESULTS Among new metformin users in 2004‒2007 (2,116 Canadians and 2,631 Americans) >65 years of age, the median time to treatment intensification was 362 days for Canadians and 170 days for Americans (adjusted hazard ratio, 1.99; 95% confidence interval, 1.69 to 2.36). In a second cohort of all adult ages with clinical data between 2008 and 2010 (23,022 Canadians and 19,318 Americans), the median time to treatment intensification was 197 days for Canadians and 119 days for Americans (adjusted hazard ratio, 5.62; 95% confidence interval, 5.246 to 6.029). At treatment intensification, the mean glycated hemoglobin was 9.0% (standard deviation, 2.0) in Canada and 8.6% (standard deviation, 2.2) in the US (p<0.01). CONCLUSIONS Although clinical practice guidelines are similar between Canada and the US, Canadian clinicians have historically demonstrated more clinical inertia compared with their US counterparts with respect to intensifying antihyperglycemic therapy. It is relatively unknown whether these differences currently exist or whether Canadian clinicians have closed the gap.
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Affiliation(s)
- Tyler B Dubois
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada; Alliance for Canadian Health Outcomes Research in Diabetes, University of Alberta, Edmonton, Alberta, Canada
| | - Scot H Simpson
- Alliance for Canadian Health Outcomes Research in Diabetes, University of Alberta, Edmonton, Alberta, Canada; Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Dean T Eurich
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada; Alliance for Canadian Health Outcomes Research in Diabetes, University of Alberta, Edmonton, Alberta, Canada.
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Escobar KM, Murariu D, Munro S, Gorey KM. Care of acute conditions and chronic diseases in Canada and the United States: Rapid systematic review and meta-analysis. J Public Health Res 2019; 8:1479. [PMID: 30997359 PMCID: PMC6444377 DOI: 10.4081/jphr.2019.1479] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 01/22/2019] [Indexed: 01/19/2023] Open
Abstract
This study tested the hypothesis that socioeconomically vulnerable Canadians with diverse acute conditions or chronic diseases have health care access and survival advantages over their counterparts in the USA. A rapid systematic review retrieved 25 studies (34 independent cohorts) published between 2003 and 2018. They were synthesized with a streamlined meta-analysis. Very low-income Canadian patients were consistently and highly advantaged in terms of health care access and survival compared with their counterparts in the USA who lived in poverty and/or were uninsured or underinsured. In aggregate and controlling for specific conditions or diseases and typically 4 to 9 comorbid factors or biomarkers, Canadians' chances of receiving better health care were estimated to be 36% greater than their American counterparts (RR=1.36, 95% CI 1.35-1.37). This estimate was significantly larger than that based on general patient or non-vulnerable population comparisons (RR=1.09, 95% CI 1.08-1.10). Contrary to prevalent political rhetoric, three studies observed that Americans experience more than twice the risk of long waits for breast or colon cancer care or of dying while they wait for an organ transplant (RR=2.36, 95% CI 2.09-2.66). These findings were replicated across externally valid national studies and more internally valid, metropolitan or provincial/state comparisons. Socioeconomically vulnerable Canadians are consistently and highly advantaged on health care access and outcomes compared to their American counterparts. Less vulnerable comparisons found more modest Canadian advantages. The Affordable Care Act ought to be fully supported including the expansion of Medicaid across all states. Canada's single payer system ought to be maintained and strengthened, but not through privatization.
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Affiliation(s)
| | | | - Sharon Munro
- Leddy Library, University of Windsor, ON, Canada
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Finke I, Behrens G, Weisser L, Brenner H, Jansen L. Socioeconomic Differences and Lung Cancer Survival-Systematic Review and Meta-Analysis. Front Oncol 2018; 8:536. [PMID: 30542641 PMCID: PMC6277796 DOI: 10.3389/fonc.2018.00536] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 10/31/2018] [Indexed: 12/14/2022] Open
Abstract
Background: The impact of socioeconomic differences on cancer survival has been investigated for several cancer types showing lower cancer survival in patients from lower socioeconomic groups. However, little is known about the relation between the strength of association and the level of adjustment and level of aggregation of the socioeconomic status measure. Here, we conduct the first systematic review and meta-analysis on the association of individual and area-based measures of socioeconomic status with lung cancer survival. Methods: In accordance with PRISMA guidelines, we searched for studies on socioeconomic differences in lung cancer survival in four electronic databases. A study was included if it reported a measure of survival in relation to education, income, occupation, or composite measures (indices). If possible, meta-analyses were conducted for studies reporting on individual and area-based socioeconomic measures. Results: We included 94 studies in the review, of which 23 measured socioeconomic status on an individual level and 71 on an area-based level. Seventeen studies were eligible to be included in the meta-analyses. The meta-analyses revealed a poorer prognosis for patients with low individual income (pooled hazard ratio: 1.13, 95 % confidence interval: 1.08–1.19, reference: high income), but not for individual education. Group comparisons for hazard ratios of area-based studies indicated a poorer prognosis for lower socioeconomic groups, irrespective of the socioeconomic measure. In most studies, reported 1-, 3-, and 5-year survival rates across socioeconomic status groups showed decreasing rates with decreasing socioeconomic status for both individual and area-based measures. We cannot confirm a consistent relationship between level of aggregation and effect size, however, comparability across studies was hampered by heterogeneous reporting of socioeconomic status and survival measures. Only eight studies considered smoking status in the analysis. Conclusions: Our findings suggest a weak positive association between individual income and lung cancer survival. Studies reporting on socioeconomic differences in lung cancer survival should consider including smoking status of the patients in their analysis and to stratify by relevant prognostic factors to further explore the reasons for socioeconomic differences. A common definition for socioeconomic status measures is desirable to further enhance comparisons between nations and across different levels of aggregation.
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Affiliation(s)
- Isabelle Finke
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Medical Faculty Heidelberg, University of Heidelberg, Heidelberg, Germany
| | - Gundula Behrens
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Linda Weisser
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Medical Faculty Heidelberg, University of Heidelberg, Heidelberg, Germany
| | - Hermann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT), Heidelberg, Germany.,German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Lina Jansen
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
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Syse A, Soneji SS, Andrew AS, Tretli S, Baili P, Bynum JPW. Short-term survival after colorectal cancer in a screened versus unscreened population. Scand J Public Health 2018; 47:528-537. [PMID: 29360010 DOI: 10.1177/1403494817744394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aims: United States' (US) colorectal cancer (CRC) screening and treatment practices seek to reduce mortality. We examined the survival of US patients compared with patients in the virtually unscreened Norwegian population. Methods: We compared short-term survival after CRC between the US and Norway using relative survival (RS) and excess mortality (EMR) analyses. The CRC patients were aged 50 and older diagnosed in the US (Surveillance, Epidemiology and End Results registry, 2004, N=9511) and in Norway (Cancer Registry of Norway, 2003-2005, N=8256). Results: Death occurred within three years for 39% of the CRC patients. Stage distributions were more favorable for US patients. Stage-specific survival was similar for localized and regional cancers, but more favorable for US distant cancers. In multivariate models of patient, tumor and treatment characteristics, patients (especially below age 80) in the US experienced longer survival (EMR 0.9, CI 0.8-0.9). Stage-specific analyses showed, however, that survival for localized cancers was relatively shorter in the US than in Norway (EMR 1.4, CI 1.1-1.8), but longer for distant cancers (EMR 0.8, CI 0.7-0.8). Conclusions: The enhanced survival for US CRC patients likely reflects a screening-related earlier diagnostic stage distribution, as well as prioritized life extension for patients with metastatic cancers, reflecting vastly different health care systems in the two countries. CRC screening is currently under consideration in Norway. For survival outcomes, the current findings do not discourage such an implementation. Other screening-related aspects such as feasibility and cost-benefit are, however, also relevant and warrant further research within a socialized health system.
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Affiliation(s)
| | | | | | | | - Paolo Baili
- 4 Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Lombardia, Italy
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8
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Alberton AM, Gorey KM. Profound barriers to basic cancer care most notably experienced by uninsured women: Historical note on the present policy considerations. SOCIAL WORK IN HEALTH CARE 2017; 56:943-949. [PMID: 28880806 PMCID: PMC5662425 DOI: 10.1080/00981389.2017.1373724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
America is considering the replacement of Obamacare with Trumpcare. This historical cohort revisited pre-Obamacare colon cancer care among people living in poverty in California (N = 5,776). It affirmed a gender by health insurance hypothesis on nonreceipt of surgery such that uninsured women were at greater risk than uninsured men. Uninsured women were three times as likely as insured women to be denied access to such basic care. Similar men were two times as likely. America is bound to repeat such profound health care inequities if Obamacare is repealed. Instead, Obamacare ought to be retained and strengthened in all states, red and blue.
