Lowest Income Quintile Research Articles

Utilization of Immunotherapy in Patients with Cancer Treated in Routine Care Settings: A Population-Based Study Using Health Administrative Data.

IntroductionThe introduction of immunotherapy (IO) in the treatment of patients with cancer has significantly improved clinical outcomes. Population level information on actual IO utilization is limited.MethodsWe conducted a retrospective cohort study using provincial health administrative data from Ontario, Canada to: (1) assess the extent of IO use from 2011 (pre-IO funding) to 2019; and (2) identify factors associated with IO use in patients with advanced cancers for which IO is reimbursed including melanoma, bladder, lung, head and neck, and kidney tumors. The datasets were linked using a unique encoded identifier. A Fine and Gray regression model with death as a competing risk was used to identify factors associated with IO use.ResultsAmong 59 510 patients assessed, 8771 (14.7%) received IO between 2011 and 2019. Use of IO increased annually from 2011 (3.3%) to 2019 (39.2%) and was highest in melanoma (52%) and lowest in head and neck cancer (6.6%). In adjusted analysis, factors associated with lower IO use included older age (hazard ratio (HR) 0.91 (95% CI, 0.89-0.93)), female sex (HR 0.85 (95% CI, 0.81-0.89)), lower-income quintile, hospital admission (HR 0.78 (95% CI, 0.75-0.82)), high Charlson score and de novo stage 4 cancer. IO use was heterogeneous across cancer centers and regions.ConclusionIO utilization for advanced cancers rose substantially since initial approval albeit use is associated with patient characteristics and system-level factors even in a universal healthcare setting. To optimize IO utilization in routine practice, survival estimates and potential inequity in access should be further investigated and addressed.

Benefits of the cigarette tax in Mexico, by sex and income quintileBenefícios do imposto sobre cigarros no México: análise por sexo e quintil de renda

RESUMENObjetivo.Estimar los beneficios económicos y en salud, por sexo y por quintil de ingreso, del incremento de los precios de los cigarros mediante impuestos en México.Métodos.Con un modelo de costo-efectividad extendido (ECEA, por su sigla en inglés) se estimaron los beneficios distributivos en mujeres y hombres con un escenario de incremento del precio de los cigarros de 44% (de 56,4 pesos mexicanos [MX$] a MX$81,2 por cajetilla), como resultado de triplicar el impuesto específico actual (de MX$0,49/cigarro a MX$1,49/cigarro). El modelo se calibró con fuentes oficiales de información nacionalResultados.Con el incremento del impuesto de un peso por cigarro, cerca de 1,5 millones de fumadores abandonarían el consumo (351 300 mujeres y 1,1 millón de hombres). Así, se evitarían aproximadamente 630 000 muertes prematuras atribuibles al tabaco. La reducción de la carga de enfermedad permitiría ahorros para el sector salud cercanos a MX$42 800 millones y evitaría que más de 250 000 personas (entre ellas, 50 200 mujeres fumadoras) cayeran en situación de pobreza. Además, se recaudarían MX$16 200 millones adicionales por año, de los cuales el quintil más bajo aportaría menos de 3% (1% en el caso de las mujeres de menores ingresos).Conclusiones.La epidemia de tabaquismo tiene patrones claramente diferenciados entre mujeres y hombres y reflejan un componente de género. Si bien los beneficios del impuesto al tabaco en México tendrían magnitudes relativas al estado actual de la epidemia en cada caso, estos podrían contribuir a un objetivo más amplio de justicia social mediante la reducción de las inequidades de género.

Are Income-based Differences in TKA Use and Outcomes Reduced in a Single-payer System? A Large-database Comparison of the United States and Canada.

