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Linking of Primary Care Records to Census Data to Study the Association between Socioeconomic Status and Cancer Incidence in Southern Europe: A Nation-Wide Ecological Study

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      Area-based measures of economic deprivation are seldom applied to large medical records databases to establish population-scale associations between deprivation and disease.


      To study the association between deprivation and incidence of common cancer types in a Southern European region.


      Retrospective ecological study using the SIDIAP (Information System for the Development of Research in Primary Care) database of longitudinal electronic medical records for a representative population of Catalonia (Spain) and the MEDEA index based on urban socioeconomic indicators in the Spanish census. Study outcomes were incident cervical, breast, colorectal, prostate, and lung cancer in 2009–2012. The completeness of SIDIAP cancer recording was evaluated through linkage of a geographic data subset to a hospital cancer registry. Associations between MEDEA quintiles and cancer incidence was evaluated using zero-inflated Poisson regression adjusted for sex, age, smoking, alcoholism, obesity, hypertension, and diabetes.


      SIDIAP sensitivity was 63% to 92% for the five cancers studied. There was direct association between deprivation and lung, colorectal, and cervical cancer: incidence rate ratios (IRR) 1.82 [1.64–2.01], IRR 1.60 [1.34–1.90], IRR 1.22 [1.07–1.38], respectively, comparing the most deprived to most affluent areas. In wealthy areas, prostate and breast cancers were more common: IRR 0.92 [0.80–1.00], IRR 0.91 [0.78–1.06]. Adjustment for confounders attenuated the association with lung cancer risk (fully adjusted IRR 1.16 [1.08–1.25]), reversed the direction of the association with colorectal cancer (IRR 0.90 [0.84–0.95]), and did not modify the associations with cervical (IRR 1.27 [1.11–1.45]), prostate (0.74 [0.69–0.80]), and breast (0.76 [0.71–0.81]) cancer.


      Deprivation is associated differently with the occurrence of various cancer types. These results provide evidence that MEDEA is a useful, area-based deprivation index for analyses of the SIDIAP database. This information will be useful to improve screening programs, cancer prevention and management strategies, to reach patients more effectively, particularly in deprived urban areas.

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      Most cited references 29

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      Overcoming the absence of socioeconomic data in medical records: validation and application of a census-based methodology.

       John Krieger (1992)
      Most US medical records lack socioeconomic data, hindering studies of social gradients in health and ascertainment of whether study samples are representative of the general population. This study assessed the validity of a census-based approach in addressing these problems. Socioeconomic data from 1980 census tracts and block groups were matched to the 1985 membership records of a large prepaid health plan (n = 1.9 million), with the link provided by each individual's residential address. Among a subset of 14,420 Black and White members, comparisons were made of the association of individual, census tract, and census block-group socioeconomic measures with hypertension, height, smoking, and reproductive history. Census-level and individual-level socioeconomic measures were similarly associated with the selected health outcomes. Census data permitted assessing response bias due to missing individual-level socioeconomic data and also contextual effects involving the interaction of individual- and neighborhood-level socioeconomic traits. On the basis of block-group characteristics, health plan members generally were representative of the total population; persons in impoverished neighborhoods, however, were underrepresented. This census-based methodology offers a valid and useful approach to overcoming the absence of socioeconomic data in most US medical records.
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        The association of sexual behaviors with socioeconomic status, family structure, and race/ethnicity among US adolescents.

        This study assessed the relation of socioeconomic status (SES), family structure, and race/ethnicity to adolescent sexual behaviors that are key determinants of pregnancy and sexually transmitted diseases (STDs). The 1992 Youth Risk Behavior Survey/Supplement to the National Health Interview Survey provided family data from household adults and behavioral data from adolescents. Among male and female adolescents, greater parental education, living in a 2-parent family, and White race were independently associated with never having had sexual intercourse. Parental education did not show a linear association with other behaviors. Household income was not linearly related to any sexual behavior. Adjustment for SES and family structure had a limited effect on the association between race/ethnicity and sexual behaviors. Differences in adolescent sexual behavior by race and SES were not large enough to fully explain differences in rates of pregnancy and STD infection. This suggests that other factors, including access to health services and community prevalence of STDs, may be important mediating variables between SES and STD transmission and pregnancy among adolescents.
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          Control of Glycemia and Cardiovascular Risk Factors in Patients With Type 2 Diabetes in Primary Care in Catalonia (Spain)

