Colon cancer care of Hispanic people in California: Paradoxical barrio protections seem greatest among vulnerable populations.

Background: We examined paradoxical and barrio advantaging effects on cancer care among socioeconomically vulnerable Hispanic people in California. Methods: We secondarily analyzed a colon cancer cohort of 3,877 non-Hispanic white (NHW) and 735 Hispanic people treated between 1995 and 2005. A third of the cohort was selected from high poverty neighborhoods. Hispanic enclaves and Mexican American (MA) barrios were neighborhoods where 40% or more of the residents were Hispanic or MA. Key analyses were restricted to high poverty neighborhoods. Results: Hispanic people were more likely to receive chemotherapy (RR=1.18), especially men in Hispanic enclaves (RR=1.33) who were also advantaged on survival (RR=1.20). A survival advantage was also suggested among MA men who resided in barrios (RR=1.80). Conclusions: The findings were supportive of Hispanic paradox and MA barrio advantage theories. They further suggested that such advantages are greater for men, perhaps due to their greater spousal and extended familial support.

Comparative Study Between Endoscopic Sinus Surgery Using Microdebrider and Conventional Techniques with It's Impact on Pulmonary Function Tests: A Randomized Control Trial.

The nasal airways and their close association to paranasal sinuses are an integral part of the respiratory tract. Mucociliary clearance is the predominant clearance mechanism for both upper and lower airways. The two components of mucociliary clearance are cilia and the secretions above them. It is known that CRS coexists in as many as 40-75% of patients with BA. CRS can present with polyposis or without polyposis. Treatment options for CRS include medical therapy, surgical intervention or both. According to recent guidelines, ESS is the most favourable surgical approach in patients who fail to respond adequately to medical therapy. To assess the extent of improvement in CRS following ESS (either microdebrider or conventional) and if it brings an improvement in the pulmonary function tests. This also assesses symptom scores, endoscopic appearances and CT findings pre-operatively and post-operatively. This study was carried out at the outpatient Department of Otorhinolaryngology and Head and Neck Surgery in Meenakshi Medical College, Hospital and Research Institute, Tamil Nadu. Patients were consented and started on medical treatment with systemic steroids for 2 weeks and topical nasal steroids for 1 month. If the disease persisted after medical therapy, patients were equally randomized into two groups of 30 each-microdebrider and conventional technique. Subjective symptoms of CRS were based on the CRS criteria. Symptoms score were given with Lund-Mckay symptoms scoring, pre-operatively 1 week before and post-operatively 2 months after surgery. Lund-Mckay CT scoring system separately assessed the extent of opacification of sinuses. PFT was assessed using Spirometer (KOKO Legend). There was a statistically considerable difference in the FEV1 values in microdebrider ESS than conventional ESS. Microdebrider ESS is considered superior when we have to address the coexistence of lower airway diseases along with CRS.

Quality of Life in Patients with Nasal Septal Deviation After Septal Correction.

Septal Correction is an age-old procedure being practiced for the major part of a century now. The aim of this study was to assess the quality of life after Septal Correction. Fifty patients with complaints of nasal obstruction, trouble breathing via the nose, headache and facial pain were selected for the study. Initial pre-operative assessment was done based on a symptomatic score [Nasal Obstruction Symptom Evaluation Scale (NOSE Scale)]. The presence of a septal deviation was confirmed with an X-ray and computed tomography of the paranasal sinuses along with a diagnostic nasal endoscopy. Based on the extent and location of deviation, the malformed part was corrected. Post-operative assessment was done after a period of 8 weeks based on the NOSE Scale. The results were co-related and documented. It was found that the scores were better post-surgery. Thus, it can be concluded that Septal Correction as a surgical procedure is still relevant in today's World for symptomatic betterment and for a healthier lifestyle.

Palliative chemotherapy among people living in poverty with metastasised colon cancer: facilitation by primary care and health insurance.

