Cancer – Health Needs
Assessment
overview and focus on Lung
Greg.fell@bradford.nhs.uk
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Approach to presentation
• This IS the report. There is no
accompanying document.
• Additional notes are contained within the
notes pages beneath each slide.
– File......print.....notes pages.....
Approach to data
•
•
•
•
•
No new data analysis.
Revised and pulled together what exists already.
NYCRIS – QAd and high quality data set – as good as there is.
A little old (but reflects QA).
We hold local data, but:
–
–
–
•
Other (mostly older) analyses done.
–
–
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•
QA / analyst capacity / ability to pull it ALL together.
Sub regional data has major issues in terms of statistical reliability and robustness.
Is Bradford different to any other multi ethnic population?
Have findings of these been implemented?
Has the epi changed since then? Probably not.
Populations, demographics, social characteristics, risk profile changes very slowly.
No major innovations in Rx?
Thus a new analysis might not give significant new conclusions – and will incur and
OC in terms of analyst time.
• Conclusions that can already be drawn from this.
What are we measuring
• Incidence – a measure of risk factor distribution
• Stage at presentation – a measure of the efficiency of pick up by health care, broader
social and cultural factors
• Mortality – a measure of effectiveness of treatment and incidence
• Survival – a measure of treatment effectiveness, and is also influenced by stage of
Dx
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Questions and issues explored
• Equality – best and worst.
• Most common cancer diagnoses
• Incidence
– A reflection on exposure to risk factors
• Survival gap?
– Survival being a key measure of effectiveness of treatment once
diagnosed.
• Late Dx? Staging or mets at presentation.
• Mortality
– A refection of incidcne and treatment effectiveness.
• What does the QOF tell us? –
– Not much!!! Prev of all Ca. Might be possible to age standardise to take
into account practice differences.
• What can be done re stage at presentation – Sx awareness?
• Dimensions of equality - Socio economic, ethnic.
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Contents
• Summary / key messages. If you read nothing else read
this.
• Populations
• Common Risk Factors
• Screening
• Overview of all Cancers
• Lung Cancer
–
–
–
–
–
–
Risk Factors
Incidence
Stage at Diagnosis
Treatment
Survival
Mortality
• Summary
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Summary
This section summarises the key
issues, limited recommendations.
Discussion with CLAN re exactly what
next is needed.
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Summary (1) – Risk Factors and
populations
•
Significant variation across groups. Smoking and other risk factors.
– Under implementation of preventive interventions – both in clinical practice and
broader public health.
– Not just smoking, though this is very important.
– Opportunities for smoking cessation referral (especially at key life points –
receptive to change. Cost effective and clinically effective)
– How do we address the epidemiology of smoking. Industrializing tobacco control.
Build into ALL care pathways. Critical life points as incentives to quit. Broader
tobacco control.
– Weight, diet, activity and alcohol consumption are also important risk factors. We
don't do enough here
– Implementation of preventive interventions should also be equitable. It does not
seem to be now (eg smoking cessation)
– Big potential for large population gain here – though long term.
– CLAN (and lots of others) should champion this among clinicians of all
flavours
• Age and deprivation structures of populations are very
important considerations. Airedale is affluent and old.
City is deprived and young
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Summary (2) – need. Incidence,
survival and mortality.
Need – incidence survival and mortality.
• incidence and mortality rates (Lung) increased dramatically with age
• There are important differences in cancer incidence, mortality (and
survival in some cancers, but NOT lung) across socioeconomic
groups. Work to reduce health inequalities in cancer needs to take
these trends into account.
• Much of the observed difference in mortality between deprivation
categories (all cancers) is explained by lung cancer (inequalities in
smoking?)
• Mortality rates for lung cancer in men fell significantly over the
decade from 1991 - 2000 for all deprivation categories.
• In contrast, lung cancer mortality in women showed a small increase
overall (significant differences in mortality by socio-economic group
remained).
