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Sasaki K, Morita K, Kantarjian H, Garcia-Manero G, Jabbour E, Ravandi F, Konopleva M, Borthakur G, Wierda W, Daver N, Takahashi K, DiNardo C, Bravo GM, Issa GC, Pierce SA, Soltysiak KA, Tingen MS, Cortes JE. Geographic Disparity of Outcome in Patients With Cancer Over Decades: The Surveillance, Epidemiology, and End Results. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:e369-e378. [PMID: 37690903 DOI: 10.1016/j.clml.2023.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 07/19/2023] [Accepted: 08/02/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND Improvements in prevention, early detection, and effective cancer therapy have decreased cancer-related mortality; however, significant health disparities exist. Therefore, we investigated the impact of these disparities on survival. METHODS In the Surveillance, Epidemiology, and End Results, we identified 784,341 patients with cancer between 1990 and 2016 in Georgia, 68,493 between 1990 and 1999; 371,353 between 2000 and 2009; and 322,932 between 2010 and 2016. We assessed the overall survival (OS) of patients with all cancers, chronic myeloid leukemia (CML), and lung cancer, given the dramatic improvement in outcomes in patients with CML since 2000 compared to the generally considerably worse outcomes in lung cancer. In addition, we assessed the distance from each county to the Georgia Cancer Center (GCC) or the National Cancer Institute-designated Cancer Center (NCI-CC). RESULTS The 5-year OS of patients with any cancer was 55%, and the 5-year OS of each county ranged from 33% to 82% (interquartile range, 51%-65%) (P < .001). In patients with lung cancer and CML, the 5-year OS rates were 15% and 52%, respectively. The geographic differences between counties were relatively small and constant over time for patients with lung cancer. However, geographic differences were more prominent in patients with CML and widened after the introduction of modern therapies. Multivariate Cox regression showed that age, median county income, race, and distance to GCC or NCI-CC were predictive factors. CONCLUSIONS Significant disparities in cancer care exist among geographic locations. Geographic differences in survival appear more prominent when highly effective therapies are available.
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Affiliation(s)
- Koji Sasaki
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kiyomi Morita
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Marina Konopleva
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Gautam Borthakur
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - William Wierda
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Naval Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Koichi Takahashi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Courtney DiNardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Ghayas C Issa
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sherry A Pierce
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kelly A Soltysiak
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Martha S Tingen
- Cancer Prevention, Control, & Population Health Program, Georgia Cancer Center, Augusta University, Augusta, GA; Department of Medicine, Medical College of Georgia, Augusta University, Augusta, GA
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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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3
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Hart SE, Momoh AO. Breast Reconstruction Disparities in the United States and Internationally. CURRENT BREAST CANCER REPORTS 2020. [DOI: 10.1007/s12609-020-00366-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Simkin J, Erickson AC, Otterstatter MC, Dummer TJB, Ogilvie G. Current State of Geospatial Methodologic Approaches in Canadian Population Oncology Research. Cancer Epidemiol Biomarkers Prev 2020; 29:1294-1303. [PMID: 32299848 DOI: 10.1158/1055-9965.epi-20-0092] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 03/25/2020] [Accepted: 04/10/2020] [Indexed: 11/16/2022] Open
Abstract
Geospatial analyses are increasingly used in population oncology. We provide a first review of geospatial analysis in Canadian population oncology research, compare to international peers, and identify future directions. Geospatial-focused peer-reviewed publications from 1992-2020 were compiled using PubMed, MEDLINE, Web of Science, and Google Scholar. Abstracts were screened for data derived from a Canadian cancer registry and use of geographic information systems. Studies were classified by geospatial methodology, geospatial unit, location, cancer site, and study year. Common limitations were documented from article discussion sections. Our search identified 71 publications using data from all provincial and national cancer registries. Thirty-nine percent (N = 28) were published in the most recent 5-year period (2016-2020). Geospatial methodologies included exposure assessment (32.4%), identifying spatial associations (21.1%), proximity analysis (16.9%), cluster detection (15.5%), and descriptive mapping (14.1%). Common limitations included confounding, ecologic fallacy, not accounting for residential mobility, and small case/population sizes. Geospatial analyses are increasingly used in Canadian population oncology; however, efforts are concentrated among a few provinces and common cancer sites, and data are over a decade old. Limitations were similar to those documented internationally, and more work is needed to address them. Organized efforts are needed to identify common challenges, develop leading practices, and identify shared priorities.
