Remoteness Of Residence Research Articles

Population-level 5-year event-free survival for children with cancer in Australia.

Event-free survival (EFS) considers other adverse events in addition to mortality. It therefore provides a more complete understanding of the effectiveness and consequences of treatment than standard survival measures, but is rarely reported at the population level for childhood cancer. Our study cohort (n=7067) was obtained from the Australian Childhood Cancer Registry, including children aged under 15 diagnosed with cancer between 2006 and 2015, with follow-up potentially available to 31 December 2020. The events of interest were relapse following remission, progressive disease, diagnosis of a second primary cancer or death from any cause. Five-year EFS and all-cause observed survival were both calculated, stratified by type of childhood cancer, remoteness of residence and stage at diagnosis. Differences in EFS were assessed using multivariable flexible parametric models. Approximately one quarter of patients (n=1605 of 7067, 23%) experienced at least one of the events of interest within 5years of diagnosis. Relapse was twice as common for children with metastatic/advanced disease (22%) versus children with localised/limited cancers (11%). Overall 5-year EFS was 75.0% (95% confidence interval [CI]: 73.9%-76.0%), compared to 85.8% observed survival (95% CI: 85.0%-86.6%). Patients with other gliomas had the lowest EFS (35.4%, 95% CI: 27.8%-43.1%). EFS was significantly lower among children with acute myeloid leukaemia in outer regional/remote areas compared to major cities (adjusted hazard ratio [HR]=1.90, 95% CI: 1.20-3.00). Reporting EFS at a population level provides further insight on a wider range of impacts apart from mortality alone, contributing towards efforts to improve the management and outcomes of childhood cancer.

Analysis of satisfaction of stroke patients with medical rehabilitation using multimodal correction technology

Introduction. The quality of medical care is determined not only by the dynamics of functional recovery, but also depends on the patient satisfaction index, which is highly informative and should be used in in its assessment. Aim. To study and analyze the level of satisfaction of patients after ischemic stroke (IS) with the quality of MR services provided using the technology of multimodal correction of motor and cognitive disorders in the early recovery period.Materials and methods. An anonymous survey was conducted of 186 patients with IS who underwent rehabilitation in inpatient and outpatient settings at the Moscow Research and Practice Center for Medical Rehabilitation, Restorative and Sports Medicine named after S.I. Spasokukotsky, using a specially designed questionnaire including 20 questions, as well as an analysis of medical and social factors affecting MR satisfaction.Results. The majority of respondents (89.8%) were generally satisfied the results of MR, while more than half (65%) plan to undergo further MR using this technology. According to respondents, the favorable result of MR is influenced by the presence of relatives next to the patient (76.0%) and in 14.0% by the presence of a nurse, the availability of special training in rehabilitation of doctors and nursing staff (38%), awareness of the impact of rehabilitation measures for their existing functional disorders (94%). Almost three quarters of respondents noted that the individual regime of the rehabilitation program has the greatest impact on the successful outcome of rehabilitation (72.0%). At the same time, two thirds of specialists consider an important aspect to be the comprehensive work of all specialists engaged in MR (64.0%). The medical staff was highly appreciated by 44.1%, 34.9% and 21.0% highly. 36% of patients are highly satisfied with the results of MR, 42% are quite satisfied, and 16% of respondents gave an assessment of “average, normal”. Among the main reasons for dissatisfaction with MR are remoteness of residence from a medical organization, absence of relatives during the course of MR, the long duration of the MR course, lack of awareness information about the impact of multimodal correction technology on the restoration of impaired functions.Conclusions. Based on the analysis of the overall patient satisfaction with the medical care provided by MR for stroke patients, using the technology of multimodal correction of motor and cognitive impairments, directions for improving the quality of medical services were identified.

The prevalence of and factors associated with prior induced abortion among women who gave birth in Victoria, 2010-2019.

