Trends in Socioeconomic Inequalities in Breast Cancer Incidence Among Women in Canada.

INTRODUCTION: Breast cancer is the most common cancer among females in Canada. This study examines trends in socioeconomic inequalities in the incidence of breast cancer in Canada over time from 1992 to 2010. METHODS: A census division level dataset was constructed using the Canadian Cancer Registry, Canadian Census of the Population and National Household Survey. A summary measure of the Concentration index (C), which captures inequality across socioeconomic groups, was used to measure income and education inequalities in breast cancer incidence over the 19-year period. RESULTS: The crude breast cancer incidence increased in Canada between 1992 and 2010. Age-standardized C values indicated no income or education inequalities in breast cancer incidence in the years from 1992 to 2004. However, the incidence was significantly concentrated among females in high income and highly educated neighbourhoods almost half the time in the 6 most recent years (2005-2010). The trend analysis indicated an increase in breast cancer incidence among females living in high income and highly educated neighbourhoods. CONCLUSION: Breast cancer incidence in Canada was associated with increased socioeconomic status in some more recent years. Our study findings provide previously unavailable empirical evidence to inform discussions on socioeconomic inequalities in breast incidence.

Socioeconomic inequalities in colorectal cancer incidence in Canada: trends over two decades.

PURPOSE: Colorectal cancer is the third most commonly diagnosed cancer in Canada. This study aimed to measure and examine trends in socioeconomic inequalities in the incidence of colorectal cancer in Canada. METHODS: This study is a time trend ecological study based on Canadian Census Division level data constructed from the Canadian Cancer Registry, Canadian Census of Population, and National Household Survey. We assessed trends in income and education inequalities in colorectal cancer incidence in Canada from 1992 to 2010. The age-standardized Concentration index ([Formula: see text]), which measures inequality across all socioeconomic groups, was used to quantify socioeconomic inequalities in colorectal cancer incidence in Canada. RESULTS: The average crude colorectal cancer incidence was found to be 61.52 per 100,000 population over the study period, with males having a higher incidence rate than females (males: 66.98; females: 56.25 per 100,000 population). The crude incidence increased over time and varied by province. The age-standardized C indicated a higher concentration of colorectal cancer incidence among lower income and less-educated neighborhoods in Canada. Income and education inequalities increased over time among males. CONCLUSION: The concentration of colorectal cancer incidence in low socioeconomic neighborhoods in Canada has implications for primary prevention and screening.

Socioeconomic Gradients in Prostate Cancer Incidence Among Canadian Males: A Trend Analysis From 1992 to 2010.

INTRODUCTION: Understanding the effects of socioeconomic status on cancer incidence and their trends over time will help inform public health interventions for cancer control. This study sought to investigate trends in socioeconomic inequalities in prostate cancer incidence among Canadian males. METHODS: Using a census division level dataset (n = 280) constructed from the Canadian Cancer Registry, Canadian Census of Population (1992, 1996, 2001, 2006) and 2011 National Household Survey, we examined the effect of socioeconomic status on prostate cancer incidence among Canadian males between 1992 and 2010. The age-adjusted concentration index was used to quantify education/income-related inequalities in prostate cancer incidence. RESULTS: The crude prostate cancer incidence increased from 115 to 137 per 100 000 males in Canada from 1992 to 2010 with a peak in 2007. The rate increased significantly in all but three of four western provinces. The age-adjusted concentration index showed a higher concentration of prostate cancer diagnoses among males living in high-income neighbourhoods in Canada in particular from 1996 to 2005. In contrast, the index was higher among males living in less-educated neighbourhoods in the most recent study years (2006-2010). CONCLUSIONS: The concentration of new prostate cancer cases among high-income populations in Canada may be explained by the rise of opportunistic screening of asymptomatic males; however, this should be studied in further detail. Since we found a higher incidence rate of prostate cancer among less-educated males in Canada in recent years, risk-benefit investigation of primary prevention and opportunistic screening for less-educated males is advised.

Population surveillance of navigation frequency and palliative care contact before death among cancer patients.