Income-based differences in the use of and outcomes in TKA have been studied; however, it is not known if different healthcare systems affect this relationship. Although Canada's single-payer healthcare system is assumed to attenuate the wealth-based differences in TKA use observed in the United States, empirical cross-border comparisons are lacking. (1) Does TKA use differ between Pennsylvania, USA, and Ontario, Canada? (2) Are income-based disparities in TKA use larger in Pennsylvania or Ontario? (3) Are TKA outcomes (90-day mortality, 90-day readmission, and 1-year revision rates) different between Pennsylvania and Ontario? (4) Are income-based disparities in TKA outcomes larger in Pennsylvania or Ontario? We identified all patients hospitalized for primary TKA in this cross-border retrospective analysis, using administrative data for 2012 to 2018, and we found a total of 161,244 primary TKAs in Ontario and 208,016 TKAs in Pennsylvania. We used data from the Pennsylvania Health Care Cost Containment Council, Harrisburg, PA, USA, and the ICES (formally the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada. We linked patient-level data to the respective census data to determine community-level income using ZIP Code or postal code of residence and stratified patients into neighborhood income quintiles. We compared TKA use (age and gender, standardized per 10,000 population per year) for patients residing in the highest-income versus the lowest-income quintile neighborhoods. Similarly secondary outcomes 90-day mortality, 90-day readmission, and 1-year revision rates were compared between the two regions and analyzed by income groups. TKA use was higher in Pennsylvania than in Ontario overall and for all income quintiles (lowest income quartile: 31 versus 18 procedures per 10,000 population per year; p < 0.001; highest income quartile: 38 versus 23 procedures per 10,000 population per year; p < 0.001). The relative difference in use between the highest-income and lowest-income quintile was larger in Ontario (28% higher) than in Pennsylvania (23% higher); p < 0.001. Patients receiving TKA in Pennsylvania were more likely to be readmitted within 90 days and were more likely to undergo revision within the first year than patients in Ontario, but there was no difference in mortality at 1 year. When comparing income groups, there were no differences between the countries in 90-day mortality, readmission, or 1-year revision rates (p > 0.05). These results suggest that universal health insurance through a single-payer may not reduce the income-based differences in TKA access that are known to exist in the United States. Future studies are needed determine if our results are consistent across other geographic regions and other surgical procedures. Level III, therapeutic study.

Age-varying effects of repeated emergency department presentations for children in Canada.

ObjectivesRepeated presentations to emergency departments (EDs) may indicate a lack of access to other health care resources. Age is an important predictor of frequent ED use; however, age-varying effects are not generally investigated. This study examines the age-specific effects of predictors on ED presentation frequency for children in Alberta and Ontario, Canada.MethodsThis retrospective study used population-based data during April 2010 to March 2017. Data were extracted from the National Ambulatory Care Reporting System for children aged <18 who were members of the top 10% of ED users in any one of the fiscal years 2011/2012 to 2015/2016 along with a comparison sample from the bottom 90%. A marginal regression model studied the age-varying associations on the frequency of ED presentations with province, sex, access to primary health care provider (for Ontario only), area of residence and lowest neighbourhood income quintile.ResultsThere were 2,481,172 patients who made 9,229,156 ED presentations. The effects of sex, lowest income quintile, rural residence, access to primary health care provider and province on the frequency of presentations varied by age. Notably, boys go from having more frequent presentations than girls when aged ≤5 (i.e. adjusted intensity ratio [IR]=1.04 at age 5, 95% confidence interval [CI] = 1.03,1.06) to less frequent for ages 8–11 years and beyond 14 (i.e. IR = 0.80 at age 15, 95% CI = 0.78,0.81). Adolescents aged ≥15 without access to a primary care provider had more frequent presentations compared to those with a primary care provider.ConclusionsWhen examining the frequency of ED presentations in children, age-varying effects of predictors should be considered. Our more nuanced examination of age provides insights into how health services might better target programmes for different ages to potentially reduce unnecessary ED use by providing other health care alternatives.

Meeting U.S. greenhouse gas emissions goals with the international air pollution provision of the clean air act

We explore economic, distributional and health consequences of U.S. greenhouse gas emissions objectives that could be achieved using Section 115 of the Clean Air Act (international air pollution), which has only recently received detailed legal analysis as a potential U.S. climate policy tool. Under it a national emissions target could be allocated among the states. This illustrative analysis considers 45% and 50% reductions of energy and industry-related CO2 emissions by 2030, below 2005 levels, via a model rule. Different approaches (based on legal precedent) for the interstate allocation are considered, along with alternative rates of technology improvement. The detail needed to analyze this approach is provided by MIT’s U.S. Regional Energy Policy model (30 individual states and multi-state regions), with its electricity sector replaced by the U.S. National Renewable Energy Laboratory’s Renewable Energy Development System (ReEDS). Air quality benefits are estimated using modeling tools developed by academic researchers and the U.S. Environmental Protection Agency. Three-quarters of emissions reductions in 2030 come in the electric sector, while reductions elsewhere illustrate the efficiency advantage of a multi-sector policy. With all states participating in allowance trading, the resulting national emissions price is lower than in older assessments. The difference is due to lower growth expectations, recent state policies, falling costs of low carbon technologies, and an improved representation of electric system flexibility by the ReEDS model. Even ignoring climate and air quality benefits, economic welfare grows at near the baseline rate for all regions regardless of the interstate allocation approach. When states distribute allowance revenue to residents on an equal per-capita basis, the policy is welfare improving to the lowest income quintile in all regions. Aggregation of control costs, the mortality effects of reduced particulates, and the value of avoided climate damages yields positive national net benefits in all cases.

