Impact of rurality on processes and outcomes in melanoma care: results from a whole-Scotland melanoma cohort in primary and secondary care

BackgroundThose living in rural areas have poorer cancer outcomes, but current evidence on how rurality impacts melanoma care and survival is contradictory.AimTo investigate the impact of rurality on setting of melanoma excision and mortality in a whole-nation cohort.Design and settingAnalysis of linked routine healthcare data comprising every individual in Scotland diagnosed with melanoma, January 2005–December 2013, in primary and secondary care.MethodMultivariate binary logistic regression was used to explore the relationship between rurality and setting of melanoma excision; Cox proportional hazards regression between rurality and mortality was used, with adjustments for key confounders.ResultsIn total 9519 patients were included (54.3% [n = 5167] female, mean age 60.2 years [SD 17.5]). Of melanomas where setting of excision was known, 90.3% (n = 8598) were in secondary care and 8.1% (n = 771) in primary care. Odds of primary care excision increased with increasing rurality/remoteness. Compared with those in urban areas, those in the most remote rural locations had almost twice the odds of melanoma excision in primary care (adjusted odds ratio [aOR] 1.92; 95% confidence interval [CI] = 1.33 to 2.77). No significant association was found between urban or rural residency and all-cause mortality. Melanoma-specific mortality was significantly lower in individuals residing in accessible small towns than in large urban areas (adjusted hazards ratio [HR] 0.53; 95% CI = 0.33 to 0.87) with no trend towards poorer survival with increasing rurality.ConclusionPatients in Scottish rural locations were more likely to have a melanoma excised in primary care. However, those in rural areas did not have significantly increased mortality from melanoma. Together these findings suggest that current UK melanoma management guidelines could be revised to be more realistic by recognising the role of primary care in the prompt diagnosis and treatment of those in rural locations.

Download Full-text

How long does it take patients to find a new primary care physician when theirs retires: a population-based, longitudinal study

Human Resources for Health ◽

10.1186/s12960-021-00633-9 ◽

2021 ◽

Vol 19 (1) ◽

Author(s):

Lindsay Hedden ◽

Megan A. Ahuja ◽

M. Ruth Lavergne ◽

Kimberlyn M. McGrail ◽

Michael R. Law ◽

...

Keyword(s):

Primary Care ◽

Primary Care Physician ◽

Rural Areas ◽

Proportional Hazards ◽

Population Based ◽

Cox Proportional Hazards ◽

Care Physician ◽

Potential Threat ◽

Patient Age ◽

Patient Âgé

Abstract Background The retirement of a family physician can represent a challenge in accessibility and continuity of care for patients. In this population-based, longitudinal cohort study, we assess whether and how long it takes for patients to find a new majority source of primary care (MSOC) when theirs retires, and we investigate the effect of demographic and clinical characteristics on this process. Methods We used provincial health insurance records to identify the complete cohort of patients whose majority source of care left clinical practice in either 2007/2008 or 2008/2009 and then calculated the number of days between their last visit with their original MSOC and their first visit with their new one. We compared the clinical and sociodemographic characteristics of patients who did and did not find a new MSOC in the three years following their original physician’s retirement using Chi-square and Fisher’s exact test. We also used Cox proportional hazards models to determine the adjusted association between patient age, sex, socioeconomic status, location and morbidity level (measured using Johns Hopkins’ Aggregated Diagnostic Groupings), and time to finding a new primary care physician. We produce survival curves stratified by patient age, sex, income and morbidity. Results Fifty-four percent of patients found a new MSOC within the first 12 months following their physician’s retirement. Six percent of patients still had not found a new physician after 36 months. Patients who were older and had higher levels of morbidity were more likely to find a new MSOC and found one faster than younger, healthier patients. Patients located in more urban regional health authorities also took longer to find a new MSOC compared to those in rural areas. Conclusions Primary care physician retirements represent a potential threat to accessibility; patients followed in this study took more than a year on average to find a new MSOC after their physician retired. Providing programmatic support to retiring physicians and their patients, as well as addressing shortages of longitudinal primary care more broadly could help to ensure smoother retirement transitions.

