high-SES Patients Research Articles

Socioeconomic and racial disparities in the selection and outcomes of a chest-wall boost in post-mastectomy radiation therapy.

14 Background: We investigated socioeconomic and racial disparities in the selection and outcomes of patients from the California Cancer Registry receiving post-mastectomy radiation therapy (PMRT) with or without a chest-wall boost (CWB). Methods: Records of 5,586 women with invasive breast cancer, diagnosed from 2005-2009, treated with PMRT were reviewed and stratified based on treatment with (n=2,482 [44%]) or without (n=3,104 [56%]) a CWB. Race and socioeconomic status (SES) between the cohorts were analyzed. Bivariate analyses of the impact of race and socio-demographic factors on breast cancer-specific survival (BCS) and overall survival (OS) were performed using the Kaplan-Meier method. Adjusting for potential confounders, we used multivariate proportional hazards models to identify predictors of BCS and OS, reported as hazard ratios (HR) with 95% confidence intervals (CI). Results: The majority of PMRT patients were white (58%), compared to Hispanic (20%), Asian/Pacific-Islander (15%), and black (6%). Most were of high SES (50%), compared to middle (21%) or low (29%). Non-white patients were more frequently of low SES (59% vs. 40%). Hispanic frequency (61%) of advanced-stage (3-4) disease was the highest of all races. Low SES was also associated with higher stage (37% vs. 60%) compared to high SES, which comparatively presented with lower-stage (1-2) disease (42% vs. 57%, p=0.0187). Low-SES patients were more likely to receive a CWB (31 vs. 26%) while high-SES patients were less likely (48% vs. 53%, p<0.0001). White women were more likely to be treated without a CWB (60 vs. 57%), while Hispanic women were less likely (23% vs. 18%, p=0.0003). Women not treated with a CWB with low SES had a lower BCS (HR 1.541 p=0.0114) and OS (HR 1.794. p=<0.001) compared to women of high SES. Black women not treated a CWB had lower OS (HR 1.712, p=0.0249) compared to similarly-treated white women. Conclusions: Low SES and Hispanic race were associated with advanced stage, and more commonly treated with a CWB. Low-SES and black women treated without a CWB had lower OS, while the former also had lower BCS. These findings suggest that economic and racial health-care disparities contribute to worse outcomes.

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Lower socioeconomic status is associated with worse outcomes after both listing and transplanting children with heart failure

The relationship between SES and outcomes surrounding pediatric cardiac transplantation is complex and influenced by recipient race. Broad-based studies of SES have not been performed. A retrospective review of all 5125 primary pediatric heart transplants performed in the United States between 2000 and 2011. Patients were stratified by SES based on zip code of residence and U.S. census data (low SES: 1637; mid-SES: 2253; high SES: 1235). Survival following listing and transplantation was compared across strata. Risk-adjusted long-term mortality on the waitlist was higher among low SES patients (hazard 1.32, CI 1.07-1.63). The relationship between SES and outcomes varied by race. Early risk-adjusted post-transplant outcomes were worst among high SES patients (10.8% vs. low SES: 8.9%, p<0.05). The incidence of non-compliance was higher among low SES patients (p<0.0001). Long-term risk-adjusted patient survival was poorer among low (hazard 1.41, CI 1.10-1.80) and mid-SES (1.29, 1.04-1.59) groups. Low SES is associated with worse outcomes on both the waitlist and late following transplantation. Higher SES patients had more complex transplants with higher early mortality. Further research should be directed at identifying and addressing underlying causal factors for these disparities.

Uptake and Patterns of Use of Gemcitabine for Metastatic Pancreatic Cancer: A Population-Based Study

Gemcitabine was approved for advanced pancreatic cancer in 1996. We investigated uptake and predictors of its use. We identified 3,231 individuals > 65 years in the SEER-Medicare database with stage IV pancreatic adenocarcinoma, diagnosed between 1998–2005, who survived >30 days. Of these, 54% received chemotherapy, 93% with gemcitabine. Gemcitabine nonreceipt was associated with advanced age and unmarried (OR: 0.65, 95% CI: 0.55–0.76). Diagnosis in 2004–2005 versus 1998–2000 was more likely to receive gemcitabine (OR: 1.51, 95% CI: 1.23–1.84) as were higher SES patients (highest versus lowest quintile, OR: 2.14, 95% CI: 1.60–2.85). Gemcitabine was rapidly adopted among elderly advanced pancreatic cancer patients; several factors are associated with use.