Does home equity liquidation reduce older adults’ poverty rate? Evidence from South Korea

We investigate relative poverty rates among older adults from a unique dataset using an actuarial method applied to a public reverse mortgage in South Korea, which liquidates home equity and converts the assets to a readily available income. We find that it increases disposable income by approximately 20 per cent on average for older adults, and the improvement is more effective in the low-income quintiles. Due to the increased income, elderly poverty rate reduces significantly by 10 percentage points to about 31 per cent. Therefore, the elderly poverty rate following the OECD standard overestimates the elderly poverty rate and could misguide welfare policies.

Rural income growth, ethnic differences, and household cooking fuel choice: Evidence from China

This paper investigates the associations between rural income growth, ethnic differences, and household cooking fuel choice, using the 2016 China Labor-force Dynamics Survey data. We consider the presence of fuel-stacking behavior (using multiple fuels) among survey households and categorize cooking fuels into clean fuels, non-clean fuels, and mixed fuels. Data collected from 6461 rural households are estimated using a multinomial logit model. Findings suggest that relative to households at the lowest income quintile 1, those at the income quintiles 2–5 are more likely to use clean fuels but are less likely to use non-clean fuels for cooking, and the magnitudes of the effects increase across the income quintiles. Compared with the majority Han Chinese households, ethnic minority households are more likely to use mixed fuels but are less likely to use clean fuels for cooking. Only those ethnic minority households at the highest income level (quintile 5) appear to be more likely to use clean cooking fuels.

The distributional effects of tobacco tax increases across regions in Mexico: an extended cost-effectiveness analysis

BackgroundSeveral studies have shown the beneficial effects of tobacco fiscal policy, but distributional effects have been less examined, especially at the subnational level. The objective of this study is to analyse the distributional effects of a one-peso tobacco tax increase (roughly equivalent to tripling the current excise tax) on health, poverty, and financial outcomes at the subnational level in Mexico.MethodsWe employ an extended cost-effectiveness analysis that estimates life-years gained, smoking attributable deaths averted, treatment costs averted, number of persons avoiding poverty and catastrophic health expenditures, and additional tax revenues by income group across five regions.ResultsWith the one-peso tax increase (or 44% price increase), about 1.5 million smokers would quit smoking across the five regions, resulting in nearly 630 thousand premature deaths averted and 12.6 million life years gained. The bottom income quintile would gain three times more life years gains than the top quintile (ratio 3:1), and the largest gain for the most deprived would occur in the South (ratio 19:1), the region with the highest poverty incidence. Costs averted and additional tax revenues would reach 44.6 and 16.2 billion pesos, respectively. Moreover, 251 thousand individuals would avoid falling into poverty, including 53.2 in the lowest income quintile, and 563.9 thousand would avoid catastrophic health expenditures. Overall, the bottom income group would obtain 26% of the life years gained and 24% of the cost averted, while only paying 3% of the additional tax revenue.ConclusionsThe most significant gains from a substantial cigarette price increase would be for the poorest 20%, especially in the South, the most impoverished region of Mexico. Therefore, tobacco taxes are an opportunity for governments to advance in equity and towards the achievement of sustainable development goals on non-communicable diseases.

Changing pattern of household income in northeast India

The paper provides an assessment of household income inequality in northeast India during 2004–05 and 2011–12 using India Human Development Survey. In two out of the eight states household annual income has doubled but has declined in one of the other states. There exits considerable inter and intra states inequality in household income and inequality is increasing over time. The pace of enhancement in household income is higher four households in the richest income quintile than among the households in lower income quintiles. Percapita annual income of individuals varies by occupations and the gaps are found to be statistically significant.

