title: Effect of Population Socioeconomic and Health System Factors on Medical Care of Childhood Cancer Survivors: A Report from the Childhood Cancer Survivor Study.
abstract: OBJECTIVE
  To determine the independent contribution of population socioeconomic and health system factors on childhood cancer survivors' medical care and screening.
  
  
  METHODS
  7899 childhood cancer survivors in the United States and Canada enrolled in the Childhood Cancer Survivor Study (CCSS). Population-level factors were derived from U.S. Area Health Resource File or 201 Canadian Census. Health service utilization and individual-level factors were self-reported. Multivariable logistic regression was used to calculate the effect of population factors on medical care (any care vs. no care; risk-based care vs. general care) and indicated echocardiogram or mammogram, adjusting for individual sociodemographic and health status.
  
  
  RESULTS
  After adjusting for individual factors, population factors had a nominal impact on childhood cancer survivors' medical care and screening. Higher population median income was associated with risk-based survivor-focused care versus general care (odds ratio [OR] 1.05, 95% confidence interval [CI], 1.01-1.09) among all participants, but not among U.S. residents only (OR 1.03, 95% CI, 0.99-1.07). For U.S. residents, the number of CCSS centers within the geographic area was associated with greater odds of receiving risk-based survivor-focused medical care (OR 1.12, 95% CI, 1.04-1.20). Areas with higher median income had higher rates of echocardiogram screening among survivors at risk of cardiomyopathy (for every $10,000 increase in median income, there is a 12% increase in odds of echocardiogram screening; 95% CI 1.05-1.20). A positive relationship was identified between greater number of physicians and surgeons in the county of residence and recommended echocardiogram (for every additional 1000 physicians and surgeons: OR 1.12, 95% CI, 1.01-1.23). We found no association between population-level factors and mammography screening.
  
  
  CONCLUSIONS
  Population socioeconomic disparities moderately affect childhood cancer survivors' risk-based medical care and screening after accounting for individual sociodemographic and health factors.
authors.affiliation: 1 University of Utah School of Medicine , Salt Lake City, Utah.
authors.forename: Deirdre A
authors.initials: DA
authors.lastname: Caplin
authors.affiliation: 1 University of Utah School of Medicine , Salt Lake City, Utah.
authors.forename: Ken R
authors.initials: KR
authors.lastname: Smith
authors.affiliation: 2 St. Jude Children's Research Hospital , Memphis, Tennessee.
authors.forename: Kirsten K
authors.initials: KK
authors.lastname: Ness
authors.affiliation: 1 University of Utah School of Medicine , Salt Lake City, Utah.
authors.forename: Heidi A
authors.initials: HA
authors.lastname: Hanson
authors.affiliation: 3 Department of Medicine, Hospital of the University of Pennsylvania , Philadelphia, Pennsylvania.
authors.forename: Stephanie M
authors.initials: SM
authors.lastname: Smith
authors.affiliation: 4 The Hospital for Sick Children , Toronto, Canada .
authors.forename: Paul C
authors.initials: PC
authors.lastname: Nathan
authors.affiliation: 2 St. Jude Children's Research Hospital , Memphis, Tennessee.
authors.forename: Melissa M
authors.initials: MM
authors.lastname: Hudson
authors.affiliation: 5 Fred Hutchison Cancer Research Center , Seattle, Washington.
authors.forename: Wendy M
authors.initials: WM
authors.lastname: Leisenring
authors.affiliation: 2 St. Jude Children's Research Hospital , Memphis, Tennessee.
authors.forename: Leslie L
authors.initials: LL
authors.lastname: Robison
authors.affiliation: 6 Memorial Sloan Kettering Cancer Center , New York, New York.
authors.forename: Kevin C
authors.initials: KC
authors.lastname: Oeffinger
mesh_terms: D000073116:Cancer Survivors / Q000523:psychology*; D002648:Child; D018672:Community Health Planning / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D012923:Social Class
keywords: childhood cancer survivor; health disparities; population-level factors; screening; socioeconomic status