Cancer patient navigation in Canada began in 2002 in Nova Scotia with oncology nurses providing support to patients from diagnosis up to and including end of life. This novel study was carried out to determine navigation frequency and palliative care contact rates, and variations in these rates among adults who were diagnosed with cancer, navigated, and then died between 2011 and 2014. Among the 2,532 study subjects, 56.7% were navigated for more than one month and 30.6% had palliative care contact reported. Variations were observed by geographic area, cancer stage, time from diagnosis to death, and whether the person died of cancer. Further study of the role of navigation is advised for persons at end of life.

Palliative care costs in Canada: A descriptive comparison of studies of urban and rural patients near end of life.

BACKGROUND: Significant gaps in the evidence base on costs in rural communities in Canada and elsewhere are reported in the literature, particularly regarding costs to families. However, it remains unclear whether the costs related to all resources used by palliative care patients in rural areas differ to those resources used in urban areas. AIM: The study aimed to compare both the costs that occurred over 6 months of participation in a palliative care program and the sharing of these costs in rural areas compared with those in urban areas. DESIGN: Data were drawn from two prior studies performed in Canada, employing a longitudinal, prospective design with repeated measures. SETTING/PARTICIPANTS: The urban sample consisted of 125 patients and 127 informal caregivers. The rural sample consisted of 80 patients and 84 informal caregivers. Most patients in both samples had advanced cancer. RESULTS: The mean total cost per patient was CAD 26,652 in urban areas, while it was CAD 31,018 in rural areas. The family assumed 20.8% and 21.9% of costs in the rural and urban areas, respectively. The rural families faced more costs related to prescription medication, out-of-pocket costs, and transportation while the urban families faced more costs related to formal home care. CONCLUSION: Despite the fact that rural and urban families assumed a similar portion of costs, the distribution of these costs was somewhat different. Future studies would be needed to gain a better understanding of the dynamics of costs incurred by families taking care of a loved one at the end of life and the determinants of these costs in urban versus rural areas.

Patterns of health care utilization preceding a colorectal cancer diagnosis are strong predictors of dying quickly following diagnosis.

BACKGROUND: Understanding the predictors of a quick death following diagnosis may improve timely access to palliative care. The objective of this study was to explore whether factors in the 24 months prior to a colorectal cancer (CRC) diagnosis predict a quick death post-diagnosis. METHODS: Data were from a longitudinal study of all adult persons diagnosed with CRC in Nova Scotia, Canada, from 01Jan2001-31Dec2005. This study included all persons who died of any cause by 31Dec2010, except those who died within 30 days of CRC surgery (n = 1885 decedents). Classification and regression tree models were used to explore predictors of time from diagnosis to death for the following time intervals: 2, 4, 6, 8, 12, and 26 weeks from diagnosis to death. All models were performed with and without stage at diagnosis as a predictor variable. Clinico-demographic and health service utilization data in the 24 months pre-diagnosis were provided via linked administrative databases. RESULTS: The strongest, most consistent predictors of dying within 2, 4, 6, and 8 weeks of CRC diagnosis were related to health services utilization in the 24 months prior to diagnosis: i.e., number of specialist visits, number of days spent in hospital, and number of family physician visits. Stage at diagnosis was the strongest predictor of dying within 12 and 26 weeks of diagnosis. CONCLUSIONS: Identifying potential predictors of a short timeframe between cancer diagnosis and death may aid in the development of strategies to facilitate timely and appropriate referral to palliative care upon a cancer diagnosis.

Examining palliative care program use and place of death in rural and urban contexts: a Canadian population-based study using linked data.