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Affiliation(s)
- Jonathan Simkin
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada. .,BC Cancer, Vancouver, British Columbia, Canada.,Women's Health Research Institute, Vancouver, British Columbia, Canada
| | - Anders C Erickson
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada.,Office of the Provincial Health Officer, Government of British Columbia, Victoria, British Columbia, Canada
| | - Michael C Otterstatter
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada.,BC Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Trevor J B Dummer
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada.,BC Cancer, Vancouver, British Columbia, Canada
| | - Gina Ogilvie
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada.,BC Cancer, Vancouver, British Columbia, Canada.,Women's Health Research Institute, Vancouver, British Columbia, Canada.,BC Centre for Disease Control, Vancouver, British Columbia, Canada
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Li J, Cornacchi SD, Farrokhyar F, Johnston N, Forbes S, Reid S, Hodgson N, Lovrics S, Lucibello K, Lovrics P. Relation between socioeconomic variables and surgical, systemic and radiation treatment in a cohort of patients with breast cancer in an urban Canadian centre. Can J Surg 2019; 62:83-92. [PMID: 30697993 DOI: 10.1503/cjs.009217] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Background Studies have shown an association between socioeconomic status and breast cancer treatment. We examined the relation between socioeconomic status and the treatment of breast cancer (surgical, systemic and radiation) in a universal health care system. Methods Data from a single urban Canadian centre were collected for consecutive patients who received a diagnosis of breast cancer from January 2010 to December 2011. Variables included patient and disease factors, surgery type, systemic and radiation treatment, and breast reconstruction. Socioeconomic variables were obtained from 2006 Canadian census data. We used multivariable logistic regression to identify predictors of breast cancer treatment. Results A total of 721 patients were treated for breast cancer during the study period. Socioeconomic variables were not related to type of breast surgery for breast cancer. Age less than 50 years, having a first-degree relative with breast cancer and income status were predictors of breast reconstruction. Employment status was a consistent predictor of systemic and radiation treatment. Conclusion Employment consistently predicted systemic and radiation treatment, and age and income were predictors of breast reconstruction in a universal health care system. Further research is required to determine precisely how socioeconomic
factors affect care and to minimize possible disparities in delivery of health care services.
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Affiliation(s)
- Jennifer Li
- From the Department of Surgery, McMaster University, Hamilton, Ont. (Li, Cornacchi, Farrokhyar, Forbes, Reid, Hodgson, Lucibello, Lovrics); the Department of Surgical Oncology, Hamilton Health Sciences and Juravinski Hospital and Cancer Centre, Hamilton, Ont. (Forbes, Rid, Hodgson, Lovrics); the Department of Surgery, St. Joseph’s Healthcare, Hamilton, Ont. (Lovrics); and the Department of Medicine, McMaster University, Hamilton, Ont. (Johnston)
| | - Sylvie D. Cornacchi
- From the Department of Surgery, McMaster University, Hamilton, Ont. (Li, Cornacchi, Farrokhyar, Forbes, Reid, Hodgson, Lucibello, Lovrics); the Department of Surgical Oncology, Hamilton Health Sciences and Juravinski Hospital and Cancer Centre, Hamilton, Ont. (Forbes, Rid, Hodgson, Lovrics); the Department of Surgery, St. Joseph’s Healthcare, Hamilton, Ont. (Lovrics); and the Department of Medicine, McMaster University, Hamilton, Ont. (Johnston)
| | - Forough Farrokhyar
- From the Department of Surgery, McMaster University, Hamilton, Ont. (Li, Cornacchi, Farrokhyar, Forbes, Reid, Hodgson, Lucibello, Lovrics); the Department of Surgical Oncology, Hamilton Health Sciences and Juravinski Hospital and Cancer Centre, Hamilton, Ont. (Forbes, Rid, Hodgson, Lovrics); the Department of Surgery, St. Joseph’s Healthcare, Hamilton, Ont. (Lovrics); and the Department of Medicine, McMaster University, Hamilton, Ont. (Johnston)
| | - Neil Johnston
- From the Department of Surgery, McMaster University, Hamilton, Ont. (Li, Cornacchi, Farrokhyar, Forbes, Reid, Hodgson, Lucibello, Lovrics); the Department of Surgical Oncology, Hamilton Health Sciences and Juravinski Hospital and Cancer Centre, Hamilton, Ont. (Forbes, Rid, Hodgson, Lovrics); the Department of Surgery, St. Joseph’s Healthcare, Hamilton, Ont. (Lovrics); and the Department of Medicine, McMaster University, Hamilton, Ont. (Johnston)
| | - Shawn Forbes