BACKGROUND: Many Americans with metastasised colon cancer do not receive indicated palliative chemotherapy. We examined the effects of health insurance and physician supplies on such chemotherapy in California. METHODS: We analysed registry data for 1199 people with metastasised colon cancer diagnosed between 1996 and 2000 and followed for 1 year. We obtained data on health insurance, census tract-based socioeconomic status and county-level physician supplies. Poor neighbourhoods were oversampled and the criterion was receipt of chemotherapy. Effects were described with rate ratios (RR) and tested with logistic regression models. RESULTS: Palliative chemotherapy was received by less than half of the participants (45%). Facilitating effects of primary care (RR=1.23) and health insurance (RR=1.14) as well as an impeding effect of specialised care (RR=0.86) were observed. Primary care physician (PCP) supply took precedence. Adjusting for poverty, PCP supply was the only significant and strong predictor of chemotherapy (OR=1.62, 95% CI 1.02 to 2.56). The threshold for this primary care advantage was realised in communities with 8.5 or more PCPs per 10 000 inhabitants. Only 10% of participants lived in such well-supplied communities. CONCLUSIONS: This study's observations of facilitating effects of primary care and health insurance on palliative chemotherapy for metastasised colon cancer clearly suggested a way to maximise Affordable Care Act (ACA) protections. Strengthening America's system of primary care will probably be the best way to ensure that the ACA's full benefits are realised. Such would go a long way towards facilitating access to palliative care.

Colon cancer care and survival: income and insurance are more predictive in the USA, community primary care physician supply more so in Canada.

BACKGROUND: Our research group advanced a health insurance theory to explain Canada's cancer care advantages over America. The late Barbara Starfield theorized that Canada's greater primary care-orientation also plays a critically protective role. We tested the resultant Starfield-Gorey theory by examining the effects of poverty, health insurance and physician supplies, primary care and specialists, on colon cancer care in Ontario and California. METHODS: We analyzed registry data for people with non-metastasized colon cancer from Ontario (n = 2,060) and California (n = 4,574) diagnosed between 1996 and 2000 and followed to 2010. We obtained census tract-based socioeconomic data from population censuses and data on county-level physician supplies from national repositories: primary care physicians, gastroenterologists and other specialists. High poverty neighborhoods were oversampled and the criterion was 10 year survival. Hypotheses were explored with standardized rate ratios (RR) and tested with logistic regression models. RESULTS: Significant inverse associations of poverty (RR = 0.79) and inadequate health insurance (RR = 0.80) with survival were observed in the California, while they were non-significant or non-existent in Ontario. The direct associations of primary care physician (RRs of 1.32 versus 1.11) and gastroenterologist (RRs of 1.56 versus 1.15) supplies with survival were both stronger in Ontario than California. The supply of primary care physicians took precedence. Probably mediated through the initial course of treatment, it largely explained the Canadian advantage. CONCLUSIONS: Poverty and health insurance were more predictive in the USA, community physician supplies more so in Canada. Canada's primary care protections were greatest among the most socioeconomically vulnerable. The protective effects of Canadian health care prior to enactment of the Affordable Care Act (ACA) clearly suggested the following. Notwithstanding the importance of insuring all, strengthening America's system of primary care will probably be the best way to ensure that the ACA's full benefits are realized. Finally, Canada's strong primary care system ought to be maintained.

Multiplicative disadvantage of being an unmarried and inadequately insured woman living in poverty with colon cancer: historical cohort exploration in California.

BACKGROUND: Many Americans diagnosed with colon cancer do not receive indicated chemotherapy. Certain unmarried women may be particularly disadvantaged. A 3-way interaction of the multiplicative disadvantages of being an unmarried and inadequately insured woman living in poverty was explored. METHODS: California registry data were analyzed for 2,319 women diagnosed with stage II to IV colon cancer between 1996 and 2000 and followed until 2014. Socioeconomic data from the 2000 census classified neighborhoods as high poverty (≥30% of households poor), middle (5-29%) or low poverty (<5% poor). Primary health insurance was private, Medicare, Medicaid or none. Comparisons of chemotherapy rates used standardized rate ratios (RR). We respectively used logistic and Cox regression models to assess chemotherapy and survival. RESULTS: A statistically significant 3-way marital status by health insurance by poverty interaction effect on chemotherapy receipt was observed. Chemotherapy rates did not differ between unmarried (39.0%) and married (39.7%) women who lived in lower poverty neighborhoods and were privately insured. But unmarried women (27.3%) were 26% less likely to receive chemotherapy than were married women (37.1%, RR = 0.74, 95% CI 0.58, 0.95) who lived in high poverty neighborhoods and were publicly insured or uninsured. When this interaction and the main effects of health insurance, poverty and chemotherapy were accounted for, survival did not differ by marital status. CONCLUSIONS: The multiplicative barrier to colon cancer care that results from being inadequately insured and living in poverty is worse for unmarried than married women. Poverty is more prevalent among unmarried women and they have fewer assets so they are probably less able to absorb the indirect and direct, but uncovered, costs of colon cancer care. There seem to be structural inequities related to the institutions of marriage, work and health care that particularly disadvantage unmarried women that policy makers ought to be cognizant of as future reforms of the American health care system are considered.

