Inadequate access to surgeons: reason for disparate cancer care?
ABSTRACT To compare the likelihood of seeing a surgeon between elderly dually eligible non-small-cell lung cancer (NSCLC) and colon cancer patients and their Medicare counterparts. Surgery rates between dually eligible and Medicare patients who were evaluated by a surgeon were also assessed.
We used statewide Medicaid and Medicare data merged with the Michigan Tumor Registry to extract a sample of patients with a first primary NSCLC (n = 1100) or colon cancer (n = 2086). The study period was from January 1, 1997 to December 31, 2000. We assessed the likelihood of a surgical evaluation using logistic models that included patient characteristics, tumor stage, and census tracts. Among patients evaluated by a surgeon, we used logistic regression to predict if a resection was performed.
Dually eligible patients were nearly half as likely to be evaluated by a surgeon as Medicare patients (odds ratio [OR] = 0.49; 95% confidence interval = 0.32, 0.77 and odds ratio = 0.59; 95% confidence interval = 0.41, 0.86 for NSCLC and colon cancer patients, respectively). Among patients who were evaluated by a surgeon, the likelihood of resection was not statistically significantly different between dually eligible and Medicare patients.
This study suggests that dually eligible patients, in spite of having Medicaid insurance, are less likely to be evaluated by a surgeon relative to their Medicare counterparts. Policies and interventions aimed toward increasing access to specialists and complete diagnostic work-ups (eg, colonoscopy, bronchoscopy) are needed.
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ABSTRACT: The rare earth zirconates have attracted interest for thermal barrier coatings (TBCs) because they have very low intrinsic thermal conductivities, are stable above 1200 degrees C and are more resistant to sintering than yttria-stabilized zirconia (YSZ). Samarium zirconate (SZO) has the lowest thermal conductivity of the rare earth zirconates and its pyrochore structure is stable to 2200 degrees C but little is known about its response to thermal cycling. Here, columnar morphology SZO coatings have been deposited on bond coated superalloy substrates using a directed vapor deposition method that facilitated the incorporation of pore volume fractions of 25 to 45%. The as-deposited coatings had a fluorite structure which transformed to the pyrochlore phase upon thermal cycling between 100 and 1100 degrees C. This cycling eventually led to delamination of the coatings, with failure occurring at the interface between the TGO and a "mixed zone" that formed between the thermally grown alumina oxide (TGO) and the SZO. While the delamination lifetime increased with coating porosity (reduction in coating modulus), it was significantly less than that of similar YSZ coatings applied to the same substrates. The reduced life resulted from a reaction between the rare earth zirconate and the alumina-rich bond coat TGO, leading to the formation of a mixed zone consisting of SZO and SmAlO(3). Thermal strain energy calculations show that the delamination driving force increases with TGO and mixed layer thicknesses and with coating modulus. The placement of a 10 mu m thick YSZ layer between the TGO and SZO layers eliminated the mixed zone and restored the thermal cyclic life to that of YSZ structures.Surface and Coatings Technology 04/2011; 205(19):4355-4365. DOI:10.1016/j.surfcoat.2011.03.028 · 2.20 Impact Factor
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ABSTRACT: Disparities may exist in the care of patients with primary hyperparathyroidism (HPT). This study examines the presentation and outcomes of underinsured patients undergoing parathyroidectomy. We divided 493 HPT patients who underwent initial parathyroidectomy from 2000 to 2008 at a single institution into 2 groups: underinsured patients (group 1; n = 94) evaluated and treated at a county hospital, and patients with insurance (group 2; n = 399). Univariate and multivariate analysis adjusting for race and ethnicity were conducted to determine the association of being underinsured with several clinical variables. More patients in group 1 compared with group 2 were of black or Hispanic background (92% vs. 44%; P < .0001). Group 1 patients had higher mean preoperative serum calcium and PTH levels: 12.1 vs. 11.8 mg/dL (P = .009) and 263 vs. 198 pg/mL (P = .03), respectively. Seven group 1 (7.4%) and 7 group 2 (1.8%) patients presented with hypercalcemic crisis (P = .003). On multivariate analysis, underinsurance was associated with higher serum calcium levels (P = .011) and hypercalcemic crisis at presentation (odds ratio, 5.59; 95% confidence interval, 1.45-21.51; P = .012). Follow-up was shorter in group 1 patients (15 vs. 24 months; P < .001) and postoperative PTH levels were higher (76 vs. 48 pg/mL; P < .001). Other perioperative data were not different between the groups. Underinsured patients with HPT may present with higher serum calcium and PTH levels, are more likely to have hypercalcemic crisis, and less likely to return for follow-up. Underfunded health insurance coverage may account for differences seen in this study.Surgery 03/2012; 151(3):471-6. DOI:10.1016/j.surg.2011.07.043 · 3.11 Impact Factor
- Cambridge Quarterly of Healthcare Ethics 07/2012; 21(3):309-19. DOI:10.1017/S0963180112000035 · 0.58 Impact Factor