- From the Department of Surgery, McMaster University, Hamilton, Ont. (Li, Cornacchi, Farrokhyar, Forbes, Reid, Hodgson, Lucibello, Lovrics); the Department of Surgical Oncology, Hamilton Health Sciences and Juravinski Hospital and Cancer Centre, Hamilton, Ont. (Forbes, Rid, Hodgson, Lovrics); the Department of Surgery, St. Joseph’s Healthcare, Hamilton, Ont. (Lovrics); and the Department of Medicine, McMaster University, Hamilton, Ont. (Johnston)
| | - Susan Reid
- From the Department of Surgery, McMaster University, Hamilton, Ont. (Li, Cornacchi, Farrokhyar, Forbes, Reid, Hodgson, Lucibello, Lovrics); the Department of Surgical Oncology, Hamilton Health Sciences and Juravinski Hospital and Cancer Centre, Hamilton, Ont. (Forbes, Rid, Hodgson, Lovrics); the Department of Surgery, St. Joseph’s Healthcare, Hamilton, Ont. (Lovrics); and the Department of Medicine, McMaster University, Hamilton, Ont. (Johnston)
| | - Nicole Hodgson
- From the Department of Surgery, McMaster University, Hamilton, Ont. (Li, Cornacchi, Farrokhyar, Forbes, Reid, Hodgson, Lucibello, Lovrics); the Department of Surgical Oncology, Hamilton Health Sciences and Juravinski Hospital and Cancer Centre, Hamilton, Ont. (Forbes, Rid, Hodgson, Lovrics); the Department of Surgery, St. Joseph’s Healthcare, Hamilton, Ont. (Lovrics); and the Department of Medicine, McMaster University, Hamilton, Ont. (Johnston)
| | - Sarah Lovrics
- From the Department of Surgery, McMaster University, Hamilton, Ont. (Li, Cornacchi, Farrokhyar, Forbes, Reid, Hodgson, Lucibello, Lovrics); the Department of Surgical Oncology, Hamilton Health Sciences and Juravinski Hospital and Cancer Centre, Hamilton, Ont. (Forbes, Rid, Hodgson, Lovrics); the Department of Surgery, St. Joseph’s Healthcare, Hamilton, Ont. (Lovrics); and the Department of Medicine, McMaster University, Hamilton, Ont. (Johnston)
| | - Kristen Lucibello
- From the Department of Surgery, McMaster University, Hamilton, Ont. (Li, Cornacchi, Farrokhyar, Forbes, Reid, Hodgson, Lucibello, Lovrics); the Department of Surgical Oncology, Hamilton Health Sciences and Juravinski Hospital and Cancer Centre, Hamilton, Ont. (Forbes, Rid, Hodgson, Lovrics); the Department of Surgery, St. Joseph’s Healthcare, Hamilton, Ont. (Lovrics); and the Department of Medicine, McMaster University, Hamilton, Ont. (Johnston)
| | - Peter Lovrics
- From the Department of Surgery, McMaster University, Hamilton, Ont. (Li, Cornacchi, Farrokhyar, Forbes, Reid, Hodgson, Lucibello, Lovrics); the Department of Surgical Oncology, Hamilton Health Sciences and Juravinski Hospital and Cancer Centre, Hamilton, Ont. (Forbes, Rid, Hodgson, Lovrics); the Department of Surgery, St. Joseph’s Healthcare, Hamilton, Ont. (Lovrics); and the Department of Medicine, McMaster University, Hamilton, Ont. (Johnston)
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Naylor KL, Knoll GA, Allen B, Li AH, Garg AX, Lam NN, McCallum MK, Kim SJ. Trends in Early Hospital Readmission After Kidney Transplantation, 2002 to 2014. Transplantation 2018; 102:e171-e179. [DOI: 10.1097/tp.0000000000002036] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Cheung K, Kaur MN, Tolliver T, Longo CJ, Naam NH, Thoma A. A Tale of Two Health-Care Systems: Cost-Utility Analysis of Open Carpal Tunnel Release in Canada and the United States. Plast Surg (Oakv) 2017; 25:7-13. [PMID: 29026806 DOI: 10.1177/2292550317693817] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Canadian health care is often criticized for extended wait times, whereas the United States suffers from increased costs. The purpose of this pilot study was to determine the cost-utility of open carpal tunnel release in Canada versus the United States. METHODS A prospective cohort study evaluated patients undergoing open carpal tunnel release at an institution in Canada and the United States. All costs from a societal perspective were captured. Utility was measured using validated health-related quality of life (HRQOL) scales-the EuroQol-5D and the Michigan Hand Outcome Questionnaire. RESULTS Twenty-one patients at the Canadian site and 8 patients at the US site participated. Mean total costs were US $1581 ± $1965 and $2179 (range: $1421-$2741) at the Canadian and US sites, respectively. Health-related quality of life demonstrated significant improvements following surgery (P < .05). Patient utilities preoperatively and at 6 weeks and 3 months postoperatively were 0.72 ± 0.20, 0.86 ± 0.11, and 0.83 ± 0.16 at the Canadian site and 0.81 ± 0.09, 0.86 ± 0.10, and 0.86 ± 0.12 at the US site. Improvements in HRQOL directly related to surgery were not significantly different between patients in Canada and the United States. American patients, however, attained improved HRQOL sooner due to shorter wait times (27 ± 10 vs 214 ± 119 days; P < .001). The incremental cost-utility of the US system was $7758/quality-adjusted life year gained compared to the Canadian system. Sensitivity analyses confirmed that these results were robust. CONCLUSION This pilot study suggests that carpal tunnel surgery is more cost-effective in the United States due to prolonged wait times in Canada.