INTRODUCTION: Palliative care has been both more available and more heavily researched in urban than in rural areas. This research studies factors associated with palliative care program (PCP) enrollment and place of death across the urban/rural continuum. Importantly, rather than simply comparing urban and rural areas, this article examines how the effects of demographic, geographic, and socioeconomic factors differ across service delivery settings within the Canadian province of Nova Scotia. METHODS: This study linked PCP patient enrollment files from three districts to Nova Scotia vital statistics death certificate data. Postal codes of the decedents were mapped to 2006 Canadian dissemination area census data. The study examined 23 860 adult residents of three district health authorities, who died from 2003 to 2009 with a terminal illness, organ failure, or frailty and who were not nursing home residents. Demographic, geographic, and socioeconomic predictors of PCP enrollment and place of death were investigated using logistic regression across the entire study area, and stratified by district of residence. Univariate and multivariate (adjusted) odds ratios (OR) and their 95% confidence intervals (CI) are reported. RESULTS: Overall, 40.3% of the study subjects were enrolled in a PCP, and 73.4% died in hospital. Odds of PCP enrollment were highest for females (OR: 1.30; 95%CI: 1.22, 1.39), persons aged 50-64 years (OR: 1.50; 95%CI: 1.35, 1.67), and persons with a terminal disease such as cancer. While in overall multivariate analysis residents of census metropolitan areas and agglomerations had higher odds of enrollment (OR: 1.51; 95%CI: 1.29, 1.77), and those at greater distance from a PCP had lower odds (OR: 0.33; 95%CI: 0.27, 0.40), stratified analysis revealed a more nuanced picture. Within each district, travel time to PCP remained a significant predictor of enrollment but the magnitude of its effect differed markedly. There was no consistent relationship with urban/rural residence, social deprivation, or economic deprivation. Enrollment in a PCP was associated with lower adjusted odds of dying in hospital (OR: 0.78; 95%CI: 0.72, 0.84), and those living at greater distance from a PCP had higher odds of hospitalization (OR: 1.52; 95%CI: 1.28, 1.81), but there was no consistent relationship for urban/rural residence or across districts. CONCLUSIONS: Geographic patterns of PCP enrollment and place of death differed by district, as did the impact of economic and social deprivation. Analysis and reporting of population-based indicators of access should be grounded in an understanding of the characteristics of geographic areas and local context of health services. Although more research is needed, these findings show promise that disparities in access between urban and rural settings are not unavoidable, and positive aspects of rural and remote communities may be leveraged to improve care at end of life.

Bereaved family member perceptions of patient-focused family-centred care during the last 30 days of life using a mortality follow-back survey: does location matter?

BACKGROUND: Improving end-of-life care is an important international issue. Recently Nova Scotia researchers conducted a mortality follow-back survey to provide a population-based description of care provided to adults during their last 30 days of life as perceived by knowledgeable bereaved family members. Here we describe the relationship between the location where the decedent received the majority of care during their last 30 days and the informant's perception of the extent of unmet need, as defined by multiple domains of patient-focused, family-centred care. METHOD: Death certificate identified informants (next-of-kin) of eligible adults who died between June 2009 and May 2011, in Nova Scotia, Canada were invited to participate in a telephone interview based on the After-Death Bereaved Family Member Interview. Whether or not the informant expressed unmet need or concerns for six patient-focused, family-centred care domains were assessed in relation to the location where the majority of care occurred during the decedent's last 30 days. RESULTS: 1358 informants took part (25% response rate). Results of 1316 eligible interviews indicated home (39%) was the most common location of care, followed by long-term care (29%), hospital (23%) and hospital-based palliative-care units (9%). Unmet need ranged from 5.6% for dyspnea help to 66% for the emotional and spiritual needs of the family. Although the mean score for overall satisfaction was high (mean = 8.7 in 1-10 scale; SD 1.8), 57% were not completely satisfied. Compared to home, adjusted results indicated greater dissatisfaction with overall care and greater communication concerns in the hospital. Greater unmet need occurred at home for dyspnea. Less overall dissatisfaction and unmet need were expressed about care provided in long-term care facilities and hospital-based palliative-care units. CONCLUSION: Bereaved informants were generally highly satisfied with the decedent's care during their last 30 days but variations were evident. Overall, no one location stood out as exceptionally different in terms of perceived unmet need within each of the patient-focused, family-centred care domains. Communication in various forms and family emotional and spiritual support were consistently viewed as lacking in all locations and identified as targeted areas for impacting quality care at end of life.

Distribution and sharing of palliative care costs in rural areas of Canada.

