Objectives-We examined the differential effects of socioeconomic status on colon cancer care and survival in Toronto, Ontario, Canada, and San Francisco, California.Methods-We analyzed registry data for colon cancer patients from Ontario (n=930) and California (n=1014), diagnosed between 1996 and 2000 and followed until 2006, on stage, surgery, adjuvant chemotherapy, and survival. We obtained socioeconomic data for individuals' residences from population censuses.Correspondence should be sent to Kevin Gorey, School of Social Work, University of Windsor, 401 Sunset Ave, Windsor, Ontario, N9B 3P4 gorey@uwindsor.ca. Reprints can be ordered at http://www.ajph.org by clicking the "Reprints/Eprints" link. ContributorsK. M. Gorey conceptualized and supervised the study and led the writing. K. Y. Fung led the analysis. All authors assisted with study design, data analysis, and interpretation and writing. Human Participant Protection CIHR Author Manuscript CIHR Author Manuscript CIHR Author ManuscriptResults-Income was directly associated with lymph node evaluation, chemotherapy, and survival in San Francisco but not in Toronto. High-income persons had better survival rates in San Francisco than in Toronto. After adjustment for stage, survival was better for low-income residents of Toronto than for those of San Francisco. Middle-to low-income patients were more likely to receive indicated chemotherapy in Toronto than in San Francisco.Conclusions-Socioeconomic factors appear to mediate colon cancer care in urban areas of the United States but not in Canada. Improvements are needed in screening, diagnostic investigations, and treatment access among low-income Americans.A study of cancer survival in low-income areas of Toronto, Ontario, and Detroit, Michigan, during the 1980s found advantages among Canadians for common cancers. 1 The Toronto survival advantage was replicated for breast cancer across diverse low-income Canadian and US contexts through the 1990s. 2 Studies of that era, however, were not able to account for differences in stage of disease at diagnosis. More recent studies that accounted for breast cancer stage again found Canadian advantages. [3][4][5][6] In the United States, women with breast cancer who lived in low-income areas waited longer for surgery and adjuvant radiation therapy and were less likely to receive radiation therapy or to survive. Similar disparities between high-and low-income women with breast cancer did not exist in Canada; thus lowincome Canadians fared better across most breast cancer care indices than their US counterparts. More inclusive health insurance in Canada was advanced as the most plausible explanation.Colon cancer care may be an even more important health care performance indicator. The second most frequent cause of cancer death in North America, its prognosis can be excellent with early diagnosis and treatment. 7,8 For several reasons, colon cancer seems particularly instructive for Canada-US cancer care comparisons. First, research on income and colon cancer survi...
Iron-overload cardiomyopathy is a restrictive cardiomyopathy that manifests itself as systolic or diastolic dysfunction secondary to increased deposition of iron in the heart and occurs with common genetic disorders such as primary hemochromatosis and beta-thalassemia major. Although the exact mechanism of iron-induced heart failure remains to be elucidated, the toxicity of iron in biological systems is believed to be attributed to its ability to catalyze the generation of oxygen-free radicals. In the current investigation, the dose-dependent effects of chronic iron-loading on heart tissue concentrations of iron, glutathione peroxidase (GPx) activity, free-radical production, and cardiac dysfunction were investigated in a murine model of iron-overload cardiomyopathy. It was shown that chronic iron-overload results in dose-dependent (a) increases in myocardial iron burden, (b) decreases in the protective antioxidant enzyme GPx activity, (c) increased free-radical production, and (d) increased mortality. These findings show that the mechanism of iron-induced heart dysfunction involves in part free radical-mediated processes.
BackgroundWe 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.MethodsWe 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.ResultsEvidence 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.ConclusionsHealth 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.
SUMMARYProcedures are developed and compared for testing the equality of two dependent kappa statistics in the case of two raters and a dichotomous outcome variable. Such problems may arise when each of a sample of subjects are rated under two distinct settings, and it is of interest to compare the observed levels of inter-observer and intra-observer agreement. The procedures compared are extensions of previously developed procedures for comparing kappa statistics computed from independent samples. The results of a Monte Carlo simulation show that adjusting for the dependency between samples tends to be worthwhile only if the between-setting correlation is comparable in magnitude to the within-setting correlations. In this case, a goodness-of-"t procedure that takes into account the dependency between samples is recommended.
This study evaluated the effectiveness of implementation of common assessment tools, collaborative care plans, and symptom management guidelines for cancer patients as a strategy to improve the quality, coordination, and integration of palliative care service across organizations and health care sectors. A pre-post design to measure the impact on symptom management, caregiver burden and satisfaction with care delivery, and service utilization was used. Two cohorts of eligible patients and caregivers completed Edmonton Symptom Assessment Scales, Caregiver Reaction Assessment and FAMCARE Scales and chart audits were conducted. Administrative data from each participating site were examined for utilization trends. Audits of 53 charts preimplementation and 63 postimplementation showed an increase in documentation of pain from 24.5% to 74.6% (P<0.001) of charts. Administrative data showed a decrease in the percentage of patients with at least one emergency room visit from 94.3% to 84.8% (P<0.001), in the percentage of patients with at least one admission to the acute care hospital (P<0.001), and deaths in acute care 43.1%-35.7% (P=0.133). There was minimal change in the intensity of symptoms (P=0.591), and no change in the burden on the caregiver (P=0.086) or caregiver satisfaction with care (P=0.942). This study showed that implementation of common assessment tools, collaborative care plans, and symptom management guidelines across health sectors can result in some increased documentation of symptoms and efficiencies in care. Future projects should consider imbedding a continuous quality improvement methodology and longer timelines into their projects to improve outcomes.
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