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Affiliation(s)
- Amy M Alberton
- a School of Social Work , University of Windsor , Windsor , Ontario , Canada
| | - Kevin M Gorey
- a School of Social Work , University of Windsor , Windsor , Ontario , Canada
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Gorey KM, Hamm C, Luginaah IN, Zou G, Holowaty EJ. Breast Cancer Care in California and Ontario: Primary Care Protections Greatest Among the Most Socioeconomically Vulnerable Women Living in the Most Underserved Places. J Prim Care Community Health 2017; 8:127-134. [PMID: 28068854 PMCID: PMC5423779 DOI: 10.1177/2150131916686284] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Better health care among Canada's socioeconomically vulnerable versus America's has not been fully explained. We examined the effects of poverty, health insurance and the supply of primary care physicians on breast cancer care. METHODS We analyzed breast cancer data in Ontario (n = 950) and California (n = 6300) between 1996 and 2000 and followed until 2014. We obtained socioeconomic data from censuses, oversampling the poor. We obtained data on the supply of physicians, primary care and specialists. The optimal care criterion was being diagnosed early with node negative disease and received breast conserving surgery followed by adjuvant radiation therapy. RESULTS Women in Ontario received more optimal care in communities well supplied by primary care physicians. They were particularly advantaged in the most disadvantaged places: high poverty neighborhoods (rate ratio = 1.65) and communities lacking specialist physicians (rate ratio = 1.33). Canadian advantages were explained by better health insurance coverage and greater primary care access. CONCLUSIONS Policy makers ought to ensure that the newly insured are adequately insured. The Medicaid program should be expanded, as intended, across all 50 states. Strengthening America's system of primary care will probably be the best way to ensure that the Affordable Care Act's full benefits are realized.
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Escobedo LA, Crew A, Eginli A, Peng D, Cousineau MR, Cockburn M. The role of spatially-derived access-to-care characteristics in melanoma prevention and control in Los Angeles county. Health Place 2017; 45:160-172. [PMID: 28391127 PMCID: PMC5470843 DOI: 10.1016/j.healthplace.2017.01.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Revised: 11/05/2016] [Accepted: 01/09/2017] [Indexed: 12/17/2022]
Abstract
Among 10,068 incident cases of invasive melanoma, we examined the effects of patient characteristics and access-to-care on the risk of advanced melanoma. Access-to-care was defined in terms of census tract-level sociodemographics, health insurance, cost of dermatological services and appointment wait-times, clinic density and travel distance. Public health insurance and education level were the strongest predictors of advanced melanomas but were modified by race/ethnicity and poverty: Hispanic whites and high-poverty neighborhoods were worse off than non-Hispanic whites and low-poverty neighborhoods. Targeting high-risk, underserved Hispanics and high-poverty neighborhoods (easily identified from existing data) for early melanoma detection may be a cost-efficient strategy to reduce melanoma mortality.
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Affiliation(s)
- Loraine A Escobedo
- Spatial Sciences Institute, Dana and David Dornsife College of Letters, Arts and Sciences, University of Southern California, Los Angeles, United States.
| | - Ashley Crew
- Keck School of Medicine, University of Southern California, United States
| | - Ariana Eginli
- Keck School of Medicine, University of Southern California, United States
| | - David Peng
- Keck School of Medicine, University of Southern California, United States
| | - Michael R Cousineau
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, United States
| | - Myles Cockburn
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, United States
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Jiang X, Lin G, Islam KM. Socioeconomic factors related to surgical treatment for localized, non-small cell lung cancer. Soc Sci Med 2017; 175:52-57. [DOI: 10.1016/j.socscimed.2016.12.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 12/25/2016] [Accepted: 12/28/2016] [Indexed: 10/20/2022]
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The Impact of Healthcare Privatization on Access to Surgical Care: Cholecystectomy as a Model. World J Surg 2016; 41:394-401. [DOI: 10.1007/s00268-016-3739-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Antunes L, Mendonça D, Bento MJ, Rachet B. No inequalities in survival from colorectal cancer by education and socioeconomic deprivation - a population-based study in the North Region of Portugal, 2000-2002. BMC Cancer 2016; 16:608. [PMID: 27495309 PMCID: PMC4975888 DOI: 10.1186/s12885-016-2639-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 07/27/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Association between cancer survival and socioeconomic status has been reported in various countries but it has never been studied in Portugal. We aimed here to study the role of education and socioeconomic deprivation level on survival from colorectal cancer in the North Region of Portugal using a population-based cancer registry dataset. METHODS We analysed a cohort of patients aged 15-84 years, diagnosed with a colorectal cancer in the North Region of Portugal between 2000 and 2002. Education and socioeconomic deprivation level was assigned to each patient based on their area of residence. We measured socioeconomic deprivation using the recently developed European Deprivation Index. Net survival was estimated using Pohar-Perme estimator and age-adjusted excess hazard ratios were estimated using parametric flexible models. Since no deprivation-specific life tables were available, we performed a sensitivity analysis to test the robustness of the results to life tables adjusted for education and socioeconomic deprivation level. RESULTS A total of 4,105 cases were included in the analysis. In male patients (56.3 %), a pattern of worse 5- and 10-year net survival in the less educated (survival gap between extreme education groups: -7 % and -10 % at 5 and 10 years, respectively) and more deprived groups (survival gap between extreme EDI groups: -5 % both at 5 and 10 years) was observed when using general life tables. No such clear pattern was found among female patients. In both sexes, when likely differences in background mortality by education or deprivation were accounted for in the sensitivity analysis, any differences in net survival between education or deprivation groups vanished. CONCLUSIONS Our study shows that observed differences in survival by education and EDI level are most likely attributable to inequalities in background survival. Also, it confirms the importance of using the relevant life tables and of performing sensitivity analysis when evaluating socioeconomic inequalities in cancer survival. Comparison studies of different healthcare systems organization should be performed to better understand its influence on cancer survival inequalities.
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Affiliation(s)
- Luís Antunes
- Department of Epidemiology, Portuguese Oncology Institute (IPO Porto), Porto, Portugal
- RORENO - North Region Cancer Registry of Portugal, Porto, Portugal
- Faculty of Sciences, University of Porto, Porto, Portugal
| | - Denisa Mendonça
- EPIUnit – Institute of Public Health – University of Porto (ISPUP), Porto, Portugal
- Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal
| | - Maria José Bento
- Department of Epidemiology, Portuguese Oncology Institute (IPO Porto), Porto, Portugal
- RORENO - North Region Cancer Registry of Portugal, Porto, Portugal
- UMIB, Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal
| | - Bernard Rachet
- Cancer Survival Group, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
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Geyman JP. Myths and Memes about Single-Payer Health Insurance in the United States: A Rebuttal to Conservative Claims. INTERNATIONAL JOURNAL OF HEALTH SERVICES 2016; 35:63-90. [PMID: 15759557 DOI: 10.2190/xk59-v3cc-1f4n-1c4x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Recent years have seen the rapid growth of private think tanks within the neoconservative movement that conduct “policy research” biased to their own agenda. This article provides an evidence-based rebuttal to a 2002 report by one such think tank, the Dallas-based National Center for Policy Analysis (NCPA), which was intended to discredit 20 alleged myths about single-payer national health insurance as a policy option for the United States. Eleven “myths” are rebutted under eight categories: access, cost containment, quality, efficiency, single-payer as solution, control of drug prices, ability to compete abroad (the “business case”), and public support for a single-payer system. Six memes (self-replicating ideas that are promulgated without regard to their merits) are identified in the NCPA report. Myths and memes should have no place in the national debate now underway over the future of a failing health care system, and need to be recognized as such and countered by experience and unbiased evidence.
