Socioeconomic Inequalities In Access Research Articles

Out-of-hours emergent surgery for degenerative spinal disease in Canada: a retrospective cohort study from a national registry

BackgroundSpinal degenerative disease represents a growing burden on our healthcare system, yet little is known about longitudinal trends in access and care. Our goal was to provide an essential portrait of surgical volume trends for degenerative spinal pathologies within Canada. MethodsThe Canadian Institute for Health Information (CIHI) database was used to identify all patients receiving surgery for a degenerative spinal condition from 2006 to 2019. Trends in number of interventions, unscheduled vs. scheduled hospitalizations, in-hours vs. out-of-hours interventions, resource utilization and adverse events were analyzed retrospectively using linear regression models. Confidence intervals were reported in the expected count ratio scale (CR). FindingsA total of 338,629 spinal interventions and 256,360 hospitalizations between 2006-2019 were analyzed. The mean and SD of the annual mean age of patients was 55.5 (SD 1.6) for elective hospitalizations and 55.6 (SD 1.6) for emergent hospitalizations. The proportion of female patients was 47.8% (91,789/192,027) for elective hospitalizations and 41.4% (26,633/64,333) for emergent hospitalizations. Elective hospitalizations increased an average of 2.0% per year, with CR=1.020 (95%CI 1.017 – 1.023, p<0.0001) while emergent hospitalizations exhibited more rapid growth with an average 3.4% annually, with CR 1.034 (95%CI 1.027 – 1.040, p<0.0001). «In-hours» surgeries increased on average 2.7% per year, with CR 1.027 (95%CI 1.021-1.033, p<0.0001), while «out-of-hours» surgeries increased 6.1% annually, with CR 1.061 (95%CI 1.051-1.071, p<0.0001). The resource utilization for unscheduled hospitalizations approximates two and a half times that of scheduled hospitalizations. The proportions of spinal interventions with at least one adverse event increased on average 6.3% per year, with CR 1.063 (95%CI 1.049-1.077, p<0.0001). InterpretationThis study provides novel data critical for all providers and stakeholders. The rapid growth of emergent out-of-hours hospitalizations demonstrates that the needs of this growing patient population have far exceeded health-care resource allocations. Future studies will analyze the health-related quality of life implications of this system shift and identify demographic and socioeconomic inequities in access to surgical care.

Socioeconomic inequalities in access to online learning and its association with early childhood development during the COVID-19 pandemic in Yunnan Province, China

While online learning was widely adopted by schools during the COVID-19 pandemic globally, little is known about its effects on preschool children’s development in China. Using a unique dataset collected in Yunnan Province, China in 2020, with a sample of 11,990 children aged 3–5 years from 285 kindergartens, we provide the first comprehensive assessment of socioeconomic inequalities in access to online learning and its association with early childhood development (ECD). The study demonstrates significant inequalities in access to online learning. Particularly, preschoolers with rural household residential registration (Hukou), lower maternal schooling, and lower family income are less likely to have access to online learning than their counterparts. Regression results based on the Generalized Linear Model (GLM) and the Instrumental Variable (IV) method show that access to online learning is positively associated with a child’s ECD score. The empirical evidence of the unequal access to online learning and its possible consequence in ECD during the pandemic has policy implications that the ever-widening developmental gap for those lacking access to online learning needs to be addressed accordingly when the pandemic is over.

Socioeconomic inequalities in hospital access for prostate cancer before and after COVID-19

