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Mehta B, Ho K, Gibbons JAB, Ling V, Goodman S, Parks M, Ravi B, Wang F, Ibrahim S, Cram P. Understanding the Influence of Single Payer Health Insurance on Socioeconomic Disparities in Total Hip Arthroplasty (THA) Utilization: A Transnational Analysis. J Am Acad Orthop Surg 2024:00124635-990000000-00959. [PMID: 38713873 DOI: 10.5435/jaaos-d-23-01178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 12/24/2023] [Indexed: 05/09/2024] Open
Abstract
OBJECTIVE Access to care varies between countries. It is theorized that income-based disparities in access may be reduced in countries with universal health insurance relative to the United States, but data are currently limited. We hypothesized that income-based differences in total hip arthroplasty (THA) utilization and outcomes would be larger in the United States than in Canada. METHODS We retrospectively compared all patients undergoing THA from 2012 to 2018 in Pennsylvania, the United States, and Ontario, Canada. We compared age-standardized and sex-standardized per-capita THA utilization in the United States and Canada overall and across different income strata, where income strata were defined by neighborhood income quintile. We also examined income-based differences in rates of 1-year revision, 90-day mortality, and 90-day readmission. RESULTS Overall THA utilization per 10,000 people per year was higher across all income groups in Pennsylvania compared with Ontario (15.1 versus 8.8, P < 0.001 in lowest-income quintile; 21.4 versus 12.6, P < 0.001 in highest-income quintile). Income-based differences in utilization in the highest-income vs lowest-income quintile groups were greater in Ontario (43.2%) than Pennsylvania (41.7%). The adjusted odds for the lowest-income group compared with the highest-income group of 1-year revision were greater in Ontario compared with Pennsylvania (P = 0.03), and risk of 90-day mortality and 90-day readmission was similar between the regions. CONCLUSION Income-based differences in THA utilization were more notable in Ontario than in Pennsylvania. In addition, patients in low-income communities in Ontario were at equal or greater risk relative to high-income community patients for adverse outcomes compared with patients in Pennsylvania. Income-based disparities in THA utilization and outcomes were smaller in the United States than in Canada, in contrast to what might be expected. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Bella Mehta
- From the Department of Medicine, Hospital for Special Surgery, New York, NY (Mehta, Goodman, and Parks), the Department of Medicine, Weill Cornell Medicine, New York, NY (Mehta, Ho, Goodman, Parks, and Wang), the Columbia University Vagelos College of Physicians & Surgeons, New York, NY (Gibbons), the Ontario Institute for Cancer Research, Toronto, ON (Ling), the Sunnybrook Health Sciences Centre, Toronto, ON (Ravi), the Northwell Health, New York, NY (Ibrahim), the The University of Texas Medical Branch, Galveston, TX (Cram), and the Faculty of Medicine, University of Toronto, Toronto, ON (Cram)
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Jackson EB, Simmons CE, Chia SK. Current Challenges and Disparities in the Delivery of Equitable Breast Cancer Care in Canada. Curr Oncol 2023; 30:7263-7274. [PMID: 37623008 PMCID: PMC10453522 DOI: 10.3390/curroncol30080527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 07/26/2023] [Accepted: 07/28/2023] [Indexed: 08/26/2023] Open
Abstract
Recent exciting advances in the diagnosis and management of breast cancer have improved outcomes for Canadians diagnosed and living with breast cancer. However, the reach of this progress has been uneven; disparities in accessing care across Canada are increasingly being recognized and are at risk of broadening. Members of racial minority groups, economically disadvantaged individuals, or those who live in rural or remote communities have consistently been shown to experience greater challenges in accessing 'state of the art' cancer care. The Canadian context also presents unique challenges-vast geography and provincial jurisdiction of the delivery of cancer care and drug funding create significant interprovincial differences in the patient experience. In this commentary, we review the core concepts of health equity, barriers to equitable delivery of breast cancer care, populations at risk, and recommendations for the advancement of health equity in the Canadian cancer system.
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Affiliation(s)
- Emily B. Jackson
- BC Cancer Vancouver, Vancouver, BC V5Z 4E6, Canada
- Department of Medicine, University of British Columbia, Vancouver, BC V6T 1Z3, Canada
| | - Christine E. Simmons
- BC Cancer Vancouver, Vancouver, BC V5Z 4E6, Canada
- Department of Medicine, University of British Columbia, Vancouver, BC V6T 1Z3, Canada
| | - Stephen K. Chia
- BC Cancer Vancouver, Vancouver, BC V5Z 4E6, Canada
- Department of Medicine, University of British Columbia, Vancouver, BC V6T 1Z3, Canada
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3
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Maxwell J, Shats O, Aldridge J, Lyden E, Krie A, Conklin R, Manning K, Fahed R, Vaziri I, Deveras RAE, Mateen Z, Crow K, Bjorling V, Meschi JT, Makoni S, Kruter F, Cowan K. The impact of the affordable care act on breast cancer care in the USA: A multi-institutional analysis. Breast J 2019; 25:948-952. [PMID: 31187577 DOI: 10.1111/tbj.13373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 12/06/2018] [Accepted: 12/10/2018] [Indexed: 11/27/2022]
Abstract
There are less data available on the effect of the ACA on breast cancer care beyond the screening level. A retrospective review at participating iCaRe2/BCCR institutions was completed before and after ACA. Post-ACA, patients were older, more urban, and more likely to be insured through Medicaid. Increased imaging use was noted post-ACA. These patients were less likely to be diagnosed with late-stage cancers, received fewer mastectomies, and were more likely to have radiation.