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Affiliation(s)
- Kevin Cheung
- Division of Plastic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Manraj N Kaur
- Division of Plastic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Tyson Tolliver
- Southern Illinois Hand Center, Southern Illinois University, Effingham, IL, USA
| | | | - Nash H Naam
- Southern Illinois Hand Center, Southern Illinois University, Effingham, IL, USA
| | - Achilles Thoma
- Division of Plastic Surgery, McMaster University, Hamilton, Ontario, Canada.,Department of Surgery, Surgical Outcomes Research Centre (SOURCE), McMaster University, Hamilton, Ontario, Canada.,Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
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Wilson K, Young K. An overview of Aboriginal health research in the social sciences: current trends and future directions. Int J Circumpolar Health 2016; 67:179-89. [DOI: 10.3402/ijch.v67i2-3.18260] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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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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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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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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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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Herndon JE, Kornblith AB, Holland JC, Paskett ED. Effect of socioeconomic status as measured by education level on survival in breast cancer clinical trials. Psychooncology 2011; 22:315-23. [PMID: 22021121 DOI: 10.1002/pon.2094] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2011] [Revised: 10/05/2011] [Accepted: 10/05/2011] [Indexed: 11/10/2022]
Abstract
OBJECTIVES This paper aims to investigate the effect of socioeconomic status, as measured by education, on the survival of breast cancer patients treated on 10 studies conducted by the Cancer and Leukemia Group B. METHODS Sociodemographic data, including education, were reported by the patient at trial enrollment. Cox proportional hazards model stratified by treatment arm/study was used to examine the effect of education on survival among patients with early stage and metastatic breast cancer, after adjustment for known prognostic factors. RESULTS The patient population included 1020 patients with metastatic disease and 5146 patients with early stage disease. Among metastatic patients, factors associated with poorer survival in the final multivariable model included African American race, never married, negative estrogen receptor status, prior hormonal therapy, visceral involvement, and bone involvement. Among early stage patients, significant factors associated with poorer survival included African American race, separated/widowed, post/perimenopausal, negative/unknown estrogen receptor status, negative progesterone receptor status, >4 positive nodes, tumor diameter >2 cm, and education. Having not completed high school was associated with poorer survival among early stage patients. Among metastatic patients, non-African American women who lacked a high school degree had poorer survival than other non-African American women, and African American women who lacked a high school education had better survival than educated African American women. CONCLUSIONS Having less than a high school education is a risk factor for death among patients with early stage breast cancer who participated in a clinical trial, with its impact among metastatic patients being less clear. Post-trial survivorship plans need to focus on women with low social status, as measured by education.
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Affiliation(s)
- James E Herndon
- Department of Biostatistics & Bioinformatics, Duke University Medical Center, Durham, NC 27710, USA.