Prostate cancer is one of the most common cancers with 36,016 registered cases in 2020 in the United Kingdom. Access to cancer care remains a policy priority across OECD countries, but there are concerns that socioeconomic inequalities have been amplified following the COVID-19 pandemic due to accumulated backlogs. Using administrative data from the Hospital Episodes Statistics, this study examines socioeconomic inequalities in different dimensions of access to prostate cancer surgery in England in 2015–22, and whether such inequalities increased after COVID-19. Access is a multifaceted concept encompassing several dimensions along the patient pathway. We investigate socioeconomic inequalities in the volume of surgeries, waiting time of patients on the list (patient responsiveness), hospital length of stay (intensity of care), 30-day emergency readmissions and 3-year mortality (health outcomes). We find that, after controlling for a range of factors (e.g. age composition, ethnicity, rurality, primary care availability), the number of prostate surgeries for the most income-deprived quintile is 41.0 % lower than the least income-deprived quintile in the pre-COVID period. The gradient appears similar in the post-COVID period in proportionate terms when volume dropped. We generally find no evidence of inequalities in other dimensions of access, such as waiting times (from patient addition to treatment list) and length of stay (from hospital admission to discharge). We also find no evidence of inequalities in the probability of being readmitted as an emergency within 30 days from discharge. Instead, patients in the most income-deprived quintile have a higher mortality rate by at least one percentage point relative to the least-deprived quintile. This difference in mortality does not appear to be related to differences in the quality of care across hospitals. The analysis highlights the need to take a multidimensional approach when assessing socioeconomic inequalities in access to hospital care along the patient pathway.

Socioeconomic Deprivation and Invasive Breast Cancer Incidence by Stage at Diagnosis: A Possible Explanation to the Breast Cancer Social Paradox.

In this study, we assessed the influence of area-based socioeconomic deprivation on the incidence of invasive breast cancer (BC) in France, according to stage at diagnosis. All women from six mainland French departments, aged 15+ years, and diagnosed with a primary invasive breast carcinoma between 2008 and 2015 were included (n = 33,298). Area-based socioeconomic deprivation was determined using the French version of the European Deprivation Index. Age-standardized incidence rates (ASIR) by socioeconomic deprivation and stage at diagnosis were compared estimating incidence rate ratios (IRRs) adjusted for age at diagnosis and rurality of residence. Compared to the most affluent areas, significantly lower IRRs were found in the most deprived areas for all-stages (0.85, 95% CI 0.81-0.89), stage I (0.77, 95% CI 0.72-0.82), and stage II (0.84, 95% CI 0.78-0.90). On the contrary, for stages III-IV, significantly higher IRRs (1.18, 95% CI 1.08-1.29) were found in the most deprived areas. These findings provide a possible explanation to similar or higher mortality rates, despite overall lower incidence rates, observed in women living in more deprived areas when compared to their affluent counterparts. Socioeconomic inequalities in access to healthcare services, including screening, could be plausible explanations for this phenomenon, underlying the need for further research.

Race and Socioeconomic Status as Predictors of Willingness to Use Digital Mental Health Interventions or One-On-One Psychotherapy: National Survey Study.

There is an ongoing debate about whether digital mental health interventions (DMHIs) can reduce racial and socioeconomic inequities in access to mental health care. A key factor in this debate involves the extent to which racial and ethnic minoritized individuals and socioeconomically disadvantaged individuals are willing to use, and pay for, DMHIs. This study examined racial and ethnic as well as socioeconomic differences in participants' willingness to pay for DMHIs versus one-on-one therapy (1:1 therapy). We conducted a national survey of people in the United States (N=423; women: n=204; mean age 45.15, SD 16.19 years; non-Hispanic White: n=293) through Prolific. After reading descriptions of DMHIs and 1:1 therapy, participants rated their willingness to use each treatment (1) for free, (2) for a small fee, (3) as a maximum dollar amount, and (4) as a percentage of their total monthly income. At the end of the study, there was a decision task to potentially receive more information about DMHIs and 1:1 therapy. Race and ethnicity was associated with willingness to pay more of one's income, as a percent or in dollar amounts, and was also associated with information-seeking for DMHIs in the behavioral task. For most outcomes, race and ethnicity was not associated with willingness to try 1:1 therapy. Greater educational attainment was associated to willingness to try DMHIs for free, the decision to learn more about DMHIs, and willingness to pay for 1:1 therapy. Income was inconsistently associated to willingness to try DMHIs or 1:1 therapy. If they are available for free or at very low costs, DMHIs may reduce inequities by expanding access to mental health care for racial and ethnic minoritized individuals and economically disadvantaged groups.

Socioeconomic inequalities in utilizing maternal health care in five South Asian countries: A decomposition analysis.