Few data are available on the costs occurring during the palliative phase of care and on the sharing of these costs in rural areas. This study aimed to evaluate the costs related to all resources used by rural palliative care patients and to examine how these costs were shared between the public healthcare system (PHCS), patients' families, and not-for-profit organizations (NFPOs). A prospective longitudinal study was undertaken of 82 palliative care patients and their main informal caregivers in rural areas of four Canadian provinces. Telephone interviews were completed at two-week intervals. The mean total cost per patient for a six-month participation in a palliative care program was CA$31,678 +/- 1,160. A large part of this cost was attributable to inpatient hospital stays and was assumed by the PHCS. The patient's family contributed less than a quarter of the mean total cost per patient, and this was mainly attributable to caregiving time.

Co-morbidities of persons dying of Parkinson's disease.

INTRODUCTION: Disease interactions can alter functional decline near the end of life (EOL). Parkinson's disease (PD) is characterized by frequent occurrences of co-morbidities but data challenges have limited studies investigating co-morbidities across a broad range of diseases. The goal of this study was to describe disease associations with PD. METHODS: We conducted an analysis of death certificate data from 1998 to 2005 in Nova Scotia. All death causes were utilized to select individuals dying of PD and compare with the general population and an age-sex-matched sample without PD. We calculated the mean number of death causes and frequency of disease co-occurrence. To account for the chance occurrence of co-morbidities and measure the strength of association, observed to expected ratios were calculated. RESULTS: PD decedents had a higher mean number of death causes (3.37) than the general population (2.77) and age-sex-matched sample (2.88). Cancer was the most common cause in the population and matched sample but fifth for those with PD. Cancer was one of nine diseases that occurred less often than what would be expected by chance while four were not correlated with PD. Dementia and pneumonia occurred with PD 2.53 ([CI] 2.21-2.85) and 1.83 (CI 1.58-2.08) times more often than expected. The strength of association for both is reduced but remains statistically significant when controlling for age and sex. DISCUSSION: Those with PD have a higher number of co-morbidities even after controlling for age and sex. Individuals dying with PD are more likely to have dementia and pneumonia, which has implications for the provision of care at EOL.

Impact of comorbidity and healthcare utilization on colorectal cancer stage at diagnosis: literature review.

PURPOSE: Individuals diagnosed with cancer close to death have low access to enrollment in palliative care programs. The purpose of this literature review was to assess the usefulness of pre-diagnostic comorbidity and healthcare utilization as indicators of late-stage colorectal cancer (CRC) diagnosis, to help with early identification of individuals who may benefit from palliative care. METHODS: A literature search was conducted in relevant databases using title/abstract terms which included "cancer," "stage," "diagnosis," "determinants," "predictors," and "associated." Included studies examined whether comorbidity and/or healthcare utilization had an impact on the stage at which CRC was diagnosed. A standardized data abstraction form was used to assess the eligibility of each study. Thirteen articles were included in the literature review. These studies were assessed and synthesized using qualitative methodology. RESULTS: We found much heterogeneity among study variables. The findings of this literature review point to the presence of comorbidity and non-emergent healthcare utilization as having no association with late-stage diagnosis. Conversely, emergency room presentation (ERP) was associated with late-stage diagnosis. CONCLUSIONS: The results of this literature review did not find strong evidence to suggest that comorbidity and healthcare utilization are potential indicators of late-stage diagnosis. However, ERP may be useful as a flag for consideration of prompt referral to palliative care. Additional research is required to identify potential indicators of late-stage diagnosis that may be available in administrative databases, particularly in the area of healthcare utilization.

The effect of an educational intervention on meperidine use in Nova Scotia, Canada: a time series analysis.

