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

Abstract

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.

First-Line Palliative Chemotherapy for Esophageal and Gastric Cancer: Practice Patterns and Outcomes in the General Population

“…A study by Cunningham et al 10 also showed that patients receiving PC for incurable esophagogastric cancer were more likely to be male (> 80%) and younger (median age, 62-65 years). Lack of receipt of PC because of lower socioeconomic status has been reported for metastatic colon cancer in the United States 22,23 and for non–small-cell lung cancer in Canada, 24 and this finding is supported by our study in that those in the lowest quintile were less likely to receive PC. Although Canada has a single-payer health insurance system, socioeconomically disadvantaged individuals may still not receive recommended care secondary to other related barriers such as travel costs, with out-of-pocket expenses, which may be prohibitive.…”

“By the time she got sick it was just kind of too late”: A qualitative study on advanced care planning among bereaved lesbian, gay, and bisexual older women

“…While prior literature has identified fear of discrimination and similar barriers based on sexual orientation or gender identity as reasons for a lack of communication, 14,49 these reasons were not overt in this study. Participants rarely attributed negative experiences to discrimination or mistrust directly, although reflections they shared did reveal behavior that structurally may have impacted the communication between patients and clinicians.…”

End-of-Life Preparations among Lesbian, Gay, Bisexual, and Transgender People: Integrative Review of Prevalent Behaviors

“…Like other structural barriers such as poverty and insurance inadequacy, barriers based on sexual orientation and identity loom largest when one is most in need of care and comfort, especially during the EOL period (Gorey et al, 2016). In the face of these realities it is imperative for LGBT people to communicate and document their EOL preferences.…”