High maternal mortality rates still today remain a significant public health concern in South Asian countries. The majority of maternal deaths occur during pregnancy, and these deaths may typically be avoided by ensuring that women have access to reliable maternity care such as antenatal care (ANC) and facility delivery. The objectives of this research were to assess socioeconomic disparities in the utilization of health care services by mothers and to determine the factors influencing this utilization among women aged 15 to 49 in five South Asian countries. For this study, nationally representative data from the Demographic and Health Survey (DHS) were analyzed. This research included a total of 262,531 women between the ages of 15 and 49. To determine the likely causes of maternal health care utilization, simple bivariate statistics and binary logistic regression were applied, and decomposition analysis and the concentration curve were used to quantify disparity (Lorenz curve). ANC and institutional delivery were both prevalent in 59.27% and 86.52% of cases, respectively. Among the five nations, Maldives has the greatest ANC (96.83%) and institutional delivery (99.39%), while Bangladesh has the lowest ANC (47.01%) and institutional delivery (49.81%). Women's and husbands' education, household wealth status, BMI, and urban residents are the most important factors influencing maternal health service utilization, whereas higher education level, affluent wealth quintiles, and place of residence are the major contributors to socioeconomic inequalities in access to maternal health care that favor the wealthy. Maternal health care services must be utilized properly in order to promote optimal health and prevent maternal mortality. Several socioeconomic and sociodemographic variables of the individual population, as well as policy issues, all have an impact on maternal mortality. This research recommends for concerted action to enhance how successfully women use maternity care services.

Racial and income inequalities in access to healthcare in Brazilian cities

IntroductionPeople's access to public healthcare can importantly contribute to reducing the prevalence of diseases and increasing life expectancy. Despite the advances of Brazil's Unified Health System (SUS), the country faces a permanent challenge in improving the coverage and equity of healthcare to reduce racial, spatial, and income inequalities in access to healthcare. Several studies have explored the spatial dimension of socioeconomic inequalities in access to healthcare in Brazil, but few analyze such inequalities within cities and bring evidence of racial inequalities. MethodsThis paper presents the first large-scale study in Brazil examining the social and racial inequalities of access to healthcare at a high spatial resolution. The analysis covers access to primary and high-complexity public healthcare by public transport, automobile, and walking for the 20 largest cities in Brazil in 2019. ResultsThe results show that individuals with low income, regardless of race, have greater accessibility to primary healthcare in general. In contrast, individuals with high-income, mostly white, have substantially better accessibility to high-complexity healthcare. Yet, we find that racial inequalities in access to healthcare become much smaller when controlling for income. ConclusionsThe results contribute to a better understanding of the geographical dimension of inequalities in access to healthcare in major Brazilian cities, showing how access to healthcare is strongly conditioned by social, economic, and transport-related factors.

Racial, Ethnic, Socioeconomic, and Geographic Inequities in Access to Mechanical Circulatory Support

BackgroundHospital admissions for cardiogenic shock have increased in the United States. Temporary mechanical circulatory support (tMCS) can be used to acutely stabilize patients. We sought to evaluate the presence of racial, ethnic, and socioeconomic inequities in access to MCS in the United States among patients with cardiogenic shock. MethodsMedicare data were used to identify patients with cardiogenic shock admitted to hospitals with advanced tMCS (microaxial left ventricular assist device [mLVAD] or extracorporeal membranous oxygenation [ECMO]) capabilities within the 25 largest core-based statistical areas, all major metropolitan areas. We modeled the association between patient race, ethnicity, and socioeconomic status and use of mLVAD or ECMO. ResultsAfter adjusting for age and clinical comorbidities, dual eligibility for Medicaid was associated with a 19.9% (95% CI, 11.5%-27.4%) decrease in odds of receiving mLVAD in a patient with cardiogenic shock (P < .001). After adjusting for age, clinical comorbidities, and dual eligibility for Medicaid, Black race was associated with 36.7% (95% CI, 28.4%-44.2%) lower odds of receiving mLVAD in a patient with cardiogenic shock. Dual eligibility for Medicaid was associated with a 62.0% (95% CI, 60.8%-63.1%) decrease in odds of receiving ECMO in a patient with cardiogenic shock (P < .001). Black race was associated with 36.0% (95% CI, 16.6%-50.9%) lower odds of receiving ECMO in a patient with cardiogenic shock, after adjusting for Medicaid eligibility. ConclusionsWe identified large and significant racial, ethnic, and socioeconomic inequities in access to mLVAD and ECMO among patients presenting with cardiogenic shock to metropolitan hospitals with active advanced tMCS programs. These findings highlight systematic inequities in access to potentially lifesaving therapies.