Download Full-text

Analysis of factors associated with changing general practice in the first 14 years of life in Wales using linked cohort and primary care records: implications for using primary care databanks for life course research

International Journal for Population Data Science ◽

10.23889/ijpds.v3i4.818 ◽

2018 ◽

Vol 3 (4) ◽

Author(s):

Ashley Akbari ◽

Ronan Lyons ◽

Amrita Bandyopadhyay ◽

Helen Bedford ◽

Sinead Brophy ◽

...

Keyword(s):

Primary Care ◽

General Practice ◽

Life Course ◽

Rural Areas ◽

Proportional Hazards ◽

Survey Design ◽

Mode Of Delivery ◽

Cox Proportional Hazards ◽

Housing Tenure ◽

Factors Associated

IntroductionPrimary care electronic health records (pcEHRs) are a valuable resource for life course research, however loss to follow up due to changing practices has received little attention. We investigated factors associated with changes in registration and record continuity in the Secure Anonymised Information Linkage (SAIL) databank, with ~80% practice coverage. Objectives and ApproachWe analysed linked pcEHRs for 1834 (882 girls) Millennium Cohort Study (MCS) participants, resident in Wales and with parental consent to health record linkage at the age seven MCS interview. We studied time from first to next general practice (GP) registration in Wales by fitting Cox proportional hazards models, and estimated mutually-adjusted hazard ratios (aHRs) for the following factors: child (sex, ethnicity, mode of delivery, gestation, birthweight, neonatal illness, wheeze, longstanding illness); maternal (age, education, lone parent status); household (income, housing tenure, residential mobility, urban/rural residence); GP type (SAIL-contributing/-non-contributing). Analyses were weighted for survey design (Stata: Release 15; StataCorp LP). ResultsThere were 3065 Welsh GP registrations for 1834 children. By age 5 years, 25% of children changed GP at least once, with 1070 (58.3%), 477 (26.0%) and 287 (15.7%) registered with 1, 2, 3+ GPs respectively up to 14 years of age. Children with older mothers (aHRs; 95% CI: 0.96; 0.95, 0.98; per year) or those residing in rural areas (0.75;0.56,0.99) were less likely, and those whose first registration was not with a SAIL contributing GP (2.16;1.60,2.93), whose mothers had no educational qualifications (1.40;1.15,1.71), or had recently changed address (1.62;1.21,2.16) more likely, to change GP. 305 (16.6%) children had never registered with a SAIL-contributing GP. Of 403 children initially registered with a SAIL contributing GP who then changed GP, 66.7% re-registered with a SAIL contributing GP. Conclusion/ImplicationsGeographically contiguous primary care databanks, such as the SAIL databank, enable a high proportion of children to be reliably followed over time despite changing GP. Similar analyses of databases based on geographically disparate volunteer GPs are needed to quality assure their suitability for life course epidemiology research.

Download Full-text

Modelling Population Changes in Small English Urban Areas

Environment and Planning A Economy and Space ◽

10.1068/a181297 ◽

1986 ◽

Vol 18 (10) ◽

pp. 1297-1322 ◽

Cited By ~ 6

Author(s):

P Congdon ◽

J Shepherd

Keyword(s):

Labour Market ◽

Rural Areas ◽

Urban Areas ◽

Physical Reality ◽

Small Towns ◽

General Tendency ◽

Retirement Migration ◽

Causal Processes ◽

Market Areas ◽

The Impact

Research on urbanisation has been hampered by discrepancies between the administrative boundaries of towns and a meaningful spatial framework of urbanism that recognises both the true extent of the built-up areas of towns and the functional linkages between urban centres and their surrounding hinterland. An ‘urban area’ definition has been recently developed for British census statistics to represent the physical reality of urban boundaries in terms of land that is urban in use, whereas the functional approach to urban definition has been implemented in terms of a set of urban-centred labour-market areas. In this paper the spatial frameworks of physical and functional definitions are combined in order to investigate processes of population growth in small- and medium-sized towns in England between 1971 and 1981. As in other studies, a general tendency to counterurbanisation— higher growth rates for smaller urban areas (physically defined)—is demonstrated. However, a variety of types of ‘counterurbanisation’ also become apparent. In addition to growth of smaller towns in rural areas beyond metropolitan influence, there has been growth of towns in the labour-market areas of newer freestanding urban centres, and also in the decentralised commuter hinterlands of large metropolitan cores. In this paper a number of causal processes which may underlie different types of growth are investigated, setting this investigation within the standard and labour-market regional context of physical urban areas. There is evidence of ‘people-led’ growth in environmentally attractive locations (for example, through retirement migration). However, growth of small- and medium-sized towns also reflects employment decentralisation and deconcentration to freestanding or satellite towns, and the extension of commuter hinterlands linked both to a growth of car commuting and to availability of land for private-sector housing. Government policies encouraging growth are also demonstrated to be significant. Conversely, decline in a minority of small towns often indicates a diminishing employment base or policy restrictions on growth. The impact on modelling growth in urban areas of a diversity of causal processes and locational contexts for growth is considered.

