title: Prostate cancer: socio-economic, geographical and private-health insurance effects on care and survival.
abstract: OBJECTIVE
  To examine the effects of demographic, geographical and socio-economic factors, and the influence of private health insurance, on patterns of prostate cancer care and 3-year survival in Western Australia (WA).
  
  
  METHODS
  The WA Record Linkage Project was used to extract all hospital morbidity, cancer and death records of men diagnosed with prostate cancer between 1982 and 2001. The likelihood of having a radical prostatectomy (RP) was estimated using logistic regression, and the likelihood of death 3 years after diagnosis was estimated using Cox regression.
  
  
  RESULTS
  The proportion of men undergoing RP increased six-fold, from 3.1% to 20.1%, over the 20 years, whilst non-radical surgery (transurethral, open or closed prostatectomy) simultaneously halved to 29%. Men who had RP were typically younger, married and with less comorbidity. Patients with a first admission to a rural hospital were much less likely to have RP (odds ratio 0.15; 95% confidence interval, CI, 0.11-0.21), whereas residence alone in a rural area had less effect (0.54, 0.29-1.03). A first admission to a private hospital increased the likelihood of having RP (2.40, 2.11-2.72), as did having private health insurance (1.77, 1.56-2.00); being more socio-economically disadvantaged reduced RP (0.63, 0.47-0.83). The 3-year mortality rate was greater with a first admission to a rural hospital (relative risk 1.22; 95% CI 1.09-1.36) and in more socio-economically disadvantaged groups (1.34, 1.10-1.64), whereas those admitted to a private hospital (0.77, 0.71-0.84) or with private health insurance (0.82, 0.76-0.89) fared better. Men who had RP had better survival than those who had non-radical surgery (4.85, 3.52-6.68) or no surgery (6.42, 4.65-8.84), although this may be an artefact of a screening effect.
  
  
  CONCLUSIONS
  The 3-year survival was poorer and the use of RP less frequent in men from socio-economically and geographically disadvantaged backgrounds, particularly those admitted to rural or public hospitals, and those with no private health insurance.
authors.affiliation: School of Population Health, The University of Western Australia, 35 Stirling Highway, Crawley, WA 6009, Australia. shall@sph.uwa.edu.au
authors.forename: Sonĵa E
authors.initials: SE
authors.lastname: Hall
authors.forename: C D'Arcy J
authors.initials: CD
authors.lastname: Holman
authors.forename: Z Stan
authors.initials: ZS
authors.lastname: Wisniewski
authors.forename: James
authors.initials: J
authors.lastname: Semmens
mesh_terms: D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D015994:Incidence; D007348:Insurance, Health; D008297:Male; D017149:Private Sector; D011468:Prostatectomy / Q000191:economics / Q000379:methods / Q000401:mortality; D011471:Prostatic Neoplasms / Q000191:economics* / Q000401:mortality / Q000601:surgery; D012044:Regression Analysis; D012111:Residence Characteristics; D012959:Socioeconomic Factors; D016019:Survival Analysis