– Change in the pattern of smoking prevalence over time? Men
quitting more?
• There is limited evidence of a survival gap between most / least
deprived. If there is a socio economic gap, it is not statistically To contents
significant. No ethnicity data.
Summary (3) – Screening and early
diagnosis. Staging
•
•
•
•
•
Little is known about stage at presentation for Lung (or others)
A range of further analysis will be undertaken with the LUCADA audit dataset,
possible links into other data sources. This is highlighted in the notes page
below.
– Likely to show socio economic difference in staging at presentation (or Dx)
This leads to consideration of the implementation of a range of early Dx strategies –
– Sx education – clinician and public. Culturally aware. Literacy. market and
message segmentation; use of peers etc etc
– earlier referral – might be warranted…….is there evidence that this will make the
difference to survival or mortality rates………….not sure…..but certainly a need
to key into the pilots mentioned in Ca Reform Strategy – are we one of them
– Clinical culture - referral to exclude a diagnosis
– Community diagnostics? Do we need to be smarter about how we route people
to diagnostics quickly?
How well do we make use of whatever screening monitoring data we can get to
monitor equality of uptake.
In cervical cancer, there is a large observed variation in screening coverage at
practice level. Some population characteristics and some health care system
characteristics are factors in this. This is an area NSC are currently activiely
exploring. This needs to be carefully considered by CLAN
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Summary (4) – service provision
and system performance.
Service Provision, treatment use and performance
•
analysis of service provision is difficult to interpret in terms of equity, as elements of service
provision are affected by many factors
Treatments
•
There is some evidence of variation in service provision related to geography and age, but not
socio economic status. This does not take into account stage at presentation, co morbidities or
other clinically relevant factors (each of which could confound). Thus it is difficult to draw firm
conclusions about treatment variation (and whether this has an impact on outcomes) without
further analysis
•
These variations did not appear to relate to, or translate to need as measured by mortality or
incidence.
•
The variations found may actually relate primarily to provider variation across West Yorkshire.
•
This analysis uses YHPHO Equity Audit from 2002. It is likely that variations in system
performance (and possibly treatment used) have equalised over time – National Standards.
•
Wide range of factors relating to the performance of a cancer system not fully considered.
prevention as well as other measures of treatment and service provision– e.g. primary care
provision, staffing numbers, survival rates
•
The system performance measures will undoubtedly have changes (62 days / 2 weeks etc etc) –
may be scope for updating some of this analysis.
•
Whether a huge focus in this area will acheive significant improvements in health
outcomes (population wide or addressing the equality gap) should be seriously
considered. The largest gain will come from industrial scale prevention and early diagnosis
strategies.
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Populations
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We have a younger population than
E&W
Bradford
England and Wales
Under 16
23.4
20.2
16 to 19
5.6
4.9
20 to 29
13.4
12.6
30 to 59
38.7
41.5
60 to 74
12.2
13.3
75 and over
6.8
7.6
Average age
36.4
38.6
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Age profile of the population
• Age is a significant factor in Cancer
• Age Profile not equally spread through the
district
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We have a more ethnically diverse population than E&W. Update? Do
we have more up to date info on Black pop – WYCSA getting some on
new reg with GP by district and country of origin…GF sourcing this
Percentage of resident
population in ethnic groups:
White
Bradford
England
78.3
90.9
0.7
1.3
Mixed
1.5
1.3
Asian or Asian British
18.9
4.6
Indian
2.7
2.1
Pakistani
14.5
1.4
Bangladeshi
1.1
0.6
Other Asian
0.6
0.5
0.9
2.1
Caribbean
0.6
1.1
African
0.2
1.0
Other Black
0.1
0.2
0.4
0.9
of which White Irish
Black or Black British
Chinese or Other Ethnic
Group
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Deprivation in Bradford by IMD 2004 Quintiles
•
Not strictly a risk factor, but a common
measure of equality of outcomes
•
43% of Bradford's population live
in the most deprived 20% of areas
in England.