Download Full-text

The Urban-Rural Divide: Spatial Inequalities and Backlash in the Investment Treaty Regime

The Italian Yearbook of International Law Online ◽

10.1163/22116133-03001008 ◽

2021 ◽

Vol 30 (1) ◽

pp. 131-153

Author(s):

Daniel Litwin

Keyword(s):

International Law ◽

Rural Areas ◽

Urban Areas ◽

Multinational Enterprises ◽

Small Towns ◽

Political Polarization ◽

Investment Treaty ◽

Spatial Inequalities ◽

Urban Rural ◽

The Impact

A growing literature in international law has examined the backlash against international institutions and norms and its links with the rise of nationalist parties and populism. Some of this backlash have been said to originate with populations in small towns and rural areas socioeconomically “left-behind” by economic globalization. These developments have made salient the growing economic and political polarization between urban and non-urban areas. Nevertheless, this urban- rural divide and its implications for international law have only started to be acknowledged. Aligned with these concerns, this article adopts the urban-rural divide as a geographical scale or frame to suggest a new perspective on the investment treaty regime, its backlash and reform. Outside of the particularly virulent nature of its backlash, the regime’s context provides fertile ground for this frame: it is structured so that urban actors principally located in global or capital cities, such as multinational enterprises, global law firms, or national executive branches, make decisions about foreign investment projects that are often located and impact non-urban areas and populations. As this article contends, this context points to the regime’s potential to impact (and address) through geographical affinities the global growth of political and economic polarization between urban and nonurban areas. The impact of these urban decisions on non-urban areas has so far principally been examined through frames that emphasize impact in terms of the “environment” or “local communities” together with calls for reforms to the regime by allocating more policy space for States. An “urban-rural” frame centers additional impacts in terms of non-urban public interest, local participation, and the distribution of resources, and queries the ability of domestic policies alone to respond to them in the pursuit of socially and economic inclusive investment.

Download Full-text

Rural and urban disparities based on zip code of residence: Analyses of 834 and 2,159 patients in NCCTG N9741 and CALGB 80405 (Alliance) trials respectively.

Journal of Clinical Oncology ◽

10.1200/jco.2020.38.15_suppl.e16076 ◽

2020 ◽

Vol 38 (15_suppl) ◽

pp. e16076-e16076

Author(s):

Midhun Malla ◽

Lucas J. Huebner ◽

Sorbarikor Piawah ◽

Heinz-Josef Lenz ◽

Charles David Blanke ◽

...

Keyword(s):