Income Disparity in Breast Cancer Incidence and Stage at Presentation: A National Population Study of South Korea.

This study aims to explore income-based disparities in breast cancer (BC) incidence and stage at presentation in a national population in South Korea, where a National Cancer Screening Program (NCSP) has been implemented. In 2007, new patients with BC were identified using the Korea Central Cancer Registry database. We calculated adjusted odds ratios (aORs) to evaluate the association between individual income level and the risk of distant stage BC at presentation, adjusting for women's age, body mass index, disability registration, employment, region of residence, and year of diagnosis. The cumulative age-standardized incidence of BC in the 11 years was highest among women in the richest quintile (2,040 per 100,000 women for 11 years), whereas the proportion of distant stage at presentation was the highest (10.2%) among the medical aid beneficiaries. The aOR of distant stage diagnosis at presentation was higher for lower-income quintiles, and the risk was the highest in the medical aid beneficiaries (aOR, 2.25; 95% confidence interval, 1.97-2.58) than in the richest quintile. The income-based gradient in aORs for distant stage did not differ between younger (< 40 years) and older patients. A higher risk of distant stage BC at presentation among the lower-income and medical aid groups in the context of a NCSP was observed. A more focused approach toward women in lower-income groups is necessary to alleviate the disparity in the risk of advanced BC.

Socioeconomic inequalities in dementia diagnostic process and medication prescription: Experience from the Swedish Dementia Registry

AbstractBackgroundLower socioeconomic position (SEP) was associated with higher risk of morbidity and mortality. However, the influence of SEP on diagnosis and medication use in dementia is understudied. Our study aimed to explore the impact of patients’ SEP on dementia diagnostic process and medications.MethodIn this longitudinal cohort study, data from 74,414 dementia patients registered in the Swedish Dementia Registry (2007‐2018) were linked with the Swedish Longitudinal Integrated Database for Health Insurance and Labor Market Studies (2006‐2017). SEP was expressed through education and disposable individual income. Outcomes included performance of the dementia diagnostic examinations and prescription of anti‐dementia drugs. The complete basic diagnostic work‐up comprising blood testing, neuroimaging, clock‐test and Mini‐Mental State Examination (MMSE) was suggested by the diagnostic guidelines for dementia from the Swedish National Board of Health and Welfare and was the main study outcome.ResultIn comparison with patients who completed compulsory education &lt; 9 years, patients with university ≥3 years had higher probability of receiving the basic diagnostic work‐up (odds ratio (OR) 1.19; 95% confidence interval (CI) 1.10‐1.29), clock test (OR 1.12; 95%CI 1.02‐1.24) and CT‐MRI (OR 1.23; 95%CI 1.09‐1.39). Compared with people in the lowest income quintile, patients in the highest income quintile presented higher chance of receiving the basic diagnostic work‐up (OR 1.35; 95%CI 1.26‐1.46), clock test (OR 1.40; 95%CI 1.28‐1.52), blood analysis (OR 1.21; 95%CI 1.06‐1.39), MMSE (OR 1.47; 95%CI 1.26‐1.70) and CT‐MRI (OR 1.30; 95%CI 1.18‐1.44). Higher SEP was significantly associated with higher chance of being diagnosed at a specialist care. People with higher income were more likely to receive a specific dementia diagnosis, as opposed to “unspecified” dementia. SEP presented no association with prescription of anti‐dementia medication, except for the association between education and the use of memantine.ConclusionInequalities in dementia diagnostic process and prescription of anti‐dementia medications occur among people with different education or income levels. Income was more decisive than education in the relation to dementia diagnostic process.

Acute kidney injury requiring renal replacement therapy in people with COVID-19 disease in Ontario, Canada: a prospective analysis of risk factors and outcomes.