Lack of access to chemotherapy for colon cancer: multiplicative disadvantage of being extremely poor, inadequately insured and African American.

BACKGROUND: Despite evidence of chemotherapy's ability to cure or comfort those with colon cancer, nearly half of such Americans do not receive it. African Americans (AA) seem particularly disadvantaged. An ethnicity by poverty by health insurance interaction was hypothesized such that the multiplicative disadvantage of being extremely poor and inadequately insured is worse for AAs than for non-Hispanic white Americans (NHWA). METHODS: California registry data were analyzed for 459 AAs and 3,001 NHWAs diagnosed with stage II to IV colon cancer between 1996 and 2000 and followed until 2011. Socioeconomic data from the 2000 census categorized neighborhoods: extremely poor (≥ 30% of households poor), middle (5-29% poor) and low poverty (< 5% poor). Participants were randomly selected from these poverty strata. Primary health insurers were Medicaid, Medicare, private or none. Chemotherapy rates were age and stage-adjusted and comparisons used standardized rate ratios (RR). Logistic and Cox regressions, respectively, modeled chemotherapy receipt and long term survival. RESULTS: A significant 3-way ethnicity by poverty by health insurance interaction effect on chemotherapy receipt was observed. Among those who did not live in extremely poor neighborhoods and were adequately insured privately or by Medicare, chemotherapy rates did not differ significantly between AAs (37.7%) and NHWAs (39.5%). Among those who lived in extremely poor neighborhoods and were inadequately insured by Medicaid or uninsured, AAs (14.6%) were nearly 60% less likely to receive chemotherapy than were NHWAs (25.5%, RR = 0.41). When the 3-way interaction effect as well as the main effects of poverty, health insurance and chemotherapy was accounted for, survival rates of AAs and NHWAs were the same. CONCLUSIONS: The multiplicative barrier to colon cancer care that results from being extremely poor and inadequately insured is worse for AAs than it is for NHWAs. AAs are more prevalently poor, inadequately insured, and have fewer assets so they are probably less able to absorb the indirect and direct, but uncovered, costs of colon cancer care. Policy makers ought to be cognizant of these factors as they implement the Affordable Care Act and consider future health care reforms.

Better colon cancer care for extremely poor Canadian women compared with American women.

Extremely poor Canadian women were recently observed to be largely advantaged on most aspects of breast cancer care as compared with similarly poor, but much less adequately insured, women in the United States. This historical study systematically replicated the protective effects of single- versus multipayer health care by comparing colon cancer care among cohorts of extremely poor women in California and Ontario between 1996 and 2011. The Canadian women were again observed to have been largely advantaged. They were more likely to have received indicated surgery and chemotherapy, and their wait times for care were significantly shorter. Consequently, the Canadian women were much more likely to experience longer survival times. Regression analyses indicated that health insurance nearly completely explained the Canadian advantages. Implications for contemporary and future reforms of U.S. health care are discussed.

Effects of being uninsured or underinsured and living in extremely poor neighborhoods on colon cancer care and survival in California: historical cohort analysis, 1996-2011.