Rural Areas ◽

Urban Areas ◽

Proportional Hazards ◽

Private Insurance ◽

Progression Free Survival ◽

Epidemiological Data ◽

Cox Proportional Hazards ◽

Chi Square ◽

Cox Proportional Hazards Models ◽

Zip Code

e16076 Background: Median overall survival (mOS) of patients (pt) with metastatic colorectal cancer (mCRC) has improved steadily over the past two decades. However, epidemiological data suggest that cancer outcomes for rural compared to urban dwelling pts are worse. In this study, we retrospectively compared progression free survival (PFS) and OS among mCRC pts residing in urban versus rural areas enrolled in N9741 (1997-2004) and CALGB 80405 (2005-2012) clinical trials. Methods: Zip code data from the Centers for Disease Control (CDC) were used to classify pts into rural or urban dwellers. Chi-square and Kruskal Wallis analyses were used to compare the groups. Survival outcomes were evaluated using Kaplan-Meier estimates, compared by stratified log rank and cox proportional hazards models. Results: In N9741 and 80405 respectively, 217 (35%) and 521 (21%) pts resided in rural areas. Median age of mCRC pts at diagnosis was 60.5 yrs. (rural) compared to 58.6 yrs. (urban) in 80405 (P < 0.01) and 59.6 yrs. to 60.2 yrs. in N9741 (P = 0.4). In 80405, pts in rural areas were less likely to be female (35% vs 43%, P < 0.01) black (6.6% vs 15.1%, P < 0.01), unmarried (51% vs 62%, P < 0.01), and to have private insurance (PI) (45% vs 50%, P = 0.03) when compared to pts in urban areas. In N9741, gender (P = 0.8) and PI (P = 0.3) distribution was similar; pts in rural areas were less likely to be black (1.4% vs 9.1%, P < 0.01). Rural vs urban pt PFS was no different in either trial. MOS was worse in pts in rural areas when compared to urban dwellers in 80405 (Table). OS outcomes stratified based on the use of cetuximab based regimen in 80405 showed worse outcomes for pts in rural compared to urban dwellers (21.9 vs 26.3 mo. HR: 1.22 (1.03-1.44), P = 0.02). Conclusions: MCRC pts from rural areas had a significantly worse mOS when compared to pts in urban areas in 80405. Furthermore, mOS with cetuximab based regimens was 4.4 months shorter in rural pts. The observed rural vs urban dweller mOS disparities in 80405 pts justifies additional research searching for causal factors and the necessity to identify actionable approaches in order to improve pt outcomes in rural areas. Support: U10CA180821, U10CA180882, U10CA180888, UG1CA180830; Pfizer, Sanofi, BMS, Genentech, https://acknowledgments.alliancefound.org . ClinicalTrials.gov Identifier: NCT00003594, NCT00265850. [Table: see text]

Download Full-text

Urban–Rural Disparities in the Incidence of Diabetes-Related Complications in Taiwan: A Propensity Score Matching Analysis

Journal of Clinical Medicine ◽

10.3390/jcm9093012 ◽

2020 ◽

Vol 9 (9) ◽

pp. 3012

Author(s):

Shu-Yu Tai ◽

Jiun-Shiuan He ◽

Chun-Tung Kuo ◽

Ichiro Kawachi

Keyword(s):

Propensity Score ◽

Propensity Score Matching ◽

Rural Areas ◽

Urban Areas ◽

Proportional Hazards ◽

Proportional Hazards Model ◽

Cox Proportional Hazards ◽

Cox Proportional Hazards Model ◽

Propensity Score Matching Analysis ◽

Urban Rural

Although a disparity has been noted in the prevalence and outcome of chronic disease between rural and urban areas, studies about diabetes-related complications are lacking. The purpose of this study was to examine the association between urbanization and occurrence of diabetes-related complications using Taiwan’s nationwide diabetic mellitus database. In total, 380,474 patients with newly diagnosed type 2 diabetes between 2000 and 2008 were included and followed up until 2013 or death; after propensity score matching, 31,310 pairs were included for analysis. Occurrences of seven diabetes-related complications of interest were identified. Cox proportional hazards model was used to determine the time-to-event hazard ratio (HR) among urban, suburban and rural groups. We found that the HRs of all cardiovascular events during the five-year follow-up was 1.04 times (95% confidence interval (CI) 1.00–1.07) and 1.15 times (95% CI 1.12–1.19) higher in suburban and rural areas than in urban areas. Patients in suburban and rural areas had a greater likelihood of congestive heart failure, stroke, and end-stage renal disease than those in urban areas. Moreover, patients in rural areas had a higher likelihood of ischemic heart disease, blindness, and ulcer than those in urban areas. Our empirical findings provide evidence for potential urban–rural disparities in diabetes-related complications in Taiwan.

Download Full-text

Analysis of factors associated with changing general practice in the first 14 years of life in Wales using linked cohort and primary care records: implications for using primary care databanks for life-course research

International Journal for Population Data Science ◽

10.23889/ijpds.v3i2.477 ◽

2018 ◽

Vol 3 (2) ◽

Author(s):

Carol Dezateux ◽

Lucy J Griffiths ◽

Bianca L De Stavola ◽

Ashley Akbari ◽

Amrita Bandyopadhyay ◽

...