What a journey! – A short history of the Finnish health care and social service reform and administrative integration of health care and social services

Abstract Finland is a Nordic welfare state with universal access to tax-funded health care. While the health system performs relatively well when measured in terms of avoidable mortality, several measures indicate that access to care, especially primary care, is poor. There are also relatively large geographical and socioeconomic inequities in access, utilization, and quality of services. To tackle these issues, a process to reform the health system was initiated in the early 2000s. However, it was not until 2021 when the large-scale reform of the system was enacted and not until 2023 when the new structure was implemented. The process involved several different reform proposals which all shaped the outcome of the reform. The key feature in almost all the reform proposals and in the final reform plan has been fostering vertical integration in health care and horizontal integration of health and social services both at the level of administration and organization as well as through processes and patient pathways. In this presentation we describe the history of the Finnish health and social care reform process and discuss, how integrated care as a policy idea and tool has shaped the reform agenda and reform proposals.

Join to connect? Voluntary involvement, social capital, and socioeconomic inequalities

Access to social capital is stratified by socioeconomic status and has been cross-sectionally linked to involvement in voluntary organizations. Yet, we know little about the origin and interplay of these empirical regularities. Regression analyses on German panel data (SC6-NEPS) reveal that people rich in social capital join organizations more often (selection). Furthermore, joiners access more and higher-status social capital after joining (socializing opportunities). Low-status individuals disproportionally extend their reach towards higher positions through involvement but join less often. Compared to a counterfactual situation in which nobody joins, current involvement patterns marginally reduce some socioeconomic inequalities in access to social capital.

Regional and socioeconomic inequalities in access to pre-primary education in India: evidence from a recent household survey

In India, the National Education Policy 2020 recommends ensuring universal access to high-quality early childhood care and education for children aged 3–6 years by 2030. Using the 75th round of National Statistical Office data (2017–2018), this paper analyses the regional and socioeconomic inequalities in access to pre-primary education. Also, we investigate the specific role of households’ economic status and educational attainment in explaining these inequalities. We find considerable regional (rural/urban) and socioeconomic inequalities in access to pre-primary education in India, with girls and children belonging to historically disadvantaged social groups (scheduled castes and scheduled tribes) less likely to attend early childhood education, particularly in rural areas. We find that a substantial portion of the rural–urban gap in access to pre-primary education can be removed by controls for households’ economic condition and household head’s educational status. In addition, we find gender and socioeconomic inequalities in the household investment in early years education. These findings highlight the need to put policy efforts and commitments to reducing barriers to accessing pre-primary education for children in disadvantaged conditions in India.

Socioeconomic Inequalities and Predictors of Cardiac Rehabilitation Referral: Real World Evidence.

To identify factors associated with CR referral following an acute coronary syndrome (ACS) at a university hospital. We analyzed 2,814 hospitalizations due to ACS between 2017 and 2019 in Centro Hospitalar São João. The hospital's morbidity database was used to retrieve patient information. CR referral and participation was identified from administrative databases and clinical records. Socioeconomic data was obtained from municipality of residence-level data rather than patient-specific data. Of 2,814 hospitalizations, 72% (2,028 cases) were eligible for CR. Mean age was 65.2 ± 13.4; 72% men, 33% diabetic, 57.1% hypertensive and 63.6% dyslipidemic. CR referral rate was low, at 18.8%, with 42 (11.0%) not attending CR and 39 (10.2%) dropping out. Females (odds ratio (OR): 0.72 (95% CI: 0.52-1.00), older patients (OR: 0.57 (0.42-0.77)); 55-64 years vs <55 years) and those coming from lower income municipalities (OR: 0.53 (0.41-0.69)), below median vs above median) with lower education level (OR: 0.70 (0.54-0,92); ≤ 4 years vs >4 years) were less likely to be referred to CR. There is a need for new strategies to promote CR in disadvantaged groups, as gender, age, and socioeconomic inequities in access to CR remain unresolved.