          OBJECTIVE The objective of this study was to analyze the clinical characteristics and levels of glycemic and cardiovascular risk factor control in patients with type 2 diabetes that are in primary health care centers in Catalonia (Spain). RESEARCH DESIGN AND METHODS This was a cross-sectional study of a total population of 3,755,038 individuals aged 31–90 years at the end of 2009. Clinical data were obtained retrospectively from electronic clinical records. RESULTS A total of 286,791 patients with type 2 diabetes were identified (7.6%). Fifty-four percent were men, mean (SD) age was 68.2 (11.4) years, and mean duration of disease was 6.5 (5.1) years. The mean (SD) A1C value was 7.15 (1.5)%, and 56% of the patients had A1C values ≤7%. The mean (SD) blood pressure (BP) values were 137.2 (13.8)/76.4 (8.3) mmHg, mean total cholesterol concentration was 192 (38.6) mg/dL, mean HDL cholesterol concentration was 49.3 (13.2) mg/dL, mean LDL cholesterol (LDL-C) concentration was 112.5 (32.4) mg/dL, and mean BMI was 29.6 (5) kg/m2. Thirty-one percent of the patients had BP values ≤130/80 mmHg, 37.9% had LDL-C values ≤100 mg/dL, and 45.4% had BMI values ≤30 kg/m2. Twenty-two percent were managed exclusively with lifestyle changes. Regarding medicated diabetic patients, 46.9, 22.9, and 2.8% were prescribed one, two, or three antidiabetic drugs, respectively, and 23.4% received insulin therapy. CONCLUSIONS The results from this study indicate a similar or improved control of glycemia, lipids, and BP in patients with type 2 diabetes when compared with previous studies performed in Spain and elsewhere.

            Author and article information

            [1 ]Research Unit, Family Medicine, Girona, Spain, and Jordi Gol Institute for Primary Care Research (IDIAP Jordi Gol), Catalunya, Spain
            [2 ]Translab Research Group, Department of Medical Sciences, School of Medicine, University of Girona, Catalunya, Spain
            [3 ]Jordi Gol Institute for Primary Care Research (IDIAP Jordi Gol), Catalunya, Spain
            [4 ]Cancer Prevention Unit and Cancer Registry, Department of Epidemiology and Evaluation, Hospital del Mar, Barcelona, Catalunya, Spain
            [5 ]Primary Care Services, Girona, Spain, and Catalan Institute of Health (ICS), Catalunya, Spain
            [6 ]Primary Care Information System, Catalan Institute of Health (ICS), Catalunya, Spain
            [7 ]Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
            Federico II University of Naples, Italy
            Author notes

            Competing Interests: The authors have declared that no competing interests exist.

            Conceived and designed the experiments: MGG DPA. Performed the experiments: MGG JME. Analyzed the data: MGG JME MB MC JB. Contributed reagents/materials/analysis tools: MGG JME MB MC JB. Contributed to the writing of the manuscript: MGG DPA. Interpretation of data: MGG DPA JME RR LMB EH BB. Revision: MGG DPA JME RR LMB EH BB MB. Final approval: MGG DPA JME RR LMB EH BB MB MC JB.

            Role: Editor
            PLoS One
            PLoS ONE
            PLoS ONE
            Public Library of Science (San Francisco, USA )
            20 October 2014
            : 9
            : 10
            25329578 4203762 PONE-D-14-18648 10.1371/journal.pone.0109706

            This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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            The authors have no support or funding to report.
            Research Article
            Medicine and Health Sciences
            Cancer Epidemiology
            Epidemiological Methods and Statistics
            Social Epidemiology
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            The authors confirm that all data underlying the findings are fully available without restriction. All relevant data are within the paper and its supporting information files.



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