Eric J. Belasco

Socioeconomic deprivation as a determinant of cancer mortality and the Hispanic paradox in Texas, USA

IntroductionWe have recently reported that delayed cancer detection is associated with the Wellbeing Index (WI) for socioeconomic deprivation, lack of health insurance, physician shortage, and Hispanic ethnicity. The current study investigates whether these factors are determinants of cancer mortality in Texas, the United States of America (USA).MethodsData for breast, colorectal, female genital system, lung, prostate, and all-type cancers are obtained from the Texas Cancer Registry. A weighted regression model for non-Hispanic whites, Hispanics, and African Americans is used with age-adjusted mortality (2004–2008 data combined) for each county as the dependent variable while independent variables include WI, percentage of the uninsured, and physician supply.ResultsHigher mortality for breast, female genital system, lung, and all-type cancers is associated with higher WI among non-Hispanic whites and/or African Americans but with lower WI in Hispanics after adjusting for physician supply and percentage of the uninsured. Mortality for all the cancers studied is in the following order from high to low: African Americans, non-Hispanic whites, and Hispanics. Lung cancer mortality is particularly low in Hispanics, which is only 35% of African Americans’ mortality and 40% of non-Hispanic whites’ mortality.ConclusionsHigher degree of socioeconomic deprivation is associated with higher mortality of several cancers among non-Hispanic whites and African Americans, but with lower mortality among Hispanics in Texas. Also, mortality rates of all these cancers studied are the lowest in Hispanics. Further investigations are needed to better understand the mechanisms of the Hispanic Paradox.

The Impact of Rural Health Care Accessibility on Cancer-Related Behaviors and Outcomes

BackgroundThis research seeks to identify the relationship between economic factors related to the ability to receive and pay for health services and adverse cancer outcomes, as well as preventative screening and behavioral factors that influence the risk of cancer. We focus on the Northern High Plains region, where we are able to compare regions with extremely low access to health services with those with relatively high levels of access.ObjectiveThis study aims to identify health disparities in rural communities, particularly among Native American populations, and, thereby, begin to determine the most effective means by which to deliver health services to areas where geography, economics, and culture might prevent traditional models of health delivery from providing sufficient incentives for the prevention of adverse cancer-related outcomes.MethodsThe Health Care Accessibility Index (HCAI) is computed through the use of principal component analysis and includes economic variables as well as variables concerning institutional and geographic access to health care. Index values are then regressed onto cancer outcomes, cancer-prevention outcomes, and cancer-related risk, using weighted least squares and quantile regressions.ResultsCounties with relatively poor access to health care (low HCAI) also have statistically (1) lower breast cancer screening rates, (2) higher smoking prevalence, (3) higher obesity prevalence, and (4) higher cancer-related mortality rates. Breast cancer screening is found to be especially sensitive to areas of low health accessibility.ConclusionsEmpirical results provide support for policy efforts to increase the accessibility of health care services that are targeted to areas with low mammography screening rates, high obesity rates, high smoking prevalence, as well as areas near Native American reservation territories.

Correlation of the ratio of metastatic to non- metastatic cancer cases with the degree of socioeconomic deprivation among Texas counties

BackgroundPrevious studies have demonstrated that cancer registrations and hospital discharge rate are closely correlated with census data-based socioeconomic deprivation indices. We hypothesized that communities with higher degrees of socioeconomic deprivation tend to have a higher ratio of metastatic to non-metastatic cancer cases (lung, breast, prostate, female genital system, colorectal cancers or all types of cancers combined). In this study, we investigate the potential link between this ratio and the Wellbeing Index (WI) among Texas counties.ResultsCancer data in 2000 were provided by the Texas Cancer Registry, while data on the ten socioeconomic variables among the 254 Texas counties in 2000 for building the WI were obtained from U.S. Census Bureau. The ten socioeconomic status variables were subjected to the principal component analysis, and the first principal component scores were grouped into deciles for the WI (1 to 10) and the 254 Texas counties were classified into 10 corresponding groups. Weighted linear regression analyses and a Cochran-Armitage trend test were performed to determine the relationship between the ratio of age-adjusted metastatic to non-metastatic cancer incidence cases and WI. The ratios of metastatic to non-metastatic cases of female genital system cancer (r2 = 0.84, p = 0.0002), all-type cancers (r2= 0.73, p = 0.0017) and lung cancer (r2= 0.54, p = 0.0156) at diagnosis were positively correlated with WI.ConclusionsThe ratios of metastatic to non-metastatic cases of all-type, female genital system and lung cancers at diagnosis were statistically correlated with socioeconomic deprivation. Potential mediators for the correlation warrant further investigation in order to reduce health disparities associated with socioeconomic inequality.