Cross-national differences in wealth inequality in health services and caregiving used near the end of life

Socioeconomic inequality in access to and use of health services and social care provided near the end oflife, or end-of-life care (EOLC), is not well understood in many countries. We examined wealth inequality in EOLC-hospital, nursing home, and hospice use and receipt of formal and informal caregiving-in 22 countries in Europe, Asia (South Korea), and North America (United States, Mexico). We used harmonized data from nationally representative studies of people aged 50 and older that collected information on healthcare utilisation and caregiving receipt in the time preceding death. We categorized countries according to their level of public long-term care (LTC) spending and examined EOLC prevalence across countries. We used logistic regression models to estimate wealth inequality in each type of EOLC. In the USA the least wealthy had more hospital (OR 1.30, p=0.008) and nursing home/care use (OR 1.88, p<0.001). In South Korea the least wealthy had more nursing home/care use (OR 2.24, p=0.003). The least wealthy in high LTC Europe had less hospice use (OR 0.56, p=0.003). The least wealthy were also less likely to be hospitalized in European countries with low LTC spending (OR 0.81, p=0.04), but more likely to receive informal caregiving (OR 1.25, p=0.033). Formal care was more common among the least wealthy in high LTC Europe (OR 1.57, p=0.002), the USA (OR 1.42, p<0.001) and South Korea (OR 1.69, p=0.028), but less common among the least wealthy in Mexico (OR 0.17, p<0.001). Wealth inequality in EOLC exists across countries and reflects differences in the organization, financing, and delivery of care in different countries. The findings highlight the need to consider equity in current and future plans to improve EOLC access. United States National Institute on Aging Grant R01AG030153.

Racial, Ethnic, and Socioeconomic Inequities in Access to Left Atrial Appendage Occlusion.

Background Inequitable access to high-technology therapeutics may perpetuate inequities in care. We examined the characteristics of US hospitals that did and did not establish left atrial appendage occlusion (LAAO) programs, the patient populations those hospitals served, and the associations between zip code-level racial, ethnic, and socioeconomic composition and rates of LAAO among Medicare beneficiaries living within large metropolitan areas with LAAO programs. Methods and Results We conducted cross-sectional analyses of Medicare fee-for-service claims for beneficiaries aged 66 years or older between 2016 and 2019. We identified hospitals establishing LAAO programs during the study period. We used generalized linear mixed models to measure the association between zip code-level racial, ethnic, and socioeconomic composition and age-adjusted rates of LAAO in the most populous 25 metropolitan areas with LAAO sites. During the study period, 507 candidate hospitals started LAAO programs, and 745 candidate hospitals did not. Most new LAAO programs opened in metropolitan areas (97.4%). Compared with non-LAAO centers, LAAO centers treated patients with higher median household incomes (difference of $913 [95% CI, $197-$1629], P=0.01). Zip code-level rates of LAAO procedures per 100 000 Medicare beneficiaries in large metropolitan areas were 0.34% (95% CI, 0.33%-0.35%) lower for each $1000 zip code-level decrease in median household income. After adjustment for socioeconomic markers, age, and clinical comorbidities, LAAO rates were lower in zip codes with higher proportions of Black or Hispanic patients. Conclusions Growth in LAAO programs in the United States had been concentrated in metropolitan areas. LAAO centers treated wealthier patient populations in hospitals without LAAO programs. Within major metropolitan areas with LAAO programs, zip codes with higher proportions of Black and Hispanic patients and more patients experiencing socioeconomic disadvantage had lower age-adjusted rates of LAAO. Thus, geographic proximity alone may not ensure equitable access to LAAO. Unequal access to LAAO may reflect disparities in referral patterns, rates of diagnosis, and preferences for using novel therapies experienced by racial and ethnic minority groups and patients experiencing socioeconomic disadvantage.

