title: Affluence and Private Health Insurance Influence Treatment and Survival in Non-Hodgkin's Lymphoma.
abstract: BACKGROUND
  The aim of this study was to investigate inequalities in survival for non-Hodgkin's lymphoma (NHL), distinguishing between direct and indirect effects of patient, social and process-of-care factors.
  
  
  METHODS
  All cases of NHL diagnosed in Ireland in 2004-2008 were included. Variables describing patient, cancer, stage and process of care were included in a discrete-time model of survival using Structural Equation Modelling software.
  
  
  RESULTS
  Emergency admissions were more common in patients with co-morbid conditions or with more aggressive cancers, and less frequent for patients from more affluent areas. Aggressive morphology, female sex, emergency admission, increasing age, comorbidity, treatment in a high caseload hospital and late stage were associated with increased hazard of mortality. Private patients had a reduced hazard of mortality, mediated by systemic therapy, admission to high caseload hospitals and fewer emergency admissions.
  
  
  CONCLUSIONS
  The higher rate of emergency presentation, and consequent poorer survival, of uninsured patients, suggests they face barriers to early presentation. Social, educational and cultural factors may also discourage disadvantaged patients from consulting with early symptoms of NHL. Non-insured patients, who present later and have more emergency admissions would benefit from better access to diagnostic services. Older patients remain disadvantaged by sub-optimal treatment, treatment in non-specialist centres and emergency admission.
authors.affiliation: National Cancer Registry, Cork, Ireland.
authors.forename: Harry
authors.identifier: http://orcid.org/0000-0003-1475-7883
authors.initials: H
authors.lastname: Comber
authors.affiliation: Brazilian National Cancer Institute, Epidemiology Division, Rio de Janeiro, Brazil.
authors.forename: Marianna
authors.initials: M
authors.lastname: De Camargo Cancela
authors.affiliation: Social and Economic Consultant, Dublin, Ireland.
authors.forename: Trutz
authors.initials: T
authors.lastname: Haase
authors.affiliation: Health & Wellbeing Directorate Health Intelligence Unit, Health Service Executive, Dublin, Ireland.
authors.forename: Howard
authors.initials: H
authors.lastname: Johnson
authors.affiliation: Institute of Health & Society, Newcastle University, Newcastle upon Tyne, United Kingdom.
authors.forename: Linda
authors.initials: L
authors.lastname: Sharp
authors.affiliation: Department of Economics and Statistics, University of Salerno, Salerno, Italy.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Pratschke
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D018572:Disease-Free Survival; D005260:Female; D006760:Hospitalization; D006801:Humans; D007348:Insurance, Health; D007494:Ireland; D008228:Lymphoma, Non-Hodgkin / Q000401:mortality* / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D012042:Registries; D012737:Sex Factors; D015996:Survival Rate