Keyword(s):

Primary Care ◽

General Practice ◽

Life Course ◽

Rural Areas ◽

Early Life ◽

Proportional Hazards ◽

Cox Proportional Hazards ◽

Factors Associated ◽

Changing Practice ◽

Cox Proportional Hazards Models

Background Databanks of primary care electronic health records (pcEHRs) are a valuable resource for life course research, however loss to follow up due to changing general practice has received little attention. ObjectiveWe investigated factors associated with changing general practice (GP) in early life and continuity of participation in the Secure Anonymised Information Linkage (SAIL) databank, to which approximately 80% of Welsh practices contribute. MethodsWe analysed linked pcEHRs for 1834 (882 girls) Millennium Cohort Study participants, resident in Wales, with consent to health record linkage. We studied time from first to next practice registration using Cox proportional hazards models, and estimated mutually-adjusted hazard ratios (aHRs) for child, household and practice factors. FindingsThere were 3065 Welsh GP registrations for 1834 children. By age 5 years, 25% changed practice at least once, with 1070 (58.3%), 477 (26.0%), 287 (15.7%) registered with 1, 2, or 3+ GPs respectively by age 14 years. Changing practice was related to maternal age (aHRs; 95% CI: 0.96; 0.95,0.98), living in rural areas (0.75;0.56,0.99), initial registration with a non-SAIL-practice (2.16;1.60,2.93), recent address change (1.62;1.21,2.16), and no maternal educational qualifications (1.40;1.15,1.71). Overall, 305 (16.6%) children had never registered with a SAIL practice. Of 403 children initially registered with a SAIL practice who then changed practice, 66.7% re-registered with a SAIL practice. ConclusionsIn a nationally representative sample of Welsh children, the majority remained registered with the same practice up to age 14 years, with change in practice varying by maternal and household factors. Continuity of participation in the Welsh SAIL databank over early life is high, reflecting the high proportion of practices contributing, and the high proportion of children registered with them. Geographically contiguous primary care databanks, such as SAIL, enable a high proportion of children to be followed over time despite changing general practice.

Download Full-text

Age at Exposure to Parental Suicide and the Subsequent Risk of Suicide in Young People

Crisis ◽

10.1027/0227-5910/a000468 ◽

2018 ◽

Vol 39 (1) ◽

pp. 27-36 ◽

Cited By ~ 5

Author(s):

Kuan-Ying Lee ◽

Chung-Yi Li ◽

Kun-Chia Chang ◽

Tsung-Hsueh Lu ◽

Ying-Yeh Chen

Keyword(s):

Young People ◽

Proportional Hazards ◽

Proportional Hazards Model ◽

Cox Proportional Hazards ◽

Cox Proportional Hazards Model ◽

Birth Registry ◽

Data Set ◽

Parental Suicide ◽

The Impact ◽

Age At Exposure

Abstract. Background: We investigated the age at exposure to parental suicide and the risk of subsequent suicide completion in young people. The impact of parental and offspring sex was also examined. Method: Using a cohort study design, we linked Taiwan's Birth Registry (1978–1997) with Taiwan's Death Registry (1985–2009) and identified 40,249 children who had experienced maternal suicide (n = 14,431), paternal suicide (n = 26,887), or the suicide of both parents (n = 281). Each exposed child was matched to 10 children of the same sex and birth year whose parents were still alive. This yielded a total of 398,081 children for our non-exposed cohort. A Cox proportional hazards model was used to compare the suicide risk of the exposed and non-exposed groups. Results: Compared with the non-exposed group, offspring who were exposed to parental suicide were 3.91 times (95% confidence interval [CI] = 3.10–4.92 more likely to die by suicide after adjusting for baseline characteristics. The risk of suicide seemed to be lower in older male offspring (HR = 3.94, 95% CI = 2.57–6.06), but higher in older female offspring (HR = 5.30, 95% CI = 3.05–9.22). Stratified analyses based on parental sex revealed similar patterns as the combined analysis. Limitations: As only register-based data were used, we were not able to explore the impact of variables not contained in the data set, such as the role of mental illness. Conclusion: Our findings suggest a prominent elevation in the risk of suicide among offspring who lost their parents to suicide. The risk elevation differed according to the sex of the afflicted offspring as well as to their age at exposure.