Austerity, economic hardship and access to medications: a repeated cross-sectional population survey study, 2013–2020

BackgroundIn Finland, austerity measures included an increase in medication and healthcare copayments and a decrease in many social security allowances. This study examines whether austerity coincided with an increase in...

Socioeconomic inequalities in utilizing facility delivery in Bangladesh: A decomposition analysis using nationwide 2017-2018 demographic and health survey data.

In many low- and middle-income countries (LMICs), including Bangladesh, socioeconomic inequalities in access to maternity care remain a substantial public health concern. Due to the paucity of research, we attempted to determine the factors affecting the facility delivery, quantify wealth-related inequality, and identify potential components that could explain the inequality. We used the latest Bangladesh Demographic and Health Survey (BDHS 2017-18) data in this study. We utilized logistic regression to investigate the associated factors of facility delivery. The concentration curves (CC), concentration index (CIX) and decomposition of CIX techniques were used to analyze the inequality in-facility delivery. Women living in the urban areas, age at first birth after (18-24 years ≥25 years), being overweight/obese, having secondary and higher-level education of the women and their husband, seeking four or more ANC, coming from more affluent households, and women with high enlightenment were significant determinants of facility delivery. The concentration curve was below the line of equality, and the relative concentration index (CIX) was 0.205 (p <0.001), indicating that women from wealthy groups were disproportionately more prevalent to facility delivery. The decomposition analysis reveals that wealth status of women (57.40%), age at first birth (10.24%), husband's education (8.96%), husband's occupation (7.35%), education of women (7.13%), women's enlightenment (6.15%), residence (8.64%) and ANC visit (6.84%) are the most major contributors to the inequalities in utilizing facility delivery. The study demonstrates a clear disparity in the use of facility delivery among Bangladeshi women; hence, immediate action is required to lower the inequalities, with a special emphasis on the contributing factors.

THE NECESSITY OF INTRODUCTION THE DRUG INSURANCE SYSTEM IN ARMENIA

The increase in the cost of the medicinal component of the treatment, the spread of chronic diseases, and the maintenance of socio-economic inequality in access to health services require the provision of adequate access to medicines. These issues create prerequisites for the improvement of the state health policy and, first, the drug supply system, which is an integral part of the treatment process. The financing of healthcare in Armenia is mainly formed from budget allocations and out of pocket expenditures of the population. Reducing the financial burden on the state and ensuring the rational use of drugs contributes to improving the health of the population. The implementation of a drug insurance scheme, which partially or fully cover the cost of drugs in RA, is one of the solutions for resolving the issue of access to medicines. This article studies the problems of financing healthcare system in Armenia and highlights the need of introduction a drug insurance system in Armenia

Effect of Socioeconomic Factors on the Choice of Health care Institutions for Delivery Care

During the past two decades, Pakistan witnessed a significant progress in maternal health outcomes. However, there exist persistent urban-rural and socio-economic inequalities in access and utilization of maternal healthcare services across the country. The overall objective of this research was to identify the significant socio-economic factors determining the choice of healthcare institutions for delivery care. This was a cross-sectional study conducted in Rajan Pur, a predominantly rural district in Punjab province. Using a multi-stage random sampling technique, 368 mothers who had childbirths from 1st October to 31st December 2020 in different healthcare institutions were interviewed. Data for the study was collected through a validated study instrument used by earlier studies on maternal healthcare utilization. The results of logistic regression analysis showed that use of public healthcare facilities for delivery care increases with increasing maternal education, monthly household income, and distance to healthcare facilities. The findings and recommendations drawn from the research would provide some insights to health policymakers and planners in developing an integrated and viable maternal healthcare program in Pakistan.

