title: 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.
authors.affiliation: School of Social Work, University of Windsor, Windsor, Ontario, Canada.
authors.forename: Kevin M
authors.initials: KM
authors.lastname: Gorey
authors.affiliation: Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, Ontario, Canada.
authors.forename: Emma
authors.initials: E
authors.lastname: Bartfay
authors.affiliation: Department of Oncology, Windsor Regional Cancer Center and Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
authors.forename: Sindu M
authors.initials: SM
authors.lastname: Kanjeekal
authors.affiliation: Division of General Surgery, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada.|Departments of Surgery and Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Frances C
authors.initials: FC
authors.lastname: Wright
authors.affiliation: Department of Oncology, Windsor Regional Cancer Center and Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
authors.forename: Caroline
authors.initials: C
authors.lastname: Hamm
authors.affiliation: Department of Geography, Western University, London, Ontario, Canada.
authors.forename: Isaac N
authors.initials: IN
authors.lastname: Luginaah
authors.affiliation: Department of Epidemiology and Biostatistics, Robarts Research Institute, Western University, London, Ontario, Canada.
authors.forename: Guangyong
authors.initials: G
authors.lastname: Zou
authors.affiliation: Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Eric J
authors.initials: EJ
authors.lastname: Holowaty
authors.affiliation: School of Social Work, University of Windsor, Windsor, Ontario, Canada.
authors.forename: Nancy L
authors.initials: NL
authors.lastname: Richter
authors.affiliation: School of Social Work, University of Windsor, Windsor, Ontario, Canada.
authors.forename: Madhan K
authors.initials: MK
authors.lastname: Balagurusamy
mesh_terms: D000328:Adult; D000970:Antineoplastic Agents / Q000191:economics*; D002140:California; D003110:Colonic Neoplasms / Q000188:drug therapy* / Q000191:economics; D005260:Female; D006801:Humans; D007348:Insurance, Health / Q000191:economics; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D010166:Palliative Care / Q000191:economics* / Q000379:methods; D058991:Patient Protection and Affordable Care Act; D010820:Physicians / Q000191:economics*; D011203:Poverty / Q000706:statistics & numerical data*; D011320:Primary Health Care / Q000191:economics*; D012042:Registries
chemical_list: D000970:Antineoplastic Agents
keywords: Chemotherapy; Colon cancer; Health insurance; Palliative care; Poverty; Primary care physicians