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Outcomes by area of residence deprivation in a cohort of oral cancer patients: Survival, health-related quality of life, and place of death. Oral Oncol 2016; 52:30-6. [DOI: 10.1016/j.oraloncology.2015.10.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Revised: 10/12/2015] [Accepted: 10/16/2015] [Indexed: 11/30/2022]
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Gorey KM, Kanjeekal SM, Wright FC, Hamm C, Luginaah IN, Bartfay E, Zou G, Holowaty EJ, Richter NL. Colon cancer care and survival: income and insurance are more predictive in the USA, community primary care physician supply more so in Canada. Int J Equity Health 2015; 14:109. [PMID: 26511360 PMCID: PMC4625439 DOI: 10.1186/s12939-015-0246-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 10/15/2015] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Our research group advanced a health insurance theory to explain Canada's cancer care advantages over America. The late Barbara Starfield theorized that Canada's greater primary care-orientation also plays a critically protective role. We tested the resultant Starfield-Gorey theory by examining the effects of poverty, health insurance and physician supplies, primary care and specialists, on colon cancer care in Ontario and California. METHODS We analyzed registry data for people with non-metastasized colon cancer from Ontario (n = 2,060) and California (n = 4,574) diagnosed between 1996 and 2000 and followed to 2010. We obtained census tract-based socioeconomic data from population censuses and data on county-level physician supplies from national repositories: primary care physicians, gastroenterologists and other specialists. High poverty neighborhoods were oversampled and the criterion was 10 year survival. Hypotheses were explored with standardized rate ratios (RR) and tested with logistic regression models. RESULTS Significant inverse associations of poverty (RR = 0.79) and inadequate health insurance (RR = 0.80) with survival were observed in the California, while they were non-significant or non-existent in Ontario. The direct associations of primary care physician (RRs of 1.32 versus 1.11) and gastroenterologist (RRs of 1.56 versus 1.15) supplies with survival were both stronger in Ontario than California. The supply of primary care physicians took precedence. Probably mediated through the initial course of treatment, it largely explained the Canadian advantage. CONCLUSIONS Poverty and health insurance were more predictive in the USA, community physician supplies more so in Canada. Canada's primary care protections were greatest among the most socioeconomically vulnerable. The protective effects of Canadian health care prior to enactment of the Affordable Care Act (ACA) clearly suggested the following. Notwithstanding the importance of insuring all, strengthening America's system of primary care will probably be the best way to ensure that the ACA's full benefits are realized. Finally, Canada's strong primary care system ought to be maintained.
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Affiliation(s)
- Kevin M Gorey
- School of Social Work, University of Windsor, 401 Sunset Avenue, Windsor, Ontario, N9B 3P4, Canada.
| | - Sindu M Kanjeekal
- Department of Oncology, Windsor Regional Cancer Center and Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
| | - Frances C Wright
- Division of General Surgery, Sunnybrook Health Sciences Center and cross appointed Departments of Surgery and Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
| | - Caroline Hamm
- Department of Oncology, Windsor Regional Cancer Center and Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
| | - Isaac N Luginaah
- Department of Geography, Western University, London, Ontario, Canada.
| | - Emma Bartfay
- Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, Ontario, Canada.
| | - Guangyong Zou
- Department of Epidemiology and Biostatistics and Robarts Research Institute, Western University, London, Ontario, Canada.
| | - Eric J Holowaty
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.
| | - Nancy L Richter
- School of Social Work, University of Windsor, Ontario, Canada.
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Peltzman S. Socialized medicine and mortality. INTERNATIONAL JOURNAL OF HEALTH CARE FINANCE AND ECONOMICS 2014; 14:179-205. [PMID: 25024038 DOI: 10.1007/s10754-014-9151-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 06/17/2014] [Indexed: 06/03/2023]
Abstract
Over the last century life expectancy has increased substantially and so has the share of health care expenditures financed by governments. In cross-country comparisons, the US, which has the lowest government health expenditure share, often has the poorest health outcomes. Is there a plausible connection between health outcomes and government financing of health care? This paper addresses this question with panel data from 20 developed countries from 1950 to 2010. I review the history of government involvement in health care financing over this period. Then I use panel regression methods to examine whether a variety of mortality based outcome measures are correlated with the extent of government involvement. The answers are robustly negative.
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Affiliation(s)
- Sam Peltzman
- Booth School of Business, University of Chicago, 5807 S Woodlawn Ave, Chicago, IL , 60637, USA,
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18
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Manser CN, Bauerfeind P. Impact of socioeconomic status on incidence, mortality, and survival of colorectal cancer patients: a systematic review. Gastrointest Endosc 2014; 80:42-60.e9. [PMID: 24950641 DOI: 10.1016/j.gie.2014.03.011] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Accepted: 03/05/2014] [Indexed: 12/13/2022]
Affiliation(s)
- Christine N Manser
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Zurich University Hospital, Zurich, Switzerland
| | - Peter Bauerfeind
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Zurich University Hospital, Zurich, Switzerland
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19
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Parvez E, Hodgson N, Cornacchi SD, Ramsaroop A, Gordon M, Farrokhyar F, Porter G, Quan ML, Wright F, Lovrics PJ. Survey of American and Canadian general surgeons' perceptions of margin status and practice patterns for breast conserving surgery. Breast J 2014; 20:481-8. [PMID: 24966093 DOI: 10.1111/tbj.12299] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Although breast conservation surgery (BCS) is commonly performed, several aspects of the procedure remain controversial. We undertook a cross-sectional survey to compare Canadian (CDN) and American (AM) general surgeons' reported BCS practice patterns to better understand the cross-border differences in early-stage breast cancer surgery care. A modified Dillman Method survey was mailed to 1,447 AM and 1,443 CDN surgeons. Factors evaluated included preoperative assessment, margin definition, surgical techniques, and re-excision practices. The response rate was 26% and 51% for AM and CDN surgeons, respectively. There was variation in use of preoperative core biopsies. American surgeons required wider margins for invasive cancer and ductal carcinoma in situ, and more often recommend re-excision for invasive cancer with 1 and 2 mm margins (p < 0.05). There was also variability in surgical techniques used for intraoperative margin assessment. Wide variation in BCS practice was observed, with some of this variability related to surgeon country.
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Affiliation(s)
- Elena Parvez
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
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20
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Gorey KM, Haji-Jama S, Bartfay E, Luginaah IN, Wright FC, Kanjeekal SM. Lack of access to chemotherapy for colon cancer: multiplicative disadvantage of being extremely poor, inadequately insured and African American. BMC Health Serv Res 2014; 14:133. [PMID: 24655931 PMCID: PMC3973249 DOI: 10.1186/1472-6963-14-133] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2013] [Accepted: 03/05/2014] [Indexed: 12/27/2022] Open
Abstract
Background Despite evidence of chemotherapy’s ability to cure or comfort those with colon cancer, nearly half of such Americans do not receive it. African Americans (AA) seem particularly disadvantaged. An ethnicity by poverty by health insurance interaction was hypothesized such that the multiplicative disadvantage of being extremely poor and inadequately insured is worse for AAs than for non-Hispanic white Americans (NHWA). Methods California registry data were analyzed for 459 AAs and 3,001 NHWAs diagnosed with stage II to IV colon cancer between 1996 and 2000 and followed until 2011. Socioeconomic data from the 2000 census categorized neighborhoods: extremely poor (≥ 30% of households poor), middle (5-29% poor) and low poverty (< 5% poor). Participants were randomly selected from these poverty strata. Primary health insurers were Medicaid, Medicare, private or none. Chemotherapy rates were age and stage-adjusted and comparisons used standardized rate ratios (RR). Logistic and Cox regressions, respectively, modeled chemotherapy receipt and long term survival. Results A significant 3-way ethnicity by poverty by health insurance interaction effect on chemotherapy receipt was observed. Among those who did not live in extremely poor neighborhoods and were adequately insured privately or by Medicare, chemotherapy rates did not differ significantly between AAs (37.7%) and NHWAs (39.5%). Among those who lived in extremely poor neighborhoods and were inadequately insured by Medicaid or uninsured, AAs (14.6%) were nearly 60% less likely to receive chemotherapy than were NHWAs (25.5%, RR = 0.41). When the 3-way interaction effect as well as the main effects of poverty, health insurance and chemotherapy was accounted for, survival rates of AAs and NHWAs were the same. Conclusions The multiplicative barrier to colon cancer care that results from being extremely poor and inadequately insured is worse for AAs than it is for NHWAs. AAs are more prevalently poor, inadequately insured, and have fewer assets so they are probably less able to absorb the indirect and direct, but uncovered, costs of colon cancer care. Policy makers ought to be cognizant of these factors as they implement the Affordable Care Act and consider future health care reforms.
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Affiliation(s)
- Kevin M Gorey
- School of Social Work, University of Windsor, 401 Sunset Avenue, Windsor, Ontario N9B, 3P4, Canada.
