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Exarchakou A, Rachet B, Lyratzopoulos G, Maringe C, Rubio FJ. What can hospital emergency admissions prior to cancer diagnosis tell us about socio-economic inequalities in cancer diagnosis? Evidence from population-based data in England. Br J Cancer 2024; 130:1960-1968. [PMID: 38671209 PMCID: PMC11182764 DOI: 10.1038/s41416-024-02688-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 04/07/2024] [Accepted: 04/09/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND More deprived cancer patients are at higher risk of Emergency Presentation (EP) with most studies pointing to lower symptom awareness and increased comorbidities to explain those patterns. With the example of colon cancer, we examine patterns of hospital emergency admissions (HEAs) history in the most and least deprived patients as a potential precursor of EP. METHODS We analysed the rates of hospital admissions and their admission codes (retrieved from Hospital Episode Statistics) in the two years preceding cancer diagnosis by sex, deprivation and route to diagnosis (EP, non-EP). To select the conditions (grouped admission codes) that best predict emergency admission, we adapted the purposeful variable selection to mixed-effects logistic regression. RESULTS Colon cancer patients diagnosed through EP had the highest number of HEAs than all the other routes to diagnosis, especially in the last 7 months before diagnosis. Most deprived patients had an overall higher rate and higher probability of HEA but fewer conditions associated with it. CONCLUSIONS Our findings point to higher use of emergency services for non-specific symptoms and conditions in the most deprived patients, preceding colon cancer diagnosis. Health system barriers may be a shared factor of socio-economic inequalities in EP and HEAs.
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Affiliation(s)
- Aimilia Exarchakou
- Inequalities in Cancer Outcomes Network (ICON), Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.
| | - Bernard Rachet
- Inequalities in Cancer Outcomes Network (ICON), Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare and Outcomes (ECHO), Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London, London, UK
| | - Camille Maringe
- Inequalities in Cancer Outcomes Network (ICON), Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Vieira RJ, Sousa-Pinto B, Pereira AM, Cordeiro CR, Loureiro CC, Regateiro F, Taborda-Barata L, Bousquet J, Fonseca J. Asthma hospitalizations: A call for a national strategy to fight health inequities. Pulmonology 2023; 29:179-183. [PMID: 36907817 DOI: 10.1016/j.pulmoe.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 11/30/2022] [Accepted: 12/01/2022] [Indexed: 03/12/2023] Open
Affiliation(s)
- R J Vieira
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Portugal; Centre for Health Technology and Services Research, Health Research Network (CINTESIS@RISE), Faculty of Medicine of the University of Porto, Portugal
| | - B Sousa-Pinto
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Portugal; Centre for Health Technology and Services Research, Health Research Network (CINTESIS@RISE), Faculty of Medicine of the University of Porto, Portugal.
| | - A M Pereira
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Portugal; Allergy Unit, CUF Porto Hospital & Institute, Portugal
| | - C R Cordeiro
- Department of Pulmonology, University Hospital of Coimbra, Portugal; Faculty of Medicine, University of Coimbra, Portugal
| | - C C Loureiro
- Department of Pulmonology, University Hospital of Coimbra, Portugal; Faculty of Medicine, University of Coimbra, Portugal
| | - F Regateiro
- Allergy and Clinical Immunology Unit, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal; Institute of Immunology, Faculty of Medicine, University of Coimbra, Coimbra, Portugal; Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - L Taborda-Barata
- UBIAir - Clinical & Experimental Lung Centre, University of Beira Interior, Covilhã, Portugal; CICS-Health Sciences Research Centre, University of Beira Interior, Covilhã, Portugal; Department of Immunoallergology, Cova da Beira University Hospital Centre, Covilhã, Portugal
| | - J Bousquet
- Institute for Allergology, Charité - Universitätsmedizin Berlin, Corporate, Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany; University Hospital, Montpellier, France; ARIA, Montpellier, France
| | - J Fonseca
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Portugal; Centre for Health Technology and Services Research, Health Research Network (CINTESIS@RISE), Faculty of Medicine of the University of Porto, Portugal; Allergy Unit, CUF Porto Hospital & Institute, Portugal
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Affiliation(s)
- Jonathan Stokes
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
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Morisod K, Luta X, Marti J, Spycher J, Malebranche M, Bodenmann P. Measuring Health Equity in Emergency Care Using Routinely Collected Data: A Systematic Review. Health Equity 2022; 5:801-817. [PMID: 35018313 PMCID: PMC8742300 DOI: 10.1089/heq.2021.0035] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Achieving equity in health care remains a challenge for health care systems worldwide and marked inequities in access and quality of care persist. Identifying health care equity indicators is an important first step in integrating the concept of equity into assessments of health care system performance, particularly in emergency care. Methods: We conducted a systematic review of administrative data-derived health care equity indicators and their association with socioeconomic determinants of health (SEDH) in emergency care settings. Following PRISMA-Equity reporting guidelines, Ovid MEDLINE, EMBASE, PubMed, and Web of Science were searched for relevant studies. The outcomes of interest were indicators of health care equity and the associated SEDH they examine. Results: Among 29 studies identified, 14 equity indicators were identified and grouped into four categories that reflect the patient emergency care pathway. Total emergency department (ED) visits and ambulatory care-sensitive condition-related ED visits were the two most frequently used equity indicators. The studies analyzed equity based on seven SEDH: social deprivation, income, education level, social class, insurance coverage, health literacy, and financial and nonfinancial barriers. Despite some conflicting results, all identified SEDH are associated with inequalities in access to and use of emergency care. Conclusion: The use of administrative data-derived indicators in combination with identified SEDH could improve the measurement of health care equity in emergency care settings across health care systems worldwide. Using a combination of indicators is likely to lead to a more comprehensive, well-rounded measurement of health care equity than using any one indicator in isolation. Although studies analyzed focused on emergency care settings, it seems possible to extrapolate these indicators to measure equity in other areas of the health care system. Further studies elucidating root causes of health inequities in and outside the health care system are needed.