To assess the prevalence of a history of induced abortion among women who gave birth in Victoria during 2010-2019; to assess the association of socio-demographic factors with a history of induced abortion. Retrospective cohort study; analysis of cross-sectional perinatal data in the Victorian Perinatal Data Collection (VPDC). All women who gave birth (live or stillborn) in Victoria, 1 January 2010 - 31 December 2019. Self-reported induced abortions prior to the index birth; outcome of the most recent pregnancy preceding the index pregnancy. Of the 766 488 women who gave birth during 2010-2019, 93 251 reported induced abortions (12.2%), including 36 938 of 338 547 nulliparous women (10.9%). Women living in inner regional (adjusted odds ratio [aOR], 0.94; 95% confidence interval [CI], 0.93-0.96) or outer regional/remote/very remote areas (aOR, 0.86; 95% CI, 0.83-0.89) were less likely than women in major cities to report induced abortions. The likelihood increased steadily with age at the index birth and with parity, and was also higher for women without partners at the index birth (aOR, 2.20; 95% CI, 2.16-2.25) and Aboriginal and Torres Strait Islander women (aOR, 1.32; 95% CI, 1.25-1.40). The likelihood was lower for women born in most areas outside Australia than for those born in Australia. The likelihood of a history of induced abortion declined across the study period overall (2019 v 2010: 0.93; 95% CI, 0.90-0.96) and for women in major cities (0.88; 95% CI, 0.84-0.91); rises in inner regional and outer regional/remote/very remote areas were not statistically significant. Access to abortion care in Victoria improved during 2010-2019, but the complex interplay between contraceptive use, unintended pregnancy, and induced abortion requires further exploration by remoteness of residence. Robust information about numbers of unintended pregnancies and access to reproductive health services are needed to guide national sexual and reproductive health policy and practice.

Association of remoteness and ethnicity with major amputation following minor amputation to treat diabetes-related foot disease.

Minor amputation is commonly needed to treat diabetes-related foot disease (DFD). Remoteness of residence is known to limit access to healthcare and has previously been associated with poor outcomes. The primary aim of this study was to examine the associations between ethnicity and remoteness of residency with the risk of major amputation and death following initial treatment of DFD by minor amputation. A secondary aim was to identify risk factors for major amputation and death following minor amputation to treat DFD. This was a retrospective analysis of data from patients who required a minor amputation to treat DFD between 2000 and 2019 at a regional tertiary hospital in Queensland, Australia. Baseline characteristics were collected together with remoteness of residence and ethnicity. Remoteness was classified according to the 2019 Modified Monash Model (MMM) system. Ethnicity was based on self-identification as an Aboriginal and Torres Strait Islander or non-Indigenous person. The outcomes of major amputation, repeat minor amputation and death were examined using Cox-proportional hazard analyses. A total of 534 participants were included, with 306 (57.3%) residing in metropolitan or regional centres, 228 (42.7%) in rural and remote communities and 144 (27.0%) were Aboriginal or Torres Strait Islander people. During a median (inter quartile range) follow-up of 4.0 (2.1-7.6) years, 103 participants (19.3%) had major amputation, 230 (43.1%) had repeat minor amputation and 250 (46.8%) died. The risks (hazard ratio [95% CI]) of major amputation and death were not significantly higher in participants residing in rural and remote areas (0.97, 0.67-1.47; and 0.98, 0.76-1.26) or in Aboriginal or Torres Strait Islander people (HR 1.44, 95% CI 0.96, 2.16 and HR 0.89, 95% CI 0.67, 1.18). Ischemic heart disease (IHD), peripheral artery disease (PAD), osteomyelitis and foot ulceration (p<0.001 in all instances) were independent risk factors for major amputation. Major amputation and death are common following minor amputation to treat DFD and people with IHD, PAD and osteomyelitis have an increased risk of major amputation. Aboriginal and Torres Strait Islander People and residents of remote areas were not at excess risk of major amputation.

Hepatitis C direct-acting antiviral treatment completion: Comparison of geographic, demographic and clinical characteristics in Australia.

Hepatitis C virus treatment uptake varies by geographic area in Australia; however, analysis has not been conducted on variations in treatment completion. Thisstudy investigated treatment completion according to remoteness, as well as demographic and clinical characteristics. A retrospective analysis was conducted on all Pharmaceutical Benefits Scheme claim data from March 2016 to June 2019. Treatment was considered completed if all prescriptions required to complete the course were dispensed. Treatment completion was compared by remoteness of residence, sex, age, state or territory, treatment duration and prescriber type. Of 68,940 patients, 85.6% completed treatment, although the completion rate decreased over time. Residents living in very remote areas had the lowest treatment completion rate (74.3%; odds ratio [OR] 0.52; 95% confidence interval [CI]: 0.39, 0.7; P < 0.005), particularly those treated by general practitioners (GPs;66.7%; OR 0.47; 95% CI: 0.22, 0.97; P = 0.042). This analysis suggests that people in very remote areas of Australia have the lowest hepatitis C treatment completion rate, particularly those accessing treatment through GPs. Further investigation into predictors of low treatment completion within these populations is required.