PURPOSE: To evaluate the impact of a prescriber focused individual educational and audit-feedback intervention undertaken by the Nova Scotia Prescription Monitoring Program (NSPMP) in March/April 2007 to reduce meperidine use. METHOD: The NSPMP records all prescriptions for controlled substances dispensed in community pharmacies in Nova Scotia, Canada. Oral meperidine use from 1 July 2005 to 31 December 2009 was examined using NSPMP data. Monthly totals for the following were obtained: number of individual patients who filled at least one meperidine prescription, number of prescriptions, and number of tablets dispensed. Data were analyzed graphically to observe overall trends. The intervention effect was estimated on the logarithmic scale with autocorrelations over time modeled by an integrated autoregressive moving average model for each outcome measure. RESULTS: An overall trend toward decreasing use from July 2005 to December 2009 was apparent for all three outcome measures. The intervention was associated with a statistically significant reduction in meperidine use, after adjusting for the overall long-term trend. Compared with the pre-intervention period, the monthly number of patients declined by 12% (p < 0.001; 95% confidence interval [CI] = 5%-18%), prescriptions by 10% (p < 0.001; 95%CI = 3%-17%), and tablets by 13.5% (p < 0.001, 95%CI = 6%-29%) in the post-intervention period. CONCLUSION: Given the risks associated with meperidine, determining that this intervention successfully reduced meperidine use is encouraging. This study highlights the potential for using population data such as the NSPMP to evaluate the effectiveness of population-level interventions to improve medication use, including professional, organizational, financial, and regulatory initiatives.

Population prevalence of high dose paracetamol in dispensed paracetamol/opioid prescription combinations: an observational study.

BACKGROUND: Paracetamol (acetaminophen) is generally considered a safe medication, but is associated with hepatotoxicity at doses above doses of 4.0 g/day, and even below this daily dose in certain populations. METHODS: The Nova Scotia Prescription Monitoring Program (NSPMP) in the Canadian province of Nova Scotia is a legislated organization that collects dispensing information on all out-of-hospital prescription controlled drugs dispensed for all Nova Scotia residents. The NSPMP provided data to track all paracetamol/opioids redeemed by adults in Nova Scotia, from July 1, 2005 to June 30, 2010. Trends in the number of adults dispensed these prescriptions and the numbers of prescriptions and tablets dispensed over this period were determined. The numbers and proportions of adults who filled prescriptions exceeding 4.0 g/day and 3.25 g/day were determined for the one-year period July 1, 2009 to June 30, 2010. Data were stratified by sex and age (<65 versus 65+). RESULTS: Both the number of prescriptions filled and the number of tablets dispensed increased over the study period, although the proportion of the adult population who filled at least one paracetamol/opioid prescription was lower in each successive one-year period. From July 2009 to June 2010, one in 12 adults (n = 59,197) filled prescriptions for over 13 million paracetamol/opioid tablets. Six percent (n = 3,786) filled prescriptions that exceeded 4.0 g/day and 18.6% (n = 11,008) exceeded 3.25 g/day of paracetamol at least once. These findings exclude non-prescription paracetamol and paracetamol-only prescribed medications. CONCLUSIONS: A substantial number of individuals who redeem prescriptions for paracetamol/opioid combinations may be at risk of paracetamol-related hepatotoxicity. Healthcare professionals must be vigilant when prescribing and dispensing these medications in order to reduce the associated risks.

Inequalities in end-of-life care for colorectal cancer patients in Nova Scotia, Canada.

Access to high-quality end-of-life (EOL) care is critical for all those with incurable cancer. The objective of this study was to examine inequalities in access to, and quality of, EOL care by assessing registration in a palliative care program, emergency room visits in the last 30 days of life, and location of death among individuals who died of colorectal cancer in Nova Scotia, Canada, between 2001 and 2008. We used population-based linked administrative data and performed multivariate logistic regression models to assess the association between socio-economic, geographic, and demographic factors and outcomes related to access to, and quality of, EOL care (n=1201). This study demonstrates that although access to, and quality of, EOL care appears to have improved, there remain significant inequalities throughout the population. Of primary concern is the variation in access to, and quality of, EOL care based on geographic location of residence and patient age.

Variation in the use of palliative radiotherapy at end of life: examining demographic, clinical, health service, and geographic factors in a population-based study.

Palliative radiotherapy (PRT) can improve quality of life for people dying of cancer. Variation in the delivery of PRT by factors unrelated to need may indicate that not all patients who may benefit from PRT receive it. In this study, 13,494 adults who died of cancer between 2000 and 2005 in Nova Scotia, Canada, were linked to radiotherapy records. Multivariate logistic regression was used to examine the relationships among demographic, clinical, service, and geographic variables, and PRT consultation and treatment. Among the decedents, 4188 (31.0%) received PRT consultation and 3032 (22.3%) treatment. PRT declined with increased travel time and community deprivation. Females, older persons, and nursing home residents also had lower PRT rates. Variations were observed by cancer site and previous oncology care. Variations in PRT use should be discussed with referring physicians, and improved means of access to PRT considered. Benchmarks for optimal rates of PRT are needed.