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21
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Fitzgerald TL, Lea CS, Atluri PM, Brinkley J, Zervos EE. Insurance Payer Status and Race Explains Much of the Variability in Colorectal Cancer Survival. ACTA ACUST UNITED AC 2014. [DOI: 10.4236/jct.2014.513124] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Ganesh A, Campbell DJT, Hurley J, Patten S. High positive psychiatric screening rates in an urban homeless population. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2013; 58:353-60. [PMID: 23768263 DOI: 10.1177/070674371305800607] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To carry out a preliminary assessment of the use of a psychiatric screening tool in an urban homeless population, and to estimate the potential prevalence of undiagnosed and (or) unmanaged mental illness in this population. METHODS Participants (n = 166) were recruited from the Calgary Drop-in and Rehab Centre to complete a questionnaire containing 6 modules screening for common psychiatric disorders. Summary statistics were used in the analysis. RESULTS Only 12 respondents (7%) screened negative on each of the 6 modules. The screening process determined that 60.2% of the sample (n = 100) had probable mental illness but reported no history of psychiatric diagnosis or treatment. CONCLUSIONS A straightforward application of screening (in which screen-positive subjects are referred for assessment) would be difficult in this population as most will screen positive. The results highlight the tremendous burden of psychiatric symptoms in this population.
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Affiliation(s)
- Aravind Ganesh
- Clinical Neurosciences, University of Calgary, Calgary, Alberta.
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23
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Gorey KM, Luginaah IN, Holowaty EJ, Zou G, Hamm C, Balagurusamy MK. Mediation of the effects of living in extremely poor neighborhoods by health insurance: breast cancer care and survival in California, 1996 to 2011. Int J Equity Health 2013; 12:6. [PMID: 23311824 PMCID: PMC3599601 DOI: 10.1186/1475-9276-12-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Accepted: 01/07/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We examined the mediating effect of health insurance on poverty-breast cancer care and survival relationships and the moderating effect of poverty on health insurance-breast cancer care and survival relationships in California. METHODS Registry data for 6,300 women with breast cancer diagnosed between 1996 and 2000 and followed until 2011 on stage at diagnosis, surgeries, adjuvant treatments and survival were analyzed. Socioeconomic data were obtained for residences from the 2000 census to categorize neighborhoods: high poverty (30% or more poor), middle poverty (5%-29% poor) and low poverty (less than 5% poor). Primary payers or health insurers were Medicaid, Medicare, private or uninsured. RESULTS Evidence of survival mediation was observed for women with node negative breast cancer. The apparent effect of poverty disappeared in the presence of Medicare or private health insurance. Women who were so insured were advantaged on 8-year survival compared to the uninsured or those insured by Medicaid (OR = 1.89). Evidence of payer moderation by poverty was also observed for women with node negative breast cancer. The survival advantaging effect of Medicare or private insurance was stronger in low poverty (OR = 1.81) than it was in middle poverty (OR = 1.57) or in high poverty neighborhoods (OR = 1.16). This same pattern of mediated and moderated effects was also observed for early stage at diagnosis, shorter waits for adjuvant radiation therapy and for the receipt of sentinel lymph node biopsies. These findings are consistent with the theory that more facilitative social and economic capital is available in low poverty neighborhoods, where women with breast cancer may be better able to absorb the indirect and direct, but uncovered, costs of care. As for treatments, main protective effects as well as moderator effects indicative of protection, particularly in high poverty neighborhoods were observed for women with private health insurance. CONCLUSIONS America's multi-tiered health insurance system mediates the quality of breast cancer care. The system is inequitable and unjust as it advantages the well insured and the well to do. Recent health care reforms ought to be enacted in ways that are consistent with their federal legislative intent, that high quality health care be truly available to all.
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Affiliation(s)
- Kevin M Gorey
- School of Social Work, University of Windsor, 401 Sunset Avenue, Windsor, Ontario, N9B 3P4, Canada
| | - Isaac N Luginaah
- Department of Geography, University of Western Ontario, London, Ontario, Canada
| | - Eric J Holowaty
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Guangyong Zou
- Department of Epidemiology and Biostatistics, University of Western Ontario and Scientist, Robarts Research Institute, London, Ontario, Canada
| | - Caroline Hamm
- Medical Oncologist, Windsor Regional Cancer Center, School of Medicine and Dentistry, Department of Medicine, Division of General Internal Medicine, University of Western Ontario, London, Ontario, Canada
| | - Madhan K Balagurusamy
- Statistician and Research Associate, School of Social Work, University of Windsor, Windsor, Ontario, Canada
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Karanikolos M, Ellis L, Coleman MP, McKee M. Health systems performance and cancer outcomes. J Natl Cancer Inst Monogr 2013; 2013:7-12. [PMID: 23962507 DOI: 10.1093/jncimonographs/lgt003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2024] Open
Abstract
Do the characteristics of health systems influence cancer outcomes? Although caveats are required when undertaking international comparisons of both health systems and cancer outcomes, observed differences cannot solely be explained by data problems or economic development. Health systems can influence cancer outcomes through three mechanisms: coverage, innovation, and quality of care. First, in countries where population coverage is incomplete, patients may find certain services excluded or face substantial copayments or deductibles. Second, there are variations in the rate at which innovative treatments are introduced, reflecting in particular the need for publicly funded health systems to compare costs and benefits of increasingly expensive treatments given demands for other treatments. Third, systematic differences in quality of care (early diagnosis, timely and equitable access to specialist care, and existence of systematic coordination between these activities) may lead to variations in cancer outcomes.
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Affiliation(s)
- Marina Karanikolos
- European Observatory on Health Systems and Policies, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK.
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25
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Gorey KM, Luginaah IN, Holowaty EJ, Zou G, Hamm C, Bartfay E, Kanjeekal SM, Balagurusamy MK, Haji-Jama S, Wright FC. Effects of being uninsured or underinsured and living in extremely poor neighborhoods on colon cancer care and survival in California: historical cohort analysis, 1996-2011. BMC Public Health 2012; 12:897. [PMID: 23092403 PMCID: PMC3507906 DOI: 10.1186/1471-2458-12-897] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Accepted: 10/16/2012] [Indexed: 01/02/2023] Open
Abstract
Background We examined the mediating effects of health insurance on poverty-colon cancer care and survival relationships and the moderating effects of poverty on health insurance-colon cancer care and survival relationships among women and men in California. Methods We analyzed registry data for 3,291 women and 3,009 men diagnosed with colon cancer between 1996 and 2000 and followed until 2011 on lymph node investigation, stage at diagnosis, surgery, chemotherapy, wait times and survival. We obtained socioeconomic data for individual residences from the 2000 census to categorize the following neighborhoods: high poverty (30% or more poor), middle poverty (5-29% poor) and low poverty (less than 5% poor). Primary health insurers were Medicaid, Medicare, private or none. Results Evidence of mediation was observed for women, but not for men. For women, the apparent effect of poverty disappeared in the presence of payer, and the effects of all forms of health insurance seemed strengthened. All were advantaged on 6-year survival compared to the uninsured: Medicaid (RR = 1.83), Medicare (RR = 1.92) and private (RR = 1.83). Evidence of moderation was also only observed for women. The effects of all forms of health insurance were stronger for women in low poverty neighborhoods: Medicaid (RR = 2.90), Medicare (RR = 2.91) and private (RR = 2.60). For men, only main effects of poverty and payers were observed, the advantaging effect of private insurance being largest. Across colon cancer care processes, Medicare seemed most instrumental for women, private payers for men. Conclusions Health insurance substantially mediates the quality of colon cancer care and poverty seems to make the effects of being uninsured or underinsured even worse, especially among women in the United States. These findings are consistent with the theory that more facilitative social and economic capital is available in more affluent neighborhoods, where women with colon cancer may be better able to absorb the indirect and direct, but uncovered, costs of care.
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Affiliation(s)
- Kevin M Gorey
- School of Social Work, University of Windsor, Windsor, Ontario, N9B 3P4, Canada.
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26
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Ellis L, Coleman MP, Rachet B. How many deaths would be avoidable if socioeconomic inequalities in cancer survival in England were eliminated? A national population-based study, 1996-2006. Eur J Cancer 2011; 48:270-8. [PMID: 22093945 DOI: 10.1016/j.ejca.2011.10.008] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Revised: 10/03/2011] [Accepted: 10/10/2011] [Indexed: 10/15/2022]
Abstract
AIM Inequalities in survival between rich and poor have been reported for most adult cancers in England. This study aims to quantify the public health impact of these inequalities by estimating the number of cancer-related deaths that would be avoidable if all patients were to have the same cancer survival as the most affluent patients. METHODS National Cancer Registry data for all adults diagnosed with one of 21 common cancers in England were used to estimate relative survival. We estimated the number of excess (cancer-related) deaths that would be avoidable within three years after diagnosis if relative survival for patients in all deprivation groups was as high as the most affluent group. RESULTS For patients diagnosed during 2004-2006, 7122 of the 64,940 excess deaths a year (11%) would have been avoidable if three-year survival for all patients had been as high as in the most affluent group. The annual number of avoidable deaths fell from 8435 (13%) a year for patients diagnosed during 1996-2000. Over 60% of the total number of avoidable deaths occurred within six months after diagnosis and approximately 70% occurred in the two most deprived groups. CONCLUSION The downward trend in the annual number of avoidable deaths reflects more an improvement in survival in England overall, rather than a narrowing of the deficit in cancer survival between poor and rich. The lack of any substantial change in the percentage of avoidable excess deaths highlights the persistent nature of the deficit in survival between affluent and deprived groups.