Meaning Bradford has more than
double the expected proportion of
people living in the most deprived
areas compared to E&W.
The age structure in the most
deprived quintiles is significantly
different
This has a bearing on cancer making interpretation of data more
complex.
Bradford also has some of the
most affluent areas across the
country
•
•
•
•
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New Entrants
Country of Origin of new entrants registering
with a GP (WYCSA 2007)
3500
2500
1970
2000
1761
1500
1229
1000
503
500
209
198
191
186
165
140
139
119
110
106
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Pa
number registering in 2007
3089
3000
• 10,100 new patients
registering from
overseas in Bradford.
• NB treat data with
suspicion until we
know more!!!!
• We know very little
about this population.
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Common risk factors to all
Cancers.
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Smoking - % Prevalence
• Close correlation with
deprivation
• There is limited
tobacco control data:
– either implementation
of tobacco control or
– smoking cessation
data below the level of
the whole population
(SHA return on
smoking cessation)
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Smoking – Adults. A more detailed consideration
Analysis of smoking. Based on population and Smoking Cessation data
Adults (15+) Registered in Bradford And Airedale
423,460
estimated 29% adults smoke. Significant variation. Socio economic and ethnic
122,803
66% want to stop - likely significant socio ecnomoc and ethnic variation
81,050
8382 people that accessed the smoking cessation service set a quit date, or
7
% of the adult smoking population
4282 successfully quit at 4 weeks, or
3
% of the adult smoking population
many of the 4 week quitters will relapse. Contined effort needed.
we have a comparitively high performing smoking cessation service
Analysis by ethnicity
estimated that 19% of Bradford population is Asian or Asian British (01 Census), or
80,457
people
applying 29% to the Asian / Asian British population. Estimated number of smokers within this
ethnic group
23,333
people
564 Asian or Asian British People set a quit date, or
2
% of the estimated adult Asian or
Asian British population
266 of this group quit at 4 weeks, or
1
% of the estimated adult Asian or
Asian British population
more to do to encourage access of service by specific ethnic groups.
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There is other data on smoking prevalence and quitting available
through the QOF. Interpret it with care
Smoking Prevalence (for those patients on a disease register).
This tells us noting about patients not on a register.
% of patients on a disease
register that are smokers
70.00
60.00
50.00
y = 0.2005x + 11.045
R2 = 0.1487
40.00
30.00
20.00
10.00
0.00
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
Practice deprivation score.
Proportion of patients (on a dis register) whose notes record they
are a smoker that have been offered a referral to smoking
cessation in last 15m
100.00
% offered smoking
cessation
90.00
80.00
70.00
y = -0.0224x + 93.489
R2 = 0.0075
60.00
50.00
40.00
30.00
20.00
10.00
0.00
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
• Correlation between
deprivation and smoking
prevalence.
• NB ONLY pt on a dis
register. We don’t know
about those that are not
on a register.
• No clear correlation
between % offered
referral and deprivation.
All referring well.
Practice Deprivation Score
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Obesity - % prevalence.
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Binge Drinking - % prevalence
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Fruit and Veg - % of adult population
consuming >5 portions per day.
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Screening
• Beverly – what Sc data do we have???
• To ADD!
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All Cancers
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DSR Mortality from All Cancers –
All Cancers. PCT level
• Remember we have a
younger, but more
deprived population
overall.
• This analysis is adjusted
for age structure.
• District level analysis
might mask sub
population effect.
• Bradford is second most
deprived district in YH.
• Spearhead areas have
stat signif higher
prevalence
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Incidence
DSR incidence per 100,000. All Sites. 02 - 04. Persons.
Local Authority
500.0
450.0
400.0
350.0
300.0
250.0
200.0
150.0
100.0
50.0
0.0
• Adjusted for age structure – ie DSR
• PCT level analysis might mask sub population
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effect.
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How does Bradford compare.