BACKGROUND: We examined the mediating effects of health insurance on poverty-colon cancer care and survival relationships and the moderating effects of poverty on health insurance-colon cancer care and survival relationships among women and men in California. METHODS: We analyzed registry data for 3,291 women and 3,009 men diagnosed with colon cancer between 1996 and 2000 and followed until 2011 on lymph node investigation, stage at diagnosis, surgery, chemotherapy, wait times and survival. We obtained socioeconomic data for individual residences from the 2000 census to categorize the following neighborhoods: high poverty (30% or more poor), middle poverty (5-29% poor) and low poverty (less than 5% poor). Primary health insurers were Medicaid, Medicare, private or none. RESULTS: Evidence of mediation was observed for women, but not for men. For women, the apparent effect of poverty disappeared in the presence of payer, and the effects of all forms of health insurance seemed strengthened. All were advantaged on 6-year survival compared to the uninsured: Medicaid (RR = 1.83), Medicare (RR = 1.92) and private (RR = 1.83). Evidence of moderation was also only observed for women. The effects of all forms of health insurance were stronger for women in low poverty neighborhoods: Medicaid (RR = 2.90), Medicare (RR = 2.91) and private (RR = 2.60). For men, only main effects of poverty and payers were observed, the advantaging effect of private insurance being largest. Across colon cancer care processes, Medicare seemed most instrumental for women, private payers for men. CONCLUSIONS: Health insurance substantially mediates the quality of colon cancer care and poverty seems to make the effects of being uninsured or underinsured even worse, especially among women in the United States. These findings are consistent with the theory that more facilitative social and economic capital is available in more affluent neighborhoods, where women with colon cancer may be better able to absorb the indirect and direct, but uncovered, costs of care.

Associations of physician supplies with colon cancer care in Ontario and California, 1996 to 2006.

BACKGROUND: This study examined the differential effects of physician supplies on colon cancer care in Ontario and California. The associations of physician supplies with colon cancer stage at diagnosis, receipt of surgery and adjuvant chemotherapy, and 5-year survival were observed within each country and compared between-country. METHODS: Random samples of Ontario and California cancer registries provided 2,461 and 2,200 colon cancer cases that were diagnosed between 1996 and 2000, and followed until 2006. Both registries included data on the stage of disease at the time of diagnosis, receipt of cancer-directed surgery, receipt of adjuvant chemotherapy, and survival. Census tract-level data on low-income prevalence were, respectively, taken from 2001 and 2000 Canadian and United States population censuses. County-level primary care physician and gastroenterologist densities were computed for the same years. RESULTS: Significant income-adjusted, gastroenterologist density threshold effects (2.0 or more vs. less than 2.0 per 100,000 inhabitants) were observed for early diagnosis (OR = 1.57) and 5-year survival (OR = 1.63) in Ontario, but not in California. Significant incremental threshold effects of primary care physician densities on chemotherapy receipt (8.0 and 9.0 or more per 10,000 inhabitants, respective ORs of 1.79 and 2.37) were also only observed in Ontario. CONCLUSIONS: These colon cancer care findings support the theory that while personal economic resources are more predictive in America, community-level resources such as physician supplies are more predictive of health care access and effectiveness in Canada.

Effects of socioeconomic status on colon cancer treatment accessibility and survival in Toronto, Ontario, and San Francisco, California, 1996-2006.

OBJECTIVES: We examined the differential effects of socioeconomic status on colon cancer care and survival in Toronto, Ontario, Canada, and San Francisco, California. METHODS: We analyzed registry data for colon cancer patients from Ontario (n = 930) and California (n = 1014), diagnosed between 1996 and 2000 and followed until 2006, on stage, surgery, adjuvant chemotherapy, and survival. We obtained socioeconomic data for individuals' residences from population censuses. RESULTS: Income was directly associated with lymph node evaluation, chemotherapy, and survival in San Francisco but not in Toronto. High-income persons had better survival rates in San Francisco than in Toronto. After adjustment for stage, survival was better for low-income residents of Toronto than for those of San Francisco. Middle- to low-income patients were more likely to receive indicated chemotherapy in Toronto than in San Francisco. CONCLUSIONS: Socioeconomic factors appear to mediate colon cancer care in urban areas of the United States but not in Canada. Improvements are needed in screening, diagnostic investigations, and treatment access among low-income Americans.