The Effect of Socioeconomic Status on Staging and Treatment Decisions in Esophageal Cancer

Optimal treatment choice for patients with esophageal cancer (EC) is complex and largely determined by tumor characteristics, comorbidity, and age. This study describes the role of patient characteristics, among which is socioeconomic status (SES), in EC treatment. Patients diagnosed with primary EC between 1990 and 2008 in the southern part of the Netherlands were identified using the Eindhoven Cancer Registry. Multivariable logistic and proportional hazard regression analyses were used to identify determinants of treatment and survival. We included 1914 patients, and 37% of them underwent intentionally curative treatment. Low-SES patients were diagnosed at older age (16% vs. 9%, age more than or equal to 80) and with more advanced tumor stages (13% vs. 10%, stage T4) than high-SES patients. Age less than 60 compared with 70 to 79 years [adjusted odds ratio, 4.51; 95% confidence interval (CI), 2.98-6.84] and high SES compared with low SES (adjusted odds ratio 1.59; 95% CI, 1.07-2.37) were independent predictors for curative treatment. Probability of death for high-SES patients undergoing palliative treatment was decreased compared with low-SES patients (hazard ratio, 0.84; 95% CI, 0.71-0.99). SES is an important factor in treatment choice of EC. As health care is equally accessible to the whole population in the Netherlands, this suggests that both patient-related and physician-related factors are involved in this phenomenon.

Dimensions of Socioeconomic Status and Clinical Outcome After Primary Percutaneous Coronary Intervention

The association between low socioeconomic status (SES) and high mortality from coronary heart disease is well-known. However, the role of SES in relation to the clinical outcome after primary percutaneous coronary intervention remains poorly understood. We studied 7385 patients treated with primary percutaneous coronary intervention. Participants were divided into high-SES and low-SES groups according to income, education, and employment status. The primary outcome was major adverse cardiac events (cardiac death, recurrent myocardial infarction, and target vessel revascularization) at maximum follow-up (mean, 3.7 years). Low-SES patients had more adverse baseline risk profiles than high-SES patients. The cumulative risk of major adverse cardiac events after maximum follow-up was higher among low-income patients and unemployed patients compared with their counterparts (income: hazard ratio, 1.68; 95% CI, 1.47-1.92; employment status: hazard ratio, 1.75; 95% CI, 1.46-2.10). After adjustment for patient characteristics, these differences were substantially attenuated (income: hazard ratio, 1.12; 95% CI, 0.93-1.33; employment status: hazard ratio, 1.27; 95% CI, 1.03-1.56). Further adjustment for admission findings, procedure-related data, and medical treatment during follow-up did not significantly affect the associations. With education as the SES indicator, no between-group differences were observed in the risk of the composite end point. Even in a tax-financed healthcare system, low-SES patients treated with primary percutaneous coronary intervention face a worse prognosis than high-SES patients. The poor outcome seems to be largely explained by differences in baseline patient characteristics. Employment status and income (but not education level) were associated with clinical outcomes.

Perceptions of readmitted patients on the transition from hospital to home

Hospital leaders have had mixed success reducing readmissions Little is known about the readmitted patient's perspective. A cross-sectional 36-item survey was administered to 1084 readmitted inpatients of The Hospital of the University of Pennsylvania (an urban academic medical center) and Penn Presbyterian Medical Center (an urban community hospital) between November 10, 2010 and July 5, 2011. The survey response rate was 32.9%. The most commonly reported issues contributing to readmission were: 1) feeling unprepared for discharge (11.8%); 2) difficulty performing activities of daily living (ADLs) (10.6%); 3) trouble adhering to discharge medications (5.7%); 4) difficulty accessing discharge medications (5.0%); and 5) lack of social support (4.7%). Low-socioeconomic status (SES) (defined as uninsured or Medicaid) patients were more likely than high-SES patients to report difficulty understanding (odds ratio [OR] 2.7; 95% confidence interval [CI] 1.1, 6.6) and executing (OR 2.2; 95% CI 1.1, 4.4) discharge instructions, difficulty adhering to medications (OR 1.8; 95% CI 1.2, 3.0), lack of social support (OR 2.0; 95% CI 1.2, 3.6), lack of basic resources (OR 2.6; 95% CI 1.1, 6.1), and substance abuse (OR 6.7; 95% CI 2.3, 19.2). Patients reported transition challenges which they believe contribute to illness relapse and readmission. Interventions designed to address these challenges, and tailored for patient characteristics such as SES, may better address the root causes of readmission.