Mortality
Cancer Mortality All sites (02-04), per 100,000. Persons. Local Authority Level
300.0
250.0
200.0
150.0
100.0
50.0
0.0
• Adjusted for age structure – ie DSR
• PCT level analysis might mask sub population
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effect.
DSR Mortality from all cancers is decreasing over time. YH rate is
higher than national. Bradford district, likely higher than YH
• Adjusted for age
• In both sexes – higher
prevalence in YH than
in England.
• Bradford will be no
different, and most
likely higher than YH
(deprivation profile).
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Cancer mortality. All sites. Old
PCT. Trends over 9 years
Crude Cancer Mortality Rate (all Cancers, all sites) / 100,000 registered population over 9 year period.
350.0
300.0
250.0
Airedale PCT
Bradford City PCT
North Bradford PCT
Bradford South & West PCT
Bradford Total
200.0
150.0
100.0
50.0
0.0
1995 Crude
Rate
•
•
•
•
•
1996 Crude
Rate
1997 Crude
Rate
1998 Crude 1999 Crude 2000 Crude 2001 Crude 2002 Crude
Rate
Rate
Rate
Rate
Rate
2003 Crude
Rate
1995 - 2003
Crude Rate
A relatively static trend in Cancer mortality (all sites) when analyzed by old PCT.
NB these are crude rates, using 2003 registered population for all years (for simplicity).
Not standardized for age structure (a significant confounder).
Airedale has the oldest population – but is least deprived. City has the youngest population but is
most deprived.
Confidence intervals are not plotted here. It is likely there would be no statistically significant
differences.
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s
% of registered population on Cancer
Register.
Ca Prevalence at practice level.
Raw prevalence. QOF 07 08
Cancer - Raw Prevalence. All sites. QOF 0708
2
1.8
1.6
1.4
820 cases, 92,341
registered
population, 0.89%
1.2
Airedale
CityCare
Independent
S&W
YCPA
1
0.8
0.6
0.4
0.2
0
Practice
• This is the raw QOF Prevalence.
• No account of age structure in practice populations
• Many weaknesses in interpretation of this data. Many data
quality issues.
To contents
Age standardising will probably not help.
Data quality is too weak to support drawing any
conclusions from a standardisation model.
0 - 44
45 - 64
>= 65
Reg Pop
B code
Observed no of
diagnosed
cases on
practice
register.
QOF 0708
Raw
Prevalence
%
Bradford and Airedale
345694
117954
70187
533835
4349
0.81
Total Airedale Alliance
54208
23076
15057
92341
820
0.89
Total City care Alliance
113689
21438
11084
146211
445
0.30
Total S&W Alliance
103463
39705
22855
166023
1432
0.86
Total YPCA Alliance
68488
30470
19009
117967
1531
1.30
5846
3265
2182
11293
121
1.07
Total Independent Alliance
Airedale is oldest, least deprived.
City youngest most deprived.
To contents
Lung Cancer
Risk Factors
Incidence
Stage at Dx
Treatment
Survival
Mortality
To contents
Risk Factors
To contents
Estimated prevalence of smoking.
To contents
NB – correlation with deprivation in Bradford by IMD
2004 Quintiles
To contents
Incidence
To contents
Incidence – national and WY
• Falling
Nationally.
• Relatively static
in WY.
• Reflects historic
trends in
smoking
prevalence and
smoking
cessation
To contents
Incidence at ‘old PCT’ level.
• Unadjusted for age
profile
• No deprivation
data.
• Trends in
incidence have an
approximate
correlation with
deprivation profile
of old PCTs.
To contents
Incidence and age
• Principally prevalent
>50yrs.
• Much higher >75 yrs
To contents
Stage at diagnosis
To contents
No data!! YET!. More to be added
here. LUCADA.
• Well certainly not much high quality data that is
‘routinely available’
• NYCRIS view is that the q of the data in this
area (particularly for Lung) is poor.
– Either stage at Dx or presence of mets at Dx
• Clini audit might get us a better answer, but
labour intensive.