Socio-environmental and clinical features of invasive group A streptococcal disease in the Northern Territory of Australia.

To describe the socio-environmental profile and clinical features of invasive group A streptococcal (iGAS) infections in the Northern Territory (NT) of Australia over 10 years. Cases of iGAS disease diagnosed between 1 May 2011 and 30 April 2021 were retrospectively identified from the NT Notifiable Diseases System and electronic health records accessed. Remoteness of residence, socio-economic index, seasonality and clinical characteristics were recorded. There were 692 cases of iGAS disease identified in the NT during the period 1 May 2011 - 30 April 2021. The age-standardised incidence of iGAS disease was significantly higher in people living in very remote (57.1 cases per 100,000 population, 95% confidence interval [95% CI]: 48.6-65.5) and remote areas (40.9 cases per 100,000 population, 95% CI: 34.7-47.2) than in outer regional areas of the NT (15.7 cases per 100,000 population, 95% CI: 13.4-17.9). People with socio-economic disadvantage were also disproportionately affected, with an incidence of 52.6 cases per 100,000 population (95% CI: 46.2-58.9) in decile 1-3 populations, compared to 8.9 cases per 100,000 population (95% CI: 6.9-10.9) for decile 7-10. For cases with recorded severity data, 135 of 378 (36%) met locally-defined criteria for severe iGAS disease. Recurrent iGAS disease was commonly observed in the dialysis cohort, affecting 17 of the 106 patients during the study period (16% recurrence rate) and causing two deaths. Five molecularly-confirmed clusters of iGAS disease were identified from the study period. iGAS disease is unevenly affecting people in the NT. Those living in areas of socio-economic disadvantage, those in remote and very remote communities, and those receiving dialysis were most affected. It is important that primordial, primary and secondary prevention measures be directed towards supporting these disadvantaged population groups.

Abstract 13115: Impact of Socioeconomic Status and Remoteness of Residence on Access to Cardiac Care for Pediatric Heart Disease in Alberta, a Jurisdiction of Universal and Centralized Cardiac Healthcare

Introduction: Socioeconomic status (SES) and remoteness of residence (RoR) impact access to care and outcomes in congenital (CHD) and acquired (AHD) pediatric heart disease. Whether the universal, centralized Canadian healthcare system mitigates such inequities is unclear. We examined associations between SES and RoR on age at cardiac diagnosis (ACD), time to first intervention (TFI), and annual primary care (PCV) and cardiology (CV) visits as evidence of healthcare access in Alberta. Methods: All children born and diagnosed in Alberta with CHD or AHD from 2005-2017 were included. CHD was classified as mild, moderate, and severe base on the Bethesda Task Force definitions. Geospatial modelling was used to determine drive times (&lt;60, 60-180, &gt;180 minutes) to 1 of 2 provincial cardiac programs. Cox proportional hazards regression models were used to examine relationships between RoR and SES with ACD and TFI, and Poisson models using generalized estimating equations for annual PCV and CV. Results: Of 12,542 children, 9347 had mild, 1733 moderate and 717 severe CHD and 745 AHD. Most (8,833, 70.4%) lived &lt;60 minutes to a cardiac center, and the largest proportion were in SES quintile 1 (least vulnerable, 3,074, 24.5%) and smallest in quintile 5 (most vulnerable, 2003, 16.0%). Median ACD was 1(IQR 0-108) days for mild, 0(0-54) days for moderate, and 0(0-0) days for severe CHD, and 340(41-1312) days for AHD. Intervention occurred in 1086(62.7%) with moderate CHD (TFI 63(7-150) days), 588(82.0%) with severe CHD (11(5-58) days), and 42 with AHD (1828(793-2866) days). ACD was impacted slightly by SES and only in AHD (Table). TFI and PCVs were not impacted by RoR or SES. Finally, CVs were inversely related to RoR for CHD and AHD. Conclusions: In Alberta, SES and RoR do not importantly impact ACD, TFI and PCVs among CHD and AHD patients. Greater RoR but not SES, however, is associated with fewer annual CVs, suggesting a need to optimize cardiac outreach services.