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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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Park MJ, Chung W, Lee S, Park JH, Chang HS. [Association between socioeconomic status and all-cause mortality after breast cancer surgery: nationwide retrospective cohort study]. J Prev Med Public Health 2010; 43:330-40. [PMID: 20689359 DOI: 10.3961/jpmph.2010.43.4.330] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES This study aims to evaluate and explain the socioeconomic inequalities of all-cause mortality after breast cancer surgery in South Korea. METHODS This population based study included all 8868 females who underwent radical mastectomy for breast cancer between January 2002 and June 2003. Follow-up for mortality continued from January 2002 to June 2006. The patients were divided into 4 socioeconomic classes according to their socioeconomic status as defined by the National Health Insurance contribution rate. The relationship between socioeconomic status and all-cause mortality after breast cancer surgery was assessed using the Cox proportional hazards model with adjusting for age, the Charlson's index score, emergency hospitalization, the type of hospital and the hospital ownership. RESULTS Those in the lowest socioeconomic status group had a significantly higher hazard ratio of 2.09 (95% CI =1.50 - 2.91) compared with those in the highest socioeconomic group after controlling for all the identifiable confounding variables. For all-cause mortality after radical mastectomy, all the other income groups showed significantly higher 3-year mortality rates than did the highest income group. CONCLUSIONS The socioeconomic status of breast cancer patients should be considered as an independent prognostic factor that affects all-cause mortality after radical mastectomy, and this is possibly due to a delayed diagnosis, limited access or minimal treatment leading to higher mortality. This study may provide tangible support to intensify surveillance and treatment for breast cancer among low socioeconomic class women.
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Affiliation(s)
- Mi Jin Park
- Graduate School of Public Health, Yonsei University, Korea.
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Feeny D, Kaplan MS, Huguet N, McFarland BH. Comparing population health in the United States and Canada. Popul Health Metr 2010; 8:8. [PMID: 20429875 PMCID: PMC2873793 DOI: 10.1186/1478-7954-8-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2009] [Accepted: 04/29/2010] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The objective of the paper is to compare population health in the United States (US) and Canada. Although the two countries are very similar in many ways, there are potentially important differences in the levels of social and economic inequality and the organization and financing of and access to health care in the two countries. METHODS Data are from the Joint Canada/United States Survey of Health 2002/03. The Health Utilities Index Mark 3 (HUI3) was used to measure overall health-related quality of life (HRQL). Mean HUI3 scores were compared, adjusting for major determinants of health, including body mass index, smoking, education, gender, race, and income. In addition, estimates of life expectancy were compared. Finally, mean HUI3 scores by age and gender and Canadian and US life tables were used to estimate health-adjusted life expectancy (HALE). RESULTS Life expectancy in Canada is higher than in the US. For those < 40 years, there were no differences in HRQL between the US and Canada. For the 40+ group, HRQL appears to be higher in Canada. The results comparing the white-only population in both countries were very similar. For a 19-year-old, HALE was 52.0 years in Canada and 49.3 in the US. CONCLUSIONS The population of Canada appears to be substantially healthier than the US population with respect to life expectancy, HRQL, and HALE. Factors that account for the difference may include access to health care over the full life span (universal health insurance) and lower levels of social and economic inequality, especially among the elderly.
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Affiliation(s)
- David Feeny
- The Center for Health Research, Kaiser Permanente Northwest, 3800 N Interstate Avenue, Portland, OR, 97227, USA
- University of Alberta and Institute of Health Economics, 10405 Jasper Avenue, #1200, Edmonton, AB, T5J 3N4, Canada
- Health Utilities Incorporated, 88 Sydenham Street, Dundas, ON, L9H 2V3, Canada
| | - Mark S Kaplan
- Department of Community Health, Portland State University, 506 SW Mill Street, Portland, OR, 97201, USA
| | - Nathalie Huguet
- Research Associate, Center for Public Health Studies, Portland State University, 506 SW Mill Street, Portland, OR, 97201, USA
| | - Bentson H McFarland
- Departments of Psychiatry and Public Health and Preventive Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
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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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19
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Saving Lives: Mammograms, Breast Cancer, and Health Insurance Reform. J Am Coll Radiol 2010; 7:243-5. [DOI: 10.1016/j.jacr.2010.01.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2010] [Accepted: 01/11/2010] [Indexed: 11/20/2022]
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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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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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Gorey KM, Luginaah IN, Holowaty EJ, Fung KY, Hamm C. Wait times for surgical and adjuvant radiation treatment of breast cancer in Canada and the United States: greater socioeconomic inequity in America. ACTA ACUST UNITED AC 2009; 32:E239-49. [PMID: 19480739 DOI: 10.25011/cim.v32i3.6113] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2009] [Indexed: 11/03/2022]
Abstract