ABSTRACTBackgroundSeverely ill people with coronavirus disease 2019 (COVID-19) are at risk of acute kidney injury treated with renal replacement therapy (AKI-RRT). The understanding of the risk factors and outcomes for AKI-RRT is incomplete.MethodsWe prospectively collected data on the incidence, demographics, area of residence, time course, outcomes and associated risk factors for all COVID-19 AKI-RRT cases during the first two waves of the pandemic in Ontario, Canada.ResultsThere were 271 people with AKI-RRT, representing 0.1% of all diagnosed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) cases. These included 10% of SARS-CoV-2 admissions to intensive care units (ICU). Median age was 65 years, with 11% <50 years, 76% were male, 47% non-White and 48% had diabetes. Overall, 59% resided in the quintile of Ontario neighborhoods with the greatest ethnocultural composition and 51% in the two lowest income quintile neighborhoods. Mortality was 58% at 30 days after RRT initiation, and 64% at 90 days. By 90 days, 20% of survivors remained RRT-dependent and 31% were still hospitalized. On multivariable analysis, people aged >70 years had higher mortality (odds ratio 2.4, 95% confidence interval 1.3, 4.6). Cases from the second versus the first COVID-19 wave were older, had more baseline comorbidity and were more likely to initiate RRT >2 weeks after SARS-CoV-2 diagnosis (34% versus 14%; P < 0.001).ConclusionsAKI-RRT is common in COVID-19 ICU admissions. Residency in areas with high ethnocultural composition and lower socioeconomic status are strong risk factors. Late-onset AKI-RRT was more common in the second wave. Mortality is high and 90-day survivors have persisting high morbidity.

The Effect of Price Changes and Teaspoon Labelling on Intention to Purchase Sugar-Sweetened Beverages: A Discrete Choice Experiment.

Childhood obesity is a major public health concern and sugar-sweetened beverages (SSBs) are a known contributor. SSB taxation and food labelling have been proposed as policies to reduce consumption by changing purchasing behaviours. The study aimed to analyse caregivers' preferences on commonly purchased SSBs in Australia and to determine the effect of price increases and teaspoon labelling on their purchasing intentions. We used a discrete choice experiment (DCE) to obtain data about choices between SSB and non-SSB alternatives. 563 caregivers, who had young children aged 3-7years, completed the experiment online. 286 were randomly allocated to receive choice sets with plain labelling while 277 were assigned to teaspoon labelling. Each participant completed nine choice scenarios where they chose between six SSB and non-SSB beverage options or a no-beverage option, with beverage prices varying between scenarios. While hypothetical, price and teaspoon labelling for sugar content for each beverage was obtained from an informal market survey. Responses from the DCE were modelled using random parameters logit within a random utility theory framework. Household income and children's consumption volumes of soft drink were used to explore preference heterogeneity. Using mixed logit as the final model, we found that higher reduction in intended purchases was observed for soft drink and fruit drink in teaspoon labelling than it was in plain labelling. Participants exposed to teaspoon labelling intended to purchase less of flavoured milk and fruit juice compared to those exposed to plain labelling. Compared to baseline prices, a hypothetical 20% increase in SSB prices and the presentation of 'teaspoons of sugar' labelling were predicted to reduce intentional SSB purchases and increase intentional non-SSB purchases. Within each labelling group, there were no significant differences of intentional purchases between the highest and the lowest income quintile, high and low consumers of soft drinks. However, compared to plain labelling, teaspoon labelling was predicted to strongly influence intentional purchases of SSBs and non-SSBs. This study suggests that a policy to increase SSB price and include teaspoon labelling would lead to a reduced consumption of SSBs and increased consumption of non-SSBs.

Community-based health financing: empirical evaluation of the socio-demographic factors determining its uptake in Awka, Anambra state, Nigeria