Small but significant socioeconomic inequalities in axillary staging and treatment of breast cancer in the Netherlands

Background:The use of sentinel node biopsy (SNB), lymph node dissection, breast-conserving surgery, radiotherapy, chemotherapy and hormonal treatment for breast cancer was evaluated in relation to socioeconomic status (SES) in the Netherlands, where access to care was assumed to be equal.Methods:Female breast cancer patients diagnosed between 1994 and 2008 were selected from the nationwide population-based Netherlands Cancer Registry (N=176 505). Socioeconomic status was assessed based on income, employment and education at postal code level. Multivariable models included age, year of diagnosis and stage.Results:Sentinal node biopsy was less often applied in high-SES patients (multivariable analyses, ⩽49 years: odds ratio (OR) 0.70 (95% CI: 0.56–0.89); 50–75 years: 0.85 (0.73–0.99)). Additionally, lymph node dissection was less common in low-SES patients aged ⩾76 years (OR 1.34 (0.95–1.89)). Socioeconomic status-related differences in treatment were only significant in the age group 50–75 years. High-SES women with stage T1–2 were more likely to undergo breast-conserving surgery (+radiotherapy) (OR 1.15 (1.09–1.22) and OR 1.16 (1.09–1.22), respectively). Chemotherapy use among node-positive patients was higher in the high-SES group, but was not significant in multivariable analysis. Hormonal therapy was not related to SES.Conclusion:Small but significant differences were observed in the use of SNB, lymph node dissection and breast-conserving surgery according to SES in Dutch breast cancer patients despite assumed equal access to health care.

DIMENSIONS OF SOCIOECONOMIC STATUS AND CLINICAL OUTCOME AFTER PRIMARY PERCUTANEOUS CORONARY INTERVENTION

Background—The association between low socioeconomic status (SES) and high mortality from coronary heart disease is well-known. However, the role of SES in relation to the clinical outcome after primary percutaneous coronary intervention remains poorly understood. Methods and Results—We studied 7385 patients treated with primary percutaneous coronary intervention. Participants were divided into high-SES and low-SES groups according to income, education, and employment status. The primary outcome was major adverse cardiac events (cardiac death, recurrent myocardial infarction, and target vessel revascularization) at maximum follow-up (mean, 3.7 years). Low-SES patients had more adverse baseline risk profiles than high-SES patients. The cumulative risk of major adverse cardiac events after maximum follow-up was higher among low-income patients and unemployed patients compared with their counterparts (income: hazard ratio, 1.68; 95% CI, 1.47–1.92; employment status: hazard ratio, 1.75; 95% CI, 1.46–2.10). Af...

Evaluation of the use of an integrated drug information system by primary care physicians for vulnerable population

Objective To investigate whether an electronic prescribing and integrated drug information system was more likely to be used by primary care physicians for patients of low socioeconomic (SES) patients. Methods Prospective 9 months follow-up study was conducted in Montreal, Canada from March to November 2003. The study included 28 primary care physicians and their 4096 respective patients with provincial drug insurance. Utilization rate was defined as the number of times the electronic medication history (EMH) and electronic prescribing system (E-rx) were accessed divided by the total number of medical visits made by those patients. System audit trails (utilization), provincial health insurance databases (visits) were used to measure system utilization rate. For each patient neighborhood-based measures of household income, derived from Statistics Canada, were used to measure socioeconomic status. Results The EMH was used 14.5 times per 100 visits. In comparison to high SES patients, there was a significant 70% increase (RR: 1.70; 95%CI: 1.15–2.47) in the EMH utilization for low SES patients. The electronic prescribing system was used 38.5 times per 100 visits and did not vary by patient SES. The EMH utilization rate for low SES patients with multiple emergency room (ER) visits was 2.4 times higher than for high SES patients with <1 ER visit (RR: 2.38; 95%CI: 1.36–4.14). The utilization rate for low SES patients, who took, at least six drugs per day, was four times higher compared to high SES patients with less complex drug management (RR: 4.00; 95%CI: 2.22–7.17). Conclusions Primary care physicians were more likely to access electronic information on current drug use for patients of low SES taking multiple medications and with fragmented care.

PAR3: THE STANDARDIZED ASTHMA-RELATED QUALITY OF LIFE QUESTIONNAIRE (AQLQ-S): DOES SOCIOECONOMIC STATUS EFFECT MEASUREMENTS?