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Affiliation(s)
- Jessica Maxwell
- Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, Nebraska
| | - Oleg Shats
- University of Nebraska Medical Center, Omaha, Nebraska
| | | | | | - Amy Krie
- Avera McKennan Hospital & University Health Center, Sioux Falls, South Dakota
| | - Richard Conklin
- Avera St. Luke's Medical Group Oncology & Hematology, Aberdeen, South Dakota
| | - Kenneth Manning
- Cape Fear Valley Health System, Fayetteville, North Carolina
| | - Rabih Fahed
- Faith Regional Health Services Carson Cancer Center, Carson, Nebraska
| | | | | | | | - Kate Crow
- CGC, Penrose Cancer Center, Colorado Springs, Colorado
| | | | | | - Stephen Makoni
- Trinity Hospital Cancer Care Center, Minot, North Dakota
| | - Flavio Kruter
- William E Kahlert Regional Cancer Center, Westminster, Maryland
| | - Kenneth Cowan
- University of Nebraska Medical Center, Omaha, Nebraska
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Higenell V, Fajzel R, Batist G, Cheema PK, McArthur HL, Melosky B, Morris D, Petrella TM, Sangha R, Savard MF, Sridhar SS, Stagg J, Stewart DJ, Verma S. A network approach to developing immuno-oncology combinations in Canada. Curr Oncol 2019; 26:73-79. [PMID: 31043804 PMCID: PMC6476440 DOI: 10.3747/co.26.4393] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Immune checkpoint inhibitors have revolutionized care for many cancer indications, with considerable effort now being focused on increasing the rate, depth, and duration of patient response. One strategy is to combine immune strategies (for example, ctla-4 and PD-1/L1-directed agents) to harness additive or synergistic efficacy while minimizing toxicity. Despite encouraging results with such combinations in multiple tumour types, numerous clinical challenges remain, including a lack of biomarkers that reliably predict outcome, the emergence of therapeutic resistance, and optimal management of immune-related toxicities. Furthermore, the selection of ideal combinations from the myriad of immune, systemic, and locoregional therapies has yet to be determined. A longitudinal network-based approach could offer advantages in addressing those critical questions, including long-term follow-up of patients beyond individual trials. The molecular cancer registry Personalize My Treatment, managed by the Networks of Centres of Excellence nonprofit organization Exactis Innovation, is uniquely positioned to accelerate Canadian immuno-oncology (io) research efforts throughout its national network of cancer sites. To gain deeper insight into how a pan-Canadian network could advance research in io combinations, Exactis invited preeminent clinical and scientific advisors from across Canada to a roundtable event in November 2017. The present white paper captures the expert advice provided: leverage longitudinal patient data collection; facilitate network collaboration and assay harmonization; synergize with existing initiatives, networks, and biobanks; and develop an io combination trial based on Canadian discoveries.
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Affiliation(s)
- V Higenell
- Exactis Innovation, Sir Mortimer B. Davis Jewish General Hospital, Montreal, QC
| | - R Fajzel
- Exactis Innovation, Sir Mortimer B. Davis Jewish General Hospital, Montreal, QC
| | - G Batist
- Exactis Innovation, Sir Mortimer B. Davis Jewish General Hospital, Montreal, QC
- Segal Cancer Centre, Sir Mortimer B. Davis Jewish General Hospital, Montreal, QC
| | - P K Cheema
- William Osler Health System, University of Toronto, Toronto, ON
| | - H L McArthur
- Division of Hematology Oncology, Cedars-Sinai Samuel Oschin Comprehensive Cancer Institute, Los Angeles, CA, U.S.A
| | - B Melosky
- Medical Oncology, BC Cancer-Vancouver Centre, Vancouver, BC
| | - D Morris
- Department of Oncology, Tom Baker Cancer Centre, Calgary, AB
| | - T M Petrella
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON
| | - R Sangha
- Department of Oncology, Cross Cancer Institute, Edmonton, AB
| | - M F Savard
- Department of Oncology, Tom Baker Cancer Centre, Calgary, AB
| | - S S Sridhar
- Medical Oncology, Princess Margaret Cancer Centre, Toronto, ON
| | - J Stagg
- Faculty of Pharmacy, University of Montreal, Montreal, QC
| | - D J Stewart
- Division of Medical Oncology, The Ottawa Hospital, Ottawa, ON
| | - S Verma
- Department of Oncology, Tom Baker Cancer Centre, Calgary, AB
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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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Thein HH, Anyiwe K, Jembere N, Yu B, De P, Earle CC. Effects of socioeconomic status on esophageal adenocarcinoma stage at diagnosis, receipt of treatment, and survival: A population-based cohort study. PLoS One 2017; 12:e0186350. [PMID: 29020052 PMCID: PMC5636169 DOI: 10.1371/journal.pone.0186350] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 10/01/2017] [Indexed: 02/07/2023] Open
Abstract
The incidence of esophageal adenocarcinoma (EAC) is increasing worldwide and has overtaken squamous histology in occurrence. We studied the impact of socioeconomic status (SES) on EAC stage at diagnosis, receipt of treatment, and survival. A population-based retrospective cohort study was conducted using Ontario Cancer Registry-linked administrative health data. Multinomial logistic regression was used to examine the association between SES (income quintile) and stage at EAC diagnosis and EAC treatment. Survival times following EAC diagnosis were estimated using Kaplan-Meier method. Cox proportional-hazards regression analysis was used to examine the association between SES and EAC survival. Between 2003–2012, 2,125 EAC cases were diagnosed. Median survival for the lowest-SES group was 10.9 months compared to 11.6 months for the highest-SES group; the 5-year survival was 9.8% vs. 15.0%. Compared to individuals in the highest-SES group, individuals in the lowest-SES category experienced no significant difference in EAC treatment (91.6% vs. 93.3%, P = 0.314) and deaths (78.9% vs. 75.6%, P = 0.727). After controlling for covariates, no significant associations were found between SES and cancer stage at diagnosis and EAC treatment. Additionally, after controlling for age, gender, urban/rural residence, birth country, health region, aggregated diagnosis groups, cancer stage, treatment, and year of diagnosis, no significant association was found between SES and EAC survival. Moreover, increased mortality risk was observed among those with older age (P = 0.001), advanced-stage of EAC at diagnosis (P < 0.001), and those receiving chemotherapy alone, radiotherapy alone, or surgery plus chemotherapy (P < 0.001). Adjusted proportional-hazards model findings suggest that there is no association between SES and EAC survival. While the unadjusted model suggests reduced survival among individuals in lower income quintiles, this is no longer significant after adjusting for any covariate. Additionally, there is an apparent association between SES and survival when considering only those individuals diagnosed with stage 0-III EAC. These analyses suggest that the observed direct relationship between SES and survival is explained by patient-level factors including receipt of treatment, something that is potentially modifiable.