PURPOSE The demand for cancer care has increased among aging North American populations as cancer treatment innovations have proliferated. Gaps between supply and demand may be growing. This study examined whether socioeconomic status has a differential effect on waits for surgical and adjuvant radiation treatment (RT) of breast cancer in Canada and the US. METHODS Ontario and California cancer registries provided 929 and 984 breast cancer cases diagnosed between 1998 and 2000 in diverse urban and rural places. Residence-based socioeconomic data were taken from censuses. Cancer care variables were reliably abstracted from health records: stage, receipt of surgery and RT, and waits from diagnosis to initial and initial to adjuvant treatment. Median waits were compared within- and between-country with the non-parametric Mann-Whitney U-test. Categorically long, age-adjusted wait comparisons used the Mantel-Haenszel chi-square test. RESULTS There were significant associations between lower socioeconomic status and longer surgical waits, lower access to adjuvant RT and to longer RT waits across diverse places in California. None were observed in Ontario. The two cohorts did not practically differ on access to surgery or on surgical waits. Compared with their counterparts in California, low-income Ontarians, particularly those in small urban places, gained greater access to RT, while high-income Americans had shorter waits for RT. CONCLUSIONS This historical study contextualized Canada's "waiting-list problems" with evidence on breast cancer care, where lower income Americans seemed to have waited as long as similar Canadians. Many more low-income Americans seemed to experience the longest wait of all for adjuvant care. They simply did not receive it. In contrast to stark American socioeconomic inequity, this study evidenced remarkable equity in Canadian breast cancer care.
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Affiliation(s)
- Kevin M Gorey
- School of Social Work, University of Windsor, 401 Sunset Avenue, Windsor, Ontario N9B3P4, 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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Herndon JE, Kornblith AB, Holland JC, Paskett ED. Patient education level as a predictor of survival in lung cancer clinical trials. J Clin Oncol 2008; 26:4116-23. [PMID: 18757325 DOI: 10.1200/jco.2008.16.7460] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To investigate the effect of socioeconomic status, as measured by education, on the survival of 1,577 lung cancer patients treated on 11 studies conducted by the Cancer and Leukemia Group B. PATIENTS AND METHODS Sociodemographic data, including education, was reported by the patient at the time of clinical trial accrual. Cox proportional hazards model stratified by treatment arm/study was used to examine the effect of education on survival after adjustment for known prognostic factors. RESULTS The patient population included 1,177 patients diagnosed with non-small-cell lung cancer (NSCLC; stage III or IV) and 400 patients diagnosed with small-cell lung cancer (SCLC; extensive or limited). Patients with less than an eighth grade education (13% of patients) were significantly more likely to be male, nonwhite, and older; have a performance status (PS) of 1 or 2; and have chest pain. Significant predictors of poor survival in the final model included male sex, PS of 1 or 2, dyspnea, weight loss, liver or bone metastases, unmarried, presence of adrenal metastases and high alkaline phosphatase levels among patients with NSCLC, and high WBC levels among patients with advanced disease. Education was not predictive of survival. CONCLUSION The physical condition of patients with low education who enroll onto clinical trials is worse than patients with higher education. Once enrolled onto a clinical trial, education does not affect the survival of patients with SCLC or stage III or IV NSCLC. The standardization of treatment and follow-up within a clinical trial, regardless of education, is one possible explanation for this lack of effect.
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Affiliation(s)
- James E Herndon
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC 27710, USA.
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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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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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Gorey KM. Regarding "Associations between socioeconomic status and cancer survival". Ann Epidemiol 2006; 16:789-91; author reply 792-3. [PMID: 16882472 PMCID: PMC2918539 DOI: 10.1016/j.annepidem.2006.04.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2006] [Accepted: 04/27/2006] [Indexed: 11/25/2022]
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Clarke JN, Everest MM. Cancer in the mass print media: Fear, uncertainty and the medical model. Soc Sci Med 2006; 62:2591-600. [PMID: 16431004 DOI: 10.1016/j.socscimed.2005.11.021] [Citation(s) in RCA: 131] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2005] [Indexed: 10/25/2022]
Abstract
Cancer is increasing in incidence and prevalence in North America and around the world. The mass print media play an important role in information provision about prevention, diagnosis and treatment of this disease, as well as informing health policy and personal experience. This paper reports on a content analysis of the portrayal of cancer in the highest circulating magazines available in Canada and published in Canada or the USA in 1991, 1996, 2001. It includes both manifest and latent analysis of the framing and content of cancer stories. Manifest analysis documented the dominance of the medical as compared to the lifestyle and political economy frames and the predominance of articles on breast as compared to other cancers. Latent themes included: an emphasis on fear of cancer in that: (1) cancer and fear are frequently conflated; cancer is said to grow outside of awareness; cancer is portrayed as (almost) inevitable; cancer is associated with normal experiences; early detection is associated with diagnosis; and scary statistics are emphasized; (2) contradictions and confusion exist within and between articles; and (3) metaphors of war and battle are used frequently. The paper concludes with a discussion of the implications of the linking of fear with cancer in the context of medicine as the solution.