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Affiliation(s)
- Libby Ellis
- Department of Non-Communicable Disease Epidemiology, Cancer Research UK Cancer Survival Group, London School of Hygiene and Tropical Medicine, London, UK.
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27
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Inequity in access to cancer care: a review of the Canadian literature. Cancer Causes Control 2011; 22:359-66. [PMID: 21221758 DOI: 10.1007/s10552-010-9722-3] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2010] [Accepted: 12/23/2010] [Indexed: 12/24/2022]
Abstract
Despite the policy and research attention on ensuring equitable access--equal access for equal need--to health care, research continues to identify inequities in access to cancer services. We conducted a literature review to identify the current state of knowledge about inequity in access to cancer health services in Canada in terms of the continuum of care, disease sites, and dimensions of inequity (e.g., income). We searched MEDLINE, CINAHL, and Embase for studies published between 1990 and 2009. We retrieved 51 studies, which examine inequity in access to cancer services from screening to end-of-life care, for multiple cancer types, and a variety of socioeconomic, geographic, and demographic factors that may cause concern for inequity in Canada. This review demonstrates that income has the most consistent influence on inequity in access to screening, while age and geography are most influential for treatment services and end-of-life care, even after adjusting for patient need. Our review also reports on methods used in the literature and new techniques to explore. Equitable access to cancer care is vitally important in all health systems. Obtaining information on the current status of inequities in access to cancer care is a critical first step toward action.
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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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Gorey KM, Fung KY, Luginaah IN, Holowaty EJ, Hamm C. Income and long-term breast cancer survival: comparisons of vulnerable urban places in Ontario and California. Breast J 2010; 16:416-9. [PMID: 20443784 DOI: 10.1111/j.1524-4741.2010.00922.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Effects of socioeconomic status on the long-term survival of 808 women with node-negative breast cancer in Canada and the United States were observed. Ontario and California samples diagnosed between 1988 and 1990 were followed until 2006. Socioeconomic data were taken from population censuses. Compared with their California counterparts, residents of low-income urban areas in Ontario experienced a significant 15-year survival advantage (RR = 1.66 [95% CI: 1.00, 2.76]). In these and other vulnerable, lower-middle- to working-class neighborhoods, significantly more Ontario residents gained access to adjuvant radiation therapy (RR = 1.75 [1.21, 2.53]) which seemed associated with better long-term survival (RR = 1.36 [0.99, 1.86]). This stage-adjusted, historical cohort analysis suggests much greater cancer care equity in Canada than in the United States.
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Affiliation(s)
- Kevin M Gorey
- School of Social Work, University of Windsor, Windsor, Ontario, Canada.
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30
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Gorey KM, Luginaah IN, Bartfay E, Fung KY, Holowaty EJ, Wright FC, Hamm C, Kanjeekal SM. Effects of socioeconomic status on colon cancer treatment accessibility and survival in Toronto, Ontario, and San Francisco, California, 1996-2006. Am J Public Health 2010; 101:112-9. [PMID: 20299655 DOI: 10.2105/ajph.2009.173112] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We examined the differential effects of socioeconomic status on colon cancer care and survival in Toronto, Ontario, Canada, and San Francisco, California. METHODS We analyzed registry data for colon cancer patients from Ontario (n = 930) and California (n = 1014), diagnosed between 1996 and 2000 and followed until 2006, on stage, surgery, adjuvant chemotherapy, and survival. We obtained socioeconomic data for individuals' residences from population censuses. RESULTS Income was directly associated with lymph node evaluation, chemotherapy, and survival in San Francisco but not in Toronto. High-income persons had better survival rates in San Francisco than in Toronto. After adjustment for stage, survival was better for low-income residents of Toronto than for those of San Francisco. Middle- to low-income patients were more likely to receive indicated chemotherapy in Toronto than in San Francisco. CONCLUSIONS Socioeconomic factors appear to mediate colon cancer care in urban areas of the United States but not in Canada. Improvements are needed in screening, diagnostic investigations, and treatment access among low-income Americans.
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Affiliation(s)
- Kevin M Gorey
- School of Social Work, University of Windsor, Windsor, Ontario, Canada.
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Abstract
BACKGROUND This study tested the hypothesis that physician supply thresholds are associated with breast cancer survival in Ontario. METHODS The 5-year survival of 17,820 female breast cancer patients diagnosed between 1995 and 1997 was surveilled until 2003 for all-cause mortality. Physician supply densities in 1991 and 2001 were computed for 49 Ontario regions. RESULTS There were independent threshold effects for general practitioners (GP; 7.25 per 10,000) and obstetrician/gynecologists (OB/GYN; 6 per 100,000) at or above which women with breast cancer were more likely to survive for 5 years. The respective risk of living in areas undersupplied with OB/GYN and GP increased 30% to nearly 5-fold during the 1990s. Five-year survival tended to be lower in provincial areas outside of Toronto, which experienced GP (odds ratio, 0.83; 90% CI, 0.70-0.99) and OB/GYN (odds ratio, 0.76; 95% CI, 0.61-0.96) supply decreases. CONCLUSION As they do in America, primary care physician supplies in Canada seem to matter in the effective provision of cancer care. Community resources such as health care service endowments, including physician supplies, may be particularly critical to the performance of health care systems such as Canada's, which aim to provide medically necessary care for all.
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Gorey KM, Luginaah IN, Hamm C, Fung KY, Holowaty EJ. Breast cancer care in the Canada and the United States: ecological comparisons of extremely impoverished and affluent urban neighborhoods. Health Place 2010; 16:156-63. [PMID: 19840902 PMCID: PMC2908703 DOI: 10.1016/j.healthplace.2009.09.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2009] [Revised: 09/18/2009] [Accepted: 09/23/2009] [Indexed: 11/18/2022]
Abstract
This study examined the differential effect of extreme impoverishment on breast cancer care in urban Canada and the United States. Ontario and California registry-based samples diagnosed between 1998 and 2000 were followed until 2006. Extremely poor and affluent neighborhoods were compared. Poverty was associated with non-localized disease, surgical and radiation therapy (RT) waits, non-receipt of breast conserving surgery, RT and hormonal therapy, and shorter survival in California, but not in Ontario. Extremely poor Ontario women were consistently advantaged on care indices over their California counterparts. More inclusive health insurance coverage in Canada seems the most plausible explanation for such Canadian breast cancer care advantages.
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Affiliation(s)
- Kevin M Gorey
- School of Social Work, University of Windsor, 401 Sunset Avenue, Windsor, Ontario, Canada N9B 3P4.
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Joyce DP, Limbos M. Identification of cognitive impairment and mental illness in elderly homeless men: Before and after access to primary health care. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2009; 55:1110-1111.e6. [PMID: 19910602 PMCID: PMC2776807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To describe the occurrence of mental health problems and cognitive impairment in a group of elderly homeless men and to demonstrate how clinical examination and screening tests used in a shelter setting might be helpful in identifying mental illness and cognitive impairment. DESIGN Cross-sectional study including face-to-face interviews and review of medical records. SETTING A community-based homeless shelter in an urban metropolitan centre (Toronto, Ont). PARTICIPANTS A total of 49 male participants 55 years of age or older. The average duration of homelessness was 8.8 (SD 10.2) years. METHODS Participants were admitted to a community-based shelter that offered access to regular meals, personal support and housing workers, nursing, and a primary care physician. Medical chart review was undertaken to identify mental illness or cognitive impairment diagnosed either before or after admission to the facility. The 15-item Geriatric Depression Scale (GDS-15) and the Folstein Mini-Mental State Examination (MMSE) were administered. MAIN OUTCOME MEASURE Previous or new diagnosis of mental illness or cognitive impairment. RESULTS Thirty-six of the participants (73.5%) had previous or new diagnoses. The most prevalent diagnosis was schizophrenia or psychotic disorders (n = 17), followed by depression (n = 11), anxiety disorders (n = 3), cognitive impairment (n = 8), and bipolar affective disorder (n = 1). A total of 37% of participants were given new mental health diagnoses during the study. The GDS-15 identified 9 people with depression and the MMSE uncovered 11 individuals with cognitive impairment who had not been previously diagnosed. CONCLUSION This study suggests that providing access to primary care physicians and other services in a community-based shelter program can assist in identification of mental illness and cognitive impairment in elderly homeless men. Use of brief screening tools for depression and cognitive impairment (like the GDS-15 and the MMSE) could be helpful in this highrisk group.