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Affiliation(s)
- Hla-Hla Thein
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- * E-mail:
| | - Kika Anyiwe
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Nathaniel Jembere
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Brian Yu
- Western University, Medical Science, London, Ontario, Canada
| | | | - Craig C. Earle
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Cancer Care Ontario, Toronto, Ontario, Canada
- Ontario Institute for Cancer Research, Toronto, 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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Zhang L, Stone TE, Zhang J. Understanding the rise ofYinaoin China: A commentary on the little known phenomenon of healthcare violence. Nurs Health Sci 2016; 19:183-187. [DOI: 10.1111/nhs.12311] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 08/16/2016] [Accepted: 08/19/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Liuyi Zhang
- Nursing Psychology Research Center of Xiangya Nursing School; Central South University; Hunan China
| | - Teresa E. Stone
- International Nursing, Faculty of Health Sciences, Graduate School of Medicine; Yamaguchi University; Yamaguchi Japan
| | - Jingping Zhang
- Nursing Psychology Research Center of Xiangya Nursing School; Central South University; Hunan China
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Haji-Jama S, Gorey KM, Luginaah IN, Zou G, Hamm C, Holowaty EJ. Disparities Report: Disparities Among Minority Women With Breast Cancer Living in Impoverished Areas of California. Cancer Control 2016; 23:157-62. [PMID: 27218793 PMCID: PMC4882162 DOI: 10.1177/107327481602300210] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Interaction effects of poverty and health care insurance coverage on overall survival rates of breast cancer among women of color and non-Hispanic white women were explored. METHODS We analyzed California registry data for 2,024 women of color (black, Hispanic, Asian, Pacific Islander, American Indian, or other ethnicity) and 4,276 non-Hispanic white women (Anglo-European ancestries and no Hispanic-Latin ethnic backgrounds) diagnosed with breast cancer between the years 1996 and 2000 who were then followed until 2011. The 2000 US census categorized rates of neighborhood poverty. Health care insurance coverage was either private, Medicare, Medicaid, or none. Cox regression was used to model rates of survival. RESULTS A 3-way interaction between ethnicity, health care insurance coverage, and poverty was observed. Women of color inadequately insured and living in poor or near-poor neighborhoods in California were the most disadvantaged. Women of color adequately insured and who lived in such neighborhoods in California were also disadvantaged. The incomes of such women of color were typically lower than the incomes of non-Hispanic white women. CONCLUSIONS Women of color with or without insurance coverage are disadvantaged in poor and near-poor neighborhoods of California. Such women may be less able to bare the indirect, direct, or uncovered costs of health care for breast cancer treatment.
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Affiliation(s)
- Sundus Haji-Jama
- School of Social Work, University of Windsor, Ontario, Canada N9B 3P4.
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10
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The Influences of Health Insurance and Access to Information on Prostate Cancer Screening among Men in Dominican Republic. J Cancer Epidemiol 2016; 2016:7284303. [PMID: 27034669 PMCID: PMC4806283 DOI: 10.1155/2016/7284303] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 01/07/2016] [Accepted: 02/08/2016] [Indexed: 11/17/2022] Open
Abstract
Objectives. Although research demonstrates the public health burden of prostate cancer among men in the Caribbean, relatively little is known about the factors that underlie the low levels of testing for the disease among this population. Study Design. A cross-sectional study of prostate cancer testing behaviours among men aged 40–60 years in Dominican Republic using the Demographic and Health Survey (2013). Methods. We use hierarchical binary logit regression models and average treatment effects combined with propensity score matching to explore the determinants of prostate screening as well as the average effect of health insurance coverage on screening. The use of hierarchical binary logit regression enabled us to control for the effect of unobserved heterogeneity at the cluster level that may affect prostate cancer testing behaviours. Results. Screening varied significantly with health insurance coverage, knowledge of cholesterol level, education, and wealth. Insured men were more likely to test for prostate cancer (OR = 1.65, p = 0.01) compared to the uninsured. Conclusions. The expansion and restructuring of Dominican Republic universal health insurance scheme to ensure equity in access may improve health access that would potentially impact positively on prostate cancer screening among men.
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11
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Kangmennaang J, Mkandawire P, Luginaah I. What Prevents Men Aged 40-64 Years from Prostate Cancer Screening in Namibia? J Cancer Epidemiol 2016; 2016:7962502. [PMID: 26880917 PMCID: PMC4736914 DOI: 10.1155/2016/7962502] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 12/12/2015] [Accepted: 12/16/2015] [Indexed: 11/20/2022] Open
Abstract
Objectives. Although a growing body of evidence demonstrates the public health burden of prostate cancer in SSA, relatively little is known about the underlying factors surrounding the low levels of testing for the disease in the context of this region. Using Namibia Demographic Health Survey dataset (NDHS, 2013), we examined the factors that influence men's decision to screen for prostate cancer in Namibia. Methods. We use complementary log-log regression models to explore the determinants of screening for prostate cancer. We also corrected for the effect of unobserved heterogeneity that may affect screening behaviours at the cluster level. Results. The results show that health insurance coverage (OR = 2.95, p = 0.01) is an important predictor of screening for prostate cancer in Namibia. In addition, higher education and discussing reproductive issues with a health worker (OR = 2.02, p = 0.05) were more likely to screening for prostate cancer. Conclusions. A universal health insurance scheme may be necessary to increase uptake of prostate cancer screening. However it needs to be acknowledged that expanded screening can have negative consequences and any allocation of scarce resources towards screening must be guided by evidence obtained from the local context about the costs and benefits of screening.