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Affiliation(s)
- Kevin Morisod
- Department of Vulnerabilities and Social Medicine, Centre for Primary Care and Public Health (Unisanté), Lausanne, Switzerland.,Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Xhyljeta Luta
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.,Department of Epidemiology and Health Systems, Centre for Primary Care and Public Health (Unisanté), Lausanne, Switzerland
| | - Joachim Marti
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.,Department of Epidemiology and Health Systems, Centre for Primary Care and Public Health (Unisanté), Lausanne, Switzerland
| | - Jacques Spycher
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.,Department of Epidemiology and Health Systems, Centre for Primary Care and Public Health (Unisanté), Lausanne, Switzerland
| | - Mary Malebranche
- Department of Vulnerabilities and Social Medicine, Centre for Primary Care and Public Health (Unisanté), Lausanne, Switzerland.,Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.,Department of Medicine, University of Calgary, Calgary, Canada
| | - Patrick Bodenmann
- Department of Vulnerabilities and Social Medicine, Centre for Primary Care and Public Health (Unisanté), Lausanne, Switzerland.,Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
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Ford J, Knight J, Brittain J, Bentley C, Sowden S, Castro A, Doran T, Cookson R. Reducing inequality in avoidable emergency admissions: Case studies of local health care systems in England using a realist approach. J Health Serv Res Policy 2021; 27:31-40. [PMID: 34289742 DOI: 10.1177/13558196211021618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE People in disadvantaged areas are more likely to have an avoidable emergency hospital admission. Socio-economic inequality in avoidable emergency hospital admissions is monitored in England. Our aim was to inform local health care purchasing and planning by identifying recent health care system changes (or other factors), as reported by local health system leaders, that might explain narrowing or widening trends. METHODS Case studies were undertaken in one pilot and at five geographically distinct local health care systems (Clinical Commissioning Groups, CCGs), identified as having consistently increasing or decreasing inequality. Local settings were explored through discussions with CCG officials and stakeholders to identify potential local determinants. Data were analysed using a realist evaluation approach to generate context-mechanism-outcome (CMO) configurations. RESULTS Of the five geographically distinct CCGs, two had narrowing inequality, two widening, and one narrowing inequality, which widened during the project. None of the CCGs had designed a large-scale package of service changes with the explicit aim of reducing socio-economic inequality in avoidable emergency admissions, and local decision makers were unfamiliar with their own trends. Potential primary and community care determinants included: workforce, case finding and exclusion, proactive care co-ordination for patients with complex needs, and access and quality. Potential commissioning determinants included: data use and incentives, and targeting of services. Other potential determinants included changes in care home services, national A&E targets, and wider issues - such as public services financial constraints, residential gentrification, and health care expectations. CONCLUSIONS We did not find any bespoke initiatives that explained the inequality trends. The trends were more likely due to an interplay of multiple health care and wider system factors. Local decision makers need greater awareness, understanding and support to interpret, use and act upon inequality indicators. They are unlikely to find simple, cheap interventions to reduce inequalities in avoidable emergency admissions. Rather, long-term multifaceted interventions are required that embed inequality considerations into mainstream decision making.