BackgroundThere is an increasing global concern of financing poor people who live in low- and middle-income countries. The burden of non-communicable diseases of these people is, by in large, connected to a lack of access to effective and affordable medical care, weak financing, and delivery of health services. Policymakers have assumed, until recently, that poor people in developing countries would not pay health insurance premiums for the cost of future hospitalization. The emergence of community-based health financing (CBHF) has brought forth a renewed and empowered alternative. CBHF schemes are designed to be sustainable, varying in size, and well organized. Developing countries, such as Nigeria, have been testing and finetuning such schemes in the hope that they may 1 day reciprocate high-income countries.MethodsA sample size of 372 respondents was used to assess the slums of Awka, the capital city of Anambra State, Nigeria, and empirically evaluate the socio-demographic characteristics of those who uptake CBHF using the provider Jamii Bora Trust (JBT). Cross-sectional research used a quantitative research approach with the instrumentality of structured questionnaires. Descriptive analysis was adopted to determine the socio-demographic characteristics of those who have CBHF uptake in Awka and evaluate the presence and benefits of CBHF in the city’s slums.ResultsThe results show that more youth and middle-aged persons from 18 to 50 years are more insured (i.e., 73.8% combined) than those who are over 50 years of age. Gender distribution confirm more females (i.e., 61.9%) to be health-insured than their male counterpart (i.e., 38.1%). This perhaps reflected the reproductive roles by women and the fact that women have better health-seeking behavioral attitude. Moreover, the results correlate with previous studies that confirm women are more involved in local sustainable associations in low-income settings, of this nature, in sub-Saharan Africa. Corroborating this further, married people are more insured (i.e., 73.8%) than those who are not married (i.e., 26.2%) and insured members report higher use of hospitalization care than the non-insured.ConclusionCBHF uptake favored members in the lower income quintiles who are more likely to use healthcare services covered by the JBT scheme. This confirmed that prepayment schemes and the pooling of risk could reduce financial barriers to healthcare among the urban poor. Recommendations are suggested to improve enrollment levels in the CBHF programs.

Cycle-network expansion plan in Oslo: Modeling cost-effectiveness analysis and health equity impact.

Physical inactivity is the leading cause of non-communicable diseases, and further research on the cost-effectiveness of interventions that target inactivity is warranted. Socioeconomic status is vital in this process. We aim to evaluate the cost-effectiveness of a cycle-network expansion plan in Oslo compared to the status quo by income quintiles. We applied a Markov model using a public payer perspective. Health outcomes were measured by quality-adjusted life years (QALYs) gained from the prevention of coronary heart disease, stroke, type 2 diabetes, and cancer. We measured equity impact by the concentration index and social welfare using the achievement index. We conducted sensitivity analyses. The intervention was generally more costly and more effective than the status quo. Incremental cost per QALY falls with income quintile, ranging from $10,098 in the richest quintile to $23,053 per QALY gained in the poorest quintile. The base-case intervention increased health inequality. However, a scenario targeting low-income quintiles reduced inequality and increased social welfare. In conclusion, the cycle-network expansion is likely to be cost-effective, but with equity concerns. If decision makers care about health inequalities, the disadvantaged groups could be targeted to produce more equitable and socially desirable outcomes instead of a uniform intervention across income quintiles.

ES15.06 Global Perspectives on Implicit Bias in Oncology Care: Canada

A cure for lung cancer may remain elusive until biases in healthcare are resolved. Accessibility, comprehensiveness, and quality of care are key cornerstones that a healthcare system must address in order to be equitable for all its citizens; unfortunately, this is not always the case in Canada. Many Canadian lung cancer patients face numerous biases in care, ranging from systemic issues, social determinants of health, clinical trials design. In Canada, lung cancer has become a postal code disease. For example, targeted therapy drug coverage varies widely across each province, such as crizotinib for ROS1 positive NSCLC received marketing authorization in August 2017. However in September 2020, it was only publicly reimbursed in four provinces (Lung Cancer Canada, 2020). Unfortunately, this equity in access is common across Canada where access to one treatment or test may be accessible in one province, but completely inaccessible in another. Stigma on lung cancer patients, structural racism on minorities and indigenous populations, and discrimination all feed the biases in the healthcare system, leading to delays in testing and treatment. Geographical concerns arise for those in remote areas, particularly Indigenous communities, as traveling long distances for care has financial and emotional implications. However, the biggest factor influencing equity is the association between lung cancer risk and socioeconomic status, where incidence rates of those in the lowest income quintile are 2.1 times higher than those in the highest quintile (Mitra, Shaw, Tjepkema, & Peters, 2015). Education is also a major factor, where lung cancer incidence is 2.8 times higher for those with less than a secondary school diploma compared to those with a university degree, and this plays a role in health literacy and their ability to understand medical terminology, utilize available educational resources, and advocate for potential treatment physicians may not be aware of (Mitra, Shaw, Tjepkema, & Peters, 2015). Clinical trials also impose implicit biases on accessibility, as trials are typically done in large city centers where higher incidence rates are found, and thus, greater opportunity to fill placements. Disadvantaged populations such as ethnic minorities, low-income individuals, those In jobs with limited flexibility, and rural residents are often underrepresented in such trials, and thus, they do not consider the patient’s perspective, leading to research that is inequitable. Significant systemic changes are needed to ensure underserved and underrepresented populations are able to access care for cancer prevention, treatment, and diagnosis. Within publicly funded healthcare systems, treatment costs are real concerns. However traditional assessments of value ignore costs such as time off work, travel to treatment. The value gained in non-traditional outcomes such as patient independence, mental wellness, and cultural preservation are real but difficult to capture. To preserve and further the medical gains in treatment advances, new assessments of value need to be developed, treatments planned with rollout and outreach in mind and clinical trials reflective of the real population they were designed to serve. Without these, a cure for lung cancer may be developed but remain unreachable for patients. Lung Cancer Canada. (2020). (rep.). The Faces of Lung Cancer Report. Retrieved from https://www.lungcancercanada.ca/LungCancerCanada/media/Documents/LCC2020_FOLCR_ENGLISH.pdf Mitra, D., Shaw, A., Tjepkema, M., & Peters, P. (2015). Social Determinants of Lung Cancer Incidence in Canada: A 13-year prospective study. Health Reports, 26(6), 12–20. Retrieved from https://www150.statcan.gc.ca/n1/pub/82-003-x/2015006/article/14195-eng.htm