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Affiliation(s)
- Joseph Kangmennaang
- Department of Geography and Environment, University of Waterloo, 200 University Avenue West, Waterloo, ON, Canada N2L 3G1
| | - Paul Mkandawire
- The Institute of Interdisciplinary Studies, 2201 Dunton Tower, 1125 Colonel By Drive, Ottawa, ON, Canada K1S 5B6
| | - Isaac Luginaah
- Department of Geography, Western University, 1151 Richmond Street, London, ON, Canada N6A 5C2
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Gorey KM, Richter NL, Luginaah IN, Hamm C, Holowaty EJ, Zou G, Balagurusamy MK. Breast Cancer among Women Living in Poverty: Better Care in Canada than in the United States. SOCIAL WORK RESEARCH 2015; 39:107-118. [PMID: 26180488 PMCID: PMC4500640 DOI: 10.1093/swr/svv006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2014] [Revised: 05/29/2014] [Accepted: 06/02/2014] [Indexed: 06/04/2023]
Abstract
This historical study estimated the protective effects of a universally accessible, single-payer health care system versus a multi-payer system that leaves many uninsured or underinsured by comparing breast cancer care of women living in high poverty neighborhoods in Ontario or California between 1996 and 2011. Women in Canada experienced better care particularly as compared to women who were inadequately insured in the United States. Women in Canada were diagnosed earlier (rate ratio [RR] = 1.12) and enjoyed better access to breast conserving surgery (RR = 1.48), radiation (RR = 1.60) and hormone therapies (RR = 1.78). Women living in high poverty Canadian neighborhoods even experienced shorter waits for surgery (RR = 0.58) and radiation therapy (RR = 0.44) than did such women in the US. Consequently, women in Canada were much more likely to survive longer. Regression analyses indicated that health insurance could explain most of the better care and better outcomes in Canada. Over this study's 15-year timeframe 31,500 late diagnoses, 94,500 sub-optimum treatment plans and 103,500 early deaths were estimated in high poverty US neighborhoods due to relatively inadequate health insurance coverage. Implications for social work practice, including advocacy for future reforms of US health care are discussed.
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Affiliation(s)
- Kevin M. Gorey
- Kevin M. Gorey, PhD, MSW, is professor, and Nancy L. Richter, MSW, is research associate, School of Social Work, University of Windsor, Windsor, Ontario, Canada. Isaac N. Luginaah, PhD, is professor, Department of Geography, and Caroline Hamm, MD, is medical oncologist and assistant professor, Windsor Regional Cancer Center and Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada. Eric J. Holowaty, MD, is professor, Dalla Lana School of Public Health, University of Toronto. Guangyong Zou, PhD, is professor and scientist, Department of Epidemiology and Biostatistics, and Robarts Resarch Institute, Western University, London, Ontario, Canada. Madham K. Balagurusamy, MSc, is research associate, School of Social Work, University of Windsor, Windsor, Ontario, Canada. Address correspondence to Kevin M. Gorey, School of Social Work, University of Windsor, 401 Sunset Avenue, Windsor, ON Canada N9B 3P4; The authors gratefully acknowledge the administrative and logistical assistance of Kurt Snipes, Janet Bates, and Gretchen Agha of the Cancer Surveillance and Research Branch, California Department of Public Health. They also gratefully acknowledge the research, technical, and administrative assistance of Mark Allen, Allyn Fernandez-Ami, and Arti Parikh-Patel of the California Cancer Registry; Sundus Haji-Jama of the University of Windsor; and Charles Sagoe, who was with Cancer Care Ontario (CCO) at the time that this study's database was created
| | - Nancy L. Richter
- Kevin M. Gorey, PhD, MSW, is professor, and Nancy L. Richter, MSW, is research associate, School of Social Work, University of Windsor, Windsor, Ontario, Canada. Isaac N. Luginaah, PhD, is professor, Department of Geography, and Caroline Hamm, MD, is medical oncologist and assistant professor, Windsor Regional Cancer Center and Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada. Eric J. Holowaty, MD, is professor, Dalla Lana School of Public Health, University of Toronto. Guangyong Zou, PhD, is professor and scientist, Department of Epidemiology and Biostatistics, and Robarts Resarch Institute, Western University, London, Ontario, Canada. Madham K. Balagurusamy, MSc, is research associate, School of Social Work, University of Windsor, Windsor, Ontario, Canada. Address correspondence to Kevin M. Gorey, School of Social Work, University of Windsor, 401 Sunset Avenue, Windsor, ON Canada N9B 3P4; The authors gratefully acknowledge the administrative and logistical assistance of Kurt Snipes, Janet Bates, and Gretchen Agha of the Cancer Surveillance and Research Branch, California Department of Public Health. They also gratefully acknowledge the research, technical, and administrative assistance of Mark Allen, Allyn Fernandez-Ami, and Arti Parikh-Patel of the California Cancer Registry; Sundus Haji-Jama of the University of Windsor; and Charles Sagoe, who was with Cancer Care Ontario (CCO) at the time that this study's database was created
| | - Isaac N. Luginaah