OBJECTIVE: The objective of this analysis was to evaluate the impact of social class on correlation between the standardized AQLQ, self-rated asthma severity and control, and patient utility. METHODS: 84 asthmatic subjects completed the AQLQ. Self-rated asthma severity and control was measured on a 5-point Likert scale and utilities were measured using a rating scale. SES was defined based on receipt of social assistance. Correlations between AQLQ scores and each other variable were measured using Spearman's Rank correlation coefficient (rS). Differences in rs between social classes (rsdiff) were analyzed using Fisher's r to z transformation (2-tailed). RESULTS: 38 (45%) patients were receiving social assistance. In the entire sample, there was significant correlation (p < 0.05) between all AQLQ scores (symptoms, activity, emotion, environment, and global), self-rated asthma severity (rS = 0.21–0.38), control (rS = 0.21–0.38), and utilities. Symptom, activity, and global AQLQ scores were correlated strongly with utility (rS = 0.53–0.54; p < 0.0001) and moderately with environment and emotion scores (rS = 0.38;p = 0.002). However, AQLQ scores were consistently more strongly correlated with self-assessed severity and control in lower SES patients. Although rS diff ranged from 0.07 to 0.55 (mean = 0.27), only the most extreme difference was significant (activity score and control − rS diff = 0.55; p = 0.01). Conversely, rS between all AQLQ scores and utility were consistently lower (mean rS diff = 0.18; range 0.9–0.23) in patients on social assistance, although not significantly. CONCLUSIONS: Correlations between AQLQ scores and utility were consistently lower in lower SES subjects, suggesting that AQLQ may be a better measure of overall health in higher SES patients. Conversely, AQLQ scores correlated more strongly with self-rated asthma severity and control in lower SES subjects. Although most differences were not significant despite their magnitude, this is likely due to a recognized lack of power of the Fisher's r to z transformation test.

Psychosocial versus biomedical risk factors in Kevorkian's first forty-seven physician-assisted deaths.

This article examines biomedical and psychosocial data on the first forty-seven cases of physician-assisted suicide (PAS) of Kevorkian as collected by means of both a physical autopsy and a preliminary psychological autopsy. The following patterns emerge: 1) The physical condition of these PAS patients was not typical of the conditions that lead to death in the United States. 2) Consistent with the above findings, our pilot data indicate that only 31.1 percent of these patients were terminal. While 73.9 percent were described as reporting pain, only 42.6 percent were revealed at autopsy to have a specific anatomical basis for their pain. However 36 percent were described as depressed, 66 percent as having some disability, and perhaps of key importance, 90 percent expressed a fear of dependency. Most important, our pilot data suggest the possibility of large gender differences, since 3) 68.1 percent of these forty-seven PAS's are women and only 31.9 percent are men. This represents the reverse of the gender pattern for completed suicides in the United States in 1995, resembling instead the approximate pattern for unsuccessful suicide attempts. 4) Approximately 75 percent of both men and women in the above sample were described as reporting pain. Men were almost twice as likely to have had an anatomical basis for the pain and three times as likely to be terminal. Our pilot data indicate PAS women are more likely to be described as depressed and twice as likely to have had a history of previous unsuccessful suicide attempts. 5) Kevorkian's patients were older than the typical unaided suicides in America. Reported pain decreases with age as does depression; however anatomical basis for pain increases slightly with age, and no age effect emerges for terminality. 6) Approximately two-thirds of those physician-assisted suicides were at middle SES levels. History of disability was the biggest risk factor for the low SES patients and fear of dependency for the high SES patients.

The influence of socioeconomic status on change in health status after hospitalization

We reviewed patients' hospital records and surveyed patients after hospital discharge to determine whether the experience of being hospitalized differentially affected the health status of persons with different socioeconomic backgrounds (as measured by income level and education level) and to determine whether the association between socioeconomic status (SES) and change in health status varied depending upon the reason for hospital admission. We studied patients admitted to six university-affiliated teaching hospitals in Massachusetts and California for chest pain (N = 797) and surgery (N = 1165). We compared the health status scores of patients for a variety of outcomes: basic activities of daily living, instrumental activities of daily living, social activities, mental well-being, work performance and housework performance. Lower-SES patients entered the hospital with worse health status than higher-SES patients. Change in health status, statistically adjusted for case-mix, varied by reason for admission. Patients with chest pain generally reported either no improvement or a decline in functioning with the amount of decline equivalent for low- and high-SES patients. Surgical patients reported improvement in functioning following hospitalization. For several measures, lower-income surgical patients reported greater improvement than did higher-income patients, but still did not reach the same level of health status as higher-income patients.

The differential perception of anxiety in medical patients: sociodemographic aspects.

An investigation of anxiety in 100 general medical inpatients showed that the attending physicians rated about one-third of the patients as highly anxious. Comparisons between the physician's and nurses' ratings and the patients' scores on four standardized anxiety scales revealed that there was differential perception of the patients' anxiety levels. An analysis of the physicians' ratings, nurses' ratings, and the scores on the anxiety scales, in terms of the patients' sociodemographic characteristics, pointed to factors associated with the differential perception of anxiety. Physicians tended to overrate young patients and high SES patients as having greater anxiety than the scales indicated and both physicians and nurses consistently underrated the blacks' and the lower SES patients' anxiety levels. The results demonstrated clinicians' problems with the identification of anxious patients and indicate some factors associated with differential perception of patients' anxiety levels. We suggest social distance and counter-transference as partial explanations for the difficulties in identification and with differential perception.