Download Full-text

Impact of Elected Women Representatives of Panchayati Raj in Physical and Financial and Business Assets Development of Rural Women: A Study among the Rural Women’s of Tiruvannamalai District, Tamil Nadu[1]

Scholarly Research Journal for Humanity Science & English Language ◽

10.21922/srjhsel.v4i24.10323 ◽

2017 ◽

Vol 4 (24) ◽

Author(s):

Kalaichelvi Sivaraman ◽

Rengasamy Stalin

Keyword(s):

Rural Women ◽

Rural Areas ◽

Urban Areas ◽

Direct Democracy ◽

Tamil Nadu ◽

Local Level ◽

Rural And Urban Areas ◽

The Government ◽

The Impact ◽

Panchayati Raj

This research paper is the part of Research Project entitled “Impact of Elected Women Representatives in the Life and Livelihood of the Women in Rural Areas: With Special Reference to Tiruvannamalai District, Tamil Nadu” funded by University of Madras under UGC-UPE Scheme.The 73rd and 74th amendments of the Constitution of India were made by the government to strengthen the position of women and to create a local-level legal foundation for direct democracy for women in both rural and urban areas. The representation for women in local bodies through reservation policies amendment in Constitution of India has stimulated the political participation of women in rural areas. However, when it’s comes to the argument of whether the women reservation in Panchayati Raj helps or benefits to the life and livelihood development of women as a group? The answer is hypothetical because the studies related to the impact of women representatives of Panchayati Raj in the life and livelihood development of women was very less. Therefore, to fill the gap in existing literature, the present study was conducted among the rural women of Tiruvannamalai district to assess the impact of elected women representatives in the physical and financial and business development of the women in rural areas. The findings revealed that during the last five years because of the women representation in their village Panjayati Raj, the Physical Asset of the rural women were increased or developed moderately (55.8%) and Highly (23.4%) and the Financial and Business Asset of the rural women were increased or developed moderately (60.4%) and Highly (18.7%).

Download Full-text

Factors that contribute to urban–rural gradients in risk of schizophrenia: Comparing Danish and Western Australian registers

Australian & New Zealand Journal of Psychiatry ◽

10.1177/00048674211009615 ◽

2021 ◽

pp. 000486742110096

Author(s):

Oleguer Plana-Ripoll ◽

Patsy Di Prinzio ◽

John J McGrath ◽

Preben B Mortensen ◽

Vera A Morgan

Keyword(s):

Confidence Interval ◽

Western Australia ◽

Urban Areas ◽

Proportional Hazards ◽

Cox Proportional Hazards ◽

Hazard Ratio ◽

Indigenous Status ◽

Increased Risk ◽

The Relationship ◽

Western Australian

Introduction: An association between schizophrenia and urbanicity has long been observed, with studies in many countries, including several from Denmark, reporting that individuals born/raised in densely populated urban settings have an increased risk of developing schizophrenia compared to those born/raised in rural settings. However, these findings have not been replicated in all studies. In particular, a Western Australian study showed a gradient in the opposite direction which disappeared after adjustment for covariates. Given the different findings for Denmark and Western Australia, our aim was to investigate the relationship between schizophrenia and urbanicity in these two regions to determine which factors may be influencing the relationship. Methods: We used population-based cohorts of children born alive between 1980 and 2001 in Western Australia ( N = 428,784) and Denmark ( N = 1,357,874). Children were categorised according to the level of urbanicity of their mother’s residence at time of birth and followed-up through to 30 June 2015. Linkage to State-based registers provided information on schizophrenia diagnosis and a range of covariates. Rates of being diagnosed with schizophrenia for each category of urbanicity were estimated using Cox proportional hazards models adjusted for covariates. Results: During follow-up, 1618 (0.4%) children in Western Australia and 11,875 (0.9%) children in Denmark were diagnosed with schizophrenia. In Western Australia, those born in the most remote areas did not experience lower rates of schizophrenia than those born in the most urban areas (hazard ratio = 1.02 [95% confidence interval: 0.81, 1.29]), unlike their Danish counterparts (hazard ratio = 0.62 [95% confidence interval: 0.58, 0.66]). However, when the Western Australian cohort was restricted to children of non-Aboriginal Indigenous status, results were consistent with Danish findings (hazard ratio = 0.46 [95% confidence interval: 0.29, 0.72]). Discussion: Our study highlights the potential for disadvantaged subgroups to mask the contribution of urban-related risk factors to risk of schizophrenia and the importance of stratified analysis in such cases.

Download Full-text