Association between physical activity and income levels in chilean adults

The Chilean population reports high levels of physical inactivity. The relationship between income level, physical activity (PA) and sedentary behaviors is not well known. To describe the levels of PA and sedentary time, according to income levels in the Chilean population. Analysis of data from the Chilean National Health Survey 2016-2017, which included 5,130 participants (52.9% women). The levels of PA and sedentary time were measured by the Global Physical Activity Questionnaire. Income levels were established according to the self-reported income per capita of the households and presented as quintiles. PA levels according to income levels were estimated by linear regression analyses. Transport-related PA was higher in the lowest income quintiles (p = 0.039). There were no trends for income levels and PA domains including moderate, vigorous, total, occupational and leisure PA. The prevalence of leisure and occupational physical inactivities were higher in the lowest quintiles of income. Sitting time was higher in the higher income levels (p < 0.01). People in the lowest quintile for income spent more time in transport-related PA and less time sitting. However, physical inactivity prevalence during leisure and work time were higher in people with lower income.

Conditional cash transfer program and child mortality: A cross-sectional analysis nested within the 100 Million Brazilian Cohort.

Brazil has made great progress in reducing child mortality over the past decades, and a parcel of this achievement has been credited to the Bolsa Família program (BFP). We examined the association between being a BFP beneficiary and child mortality (1-4 years of age), also examining how this association differs by maternal race/skin color, gestational age at birth (term versus preterm), municipality income level, and index of quality of BFP management. This is a cross-sectional analysis nested within the 100 Million Brazilian Cohort, a population-based cohort primarily built from Brazil's Unified Registry for Social Programs (Cadastro Único). We analyzed data from 6,309,366 children under 5 years of age whose families enrolled between 2006 and 2015. Through deterministic linkage with the BFP payroll datasets, and similarity linkage with the Brazilian Mortality Information System, 4,858,253 children were identified as beneficiaries (77%) and 1,451,113 (23%) were not. Our analysis consisted of a combination of kernel matching and weighted logistic regressions. After kernel matching, 5,308,989 (84.1%) children were included in the final weighted logistic analysis, with 4,107,920 (77.4%) of those being beneficiaries and 1,201,069 (22.6%) not, with a total of 14,897 linked deaths. Overall, BFP participation was associated with a reduction in child mortality (weighted odds ratio [OR] = 0.83; 95% CI: 0.79 to 0.88; p < 0.001). This association was stronger for preterm children (weighted OR = 0.78; 95% CI: 0.68 to 0.90; p < 0.001), children of Black mothers (weighted OR = 0.74; 95% CI: 0.57 to 0.97; p < 0.001), children living in municipalities in the lowest income quintile (first quintile of municipal income: weighted OR = 0.72; 95% CI: 0.62 to 0.82; p < 0.001), and municipalities with better index of BFP management (5th quintile of the Decentralized Management Index: weighted OR = 0.76; 95% CI: 0.66 to 0.88; p < 0.001). The main limitation of our methodology is that our propensity score approach does not account for possible unmeasured confounders. Furthermore, sensitivity analysis showed that loss of nameless death records before linkage may have resulted in overestimation of the associations between BFP participation and mortality, with loss of statistical significance in municipalities with greater losses of data and change in the direction of the association in municipalities with no losses. In this study, we observed a significant association between BFP participation and child mortality in children aged 1-4 years and found that this association was stronger for children living in municipalities in the lowest quintile of wealth, in municipalities with better index of program management, and also in preterm children and children of Black mothers. These findings reinforce the evidence that programs like BFP, already proven effective in poverty reduction, have a great potential to improve child health and survival. Subgroup analysis revealed heterogeneous results, useful for policy improvement and better targeting of BFP.