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Affiliation(s)
- David P Joyce
- Pender Community Health Centre, 59 Pender St W, Vancouver, BC V6B 1R3.
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McGrail KM, van Doorslaer E, Ross NA, Sanmartin C. Income-related health inequalities in Canada and the United States: a decomposition analysis. Am J Public Health 2009; 99:1856-63. [PMID: 19150915 PMCID: PMC2741511 DOI: 10.2105/ajph.2007.129361] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2008] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We examined income-related inequalities in self-reported health in the United States and Canada and the extent to which they are associated with individual-level risk factors and health care system characteristics. METHODS We estimated income inequalities with concentration indexes and curves derived from comparable survey data from the 2002 to 2003 Joint Canada-US Survey of Health. Inequalities were then decomposed by regression and decomposition analysis to distinguish the contributions of various factors. RESULTS The distribution of income accounted for close to half of income-related health inequalities in both the United States and Canada. Health care system factors (e.g., unmet needs and health insurance status) and risk factors (e.g., physical inactivity and obesity) contributed more to income-related health inequalities in the United States than to those in Canada. CONCLUSIONS Individual-level health risk factors and health care system characteristics have similar associations with health status in both countries, but they both are far more prevalent and much more concentrated among lower-income groups in the United States than in Canada.
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Affiliation(s)
- Kimberlyn M McGrail
- Centre for Health Services and Policy Research, The University of British Columbia, 201-2206 East Mall, Vancouver, BC, Canada.
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Gorey KM, Luginaah IN, Holowaty EJ, Fung KY, Hamm C. Associations of physician supplies with breast cancer stage at diagnosis and survival in Ontario, 1988 to 2006. Cancer 2009; 115:3563-70. [PMID: 19484796 DOI: 10.1002/cncr.24401] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The authors examined whether the supply of primary care physicians had protective effects on breast cancer stage and survival in Ontario and whether supply losses during the 1990s were associated with diminished protection. METHODS Random samples of the Ontario Cancer Registry, respectively, provided 879 women and 951 women who were diagnosed with breast cancer between 1988 and 1990 (followed until 1996) and 1998 and 2000 (followed until 2006), respectively. Active physician supply data (1991 and 2001) joined to each woman's census division of residence was taken from the Scott's Medical Database. RESULTS Protective thresholds were observed among the earlier cohort for supplies of general practitioners (7 per 10,000 population) and supplies of obstetricians/gynecologists (6 per 100,000 population) at or above which women with breast cancer were significantly more likely to have been diagnosed with localized disease and to have survived for >or=5 years. These protective effects seemed generally attenuated among the more recent cohort. The risk of living in primary care physician-undersupplied areas increased significantly between 1991 and 2001 (10%-30%), and such physician supply losses were associated with reduced cancer care protection, including less prevalent early diagnoses (odds ratio [OR], 1.60; 95% confidence interval [95% CI], 1.00-2.58) and lower 5-year survival rates (OR, 1.62; 95% CI, 1.03-2.55). CONCLUSIONS Primary care physician supplies appeared to matter very much in the effective provision of cancer care in Canada. Community healthcare service endowments that include adequate physician supplies may be particularly critical to the performance of a healthcare system such as that in Canada, which provides universal accessibility to medically necessary care.
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Affiliation(s)
- Kevin M Gorey
- School of Social Work, University of Windsor, Department of Mathematics and Statistics, Windsor, Ontario, Canada.
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Krajewski SA, Hameed SM, Smink DS, Rogers SO. Access to emergency operative care: a comparative study between the Canadian and American health care systems. Surgery 2009; 146:300-7. [PMID: 19628089 DOI: 10.1016/j.surg.2009.04.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2009] [Accepted: 04/06/2009] [Indexed: 01/07/2023]
Abstract
BACKGROUND Canada provides universal health insurance to all citizens, whereas 47 million Americans are uninsured. There has not been a study comparing access to emergency operative care between the 2 countries. As both countries contemplate changes in health care delivery, such comparisons are needed to guide health policy decisions. The purpose of this study is to determine whether or not there is a difference in access to emergency operative care between Canada and the United States. METHODS All patients diagnosed with acute appendicitis from 2001 to 2005 were identified in the Canadian Institute for Health Information database and the US Nationwide Inpatient Sample. Severity of appendicitis was determined by ICD-9 codes. Patients were further characterized by age, gender, insurance status, race, and socioeconomic status (SES; income). Univariate and multivariate analyses were performed to determine the odds of appendiceal perforation at different levels of SES in each country. RESULTS There were 102,692 Canadian patients and 276,890 American patients with acute appendicitis. In Canada, there was no difference in the odds of perforation between income levels. In the United States, there was a significant, inverse relationship between income level and the odds of perforation. The odds of perforation in the lowest income quartile were significantly higher than the odds of perforation in the highest income bracket (odds ratio, 1.20; 95% confidence interval, 1.16-1.24). CONCLUSION The results suggest that access to emergency operative care is related to SES in the United States, but not in Canada. This difference could result from the concern over the ability to pay medical bills or the lack of a stable relationship with a primary care provider that can occur outside of a universal health care system.
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Affiliation(s)
- Susan A Krajewski
- Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada.
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Gorey KM, Luginaah IN, Holowaty EJ, Fung KY, Hamm C. Breast cancer survival in ontario and california, 1998-2006: socioeconomic inequity remains much greater in the United States. Ann Epidemiol 2009; 19:121-4. [PMID: 19185806 DOI: 10.1016/j.annepidem.2008.10.010] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2008] [Revised: 10/21/2008] [Accepted: 10/21/2008] [Indexed: 11/20/2022]
Abstract
This study re-examined the differential effect of socioeconomic status on the survival of women with breast cancer in Canada and the United States. Ontario and California cancer registries provided 1,913 cases from urban and rural places. Stage-adjusted cohorts (1998-2000) were followed until 2006. Socioeconomic data were taken from population censuses. SES-survival associations were observed in California, but not in Ontario, and Canadian survival advantages in low-income areas were replicated. A better controlled and updated comparison reaffirmed the equity advantage of Canadian health care.
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Affiliation(s)
- Kevin M Gorey
- School of Social Work, University of Windsor, Ontario.
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Gorey KM. Breast cancer survival in Canada and the USA: meta-analytic evidence of a Canadian advantage in low-income areas. Int J Epidemiol 2009; 38:1543-51. [PMID: 19386825 DOI: 10.1093/ije/dyp193] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND This study tested the hypothesis that relatively poor Canadian women with breast cancer have a survival advantage over their counterparts in the USA. METHODS Seventy-eight independent retrospective cohort (incidence between 1984 and 2000, followed until 2006) outcomes were synthesized. Fixed effects meta-regression models compared women with breast cancer in low-income areas of Canada and the USA. RESULTS Low-income Canadian women were advantaged on survival [rate ratio (RR) = 1.14; 95% confidence interval (CI) 1.13-1.15] and their advantage was even larger among women <65 years of age who are not yet eligible for Medicare coverage in the USA (RR = 1.21, 95% CI 1.18-1.24). Canadian advantages were also larger for node positive breast cancer, which may present with greater clinical and managerial discretion (RR = 1.40, 95% CI 1.30-1.50), and smaller when Hawaii, the state providing the most Canadian-like access, was the US comparator (RR = 1.12, 95% CI 1.01-1.20). CONCLUSIONS More inclusive health care insurance coverage in Canada vs the USA, particularly among each country's relatively poor people, seems the most plausible explanation for such Canadian advantages. Provision of health care for all Americans would likely prevent countless early deaths, particularly among the relatively poor.
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Affiliation(s)
- Kevin M Gorey
- Professor and Assumption University Research Chair in Canadian and American Population Health, School of Social Work, University of Windsor, 401 Sunset Avenue, Windsor, Ontario N9B 3P4, Canada.