• Clinicians gut feel for this issue – qualitative
evidence. Worth adding in if there is a means to
assess systematically.
• LUCADA information might help elaborate this
To contents
further.
Treatment for Lung Ca
To contents
Waiting Times – GP referral to diagnosis
‘old PCTs’. Lung
• There is (was – this is
old data) variation in
waiting time to Dx for
GP referred patients.
• 2002.
• A greater proportion
referred quickly in N
and S&W compared
to Airedale and City.
• Has this changed?
To contents
Waiting Times – GP referral to diagnosis.
Deprivation Quintiles. Lung
• Variation in waiting time to
diagnosis for patients referred
by their GP by deprivation
quintile in 2002.
• The most affluent quintile
(46%) were most likely to wait
less than 2 weeks from referral
to diagnosis,
• Little evidence of socio –
economic gradient across all
other groups.
• 2002 Data. Has this changed.
• All W Yorks
To contents
Waiting Times - diagnosis to treatment
- ‘old PCTs’ . Lung
• Similar variation in
diagnosis to
treatment.
• 2002 data.
• Has this changed?
To contents
Waiting Times - diagnosis to
treatment. Deprivation quintiles. Lung
• There is inequality in wait
from Dx to Rx
• In diagnosis to treatment
times by deprivation
quintile, 42% of the most
affluent quintile waiting
less than four weeks from
diagnosis to first
treatment compared with
29% in the most deprived
quintile.
• 2002 data. All W
Yorkshire. Has this
changed.
To contents
Treatment for Lung Cancer
•
•
•
In 2002, 51% of persons
diagnosed with lung cancer
received treatment for the
disease, with males and females
equally likely to have received
similar treatment.
There is a direct relationship
between age and treatment, with
82% of persons aged under 50
and 34% of persons aged over 75
receiving treatment.
Most treatment types reduced with
age: persons aged under 50 were
most likely to receive
chemotherapy, and the group
aged 50-74 were more likely to
receive radiotherapy.
To contents
Geographic variation in treatment
modalities. Lung
• V few (4.9%) Bradford
City receive surgery ?late presentation.
• But not explained by
deprivation alone –
compare to S Leeds.
• 5.9% Airedale
patients receive RT
To contents
Treatment and Deprivation. Lung
• The poor less likely to
be treated.
• When aggregated into
deprivation quintiles,
limited difference in
actual treatment type.
• Certainly – unlikely to
be statistically
significant.
To contents
Survival
To contents
Survival. Lung Cancer. PCT level
Lung Cancer - Three year survival, persons. PCTs ranked by deprivation profile at LA level.
Cases diagnosed between 1999 and 2003
16.0
14.0
y = -0.1424x + 10.318
R2 = 0.1449
Relative Survival (%)
12.0
10.0
8.0
6.0
4.0
2.0
or
ks
rth
Y
No
5N
V
5N
W
Ea
st
Ri
di n
g
of
Yo
rk s
hi r
e
hir
ea
nd
5E
F
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No
rk
rth
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co
lns
hir
e
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ald
er
da
le
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irk
l ee
s
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1L
ee
ds
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8R
oth
erh
am
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4S
he
ffie
ld
5
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N3
N
W
No
ak
rth
efi
led
Ea
st
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co
5N
lns
Y
hir
Br
e
5N
ad
5D
for
da
on
ca
nd
s te
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re
r
da
le
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ac
hi n
g
5J
E
Ba
rn
s le
5N
y
X
Hu
ll T
ea
ch
i ng
0.0
• Populations with
greater deprivation
have poorer
observed 3y survival
• Trend, but NOT stat
significant – see CI
• Simple analysis linking
deprivation at PCT
(matched LA
boundaries – far from
perfect) (IMD) with
survival data from
NYCRIS.
• Also have 1 and 5y
survival by PCT –
similar pattern
PCT - ranked by deprivation at LA level
To contents
1 and 5 year survival by deprivation quintile
• When analysed by deprivation quintile (NYCRIS
area – large population), non significant relationship
between deprivation and survival.