Abstract 12635: Mortality Risks and Need For Transplant in Pediatric Heart Disease Associated With Lower Ses and Greater Remoteness of Residence From Cardiac Care

Introduction: Socioeconomic status (SES) and remoteness of residence (RoR) may contribute to worse clinical outcomes. Whether this is true in universal healthcare is not certain. We sought to explore associations between SES and RoR, from centralized pediatric cardiac care, and a composite of mortality and need for transplant (Tx) in children with congenital (CHD) and acquired heart disease (AHD). Methods: All infants born in Alberta, Canada between 01/01/05 and 31/12/17, and diagnosed before 31/12/17 were included. CHD was categorized as mild, moderate or severe based on the Bethesda Task Force. AHD included cardiomyopathy, myocarditis, heart failure, rheumatic heart disease and endocarditis. Socioeconomic status (SES) was defined by the Canadian Index of Multiple Depravation’s vulnerability index and RoR was calculated using the drive time to one of two pediatric cardiology centers. Risk factors for a composite of mortality and Tx were explored using Cox proportional hazard regression. Results: Among 12,542 children, 74.5% (n=9347) had mild CHD, 13.8% (n=1733) moderate, 5.7% (n=717), severe and 5.9% (n=745) AHD. The composite outcome was highest in severe CHD (19.0%), compared to 13.0% in moderate, 0.5% for mild and 6.9% in AHD, with n=41 undergoing Tx. Among children with CHD, RoR (&gt;180mins, p=0.018), but not SES, was associated with all-cause mortality/Tx (Table 1), while neither RoR (p=0.73) nor SES (p=0.98) were associated with cardiovascular (CV)-specific mortality/Tx. For AHD there was no association between RoR (p=0.73) and SES (p=0.98) with all-cause mortality/Tx (Table 1). Conclusions: Despite Canada’s universal healthcare, children with CHD who live remotely are at increased risk of all-cause mortality/Tx. This is independent of SES and was not true for children with AHD or CV mortality/Tx in those with CHD. Therefore, further understanding of the causes of death in children who live remotely with CHD may help in improving overall outcomes.

298. COMPLIANCE FOR TRIMODALITY TREATMENT OF LOCALLY ADVANCED ESOPHAGEAL CANCER: EXPERIENCE FROM A CANCER CENTRE IN NORTH-EAST INDIA

Abstract Neoadjuvant chemoradiation (NACRT) is a standard approach for treatment of locally advanced esophageal cancer. In real-world scenario, there are several challenges to the completion of such treatment. We aim to estimate the completion rates of such treatment and also estimate the treatment response. Retrospective, observation single-institute study. Study duration was from 1st June 2018 to 30th June 2021. Data was collected from patient’s records and results were presented in median values, range and percentages. A total of 82 patients were planned for trimodality treatment in the Joint Tumour Board during the study period. The number of patients who completed the NACRT was 55 (67.1%). Of them, 11 (13.4%) defaulted by not undergoing esophagectomy and 4 patients (4.9%) had inoperable disease at surgery. A total of 42 patients (51.2% of intention to treat population) actually completed the trimodality treatment. Trans-thoracic esophagectomy was done in 35 and transhiatal esophagectomy in 7 patients. Complete pathological response of both the primary and the nodes (pCR) was noted in 12 patients (26.1%). The compliance for trimodality treatment approach is a key area for improvement in esophageal cancer treatment and we need to decrease ‘drop outs’ due to temporary symptom relief, remoteness of residence, financial hurdles, treatment toxicity with an efficient system of care delivery.

Impact of Socioeconomic Status and Residence Distance on Infant Heart Disease Outcomes in Canada.