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Chan RHM, Gordon NF, Chong A, Alter DA. Influence of socioeconomic status on lifestyle behavior modifications among survivors of acute myocardial infarction. Am J Cardiol 2008; 102:1583-8. [PMID: 19064009 DOI: 10.1016/j.amjcard.2008.08.022] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2008] [Revised: 08/02/2008] [Accepted: 08/02/2008] [Indexed: 11/17/2022]
Abstract
The impact of secondary prevention initiatives on survival in higher-risk socioeconomically disadvantaged patients after acute myocardial infarction (AMI) may depend on behavioral adaptive responsiveness, uptake, and adherence to healthier lifestyles. From December 1999 to February 2003, 1,801 patients in Ontario, Canada were interviewed regarding their lifestyle behaviors at 30 days after their index AMI hospitalization. Data were obtained using self-reported surveys, medical chart abstraction, and administrative data linkage. Multivariate analyses were adjusted for baseline sociodemographic, cardiac risk severity, and co-morbid conditions. Socioeconomically disadvantaged patients had greater cardiac risk severity at baseline than did their wealthier better-educated counterparts. Compared with lower-income patients, patients with higher incomes were less likely to smoke (adjusted odds ratio [OR] for highest vs lowest income tertiles 0.36, 95% confidence interval [CI] 0.21 to 0.63, p <0.001), more likely to participate in exercise (adjusted OR 1.40, 95% CI 1.07 to 1.85, p = 0.02), and more likely to decrease or discontinue alcohol use (adjusted OR 1.64, 95% CI 1.16 to 2.34, p = 0.06). The relation between education and lifestyle behaviors was less pronounced for education than for income. After adjustment for baseline factors, patients who acknowledged participation in regular physical exercise at 1 month had a significantly lower long-term mortality than those who did not. In conclusion, socioeconomically disadvantaged patients were sicker at baseline and less behaviorally responsive to embarking on healthy lifestyle changes after AMI than were those of higher socioeconomic status.
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Affiliation(s)
- Raymond H M Chan
- Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, Ontario, Canada
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Haynes R, Pearce J, Barnett R. Cancer survival in New Zealand: Ethnic, social and geographical inequalities. Soc Sci Med 2008; 67:928-37. [DOI: 10.1016/j.socscimed.2008.05.005] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2007] [Indexed: 01/11/2023]
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Shugarman LR, Sorbero MES, Tian H, Jain AK, Ashwood JS. An exploration of urban and rural differences in lung cancer survival among medicare beneficiaries. Am J Public Health 2008; 98:1280-7. [PMID: 17971555 PMCID: PMC2424098 DOI: 10.2105/ajph.2006.099416] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2007] [Indexed: 01/16/2023]
Abstract
OBJECTIVES We tested the relationship between urban or rural residence as defined by rural-urban commuting area codes and risk of mortality in a sample of Medicare beneficiaries with lung cancer. METHODS We used Surveillance, Epidemiology, and End Results data linked with Medicare claims to build proportional hazards models. The models tested hypothesized relationships between individual and community characteristics and overall survival for a cohort of Medicare beneficiaries 65 years and older who were diagnosed with lung cancer between 1995 and 1999 (N=26073). RESULTS We found no evidence that lung cancer patients in rural areas have poorer survival than those in urban areas. Rather, individual (Medicaid coverage) and regional (lower census tract-level median income) socioeconomic factors and a smaller supply of subspecialists per 10000 individuals 65 years and older were positively associated with a higher risk of mortality. CONCLUSIONS Although urban versus rural residence did not directly influence survival, rural residents were more likely to live in poorer areas with a smaller supply of health care providers. Therefore, we still need to be aware of rural beneficiaries' potential disadvantage when it comes to receiving needed care in a timely fashion.
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Cancer survival in Ontario, 1986-2003: evidence of equitable advances across most diverse urban and rural places. Canadian Journal of Public Health 2008. [PMID: 18435383 DOI: 10.1007/bf03403733] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVES This study examined whether place and socio-economic status had differential effects on the survival of women diagnosed with breast cancer in Ontario during the 1980s and the 1990s. METHODS The Ontario Cancer Registry provided 29,934 primary malignant breast cancer cases. Successive historical cohorts (1986-1988 and 1995-1997) were, respectively, followed until 1994 and 2003. Diverse places were compared: the greater metropolitan Toronto area, other cities, ranging in size from 50,000 to a million people, smaller towns and villages, and rural and remote areas. Socio-economic data for each woman's residence at the time of diagnosis were taken from population censuses. RESULTS Very small cities (6%) with populations between 50,000 and 100,000 were the only places where breast cancer survival had advanced less compared to the province as a whole. Income gradients began to appear, however, in larger cities. Urban residents in the lowest income areas were significantly disadvantaged compared to the highest income areas during the 1990s, but not during the 1980s. CONCLUSION This historical analysis of breast cancer survival evidenced remarkably equitable advances across nearly all of Ontario's diverse places. The most likely explanation for such substantial equity seems to be Canada's universally accessible, single-payer, health care system.
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Increased racial differences on breast cancer care and survival in America: historical evidence consistent with a health insurance hypothesis, 1975-2001. Breast Cancer Res Treat 2008; 113:595-600. [PMID: 18330694 DOI: 10.1007/s10549-008-9960-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2008] [Accepted: 02/27/2008] [Indexed: 10/22/2022]
Abstract
PURPOSE This study examined whether race/ethnicity had differential effects on breast cancer care and survival across age strata and cohorts within stages of disease. METHODS The Detroit Cancer Registry provided 25,997 breast cancer cases. African American and non-Hispanic white, older Medicare-eligible and younger non-eligible women were compared. Successive historical cohorts (1975-1980 and 1990-1995) were, respectively, followed until 1986 and 2001. RESULTS African American disadvantages on survival and treatments increased significantly, particularly among younger women who were much more likely to be uninsured. Within node positive disease all treatment disadvantages among younger African American women disappeared with socioeconomic adjustment. CONCLUSIONS Growth of this racial divide implicates social, rather than biological, forces. Its elimination will require high quality health care for all.
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Sargeran K, Murtomaa H, Safavi SMR, Vehkalahti MM, Teronen O. Survival after diagnosis of cancer of the oral cavity. Br J Oral Maxillofac Surg 2007; 46:187-191. [PMID: 18096283 DOI: 10.1016/j.bjoms.2007.11.004] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2007] [Indexed: 12/16/2022]
Abstract
In this retrospective study we analysed the survival in 470 patients with oral cancer. Patients who attended five university hospitals in Tehran, Iran, during the period 1996-2002 were included. Data were obtained from a combination of sources including patients' records, telephone calls, and deaths registered by the Ministry of Health. Survival curves were generated using Kaplan-Maier curves. Univariate and multivariate analyses of the relations between survival and age, sex, site of primary tumour, stage, and histopathological type were made using the log-rank test and Cox's regression analysis. Sex and age were not associated with survival. Treatment and stage of tumour at the time of diagnosis were related to survival. The overall survival rates were higher in patients with stages I or II cancer than those in stages III (OR=2.8, 95% CI=1.8 to 4.4) or IV (OR=4.6, 95% CI=3.1 to 6.8) at the time of diagnosis. Patients treated with radiotherapy had lower survival than those who had been operated on and had radiotherapy or operation alone (OR=2.8, 95% CI=1.7 to 4.5). There was no difference in survival depending on the histological type of tumour. To achieve higher survival, early detection and diagnosis of oral cancers should be emphasised in oral health programmes to improve public awareness and preventive activities among dentists in Iran.
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Affiliation(s)
- Katayoun Sargeran
- Department of Oral Public Health, Institute of Dentistry, University of Helsinki, P.O. Box 41, FI-00014, Helsinki, Finland; Department of Community Oral Health, School of Dentistry, Shaheed Beheshti Medical University (SBMU), Tehran, Iran; Iran Centre for Dental Research (ICDR), School of Dentistry, Shaheed Beheshti Medical University (SBMU), Tehran, Iran.
| | - Heikki Murtomaa
- Department of Oral Public Health, Institute of Dentistry, University of Helsinki, P.O. Box 41, FI-00014, Helsinki, Finland.
| | - Seyed Mohammad Reza Safavi
- Iran Centre for Dental Research (ICDR), School of Dentistry, Shaheed Beheshti Medical University (SBMU), Tehran, Iran.
| | - Miira M Vehkalahti
- Department of Oral Public Health, Institute of Dentistry, University of Helsinki, P.O. Box 41, FI-00014, Helsinki, Finland.
| | - Olli Teronen
- Institute of Dentistry, University of Helsinki, P.O. Box 41, FI-00014, Helsinki, Finland.