Identifying population groups with low palliative care program enrolment using classification and regression tree analysis.

Classification and regression tree (CART) analysis was used to identify subpopulations with lower palliative care program (PCP) enrolment rates. CART analysis uses recursive partitioning to group predictors. The PCP enrolment rate was 72 percent for the 6,892 adults who died of cancer from 2000 and 2005 in two counties in Nova Scotia, Canada. The lowest PCP enrolment rates were for nursing home residents over 82 years (27 percent), a group residing more than 43 kilometres from the PCP (31 percent), and another group living less than two weeks after their cancer diagnosis (37 percent). The highest rate (86 percent) was for the 2,118 persons who received palliative radiation. Findings from multiple logistic regression (MLR) were provided for comparison. CART findings identified low PCP enrolment subpopulations that were defined by interactions among demographic, social, medical, and health system predictors.

Preventive medication use among persons with limited life expectancy.

Persons with limited life expectancy (LLE) - less than 1 year - are significant consumers of health care, are at increased risk of polypharmacy and adverse drug events, and have dynamic health statuses. Therefore, medication use among this population must be appropriate and regularly evaluated. The objective of this review is to assess the current state of knowledge and clinical practice presented in the literature regarding preventive medication use among persons with LLE. We searched Medline, Embase, and CINAHL using Medical Subject Headings. Broad searches were first conducted using the terms 'terminal care or therapy' or 'advanced disease' and 'polypharmacy' or 'inappropriate medication' or 'preventive medicine', followed by more specific searches using the terms 'statins' or 'anti-hypertensives' or 'bisphosphonates' or 'laxatives' and 'terminal care'. Frameworks to assess appropriate versus inappropriate medications for persons with LLE, and the prevalence of potentially inappropriate medication use among this population, are presented. A considerable proportion of individuals with a known terminal condition continue to take chronic disease preventive medications until death despite questionable benefit. The addition of palliative preventive medications is advised. There is an indication that as death approaches the shift from a curative to palliative goal of care translates into a shift in medication use. This literature review is a first step towards improving medication use and decreasing polypharmacy in persons at the end of life. There is a need to develop consensus criteria to assess appropriate versus inappropriate medication use, specifically for individuals at the end of life.

Workforce Planning for Community-Based Palliative Care Specialist Teams Using Operations Research.

CONTEXT: Many countries have aging populations. Thus, the need for palliative care will increase. However, the methods to estimate optimal staffing for specialist palliative care teams are rudimentary as yet. OBJECTIVES: To develop a population-need workforce planning model for community-based palliative care specialist teams and to apply the model to forecast the staff needed to care for all patients with terminal illness, organ failure, and frailty during the next 20 years, with and without the expansion of primary palliative care. METHODS: We used operations research (linear programming) to model the problem. We used the framework of the Canadian Society of Palliative Care Physicians and the Nova Scotia palliative care strategy to apply the model. RESULTS: To meet the palliative care needs for persons dying across Nova Scotia in 2019, the model generated an estimate of 70.8 nurses, 23.6 physicians, and 11.9 social workers, a total of 106.3 staff. Thereby, the model indicated that a 64% increase in specialist palliative care staff was needed immediately, and a further 13.1% increase would be needed during the next 20 years. Trained primary palliative care providers currently meet 3.7% of need, and with their expansion are expected to meet 20.3% by 2038. CONCLUSION: Historical, current, and projected data can be used with operations research to forecast staffing levels for specialist palliative care teams under various scenarios. The forecast can be updated as new data emerge, applied to other populations, and used to test alternative delivery models.

Heterocyclic cycloalkanol ethylamines as norepinephrine reuptake inhibitors.

A series of heterocyclic cycloalkanol ethylamines have been prepared to expand our norepinephrine reuptake inhibitor (NRI) program. Synthesis of a variety of heterocycles identified (+)-S-21, a potent NRI efficacious in an animal model for thermoregulatory dysfunction.