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Kim SJ, Schaubel DE, Fenton SSA, Leichtman AB, Port FK. Mortality after kidney transplantation: a comparison between the United States and Canada. Am J Transplant 2006; 6:109-14. [PMID: 16433764 DOI: 10.1111/j.1600-6143.2005.01141.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
There is a paucity of comparative studies on country-specific outcomes in kidney transplantation. We compared post-transplant mortality among primary, adult, solitary kidney transplant recipients (KTR) from the United States (n = 70 708) and Canada (n = 5773), between January 1, 1991 and December 31, 1998, using data from the Scientific Registry of Transplant Recipients and the Canadian Organ Replacement Register. Multivariable Cox regression revealed higher adjusted post-transplant mortality among U.S. (vs. Canadian) KTR (HR = 1.35 [95% CI 1.24, 1.47; p < 0.005]). Mortality risk in the first post-transplant year was similar in both countries but higher in the United States beyond the first year (HR = 1.49-1.53; p < 0.005). There was no difference in mortality among patients transplanted within 1 year of starting dialysis, but mortality was increased in U.S. (vs. Canadian) patients after 1-2 and 4+ years on dialysis (HR = 1.36-1.66; p < 0.005). Greater mortality was also seen in U.S. patients with diabetes mellitus and/or graft failure. In conclusion, there are considerable differences in the survival of KTR in the United States and Canada. A detailed examination of factors contributing to this variation may yield important insights into improving outcomes for all KTR.
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Affiliation(s)
- S J Kim
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Woods LM, Rachet B, Coleman MP. Origins of socio-economic inequalities in cancer survival: a review. Ann Oncol 2006; 17:5-19. [PMID: 16143594 DOI: 10.1093/annonc/mdj007] [Citation(s) in RCA: 478] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Cancer survival is known to vary by socio-economic group. A review of studies published by 1995 showed this association to be universal and resilient to the many different ways in which socio-economic status was determined. Differences were most commonly attributed to differences in stage of disease at diagnosis. MATERIALS AND METHODS A review of research published since 1995 examining the association of cancer survival with socio-economic variables. RESULTS An association between socio-economic status and cancer survival has continued to be demonstrated in the last decade of research. Stage at diagnosis and differences in treatment have been cited as the most important explanatory factors. Some research has evaluated the psychosocial elements of this association. CONCLUSIONS Socio-economic differences in cancer survival are now well documented. The explanatory power of stage at diagnosis, although great, should not detract from the evidence of differential treatment between social groups. Neither factor can completely explain the observed socio-economic differences in survival, however, and the importance of differences in tumour and patient factors should now be quantified.
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Affiliation(s)
- L M Woods
- Non-Communicable Disease Epidemiology Unit, London School of Hygiene and Tropical Medicine, London, UK.
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Kunitz SJ, Pesis-Katz I. Mortality of white Americans, African Americans, and Canadians: the causes and consequences for health of welfare state institutions and policies. Milbank Q 2005; 83:5-39. [PMID: 15787952 PMCID: PMC2690387 DOI: 10.1111/j.0887-378x.2005.00334.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The life expectancy of African Americans has been substantially lower than that of white Americans for as long as records are available. The life expectancy of all Americans has been lower than that of all Canadians since the beginning of the 20th century. Until the 1970s this disparity was the result of the low life expectancy of African Americans. Since then, the life expectancy of white Americans has not improved as much as that of all Canadians. This article discusses two issues: racial disparities in the United States, and the difference in life expectancy between all Canadians and white Americans. Each country's political culture and institutions have shaped these differences, especially national health insurance in Canada and its absence in the United States. The American welfare state has contributed to and explains these differences.
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Affiliation(s)
- Stephen J Kunitz
- Department of Community and Preventive Medicine, University of Rochester, Rochester, NY 14642, USA.