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Huguet N, Kaplan MS, Feeny D. Socioeconomic status and health-related quality of life among elderly people: results from the Joint Canada/United States Survey of Health. Soc Sci Med 2007; 66:803-10. [PMID: 18155337 DOI: 10.1016/j.socscimed.2007.11.011] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2007] [Indexed: 10/22/2022]
Abstract
The objective of this study was to assess the independent effect of income on health-related quality of life (HRQL) among older adults in Canada and the United States. Data were obtained from the 2002-2003 Joint Canada/United States Survey of Health. The sample consisted of 755 Canadians and 1,151 Americans aged 65 years or older. HRQL was measured with the multidimensional Health Utilities Index Mark 3 (HUI3). The results indicated that in the elderly population, HRQL was significantly associated with household income in the United States but not in Canada, controlling for sociodemographic and health indicators. Various explanations for the positive linear relationship between HRQL and income in the elderly population are discussed, including the roles of access to health care and socioeconomic inequalities in the United States and Canada.
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Affiliation(s)
- Nathalie Huguet
- Center for Public Health Studies, Portland State University, Portland, OR 97207-0751, USA.
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Erridge SC, Møller H, Price A, Brewster D. International comparisons of survival from lung cancer: pitfalls and warnings. ACTA ACUST UNITED AC 2007; 4:570-7. [PMID: 17898807 DOI: 10.1038/ncponc0932] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2007] [Accepted: 05/14/2007] [Indexed: 12/25/2022]
Abstract
Population-based survival data can provide valuable comparative data on outcome but should be interpreted with caution. Differences in data collection and analysis, patient and tumor characteristics and treatment options can have an impact on reported results. Ideally, data from the whole population, including clinical-only diagnoses, should be reported and the methods of case identification described. The relative survival rates should preferably be given. Data on patient characteristics such as age, sex, ethnicity and socioeconomic deprivation should be described, together with tumor details such as pathology and clinical stage. Whenever possible, details on the use of treatments should be reported.
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Affiliation(s)
- Sara C Erridge
- Radiation Oncology at the University of Edinburgh and Edinburgh Cancer Centre, Edinburgh, UK.
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A systematic review of studies comparing health outcomes in Canada and the United States. OPEN MEDICINE : A PEER-REVIEWED, INDEPENDENT, OPEN-ACCESS JOURNAL 2007; 1:e27-36. [PMID: 20101287 PMCID: PMC2801918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/10/2006] [Revised: 10/24/2006] [Accepted: 01/25/2007] [Indexed: 11/10/2022]
Abstract
BACKGROUND Differences in medical care in the United States compared with Canada, including greater reliance on private funding and for-profit delivery, as well as markedly higher expenditures, may result in different health outcomes. OBJECTIVES To systematically review studies comparing health outcomes in the United States and Canada among patients treated for similar underlying medical conditions. METHODS We identified studies comparing health outcomes of patients in Canada and the United States by searching multiple bibliographic databases and resources. We masked study results before determining study eligibility. We abstracted study characteristics, including methodological quality and generalizability. RESULTS We identified 38 studies comparing populations of patients in Canada and the United States. Studies addressed diverse problems, including cancer, coronary artery disease, chronic medical illnesses and surgical procedures. Of 10 studies that included extensive statistical adjustment and enrolled broad populations, 5 favoured Canada, 2 favoured the United States, and 3 showed equivalent or mixed results. Of 28 studies that failed one of these criteria, 9 favoured Canada, 3 favoured the United States, and 16 showed equivalent or mixed results. Overall, results for mortality favoured Canada (relative risk 0.95, 95% confidence interval 0.92-0.98, p= 0.002) but were very heterogeneous, and we failed to find convincing explanations for this heterogeneity. The only condition in which results consistently favoured one country was end-stage renal disease, in which Canadian patients fared better. INTERPRETATION Available studies suggest that health outcomes may be superior in patients cared for in Canada versus the United States, but differences are not consistent.
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James PD, Wilkins R, Detsky AS, Tugwell P, Manuel DG. Avoidable mortality by neighbourhood income in Canada: 25 years after the establishment of universal health insurance. J Epidemiol Community Health 2007; 61:287-96. [PMID: 17372287 PMCID: PMC2652935 DOI: 10.1136/jech.2006.047092] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2006] [Indexed: 11/03/2022]
Abstract
AIM To examine neighbourhood income differences in deaths amenable to medical care and public health over a 25-year period after the establishment of universal insurance for doctors and hospital services in Canada. METHODS Data for census metropolitan areas were obtained from the Canadian Mortality Database and population censuses for the years 1971, 1986, 1991 and 1996. Deaths amenable to medical care, amenable to public health, from ischaemic heart disease and from other causes were considered. Data on deaths were grouped into neighbourhood income quintiles on the basis of the census tract percentage of population below Canada's low-income cut-offs. RESULTS From 1971 to 1996, differences between the richest and poorest quintiles in age-standardised expected years of life lost amenable to medical care decreased 60% (p<0.001) in men and 78% (p<0.001) in women, those amenable to public health increased 0.7% (p = 0.94) in men and 20% (p = 0.55) in women, those lost from ischaemic heart disease decreased 58% in men and 38% in women, and from other causes decreased 15% in men and 9% in women. Changes in the age-standardised expected years of life lost difference for deaths amenable to medical care were significantly larger than those for deaths amenable to public health or other causes for both men and women (p<0.001). CONCLUSIONS Reductions in rates of deaths amenable to medical care made the largest contribution to narrowing socioeconomic mortality disparities. Continuing disparities in mortality from causes amenable to public health suggest that public health initiatives have a potentially important, but yet un-realized, role in further reducing mortality disparities in Canada.
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Affiliation(s)
- Paul D James
- Institute for Clinical Evaluative Sciences, G-119, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada
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Abstract
Serum pepsinogen (PG) has been used as biomarkers of gastric inflammation and mucosal status, including atrophic change, before the discovery of Helicobacter pylori (H. pylori). Serum pepsinogen I (PG I) and pepsinogen II (PG II) levels are known to increase in the presence of H. pylori-related nonatrophic chronic gastritis. The measurement of serum PG provides much information on the presence of intestinal metaplasia as well as atrophic gastritis. The eradication of H. pylori provokes a significant change in serum PG values: it reduces both PG I and PG II and elevates the PG I to PG II ratio. Recently, the serum PG test method has been the first screening step in Japan, as well as photofluorography. Serum PG tests are used to screen for high risk subjects with atrophic gastritis, rather than as a test for cancer itself. Unlike photofluorography or endoscopy, serum PG screening can identify non-ulcerated differentiated asymptomatic cancer, irrespective of the size and location of the lesion. Most cases detected by the PG method are asymptomatic early gastric cancers and are limited to the mucosa, which are particularly well suited for endoscopic treatment. The PG method can contribute greatly to the patients' quality of life.
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Affiliation(s)
- Kazumasa Miki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine (Ohmori), School of Medicine, Faculty of Medicine, Toho University, Tokyo, Japan.
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Blais S, Dejardin O, Boutreux S, Launoy G. Social determinants of access to reference care centres for patients with colorectal cancer – A multilevel analysis. Eur J Cancer 2006; 42:3041-8. [PMID: 17029939 DOI: 10.1016/j.ejca.2006.06.032] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2006] [Revised: 06/06/2006] [Accepted: 06/08/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND Although social disparities in survival for patients with cancer are documented in an increasing number of papers, knowledge on the underlying mechanisms concerning screening, diagnosis, treatment or follow-up, is relatively poor. Our study was aimed at investigating the social determinants of access to reference cancer care centres for surgery for colorectal cancer in France. METHODS Retrospective analysis was conducted on population-based data from a specialised cancer registry (County of Calvados, France). The population consisted of 5156 patients with surgical treatment for colorectal cancer recorded between January 1st 1981 and December 31st 2000. RESULTS The probability of being cared for in a reference care centre was 1.3-fold lower for people living in a deprived district (mean income < 15000 euros) and 3-fold lower for people living in a district where more than 7% of houses were devoid of bath and shower in comparison with districts where this rate was under 2%. After adjustment for distance from reference care centre, the probability of being cared for in a reference care centre was still over one third lower for people living in a district with more than 7% of houses devoid of bath and shower. Social disparities in management of patients with colorectal cancer have increased in the last decade. The reduction of access to reference care with distance was stronger in elderly patients. CONCLUSIONS There is a social and geographical determination of type of treatment centre for care management of colorectal cancer in France. Special attention needs to be paid to the high quality of care management in non-specialised care centres in order to avoid an increased social gradient in cancer mortality in France.
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Affiliation(s)
- S Blais
- Cancers & Populations, ERI3 Inserm, Faculty of Medicine, 14032 Caen cedex, France
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