Background Socioeconomic status (SES) impacts clinical outcomes associated with severe congenital heart disease (sCHD). We examined the impact of SES and remoteness of residence (RoR) on congenital heart disease (CHD) outcomes in Canada, a jurisdiction with universal health insurance. Methods and Results All infants born in Canada (excluding Quebec) from 2008 to 2018 and hospitalized with CHD requiring intervention in the first year were identified. Neighborhood level SES income quintiles were calculated, and RoR was categorized as residing <100 km, 100 to 299 km, or >300 km from the closest of 7 cardiac surgical programs. In-hospital mortality at <1 year was the primary outcome, adjusted for preterm birth, low birth weight, and extracardiac pathology. Among 7711 infants, 4485 (58.2%) had moderate CHD (mCHD) and 3226 (41.8%) had sCHD. Overall mortality rate was 10.5%, with higher rates in sCHD than mCHD (13.3% versus 8.5%, respectively). More CHD infants were in the lowest compared with the highest SES category (27.1% versus 15.0%, respectively). The distribution of CHD across RoR categories was 52.3%, 21.3%, and 26.4% for <100 km, 100 to 299 km, and >300 km, respectively. Although SES and RoR had no impact on sCHD mortality, infants with mCHD living >300 km had a higher risk of mortality relative to those living <100 km (adjusted odds ratio [aOR], 1.43 [95% CI, 1.11-1.84]). Infants with mCHD within the lowest SES quintile and living farthest away had the highest risk for mortality (aOR, 1.74 [95% CI, 1.08-2.81]). Conclusions In Canada, neither RoR nor SES had an impact on outcomes of infants with sCHD. Greater RoR, however, may contribute to higher risk of mortality among infants with mCHD.

Impact of rural residence and low socioeconomic status on rate and timing of prenatal detection of major congenital heart disease in a jurisdiction of universal health coverage.

Socioeconomic status (SES) and distance of residence from tertiary care may impact fetal detection of congenital heart disease (CHD), partly through reduced access to and quality of obstetric ultrasound screening. It is unknown whether SES and remoteness of residence (RoR) affect prenatal detection of CHD in jurisdictions with universal health coverage. We examined the impact of SES and RoR on the rate and timing of prenatal diagnosis of major CHD within the province of Alberta in Canada. In this retrospective study, we identified all fetuses and infants diagnosed with major CHD in Alberta, from 2008 to 2018, that underwent cardiac surgical intervention within the first year after birth, died preoperatively, were stillborn or underwent termination. Using maternal residence postal code and geocoding, Chan SES index quintile, geographic distance from a tertiary-care fetal cardiology center and the Canadian Index of Remoteness (IoR) were calculated. Outcome measures included rates of prenatal diagnosis and diagnosis after 22 weeks' gestation. Risk ratios (RR) were calculated using log-binomial regression and stratified by rural (≥ 100 km from tertiary care) or metropolitan (< 100 km from tertiary care) residence, adjusting for year of birth and the obstetric ultrasound screening view in which CHD would most likely be detected (four-chamber view; outflow-tract view; three-vessel or three-vessels-and-trachea or non-standard view; septal view). Of 1405 fetuses/infants with major CHD, prenatal diagnosis occurred in 814 (57.9%). Residence ≥ 100 km from tertiary care (adjusted RR, 1.19; 95% CI, 1.05-1.34) and higher IoR (adjusted RR, 1.9; 95% CI, 1.1-3.3) were associated with missed prenatal diagnosis of major CHD. Similarly, residence ≥ 100 km from tertiary care (adjusted RR, 1.41; 95% CI, 1.22-1.62) and higher IoR (adjusted RR, 3.6; 95% CI, 2.2-8.2) were associated with prenatal diagnosis after 22 weeks. Although adjusted and unadjusted analyses showed no association between Chan SES index quintile and prenatal-diagnosis rate overall nor for residence in rural areas, in metropolitan regions, lower SES quintiles were associated with missed prenatal diagnosis (quintile 1: RR, 1.24; 95% CI, 1.02-1.50) and higher risk of diagnosis after 22 weeks' gestation (quintile 1: RR, 1.46; 95% CI, 1.10-1.93; quintile 2: RR, 1.66; 95% CI, 1.24-2.23). Despite universal healthcare, rural residence in Alberta is associated with lower rate of prenatal diagnosis of major CHD and higher risk of late prenatal diagnosis (≥ 22 weeks). Within metropolitan regions, lower SES impacts negatively prenatal-diagnosis rate and timing. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Addressing adverse breast cancer pathobiology in indigenous Australian women

Indigenous women in Australia diagnosed with breast cancer are twice as likely to die of the disease, even after remoteness of residence, socioeconomic factors and higher stage are accounted for. No research to date has identified any underlying cause.