• there was no significant difference in five-year
survival between the deprivation groups.
To contents
Time trend in survival
• Small but significant improvement in five-year survival
over time, from 5.8% (95% CI 5.2% - 6.6%) in 1991 to
7.5% (95% CI 6.7% - 8.3%) in 1997.
• Again, this improvement can be seen across all
To contents
deprivation quintiles.
Mortality
To contents
Mortality
• Consistent fall
• ?slight leveling over
recent years
To contents
How does Bradford compare?
Incidence
• Taken from NYCRIS data.
• Age Standardized. 3 years data – statistically
To contents
robust.
sh
ire
Ed
en
Ry
ed
ale
W
es
tL
ind
se
y
Yo
rk
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rro
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up
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on
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sb
ro
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rtle
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gto
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How does Bradford compare?
Mortality
DSR Lung Cancer Mortality (02-04). Persons. Local Authority Level.
80.0
70.0
60.0
50.0
40.0
30.0
20.0
10.0
0.0
• Taken from NYCRIS data.
• Age Standardised. 3 years data – statistically
To contents
robust.
Cancer mortality. All sites. Old
PCT. Trends over 9 years
Crude Cancer Mortality Rate (lung cancers) / 100,000 registered population over 9 year period.
90.0
80.0
70.0
60.0
Airedale PCT
Bradford City PCT
North Bradford PCT
Bradford South & West PCT
Bradford Total
50.0
40.0
30.0
20.0
10.0
0.0
1995 Crude
Rate
1996 Crude
Rate
1997 Crude
Rate
1998 Crude
Rate
1999 Crude
Rate
2000 Crude
Rate
2001 Crude
Rate
2002 Crude
Rate
2003 Crude
Rate
1995 - 2003
Crude Rate
• A relatively static trend in Lung Cancer mortality (all sites) when
analyzed by old PCT.
• NB these are crude rates, using 2003 registered population for all
years (for simplicity). Not standardized for age structure (a significant
confounder). Confidence intervals are not plotted here. It is likely
there would be no statistically significant differences.
To contents
Mortality by geography – How does Bradford
sub areas compare with W Yorkshire
• Crude Rates – not
standardised. YHPHO
• Mortality rates for lung
cancer by PCT for 19982002 (five year average).
• Mortality rates showed
similar variation for the
period, and these
appeared to relate closely
to incidence in terms of
individual PCTs.
To contents
Mortality (and incidence) for
deprivation quintiles - WY.
• incidence and mortality
rates for lung cancer by
quintile of socioeconomic
deprivation for West
Yorkshire for 1998 to
2002 (five year average).
• These rates show a
strong socio-economic
gradient, with higher rates
in the more deprived
quintiles.
To contents
Commentary to add.
• Mortality rates for males were
significantly higher than
females for each deprivation
quintile.
• The overall mortality rate for
males was 75.1 per 100,000
(95% CI 74.4 - 75.8), and 38.3
for
• females per 100,000 (95% CI
37.7 - 38.8). There were
consistently higher mortality
rates in
• the most deprived areas for
each age group, both for males
and females.
To contents
Time trends in mortality - NYCRIS
To contents
Summary
This section summarises the key
issues, limited recommendations.
Discussion with CLAN re exactly what
next is needed.
To contents
Summary (1) – Risk Factors and
populations
•
Significant variation across groups. Smoking and other risk factors.
– Under implementation of preventive interventions – both in clinical practice and
broader public health.
– Not just smoking, though this is very important.
– Opportunities for smoking cessation referral (especially at key life points –
receptive to change. Cost effective and clinically effective)
– How do we address the epidemiology of smoking. Industrializing tobacco control.
Build into ALL care pathways. Critical life points as incentives to quit. Broader
tobacco control.