- Kevin M. Gorey, PhD, MSW, is professor, and Nancy L. Richter, MSW, is research associate, School of Social Work, University of Windsor, Windsor, Ontario, Canada. Isaac N. Luginaah, PhD, is professor, Department of Geography, and Caroline Hamm, MD, is medical oncologist and assistant professor, Windsor Regional Cancer Center and Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada. Eric J. Holowaty, MD, is professor, Dalla Lana School of Public Health, University of Toronto. Guangyong Zou, PhD, is professor and scientist, Department of Epidemiology and Biostatistics, and Robarts Resarch Institute, Western University, London, Ontario, Canada. Madham K. Balagurusamy, MSc, is research associate, School of Social Work, University of Windsor, Windsor, Ontario, Canada. Address correspondence to Kevin M. Gorey, School of Social Work, University of Windsor, 401 Sunset Avenue, Windsor, ON Canada N9B 3P4; The authors gratefully acknowledge the administrative and logistical assistance of Kurt Snipes, Janet Bates, and Gretchen Agha of the Cancer Surveillance and Research Branch, California Department of Public Health. They also gratefully acknowledge the research, technical, and administrative assistance of Mark Allen, Allyn Fernandez-Ami, and Arti Parikh-Patel of the California Cancer Registry; Sundus Haji-Jama of the University of Windsor; and Charles Sagoe, who was with Cancer Care Ontario (CCO) at the time that this study's database was created
| | - Caroline Hamm
- Kevin M. Gorey, PhD, MSW, is professor, and Nancy L. Richter, MSW, is research associate, School of Social Work, University of Windsor, Windsor, Ontario, Canada. Isaac N. Luginaah, PhD, is professor, Department of Geography, and Caroline Hamm, MD, is medical oncologist and assistant professor, Windsor Regional Cancer Center and Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada. Eric J. Holowaty, MD, is professor, Dalla Lana School of Public Health, University of Toronto. Guangyong Zou, PhD, is professor and scientist, Department of Epidemiology and Biostatistics, and Robarts Resarch Institute, Western University, London, Ontario, Canada. Madham K. Balagurusamy, MSc, is research associate, School of Social Work, University of Windsor, Windsor, Ontario, Canada. Address correspondence to Kevin M. Gorey, School of Social Work, University of Windsor, 401 Sunset Avenue, Windsor, ON Canada N9B 3P4; The authors gratefully acknowledge the administrative and logistical assistance of Kurt Snipes, Janet Bates, and Gretchen Agha of the Cancer Surveillance and Research Branch, California Department of Public Health. They also gratefully acknowledge the research, technical, and administrative assistance of Mark Allen, Allyn Fernandez-Ami, and Arti Parikh-Patel of the California Cancer Registry; Sundus Haji-Jama of the University of Windsor; and Charles Sagoe, who was with Cancer Care Ontario (CCO) at the time that this study's database was created
| | - Eric J. Holowaty
- Kevin M. Gorey, PhD, MSW, is professor, and Nancy L. Richter, MSW, is research associate, School of Social Work, University of Windsor, Windsor, Ontario, Canada. Isaac N. Luginaah, PhD, is professor, Department of Geography, and Caroline Hamm, MD, is medical oncologist and assistant professor, Windsor Regional Cancer Center and Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada. Eric J. Holowaty, MD, is professor, Dalla Lana School of Public Health, University of Toronto. Guangyong Zou, PhD, is professor and scientist, Department of Epidemiology and Biostatistics, and Robarts Resarch Institute, Western University, London, Ontario, Canada. Madham K. Balagurusamy, MSc, is research associate, School of Social Work, University of Windsor, Windsor, Ontario, Canada. Address correspondence to Kevin M. Gorey, School of Social Work, University of Windsor, 401 Sunset Avenue, Windsor, ON Canada N9B 3P4; The authors gratefully acknowledge the administrative and logistical assistance of Kurt Snipes, Janet Bates, and Gretchen Agha of the Cancer Surveillance and Research Branch, California Department of Public Health. They also gratefully acknowledge the research, technical, and administrative assistance of Mark Allen, Allyn Fernandez-Ami, and Arti Parikh-Patel of the California Cancer Registry; Sundus Haji-Jama of the University of Windsor; and Charles Sagoe, who was with Cancer Care Ontario (CCO) at the time that this study's database was created
| | - Guangyong Zou
- Kevin M. Gorey, PhD, MSW, is professor, and Nancy L. Richter, MSW, is research associate, School of Social Work, University of Windsor, Windsor, Ontario, Canada. Isaac N. Luginaah, PhD, is professor, Department of Geography, and Caroline Hamm, MD, is medical oncologist and assistant professor, Windsor Regional Cancer Center and Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada. Eric J. Holowaty, MD, is professor, Dalla Lana School of Public Health, University of Toronto. Guangyong Zou, PhD, is professor and scientist, Department of Epidemiology and Biostatistics, and Robarts Resarch Institute, Western University, London, Ontario, Canada. Madham K. Balagurusamy, MSc, is research associate, School of Social Work, University of Windsor, Windsor, Ontario, Canada. Address correspondence to Kevin M. Gorey, School of Social Work, University of Windsor, 401 Sunset Avenue, Windsor, ON Canada N9B 3P4; The authors gratefully acknowledge the administrative and logistical assistance of Kurt Snipes, Janet Bates, and Gretchen Agha of the Cancer Surveillance and Research Branch, California Department of Public Health. They also gratefully acknowledge the research, technical, and administrative assistance of Mark Allen, Allyn Fernandez-Ami, and Arti Parikh-Patel of the California Cancer Registry; Sundus Haji-Jama of the University of Windsor; and Charles Sagoe, who was with Cancer Care Ontario (CCO) at the time that this study's database was created
| | - Madham K. Balagurusamy
- Kevin M. Gorey, PhD, MSW, is professor, and Nancy L. Richter, MSW, is research associate, School of Social Work, University of Windsor, Windsor, Ontario, Canada. Isaac N. Luginaah, PhD, is professor, Department of Geography, and Caroline Hamm, MD, is medical oncologist and assistant professor, Windsor Regional Cancer Center and Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada. Eric J. Holowaty, MD, is professor, Dalla Lana School of Public Health, University of Toronto. Guangyong Zou, PhD, is professor and scientist, Department of Epidemiology and Biostatistics, and Robarts Resarch Institute, Western University, London, Ontario, Canada. Madham K. Balagurusamy, MSc, is research associate, School of Social Work, University of Windsor, Windsor, Ontario, Canada. Address correspondence to Kevin M. Gorey, School of Social Work, University of Windsor, 401 Sunset Avenue, Windsor, ON Canada N9B 3P4; The authors gratefully acknowledge the administrative and logistical assistance of Kurt Snipes, Janet Bates, and Gretchen Agha of the Cancer Surveillance and Research Branch, California Department of Public Health. They also gratefully acknowledge the research, technical, and administrative assistance of Mark Allen, Allyn Fernandez-Ami, and Arti Parikh-Patel of the California Cancer Registry; Sundus Haji-Jama of the University of Windsor; and Charles Sagoe, who was with Cancer Care Ontario (CCO) at the time that this study's database was created