Determinants of delayed detection of cancers in Texas Counties in the United States of America

IntroductionPrevious studies have shown that delayed detection of several cancers is related to socioeconomic deprivation as measured by the Wellbeing Index (WI) in Texas, the United States of America (USA). The current study investigates whether delayed cancer detection is related to lack of health insurance, physician shortage and higher percentages of Hispanics rather than WI per se since these factors are directly related to delayed cancer detection and may confound WI.MethodsCancer data and potential determinants of delayed cancer detection are derived from Texas Cancer Registry, Texas State Data Center, and Texas Department of State Health Services and U.S. Census Bureau. Texas cancer data from 1997 to 2003 are aggregated to calculate age-adjusted late- and early-stage cancer detection rates. The WI for each county is computed using data from the USA Census 2000. A weighted Tobit regression model is used to account for population size and censoring. The percentage of late-stage cancer cases is the dependent variable while independent variables include WI and the aforementioned potential confounders.ResultsDelayed detection of breast, lung, colorectal and female genital cancers is associated with higher percentage of uninsured residents (p < 0.05). Delayed detection is also associated with physician shortage and lower percentages of Hispanics for certain cancers ceteris paribus ( p < 0.05). The percentage of late-stage cases is positively correlated with WI for lung, and prostate cancers after adjusting for confounders ( p < 0.05).ConclusionsThe percentages of uninsured and Hispanic residents as well as physician supply are determinants of delayed detection for several cancers independently of WI, and vice versa. Identification of these determinants provides the evidence-base critical for decision makers to address specific issues for promoting early detection in effective cancer control.

The Chronic Kidney Disease Model: A General Purpose Model of Disease Progression and Treatment

BackgroundChronic kidney disease (CKD) is the focus of recent national policy efforts; however, decision makers must account for multiple therapeutic options, comorbidities and complications. The objective of the Chronic Kidney Disease model is to provide guidance to decision makers. We describe this model and give an example of how it can inform clinical and policy decisions.MethodsMonte Carlo simulation of CKD natural history and treatment. Health states include myocardial infarction, stroke with and without disability, congestive heart failure, CKD stages 1-5, bone disease, dialysis, transplant and death. Each cycle is 1 month. Projections account for race, age, gender, diabetes, proteinuria, hypertension, cardiac disease, and CKD stage. Treatment strategies include hypertension control, diabetes control, use of HMG-CoA reductase inhibitors, use of angiotensin converting enzyme inhibitors, nephrology specialty care, CKD screening, and a combination of these. The model architecture is flexible permitting updates as new data become available. The primary outcome is quality adjusted life years (QALYs). Secondary outcomes include health state events and CKD progression rate.ResultsThe model was validated for GFR change/year -3.0 ± 1.9 vs. -1.7 ± 3.4 (in the AASK trial), and annual myocardial infarction and mortality rates 3.6 ± 0.9% and 1.6 ± 0.5% vs. 4.4% and 1.6% in the Go study. To illustrate the models utility we estimated lifetime impact of a hypothetical treatment for primary prevention of vascular disease. As vascular risk declined, QALY improved but risk of dialysis increased. At baseline, 20% and 60% reduction: QALYs = 17.6, 18.2, and 19.0 and dialysis = 7.7%, 8.1%, and 10.4%, respectively.ConclusionsThe CKD Model is a valid, general purpose model intended as a resource to inform clinical and policy decisions improving CKD care. Its value as a tool is illustrated in our example which projects a relationship between decreasing cardiac disease and increasing ESRD.