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Roos LL, Magoon J, Gupta S, Chateau D, Veugelers PJ. Socioeconomic determinants of mortality in two Canadian provinces: Multilevel modelling and neighborhood context. Soc Sci Med 2004; 59:1435-47. [PMID: 15246172 DOI: 10.1016/j.socscimed.2004.01.024] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The influence of individual and contextual socioeconomic variables on mortality is compared in two Canadian provinces, Manitoba and Nova Scotia. Although differing substantially in size, ethnic mix, and history, both provinces provide greater access to health and social services as well as fewer income inequalities than the United States. A total of 8032 Manitoba respondents (followed from 1996-97 to 2002) and 2116 Nova Scotia respondents (followed from 1990 to 1999) were linked to the appropriate Canadian census as a source of neighborhood characteristics. Data were analyzed using individual- and multi-level logistic regression. Well-educated and higher income individuals were less likely to die during follow-up. No significant direct effect was found between neighborhood socioeconomic characteristics and mortality. However, both provinces showed an increased importance of individual income vis-à-vis mortality in advantaged neighborhoods relative to disadvantaged neighborhoods. Additional Manitoba analyses showed a "healthy mover" effect among respondents changing place of residence, regardless of whether they moved to more advantaged or more disadvantaged neighborhoods. The findings are discussed in the context of differences in health and health care among Canada, the United States, and other OECD countries.
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Affiliation(s)
- Leslie L Roos
- Department of Community Health Sciences, Faculty of Medicine, Manitoba Centre for Health Policy, University of Manitoba, 408-727 McDermot Avenue, Winnipeg, Man., R3E 3P5, Canada.
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Brackley ME, Penning MJ. Residence, income and cancer hospitalizations in British Columbia during a decade of policy change. Int J Equity Health 2004; 3:2. [PMID: 15086955 PMCID: PMC421740 DOI: 10.1186/1475-9276-3-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2003] [Accepted: 04/15/2004] [Indexed: 11/10/2022] Open
Abstract
Background Through the 1990s, governments across Canada shifted health care funding allocation and organizational foci toward a community-based population health model. Major concerns of reform based on this model include ensuring equitable access to health and health care, and enhancing preventive and community-based resources for care. Reforms may act differentially relative to specific conditions and services, including those geared to chronic versus acute conditions. The present study therefore focuses on health service utilization, specifically cancer hospitalizations, in British Columbia during a decade of health system reform. Methods Data were drawn from the British Columbia Linked Health Data resource; income measures were derived from Statistics Canada 1996 Census public use enumeration area income files. Records with a discharge (separation) date between 1 January 1991 and 31 December 1998 were selected. All hospitalizations with ICD-9 codes 140 through 208 (except skin cancer, code 173) as principal diagnosis were included. Specific cancers analyzed include lung; colorectal; female breast; and prostate. Hospitalizations were examined in total (all separations), and as divided into first and all other hospitalizations attributed to any given individual. Annual trends in age-sex adjusted rates were analyzed by joinpoint regression; longitudinal multivariate analyses assessing association of residence and income with hospitalizations utilized generalised estimating equations. Results are evaluated in relation to cancer incidence trends, health policy reform and access to care. Results Age-sex adjusted hospitalization rates for all separations for all cancers, and lung, breast and prostate cancers, decreased significantly over the study period; colorectal cancer separations did not change significantly. Rates for first and other hospitalizations remained stationary or gradually declined over the study period. Area of residence and income were not significantly associated with first hospitalizations; effects were less consistent for all and other hospitalizations. No interactions were observed for any category of separations. Conclusions No discontinuities were observed with respect to total hospitalizations that could be associated temporally with health policy reform; observed changes were primarily gradual. These results do not indicate whether equity was present prior to health care reform. However, findings concur with previous reports indicating no change in access to health care across income or residence consequent on health care reform.
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Affiliation(s)
- ME Brackley
- Centre on Aging, University of Victoria, PO Box 1700, STN CSC, Victoria, British Columbia, V8W 2Y2, CANADA
| | - MJ Penning
- Centre on Aging, University of Victoria, PO Box 1700, STN CSC, Victoria, British Columbia, V8W 2Y2, CANADA
- Department of Sociology, University of Victoria, PO Box 3050 STN CSC, Victoria, British Columbia, V8W 3P5, CANADA
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Gorey KM, Holowaty EJ, Laukkanen E, Luginaah IN. Social, prognostic, and therapeutic factors associated with cancer survival: a population-based study in metropolitan Detroit, Michigan. J Health Care Poor Underserved 2003; 14:478-88. [PMID: 14619550 PMCID: PMC2919559 DOI: 10.1353/hpu.2010.0694] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Kevin M Gorey
- School of Social Work, University of Windsor, Windsor, Canada
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