Socioeconomic inequalities in cancer incidence and access to health services among children and adolescents in China: a cross-sectional study

Despite the substantial burden caused by childhood cancer globally, childhood cancer incidence obtained in a nationwide childhood cancer registry and the accessibility of relevant health services are still unknown in China. We comprehensively assessed the most up-to-date cancer incidence in Chinese children and adolescents, nationally, regionally, and in specific population subgroups, and also examined the association between cancer incidence and socioeconomic inequality in access to health services. In this national cross-sectional study, we used data from the National Center for Pediatric Cancer Surveillance, the nationwide Hospital Quality Monitoring System, and public databases to cover 31 provinces, autonomous regions, and municipalities in mainland China. We estimated the incidence of cancer among children (aged 0-14 years) and adolescents (aged 15-19 years) in China through stratified proportional estimation. We classified regions by socioeconomic status using the human development index (HDI). Incidence rates of 12 main groups, 47 subgroups, and 81 subtypes of cancer were reported and compared by sex, age, and socioeconomic status, according to the third edition of the International Classification of Childhood Cancer. We also quantified the geographical and population density of paediatric oncologists, pathology workforce, diagnoses and treatment institutions of paediatric cancer, and paediatric beds. We used the Gini coefficient to assess equality in access to these four health service indicators. We also calculated the proportions of cross-regional patients among new cases in our surveillance system. We estimated the incidence of cancer among children (aged 0-14 years) and adolescents (aged 15-19 years) in China from Jan 1, 2018, to Dec 31, 2020. An estimated 121 145 cancer cases were diagnosed among children and adolescents in China between 2018 and 2020, with world standard age-standardised incidence rates of 122·86 (95% CI 121·70-124·02) per million for children and 137·64 (136·08-139·20) per million for adolescents. Boys had a higher incidence rate of childhood cancer (133·18 for boys vs 111·21 for girls per million) but a lower incidence of adolescent cancer (133·92 for boys vs 141·79 for girls per million) than girls. Leukaemias (42·33 per million) were the most common cancer group in children, whereas malignant epithelial tumours and melanomas (30·39 per million) surpassed leukaemias (30·08 per million) in adolescents as the cancer with the highest incidence. The overall incidence rates ranged from 101·60 (100·67-102·51) per million in very low HDI regions to 138·21 (137·14-139·29) per million in high HDI regions, indicating a significant positive association between the incidence of childhood and adolescent cancer and regional socioeconomic status (p<0·0001). The incidence in girls showed larger variation (48·45% from the lowest to the highest) than boys (36·71% from lowest to highest) in different socioeconomic regions. The population and geographical densities of most health services also showed a significant positive correlation with HDI levels. In particular, the geographical density distribution (Gini coefficients of 0·32-0·47) had higher inequalities than population density distribution (Gini coefficients of 0·05-0·19). The overall proportion of cross-regional patients of childhood and adolescent cancer was 22·16%, and the highest proportion occurred in retinoblastoma (56·54%) and in low HDI regions (35·14%). Our study showed that the burden of cancer in children and adolescents in China is much higher than previously nationally reported from 2000 to 2015. The distribution of the accessibility of health services, as a social determinant of health, might have a notable role in the socioeconomic inequalities in cancer incidence among Chinese children and adolescents. With regards to achieving the Sustainable Development Goals, policy approaches should prioritise increasing the accessibility of health services for early diagnosis to improve outcomes and subsequently reduce disease burdens, as well as narrowing the socioeconomic inequalities of childhood and adolescent cancer. National Major Science and Technology Projects of China, National Natural Science Foundation of China, Chinese Academy of Engineering Consulting Research Project, Wu Jieping Medical Foundation, Beijing Municipal Administration of Hospitals Incubating Program.

Socioeconomic inequality in access to timely and appropriate care in emergency departments

In publicly-funded healthcare systems, waiting times for care should be based on need rather than ability to pay. Studies have shown that individuals with lower socioeconomic status face longer waits for planned inpatient care, but there is little evidence on inequalities in waiting times for emergency care. We study waiting times in emergency departments (EDs) following arrival by ambulance, where health consequences of extended waits may be severe. Using data from all major EDs in England during the 2016/17 financial year, we find patients from more deprived areas face longer waits during some parts of the ED care pathway. Inequalities in waits are small, but more deprived individuals also receive less complex ED care, are less likely to be admitted for inpatient care, and are more likely to re-attend ED or die shortly after attendance. Patient-physician interactions and unconscious bias towards more deprived patients may be important sources of inequalities.