– Weight, diet, activity and alcohol consumption are also important risk factors. We
don't do enough here
– Implementation of preventive interventions should also be equitable. It does not
seem to be now (eg smoking cessation)
– Big potential for large population gain here – though long term.
– CLAN (and lots of others) should champion this among clinicians of all
flavours
• Age and deprivation structures of populations are very
important considerations. Airedale is affluent and old.
City is deprived and young
To contents
Summary (2) – need. Incidence,
survival and mortality.
Need – incidence survival and mortality.
• incidence and mortality rates (Lung) increased dramatically with age
• There are important differences in cancer incidence, mortality (and
survival in some cancers, but NOT lung) across socioeconomic
groups. Work to reduce health inequalities in cancer needs to take
these trends into account.
• Much of the observed difference in mortality between deprivation
categories (all cancers) is explained by lung cancer (inequalities in
smoking?)
• Mortality rates for lung cancer in men fell significantly over the
decade from 1991 - 2000 for all deprivation categories.
• In contrast, lung cancer mortality in women showed a small increase
overall (significant differences in mortality by socio-economic group
remained).
– Change in the pattern of smoking prevalence over time? Men
quitting more?
• There is limited evidence of a survival gap between most / least
deprived. If there is a socio economic gap, it is not statistically To contents
significant. No ethnicity data.
Summary (3) – Screening and early
diagnosis. Staging
•
•
•
•
•
Little is known about stage at presentation for Lung (or others)
A range of further analysis will be undertaken with the LUCADA audit dataset,
possible links into other data sources. This is highlighted in the notes page
below.
– Likely to show socio economic difference in staging at presentation (or Dx)
This leads to consideration of the implementation of a range of early Dx strategies –
– Sx education – clinician and public. Culturally aware. Literacy. market and
message segmentation; use of peers etc etc
– earlier referral – might be warranted…….is there evidence that this will make the
difference to survival or mortality rates………….not sure…..but certainly a need
to key into the pilots mentioned in Ca Reform Strategy – are we one of them
– Clinical culture - referral to exclude a diagnosis
– Community diagnostics? Do we need to be smarter about how we route people
to diagnostics quickly?
How well do we make use of whatever screening monitoring data we can get to
monitor equality of uptake.
In cervical cancer, there is a large observed variation in screening coverage at
practice level. Some population characteristics and some health care system
characteristics are factors in this. This is an area NSC are currently activiely
exploring. This needs to be carefully considered by CLAN
To contents
Summary (4) – service provision
and system performance.
Service Provision, treatment use and performance
•
analysis of service provision is difficult to interpret in terms of equity, as elements of service
provision are affected by many factors
Treatments
•
There is some evidence of variation in service provision related to geography and age, but not
socio economic status. This does not take into account stage at presentation, co morbidities or
other clinically relevant factors (each of which could confound). Thus it is difficult to draw firm
conclusions about treatment variation (and whether this has an impact on outcomes) without
further analysis
•
These variations did not appear to relate to, or translate to need as measured by mortality or
incidence.
•
The variations found may actually relate primarily to provider variation across West Yorkshire.
•
This analysis uses YHPHO Equity Audit from 2002. It is likely that variations in system
performance (and possibly treatment used) have equalised over time – National Standards.
•
Wide range of factors relating to the performance of a cancer system not fully considered.
prevention as well as other measures of treatment and service provision– e.g. primary care
provision, staffing numbers, survival rates
•
The system performance measures will undoubtedly have changes (62 days / 2 weeks etc etc) –
may be scope for updating some of this analysis.
•
Whether a huge focus in this area will acheive significant improvements in health
outcomes (population wide or addressing the equality gap) should be seriously
considered. The largest gain will come from industrial scale prevention and early diagnosis
strategies.
To contents
And finally....
Problems and issues
• There are a number of dimensions of
equality – disability, ethnicity that have not
been considered.
• Some of the data is old.
• Indebted to NYCRIS and YHPHO from
whom much of the data and analysis has
been lifted!
To contents