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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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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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Gillan C, Briggs K, Pazos AG, Maurus M, Harnett N, Catton P, Wiljer D. Barriers to accessing radiation therapy in Canada: a systematic review. Radiat Oncol 2012; 7:167. [PMID: 23062109 PMCID: PMC3551743 DOI: 10.1186/1748-717x-7-167] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Accepted: 09/26/2012] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Radiation therapy (RT) is effective treatment for curing and palliating cancer, yet concern exists that not all Canadians for whom RT is indicated receive it. Many factors may contribute to suboptimal use of RT. A review of recent Canadian literature was undertaken to identify such barriers. METHODS MEDLINE, CINAHL, and EMBase databases were used to search keywords relating to barriers to accessing or utilizing RT in Canada. Collected abstracts were reviewed independently. Barriers identified in relevant articles were categorized as relating to the health systems, patient socio-demographic, patient factors, or provider factors contexts and thematic analysis performed for each context. RESULTS 535 unique abstracts were collected. 75 met inclusion criteria. 46 (61.3%) addressed multiple themes. The most cited barriers to accessing RT when indicated were patient age (n = 26, 34.7%), distance to treatment centre (n = 23, 30.7%), wait times (n = 22, 29.3%), and lack of physician understanding about the use of RT (n = 16, 21.6%). CONCLUSIONS Barriers to RT are reported in many areas. The role of provider factors and the lack of attention to patient fears and mistrust as potential barriers were unexpected findings demanding further attention. Solutions should be sought to overcome identified barriers facilitating more effective cancer care for Canadians.
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Affiliation(s)
- Caitlin Gillan
- Radiation Medicine Program, Princess Margaret Hospital, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Kaleigh Briggs
- Radiation Medicine Program, Princess Margaret Hospital, Toronto, Canada
| | | | - Melanie Maurus
- ELLICSR: Health, Wellness, and Cancer Survivorship Centre, Toronto, Canada
| | - Nicole Harnett
- Radiation Medicine Program, Princess Margaret Hospital, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Pamela Catton
- Radiation Medicine Program, Princess Margaret Hospital, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
- ELLICSR: Health, Wellness, and Cancer Survivorship Centre, Toronto, Canada
| | - David Wiljer
- Radiation Medicine Program, Princess Margaret Hospital, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
- ELLICSR: Health, Wellness, and Cancer Survivorship Centre, Toronto, Canada
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Jembere N, Campitelli MA, Sherman M, Feld JJ, Lou W, Peacock S, Yoshida E, Krahn MD, Earle C, Thein HH. Influence of socioeconomic status on survival of hepatocellular carcinoma in the Ontario population; a population-based study, 1990-2009. PLoS One 2012; 7:e40917. [PMID: 22808283 PMCID: PMC3396620 DOI: 10.1371/journal.pone.0040917] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2012] [Accepted: 06/14/2012] [Indexed: 11/21/2022] Open
Abstract
Background Research has shown that people from higher socioeconomic status (SES) have better hepatocellular carcinoma (HCC) survival outcomes, although no such research has been carried out in Canada. We aimed to assess if an association between SES and HCC survival existed in the Canadian context. Methodology/Prinicpal Findings We conducted a population-based cohort study linking HCC cases identified in the Ontario Cancer Registry between 1990 and 2009 to administrative and hospital data. Logistic regression and chi-squared tests were used to evaluate associations between SES (income quintile) and covariates. The Kaplan-Meier method was used to estimate survival. Sequential analysis of the proportional-hazards models were used to determine the association between SES and HCC survival controlling for potential prognostic covariates. During the period 1990–2009, 5,481 cases of HCC were identified. A significant association was found between SES and curative treatment (p = 0.0003), but no association was found between SES and non-curative treatment (p = 0.064), palliative treatment (p = 0.680), or ultrasound screening (p = 0.615). The median survival for the lowest SES was 8.5 months, compared to 8.8 months for the highest SES group. The age- and sex-adjusted proportional-hazards model showed statistically significant difference in HCC survival among the SES groups, with hazard ratio 0.905 (95% confidence intervals 0.821, 0.998) when comparing highest to lowest SES group. Further adjustments indicated that potentially curative treatment was the likely explanation for the association between SES and HCC survival. Conclusions/Significance Our findings suggest that a 10% HCC survival advantage exists for the higher SES groups. This association between SES and HCC survival is most likely a reflection of lack of access to care for low SES groups, revealing inequities in the Canadian healthcare system.