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Affiliation(s)
- John Ford
- Clinical Lecturer, Department of Public Health and Primary Care, University of Cambridge
| | - Julia Knight
- Public Health Registrar, Leicestershire County Council, UK
| | - John Brittain
- Principal Operational Researcher, NHS England and NHS Improvement, UK
| | | | - Sarah Sowden
- Clinical Lecturer and Honorary Public Health Consultant, Population Health Sciences Institute, University of Newcastle, UK
| | - Ana Castro
- Research Fellow, Health Sciences, University of York, UK
| | - Tim Doran
- Professor, Health Sciences, University of York, UK
| | - Richard Cookson
- Professor, Centre for Health Economics, University of York, UK
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Are more GPs associated with a reduction in emergency hospital admissions? A quantitative study on GP referral in England. Br J Gen Pract 2021; 71:e287-e295. [PMID: 33685922 DOI: 10.3399/bjgp.2020.0737] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 10/27/2020] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Recent studies have found an association between access to primary care and accident and emergency attendances, with better access associated with fewer attendances. Analyses of an association with emergency admissions, however, have produced conflicting findings. AIM This study investigated whether emergency admission rates in an area are associated with 1) the number of GPs, and 2) mean size of GP practice. DESIGN AND SETTING Analysis was conducted utilising Hospital Episode Statistics, the numbers of GPs and GP practices, Office for National Statistics population data, Quality and Outcomes Framework prevalence data, and Index of Multiple Deprivation data, from 2004/2005 to 2011/2012, for all practices in England. METHOD Regression analysis of panel data with fixed effects to address 1) a potential two-way relationship between the numbers of GPs and emergency admissions, and 2) unobservable characteristics of GP practices. RESULTS There is not a statistically significant relationship between the number of GPs in a primary care trust area and the number of emergency admissions, when analysing all areas. In deprived areas, however, a higher number of GPs is associated with lower emergency admissions. There is also a lower emergency admission rate in areas in which practices are on average larger, holding GP supply constant. CONCLUSION An increase in GPs was found to reduce emergency admissions in deprived areas, but not elsewhere. Areas in which GPs are concentrated into larger practices showed reduced levels of emergency admissions, all else being equal.
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Nicodemo C, Barzin S, Cavalli N, Lasserson D, Moscone F, Redding S, Shaikh M. Measuring geographical disparities in England at the time of COVID-19: results using a composite indicator of population vulnerability. BMJ Open 2020; 10:e039749. [PMID: 32994257 PMCID: PMC7526277 DOI: 10.1136/bmjopen-2020-039749] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES The growth of COVID-19 infections in England raises questions about system vulnerability. Several factors that vary across geographies, such as age, existing disease prevalence, medical resource availability and deprivation, can trigger adverse effects on the National Health System during a pandemic. In this paper, we present data on these factors and combine them to create an index to show which areas are more exposed. This technique can help policy makers to moderate the impact of similar pandemics. DESIGN We combine several sources of data, which describe specific risk factors linked with the outbreak of a respiratory pathogen, that could leave local areas vulnerable to the harmful consequences of large-scale outbreaks of contagious diseases. We combine these measures to generate an index of community-level vulnerability. SETTING 91 Clinical Commissioning Groups (CCGs) in England. MAIN OUTCOME MEASURES We merge 15 measures spatially to generate an index of community-level vulnerability. These measures cover prevalence rates of high-risk diseases; proxies for the at-risk population density; availability of staff and quality of healthcare facilities. RESULTS We find that 80% of CCGs that score in the highest quartile of vulnerability are located in the North of England (24 out of 30). Here, vulnerability stems from a faster rate of population ageing and from the widespread presence of underlying at-risk diseases. These same areas, especially the North-East Coast areas of Lancashire, also appear vulnerable to adverse shocks to healthcare supply due to tighter labour markets for healthcare personnel. Importantly, our index correlates with a measure of social deprivation, indicating that these communities suffer from long-standing lack of economic opportunities and are characterised by low public and private resource endowments. CONCLUSIONS Evidence-based policy is crucial to mitigate the health impact of pandemics such as COVID-19. While current attention focuses on curbing rates of contagion, we introduce a vulnerability index combining data that can help policy makers identify the most vulnerable communities. We find that this index is positively correlated with COVID-19 deaths and it can thus be used to guide targeted capacity building. These results suggest that a stronger focus on deprived and vulnerable communities is needed to tackle future threats from emerging and re-emerging infectious disease.
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Affiliation(s)
- Catia Nicodemo
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
- CHSEO, University of Oxford, Oxford, UK
| | - Samira Barzin
- Mathematical Institute, Oxford University, Oxford, UK
- Oxford Martin School, Unviersity of Oxford, Oxford, UK
| | - Nicolo' Cavalli
- Nuffield College, University of Oxford, Oxford, UK
- Bocconi Unviersity, Milan, Italy
| | - Daniel Lasserson
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Francesco Moscone
- Brunel University of London, London, UK
- Department of Economics, Università Ca' Foscari Venezia, Venice, Italy
| | - Stuart Redding
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
- CHSEO, University of Oxford, Oxford, UK
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