Changes in five-year survival for people with acute leukaemia in South Australia, 1980-2016.

To examine population changes in 5-year survival for people in South Australia diagnosed with acute leukaemia during 1980-2016, by socio-demographic characteristics. Retrospective analysis of South Australian Cancer Registry data for the period 1980-2016. All South Australian residents diagnosed with primary acute lymphoblastic leukaemia (ALL) or acute myeloid leukaemia (AML) during 1980-2016. 5-year disease-specific survival and disease-specific mortality. Crude 5-year disease-specific survival was 58% (95% CI, 54-61%) for the 1035 people diagnosed with ALL during 1980-2016, and 18% (95% CI, 17-20%) for the 2814 people diagnosed with AML. Survival improved steadily across the study period: from 44% (95% CI, 35-52%) for people with ALL diagnosed during 1980-1984 to 69% (95% CI, 63-75%) for those diagnosed during 2010-2016; and from 9% (95% CI, 5-15%) to 23% (95% CI, 20-26%) for people diagnosed with AML. Disease-specific mortality increased with age, but was not influenced by socio-economic status or remoteness of residence. After adjusting for other factors, rates of change in risk of leukaemia-related death were greater for younger than older patients with ALL (for interaction: P=0.004) or AML (P=0.005), but were not significantly influenced by socio-economic status or remoteness. Five-year survival for people with acute leukaemia in South Australia continuously improved during 1980-2016, and socio-economic status and remoteness did not influence survival. It improved markedly for younger patients (under 50 years of age). However, survival is still relatively poor, especially for people over 50 years with AML.

Remoteness of residence predicts tumor stage, receipt of treatment, and mortality in patients with hepatocellular carcinoma.

Background and AimSurveillance and early detection and curative treatment of hepatocellular carcinoma (HCC) are the mainstay of improving survival for patients, but there are several barriers to achieving this goal. We reported the impact of remoteness of residence on receipt of treatment, tumor stage, and survival in patients with HCC in Queensland.MethodsWe conducted a retrospective cohort study of 1651 HCC patients (147 migrants) from 1 January 2007 to 31 December 2016. We used Wilcoxon rank‐sum test to compare the median age at the time of diagnosis and Bayesian Weibull accelerated failure time regression to identify independent predictors of time to death.ResultsThe median survival time after HCC diagnosis was 9.0 months (interquartile range 2.0–24.0). Metropolitan residence (P = 0.02), non‐English language (P < 0.001), foreign country of origin (P < 0.001), and HBV etiology (P < 0.001) were significantly associated with receiving surgical resection for HCC treatment. The strongest predictors of time to death were undifferentiated tumor at presentation (time ratio [TR] = 0.30, 95% credible interval (CrI) 0.23–0.39), age ≥70 years (TR = 0.42, 95% CrI 0.34–0.53), living in remote areas (TR = 0.67, 95% CrI 0.55–0.80), and presence of ≥1 comorbidity (TR = 0.69 95% CrI 0.54–0.90). All the other covariates adjusted, including country of birth (TR = 0.76, 95% CrI 0.49–1.06), did not predict survival time.ConclusionsPatients living in rural and remote areas had late stage clinical presentation and poor survival. Remoteness of residence may limit access to HCC surveillance in at‐risk patients such as those with cirrhosis, and timely curative treatment to improve survival in these patients.

Breast cancer treatment and survival differences in women in remote and socioeconomically disadvantaged areas, as demonstrated by linked data from New South Wales (NSW), Australia

IntroductionReducing variations in cancer treatment and survival is a key aim of the NSW Cancer Plan. Variations in breast cancer treatment and survival in NSW by remoteness and socioeconomic status of residence were investigated to determine benchmarks. Reducing variations in cancer treatment and survival is a key aim of the NSW Cancer Plan. Variations in breast cancer treatment and survival in NSW by remoteness and socioeconomic status of residence were investigated to determine benchmarks.MethodsA retrospective cohort study used linked data for invasive breast cancers, diagnosed in May 2002 to December 2015 from the NSW Cancer Registry, with corresponding inpatient, and medical and pharmaceutical insurance data. Associations between treatment modalities, area socioeconomic status and residential remoteness were explored using logistic regression. Predictors of breast cancer survival were investigated using Kaplan–Meier product-limit estimates and multivariate competing risk regression.ResultsResults indicated a high 5-year disease-specific survival in NSW of 90%. Crude survival was equivalent by residential remoteness and marginally lower in lower socioeconomic areas. Competing risk regression showed equivalent outcomes by area socioeconomic status, except for the least disadvantaged quintile, which showed a higher survival. Higher sub-hazard ratios for death occurred for women with breast cancer aged 70 + years, and more advanced stage. Adjusted analyses indicated more advanced stage in lower socioeconomic areas, with less breast reconstruction and radiotherapy, and marginally less hormone therapy for women from these areas. Conversely, among these women who had breast conserving surgery, there was higher use of chemotherapy. Remoteness of residence was associated in adjusted analyses with less radiotherapy and less immediate breast reconstruction. In these short term data, remoteness of residence was not associated with lower survival.ConclusionThis study provides benchmarks for monitoring future variations in treatment and survival.