The Health Care Access Index as a Determinant of Delayed Cancer Detection Through Principal Component Analysis

In the past two decades, cancer mortality declined significantly in the United States (Byers, 2010). Although the reasons for the decline have not been well-established, many factors such as the reduction in the number of smokers, increased cancer screening, and better treatment may have played an important role (Byers, 2010, Richardson et al. 2010). However, disparities in cancer mortality persisted among different ethnic groups and social classes (Byers, 2010). Health status and health disparities among different social and ethnic groups are to a large degree determined by socioeconomic status and living conditions in general (Pamies and Nsiah-Kumi, 2008; World Health Organization [WHO], 2008). For example, life expectancy worldwide increased from 48 years in 1955 to 66 years in 2000 mainly as a result of improvement of overall living conditions in addition to advancement in medical science and large-scale preventive interventions (Centers for Disease Control and Prevention [CDC], 2011). Large health disparities exist between poor and rich countries or within any given rich or poor country (WHO 2008). In the case of cancer mortality due to delayed detection, socioeconomic status may determine health insurance coverage status, which in turn affects health behaviour including regular check-ups and participation in cancer surveillance among high risk groups. Regular cancer surveillance is critical for cancer control (Byers, 2010, Richardson et al. 2010). Lack of health insurance due to economic hardship may result in the delay in cancer detection.

High Tunnels Are My Crop Insurance: An Assessment of Risk Management Tools for Small-Scale Specialty Crop Producers

High tunnels are being used by specialty crop producers to enhance production yields and quality, extend growing seasons, and protect crops from extreme weather. The tunnels are unheated, plastic-covered structures under which crops are planted directly in the soil, and they provide greater environmental protection and control than open-field production. This study uses field-level experiments to evaluate high-tunnel production. The results suggest that investments in high tunnels can provide increased profits and superior protection against adverse risks relative to crop insurance.

Spatial producer heterogeneity in crop insurance product decisions within major corn producing states

Purpose - The purpose of this paper is to examine the spatial components of producer heterogeneity in crop insurance product selection among US corn producers and identifies neighborhood spillover or agent marketing effects in these decisions. Design/methodology/approach - County-level insurance and yield data are used to demonstrate that a gradual shift from yield-based insurance to revenue-based insurance has spatial patterns. Conventional risk variables such as yield variability, price variability, prevalence of irrigation, other crops, and yield-price relationships play an important role in this shift and are consistently estimated only when spatial components are included. A spatial random effects model is used to also identify the impact of spatial lag effects, which include neighborhood spillover and agent marketing effects, on the share of corn acres insured with revenue-based plans vs yield-based plans. Findings - Theoretically consistent variables associated with risk are found to significantly influence the choice between crop revenue and yield insurance. Non-linear parameters identify the region-specific effects from changes in irrigation, yield price correlation, and the prevalence of corn production on insurance decisions. In addition, spatial components such as the decisions made by nearby producers and marketing drives are also found to influence decisions. These results may demonstrate the relative influence of trusted sources, such as nearby producers and insurance agents, on insurance decisions. Originality/value - Traditional risk variables are consistently estimated by controlling for spatial heterogeneity. This study also reveals the propensity of producers to rely on the opinions of other producers or agents that they know.

Combination Aspirin and/or Calcium Chemoprevention with Colonoscopy in Colorectal Cancer Prevention: Cost-effectiveness Analyses

Background: Clinical and cohort studies have shown that low-dose aspirin and calcium are effective low-risk strategies for primary prevention of colorectal cancer (CRC). We compared the cost-effectiveness of aspirin and calcium chemoprevention used with colonoscopy for primary prevention of CRCs. Methods: Markov chain Monte Carlo simulations for a population of 100,000 persons, with a colonoscopy compliance rate of 50%, were used for the analysis. If adenomas were detected, colonoscopy was repeated every 4 years until no adenomas were evident. Data sources included adenoma transition rates, initial adenoma and CRC incidences, and treatment complication rates from existing literature. Age-adjusted U.S. standard population mortality rates were used and costs were from Medicare reimbursement data. The target population was U.S. adults, undergoing CRC screening from ages 50 to 75 years. Results: Outcomes included incremental cost-effectiveness ratios (ICER), life-years saved (LYS), and cancer-free years saved (CFYS). The ICER per LYS for colonoscopy alone dominated compared with no screening. Compared with colonoscopy alone, colonoscopies with aspirin (ICER =

Evaluation of Crop Insurance Yield Guarantees and Producer Welfare with Upward-Trending Yields

12,950/LYS) or calcium (ICER =