Radiation Oncologist Consultations Prior to Radical Prostatectomy: Disparities and Opportunities.

In 2015, men undergoing radical prostatectomy in Ontario, Canada were recommended to undergo multidisciplinary care by seeing a radiation oncologist or discussion at multidisciplinary rounds before surgery. The a priori target rate was ≥76%. We used population-based data to explore factors associated with not receiving multidisciplinary care prior to radical prostatectomy. Men who underwent radical prostatectomy for localized prostate cancer in Ontario between 2007 and 2017 were identified using administrative data. Physician billings identified patients who received multidisciplinary care. Multivariable logistic regression was used to predict receipt of multidisciplinary care. A total of 31,485 men underwent radical prostatectomy between 2007 and 2017. Of these patients 28.7% saw a radiation oncologist, 1.2% underwent multidisciplinary discussion and 1.9% had both before surgery. Multidisciplinary care receipt increased from 17.8% in 2007 to 47.8% in 2017 (p <0.001). The odds ratio between the highest and lowest geographic regions was 7.93 (95% CI 6.17-10.18, p <0.001). Lower odds of multidisciplinary care receipt were observed for men further from the nearest cancer center (OR 0.74 per 50 km, 95% CI 0.71-0.78, p <0.001) and higher odds for the highest versus lowest income quintile (OR 1.41, 95% CI 1.29-1.54, p <0.001). Of 128 urologists who performed ≥10 radical prostatectomies between 2016 and 2017, 29 (22.7%) met the target of having ≥76% of men seen for multidisciplinary care prior to surgery. Despite increasing utilization, many men do not receive multidisciplinary care prior to radical prostatectomy. While geography and the urologist appear to be the greatest factors predicting multidisciplinary care receipt, these factors are closely intertwined.

Income Inequalities and Risk of Early Rehospitalization for Diabetes, Hypertension and Congestive Heart Failure in the Canadian Working-Age Population

ObjectivesIn the Canadian context of universal health-care coverage, income inequalities are understudied as potentially predictive of the timings and patterns of repeat hospitalizations for diabetes, despite this condition requiring self-care practices entailing appreciable out-of-pocket expenses in daily life. In this study, we examined the relationships between income disparities and risk of earlier readmission for diabetes and commonly comorbid chronic conditions in the working-age population. MethodsThe cohort study exploited 2006 population census data linked longitudinally to 3 years of hospital records from the Discharge Abstract Database among adults 25 to 64 years of age. Multiple regression survival models were used to test the associations of income group with cause-specific times to rehospitalization for diabetes (types 1 and 2) and 5 additional conditions, controlling for other individual sociodemographics. ResultsThe mean time to rehospitalization for diabetes was 223 days (N=4,540). Compared with those in the lowest income quintile, the adjusted risk of earlier readmission was significantly lower among inpatients in the highest income quintile for diabetes (hazard ratio [HR]=0.89; 95% confidence interval [CI], 0.80 to 0.99) and for the diabetes-concordant conditions of congestive heart failure (HR=0.81; 95% CI, 0.66 to 0.99) and hypertension (HR=0.85; 95% CI, 0.76 to 0.95). No significant associations between income and readmission intervals were observed for the discordant conditions of angina, asthma and chronic obstructive pulmonary disease. ConclusionsDelays in rehospitalization for diabetes and concordant conditions among the most affluent suggest the persistence of income-mediated differences in individuals’ ability to manage these conditions. Further research is needed to understand the specific financial burdens of disease management on patients and their households that may accelerate the risk of repeat hospitalization.