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Affiliation(s)
- Nathaniel Jembere
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Michael A. Campitelli
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Morris Sherman
- Toronto General Hospital, University Health Network/University of Toronto, Toronto, Ontario, Canada
| | - Jordan J. Feld
- Liver Centre, Toronto Western Hospital, University Health Network/University of Toronto, Toronto, Ontario, Canada
| | - Wendy Lou
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Stuart Peacock
- Canadian Centre for Applied Research in Cancer Control (ARCC), University of British Columbia, Vancouver, British Columbia, Canada
| | - Eric Yoshida
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Murray D. Krahn
- Toronto General Hospital, University Health Network/University of Toronto, Toronto, Ontario, Canada
- Toronto Health Economics and Technology Assessment Collaborative (THETA), Toronto, Ontario, Canada
- Departments of Medicine and Health Policy, Management and Evaluation and Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Craig Earle
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Ontario Institute for Cancer Research/Cancer Care Ontario, Toronto, Ontario, Canada
| | - Hla-Hla Thein
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Ontario Institute for Cancer Research/Cancer Care Ontario, Toronto, Ontario, Canada
- * E-mail:
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Milewski I. Identifying at-risk communities for action on cancer prevention: a case study in new brunswick (Canada) communities. New Solut 2012; 22:79-107. [PMID: 22436208 DOI: 10.2190/ns.22.1.f] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Health statistics reported by large geographic area such as province, state, county or health region offer little insight into disease conditions at the community level where people live and work, where occupational and environmental exposures occur, and where industrial emissions are often concentrated. This study investigated overall patterns of cancer incidence and socioeconomic status (SES) among 14 communities in the province of New Brunswick (Canada). A multivariate ordination technique, hierarchical clustering, and permutation procedures were used to identify and test significance of community clusters and whether the overall pattern of SES was correlated with patterns of cancer among communities. Communities with significantly high or significantly low overall rates of cancers were identified, patterns that were not related to SES. The potential influence of age, small populations, diagnostic screening, smoking and environmental risk factors contributing to locally elevated cancer rates are discussed. Cancer incidence reported at smaller spatial scales provides health officials and researchers with a basis for identifying communities potentially at-risk and aids in the development of appropriate community-based risk reduction actions and cancer prevention.
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Affiliation(s)
- Inka Milewski
- Conservation Council of New Brunswick, 180 St. John Street Fredericton, New Brunswick, E3B 4A9, Canada.
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Luginaah IN, Gorey KM, Oiamo TH, Tang KX, Holowaty EJ, Hamm C, Wright FC. A geographical analysis of breast cancer clustering in southern Ontario: generating hypotheses on environmental influences. INTERNATIONAL JOURNAL OF ENVIRONMENTAL HEALTH RESEARCH 2011; 22:232-248. [PMID: 22129067 DOI: 10.1080/09603123.2011.634386] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
This article presents the results of spatial analysis of breast cancer clustering in southern Ontario. Data from the Cancer Care Ontario were analyzed using the Scan Statistic at the level of county, with further analysis conducted within counties that were identified as primary clusters at the dissemination area level. The results identified five counties as primary clusters of women diagnosed with breast cancer between 1986 and 2002: Essex (relative risk [RR] =1.096-1.061; p<0.001), Lambton (RR=1.05-1.167), Chatham-Kent (RR=1.133-1.191), Niagara (RR=1.228-1.290) and Toronto (RR=1.152-1.146). The within county analysis revealed several DAs with significantly higher (RR>3, p<0.05) rates of breast cancer, and supports our hypothesis that breast cancer risk in southern Ontario may be associated with industrial and environmental (such as pesticides) pollutants. Further research is needed to verify the environmental links within the identified clusters.
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Affiliation(s)
- Isaac N Luginaah
- Department of Geography, The University of Western Ontario, London, ON, Canada.
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Blum K, Sherman DW. Understanding the experience of caregivers: a focus on transitions. Semin Oncol Nurs 2011; 26:243-58. [PMID: 20971405 DOI: 10.1016/j.soncn.2010.08.005] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To review the current knowledge on the challenges and benefits of informal family caregiving; and propose two conceptual frameworks for studying transitions common to patients with cancer and their family caregivers through the trajectory of the disease process leading to better, more focused, individualized interventions; DATA SOURCES A review of current and classic literature on patients with cancer and their caregivers. CONCLUSION Caregivers often take on burdens that they are not prepared for. As they become overwhelmed with the work, they often neglect themselves, leading to physical and emotional illnesses. Not all caregivers perceive the same amount of burden. Careful assessment of each caregiver/cared-for dyad to individualize their support is critical to supporting them along the journey of a cancer diagnosis. IMPLICATIONS FOR NURSING PRACTICE Operationalizing conceptual frameworks can accelerate nurses' understanding of patient and caregiver transitions, leading to more focused interventions and allocation of resources to assist them in these transitions.
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Affiliation(s)
- Kay Blum
- Department of Organizational Systems and Adult Health, University of Maryland School of Nursing, Baltimore, MD, USA.
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Gorey KM, Luginaah IN, Bartfay E, Fung KY, Holowaty EJ, Wright FC, Hamm C, Kanjeekal SM, Balagurusamy MK. Associations of physician supplies with colon cancer care in Ontario and California, 1996 to 2006. Dig Dis Sci 2011; 56:523-31. [PMID: 20521113 PMCID: PMC3035641 DOI: 10.1007/s10620-010-1284-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2009] [Accepted: 05/11/2010] [Indexed: 12/09/2022]
Abstract
BACKGROUND This study examined the differential effects of physician supplies on colon cancer care in Ontario and California. The associations of physician supplies with colon cancer stage at diagnosis, receipt of surgery and adjuvant chemotherapy, and 5-year survival were observed within each country and compared between-country. METHODS Random samples of Ontario and California cancer registries provided 2,461 and 2,200 colon cancer cases that were diagnosed between 1996 and 2000, and followed until 2006. Both registries included data on the stage of disease at the time of diagnosis, receipt of cancer-directed surgery, receipt of adjuvant chemotherapy, and survival. Census tract-level data on low-income prevalence were, respectively, taken from 2001 and 2000 Canadian and United States population censuses. County-level primary care physician and gastroenterologist densities were computed for the same years. RESULTS Significant income-adjusted, gastroenterologist density threshold effects (2.0 or more vs. less than 2.0 per 100,000 inhabitants) were observed for early diagnosis (OR = 1.57) and 5-year survival (OR = 1.63) in Ontario, but not in California. Significant incremental threshold effects of primary care physician densities on chemotherapy receipt (8.0 and 9.0 or more per 10,000 inhabitants, respective ORs of 1.79 and 2.37) were also only observed in Ontario. CONCLUSIONS These colon cancer care findings support the theory that while personal economic resources are more predictive in America, community-level resources such as physician supplies are more predictive of health care access and effectiveness in Canada.