The change from UMAT to UCAT for undergraduate medical school applicants: impact on selection outcomes.

To assess whether the change from the Undergraduate Medical and Health Sciences Admissions Test (UMAT; 1991-2019) to the University Clinical Aptitude Test (UCAT) for the 2020 New South Wales undergraduate medical degree intake was associated with changes in the impact of sex, socio-economic status and remoteness of residence, and professional coaching upon selection for interview. Cross-sectional study of applicants for the three NSW undergraduate medical programs for entry in 2019 (4114 applicants) or 2020 (4270); 703 people applied for both intakes. Applicants selected for interview were surveyed about whether they had received professional coaching for the selection test. Scores on the three sections of the UMAT (2019 entry cohort) and the five subtests of the UCAT (2020 entry); total UMAT and UCAT scores. Mean scores for UMAT 1 and 3 and for all four UCAT cognitive subtests were higher for men than women; the differences were statistically significant after adjusting for age, socio-economic status, and remoteness. The effect size for sex was 0.24 (95% CI, 0.18-0.30) for UMAT total score, 0.38 (95% CI, 0.32-0.44) for UCAT total score. For the 2020 intake, 2303 of 4270 applicants (53.9%) and 476 of 1074 interviewees (44.3%) were women. The effect size for socio-economic status was 0.47 (95% CI, 0.39-0.54) for UMAT, 0.43 (95% CI, 0.35-0.50) for UCAT total score; the effect size for remoteness was 0.54 (95% CI, 0.45-0.63) for UMAT, 0.48 (95% CI, 0.39-0.58) for UCAT total score. The impact of professional coaching on UCAT performance was not statistically significant among those accepted for interview. Women and people from areas outside major cities or of lower socio-economic status perform less well on the UCAT than other applicants. Reviewing the test and applicant quotas may be needed to achieve selection equity.

Survival following abdominal aortic aneurysm repair in North Queensland is not associated with remoteness of place of residence.

ObjectiveTo assess whether survival and clinical events following elective abdominal aortic aneurysm (AAA) repair were associated with remoteness of residence in North Queensland, Australia.MethodsThis retrospective cohort study included participants undergoing elective AAA repair between February 2002 and April 2020 at two hospitals in Townsville, North Queensland, Australia. Outcomes were all-cause survival and AAA-related events, defined as requirement for repeat AAA repair or AAA-related mortality. Remoteness of participant’s place of residence was assessed by the Modified Monash Model classifications and estimated distance from the participants’ home to the tertiary vascular centre. Cox proportional hazard analysis examined the association of remoteness with outcome.ResultsThe study included 526 participants undergoing elective repair by open (n = 204) or endovascular (n = 322) surgery. Fifty-four (10.2%) participants had a place of residence at a remote or very remote location. Participants' were followed for a median of 5.2 (inter-quartile range 2.5–8.3) years, during which time there were 252 (47.9%) deaths. Survival was not associated with either measure of remoteness. Fifty (9.5%) participants had at least one AAA-related event, including 30 (5.7%) that underwent at least one repeat AAA surgery and 23 (4.4%) that had AAA-related mortality. AAA-related events were more common in participants resident in the most remote areas (adjusted hazard ratio 2.83, 95% confidence intervals 1.40, 5.70) but not associated with distance from the participants’ residence to the tertiary vascular centreConclusionsThe current study found that participants living in more remote locations were more likely to have AAA-related events but had no increased mortality following AAA surgery. The findings emphasize the need for careful follow-up after AAA surgery. Further studies are needed to examine the generalisability of the findings.

