Gorey Kevin M, Kanjeekal Sindu M, Wright Frances C, Hamm Caroline, Luginaah Isaac N, Bartfay Emma, Zou Guangyong, Holowaty Eric J, Richter Nancy L
School of Social Work, University of Windsor, 401 Sunset Avenue, Windsor, Ontario, N9B 3P4, Canada.
Department of Oncology, Windsor Regional Cancer Center and Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
Int J Equity Health. 2015 Oct 29;14:109. doi: 10.1186/s12939-015-0246-z.
Our research group advanced a health insurance theory to explain Canada's cancer care advantages over America. The late Barbara Starfield theorized that Canada's greater primary care-orientation also plays a critically protective role. We tested the resultant Starfield-Gorey theory by examining the effects of poverty, health insurance and physician supplies, primary care and specialists, on colon cancer care in Ontario and California.
We analyzed registry data for people with non-metastasized colon cancer from Ontario (n = 2,060) and California (n = 4,574) diagnosed between 1996 and 2000 and followed to 2010. We obtained census tract-based socioeconomic data from population censuses and data on county-level physician supplies from national repositories: primary care physicians, gastroenterologists and other specialists. High poverty neighborhoods were oversampled and the criterion was 10 year survival. Hypotheses were explored with standardized rate ratios (RR) and tested with logistic regression models.
Significant inverse associations of poverty (RR = 0.79) and inadequate health insurance (RR = 0.80) with survival were observed in the California, while they were non-significant or non-existent in Ontario. The direct associations of primary care physician (RRs of 1.32 versus 1.11) and gastroenterologist (RRs of 1.56 versus 1.15) supplies with survival were both stronger in Ontario than California. The supply of primary care physicians took precedence. Probably mediated through the initial course of treatment, it largely explained the Canadian advantage.
Poverty and health insurance were more predictive in the USA, community physician supplies more so in Canada. Canada's primary care protections were greatest among the most socioeconomically vulnerable. The protective effects of Canadian health care prior to enactment of the Affordable Care Act (ACA) clearly suggested the following. Notwithstanding the importance of insuring all, strengthening America's system of primary care will probably be the best way to ensure that the ACA's full benefits are realized. Finally, Canada's strong primary care system ought to be maintained.
我们的研究团队提出了一种医疗保险理论，以解释加拿大在癌症治疗方面相对于美国的优势。已故的芭芭拉·斯塔菲尔德提出理论，认为加拿大更注重初级保健也起到了至关重要的保护作用。我们通过研究贫困、医疗保险、医生供应、初级保健和专科医生对安大略省和加利福尼亚州结肠癌治疗的影响，对由此产生的斯塔菲尔德 - 戈里理论进行了检验。
我们分析了1996年至2000年期间在安大略省（n = 2060）和加利福尼亚州（n = 4574）被诊断出患有非转移性结肠癌且随访至2010年的患者的登记数据。我们从人口普查中获取了基于普查区的社会经济数据，并从国家资料库中获取了县级医生供应数据：初级保健医生、胃肠病学家和其他专科医生。对高贫困社区进行了过度抽样，标准是10年生存率。使用标准化率比（RR）探索假设，并通过逻辑回归模型进行检验。
在加利福尼亚州，观察到贫困（RR = 0.79）和医疗保险不足（RR = 0.80）与生存率存在显著负相关，而在安大略省这些相关性不显著或不存在。安大略省初级保健医生（RR分别为1.32和1.11）和胃肠病学家（RR分别为1.56和1.15）供应与生存率的直接关联都比加利福尼亚州更强。初级保健医生的供应起了主导作用。可能是通过初始治疗过程介导的，它在很大程度上解释了加拿大的优势。
在美国，贫困和医疗保险的预测性更强，在加拿大社区医生供应的预测性更强。加拿大的初级保健保护在社会经济最脆弱的人群中最为显著。在《平价医疗法案》（ACA）颁布之前，加拿大医疗保健的保护作用清楚地表明了以下几点。尽管确保全民参保很重要，但加强美国的初级保健系统可能是确保充分实现ACA全部益处的最佳方式。最后，加拿大强大的初级保健系统应该得到维持。