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Affiliation(s)
- Kevin M Gorey
- School of Social Work, University of Windsor, Windsor, ON, Canada.
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21
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Gorey KM, Luginaah IN, Hamm C, Balagurusamy M, Holowaty EJ. The supply of physicians and care for breast cancer in Ontario and California, 1998 to 2006. CANADIAN JOURNAL OF RURAL MEDICINE 2011; 16:47-54. [PMID: 21453604 PMCID: PMC3174215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
INTRODUCTION We examined the differential effects of the supply of physicians on care for breast cancer in Ontario and California. We then used criteria for optimum care for breast cancer to estimate the regional needs for the supply of physicians. METHODS Ontario and California registries provided 951 and 984 instances of breast cancer diagnosed between 1998 and 2000 and followed until 2006. These cohorts were joined with the supply of county-level primary care physicians (PCPs) and specialists in cancer care and compared on care for breast cancer. RESULTS Significant protective PCP thresholds (7.75 to = 8.25 PCPs per 10 000 inhabitants) were observed for breast cancer diagnosis (odds ratio [OR] 1.62), receipt of adjuvant radiotherapy (OR 1.64) and 5-year survival (OR 1.87) in Ontario, but not in California. The number of physicians seemed adequate to optimize care for breast cancer across diverse places in California and in most Ontario locations. However, there was an estimated need for 550 more PCPs and 200 more obstetrician-gynecologists in Ontario's rural and small urban areas. We estimated gross physician surpluses for Ontario's 2 largest cities. CONCLUSION Policies are needed to functionally redistribute primary care and specialist physicians. Merely increasing the supply of physicians is unlikely to positively affect the health of Ontarians.
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Affiliation(s)
- Kevin M Gorey
- School of Social Work, University of Windsor, Ont., Canada.
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Chien CR, Pan IW, Tsai YW, Tsai T, Liang JA, Buchholz TA, Shih YCT. Radiation therapy after breast-conserving surgery: does hospital surgical volume matter? A population-based study in Taiwan. Int J Radiat Oncol Biol Phys 2010; 82:43-50. [PMID: 21075558 DOI: 10.1016/j.ijrobp.2010.09.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2010] [Revised: 09/02/2010] [Accepted: 09/12/2010] [Indexed: 10/18/2022]
Abstract
PURPOSE To examine the association between hospital surgical volume and the use of radiation therapy (RT) after breast-conserving surgery (BCS) in Taiwan. METHODS AND MATERIALS We used claims data from the National Health Insurance program in Taiwan (1997-2005) in this retrospective population-based study. We identified patients with breast cancer, receipt of BCS, use of radiation, and the factors that could potentially associated with the use of RT from enrollment records, and the ICD-9 and billing codes in claims. We conducted logistic regression to examine factors associated with RT use after BCS, and performed subgroup analyses to examine whether the association differs by medical center status or hospital volumes. RESULTS Among 5,094 patients with newly diagnosed invasive breast cancer who underwent BCS, the rate of RT was significantly lower in low-volume hospitals (74% vs. 82%, p < 0.01). Patients treated in low-volume hospitals were less likely to receive RT after BCS (odds ratio = 0.72, 95% confidence interval = 0.62-0.83). In addition, patients treated after the implementation of the voluntary pay-for-performance policy in 2001 were more likely to receive RT (odds ratio = 1.23; 95% confidence interval = 1.05-1.45). Subgroup analyses indicated that the high-volume effect was limited to hospitals accredited as non-medical centers, and that the effect of the pay-for-performance policy was most pronounced among low-volume hospitals. CONCLUSIONS Using population-based data from Taiwan, our study concluded that hospital surgical volume and pay-for-performance policy are positively associated with RT use after BCS.
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Affiliation(s)
- Chun-Ru Chien
- Section of Health Services Research, Department of Biostatistics, Division of Quantitative Sciences, The University of Texas MD Anderson Cancer Center, Houston, TX 77230-1402, USA
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Boulos DNK, Ghali RR, Ibrahim EM, Boulos MNK, AbdelMalik P. An eight-year snapshot of geospatial cancer research (2002-2009): clinico-epidemiological and methodological findings and trends. Med Oncol 2010; 28:1145-62. [PMID: 20589539 DOI: 10.1007/s12032-010-9607-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2010] [Accepted: 06/16/2010] [Indexed: 12/14/2022]
Abstract
Geographic information systems (GIS) offer a very rich toolbox of methods and technologies, and powerful research tools that extend far beyond the mere production of maps, making it possible to cross-link and study the complex interaction of disease data and factors originating from a wide range of disparate sources. Despite their potential indispensable role in cancer prevention and control programmes, GIS are underrepresented in specialised oncology literature. The latter has provided an impetus for the current review. The review provides an eight-year snapshot of geospatial cancer research in peer-reviewed literature (2002-2009), presenting the clinico-epidemiological and methodological findings and trends in the covered corpus (93 papers). The authors concluded that understanding the relationship between location and cancer/cancer care services can play a crucial role in disease control and prevention, and in better service planning, and appropriate resource utilisation. Nevertheless, there are still barriers that hinder the wide-scale adoption of GIS and related technologies in everyday oncology practice.
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Affiliation(s)
- Dina N Kamel Boulos
- Department of Community, Environmental and Occupational Medicine, Faculty of Medicine, Ain Shams University, Abbassia, Cairo, Egypt
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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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