Does Prison Deter Drunk-Drivers?

To examine the specific deterrent effect of prison on driving under the influence of alcohol (DUI) recidivism. The study outcomes were the probabilities of DUI re-offending over 6 months, 24 months and 5 years ‘free time’ (i.e. time not spent in custody). The comparison group consisted of offenders convicted of DUI offending who received a suspended sentence of imprisonment. The effect of imprisonment was examined in a series of 2SLS models; employing an extensive set of controls (age, gender, race, remoteness of residence, socioeconomic status, legal representation, number of concurrent offences, DUI blood alcohol range, number of prior court appearances, prior penalties) and variation in the judicial proclivity to imprison convicted drunk drive offenders as an instrument to identify the effect of prison on DUI re-offending. Our free-time analyses reveal no evidence that imprisonment reduces the risk of DUI recidivism. Separate analyses for first-time DUI offenders revealed a slight (5%) reduction in re-offending over 24 months free time but no effect over 5 years. We conclude that the funds currently spent on imprisoning DUI offenders could be more fruitfully be invested in measures that show more promise in reducing DUI recidivism.

Incidence and factors associated with geographical relocation in patients receiving renal replacement therapy

BackgroundRenal replacement therapy (RRT) places a burden on patients, and geographical relocation for easier access to healthcare facilities is a necessity for some. Incidence and factors associated with relocation has not been comprehensively examined at a national level. We aimed to determine proportion, incidence, characteristics of RRT patients who relocate and relocation rate by remoteness of residence and dialysis modality.MethodsRetrospective cohort analysis using Australian and New Zealand Dialysis and Transplant Registry to examine RRT patients in Australia from January 2005 to December 2015. Relocation incidence was calculated for remoteness of residence and RRT modality as rate per 100 patient years. Factors associated with relocation were examined using competing risk regression models with death as a competing event.ResultsOf 24,676 incident patients on RRT, 5888 (23.9%) relocated with a median time of 1.6 years [IQR 0.7–3.4] years. Relocation incidence was 7.9 per 100 patient years and increased from major cities to very remote regions (7.2 to 48.8 per 100 patient years respectively, p < 0.001). Remoteness of residence was associated with geographical relocation in competing risk analysis especially in remote (SHR 1.20, 95%CI 1.01, 1.41 p = 0.034) and very remote regions (SHR 3.51 95% 3.05, 4.04 p < 0.001). Aboriginal or Torres Strait Islander ethnicity, compared to Caucasian, was independently associated with relocation (SHR 1.18, 95% CI 1.06,1.31, p = 0.002) while transplant patients were less likely to relocate compared to haemodialysis patients (HR 0.37, 95%CI 0.34, 0.39, p < 0.001).ConclusionsRelocation in patients receiving RRT is associated with remoteness of residence, RRT modality and ethnicity. Reasons for relocation and its impact on patient wellbeing and outcome should be further explored.

Differences in cancer survival by remoteness of residence: an analysis of data from a population-based cancer registry.

Cancer survival is generally lower for rural compared with urban residents, but findings have been inconsistent. We aimed to assess inequalities in cancer survival by remoteness of residence in Victoria, Australia. Incident cancer cases diagnosed in 2001-2015 with 30 cancer types (n = 331,302) were identified through the Victorian Cancer Registry and followed to the end of 2015 through death registries. Five-year net survival was estimated using the Pohar-Perme method and differences assessed by excess mortality rate ratios (EMRRs) using Poisson regression, adjusting for sex, age and year of diagnosis. EMRRs adjusted for socio-economic disadvantage were also estimated. People living outside major cities had lower survival for 11 cancers: esophagus, stomach, colorectum, liver, gallbladder/biliary tract, pancreas, lung, connective/soft tissue, ovary, prostate, kidney. No differences in survival were found for cancers of uterus, small intestine and mesothelioma. After adjusting for socio-economic disadvantage, the observed differences in survival decreased for most cancers and disappeared for colorectal cancer, but they remained largely unchanged for cancers of esophagus, stomach, liver, pancreas, lung, connective/soft tissue, ovary and kidney. People with cancer residing outside major cities had lower survival from some cancers, which is partly due to the greater socio-economic disadvantage of rural residents.