Economic downturns, universal health coverage, and cancer mortality in high-income and middle-income countries, 1990-2010: a longitudinal analysis
Economic downturns, universal health coverage, and cancer mortality in high-income and middle-income countries, 1990-2010: a longitudinal analysis
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DOI：
10.1016/s0140-6736(16)00577-8
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发表时间：
2016-08-13
期刊：
影响因子：
168.9
通讯作者：
Atun, Rifat
中科院分区：
文献类型：
--
作者：
Maruthappu, Mahiben;Watkins, Johnathan;Atun, Rifat
背景全球经济危机与失业率上升和公共部门医疗保健支出（PEH）减少有关。我们估计了失业率和PEH的变化对癌症死亡率的影响，并确定了全民健康覆盖（UHC）如何影响这些关系。方法对于这种纵向分析，我们从世界银行和世界卫生组织（1990 - 2010年）获得的数据。我们汇总了女性乳腺癌、男性前列腺癌和男性和女性结直肠癌的死亡率数据，这些数据与超过50%的生存率相关，并将其归类为可治疗的癌症类别。我们同样将5年生存率低于10%的肺癌和胰腺癌的数据汇总为不可治疗的癌症类别。我们使用多变量回归分析，控制特定国家的人口统计和基础设施，时滞分析和稳健性检查，以调查失业，PEH和癌症死亡率之间的关系，有和没有UHC。根据2008年至2010年许多国家失业率急剧上升之前的趋势，使用趋势分析预测死亡率，并将其与观察到的死亡率进行比较。结果失业分析中有75个国家的数据，代表21.06亿人，PEH分析中有79个国家的数据，代表21.56亿人。失业率的上升与所有癌症死亡率和除妇女肺癌以外的所有特定癌症死亡率的上升有着显著的联系。相比之下，无法治疗的癌症死亡率与失业率的变化没有显着联系。滞后分析显示，在失业率上升5年后，可治疗的癌症类别仍然存在显着的关联。重新运行分析，同时考虑UHC状态，删除了显着的关联。随着PEH的增加，所有癌症、可治疗癌症和特定癌症的死亡率显著降低。根据2000 - 2007年的趋势，时间序列分析提供了2008年至2010年因可治疗癌症子集导致的4万多例额外死亡的估计。这些死亡大多发生在非全民健康覆盖国家。解释失业率的增加与癌症死亡率的上升有关;全民健康覆盖似乎可以防止这种影响。PEH增加与癌症死亡率降低有关。获得医疗保健可能是这些联系的基础。我们估计，2008 - 10年的经济危机仅在经济合作与发展组织就与约26万例癌症相关死亡有关。
Background The global economic crisis has been associated with increased unemployment and reduced public-sector expenditure on health care (PEH). We estimated the effects of changes in unemployment and PEH on cancer mortality, and identified how universal health coverage (UHC) affected these relationships.Methods For this longitudinal analysis, we obtained data from the World Bank and WHO (1990-2010). We aggregated mortality data for breast cancer in women, prostate cancer in men, and colorectal cancers in men and women, which are associated with survival rates that exceed 50%, into a treatable cancer class. We likewise aggregated data for lung and pancreatic cancers, which have 5 year survival rates of less than 10%, into an untreatable cancer class. We used multivariable regression analysis, controlling for country-specific demographics and infrastructure, with time-lag analyses and robustness checks to investigate the relationship between unemployment, PEH, and cancer mortality, with and without UHC. We used trend analysis to project mortality rates, on the basis of trends before the sharp unemployment rise that occurred in many countries from 2008 to 2010, and compared them with observed rates.Results Data were available for 75 countries, representing 2.106 billion people, for the unemployment analysis and for 79 countries, representing 2.156 billion people, for the PEH analysis. Unemployment rises were significantly associated with an increase in all-cancer mortality and all specific cancers except lung cancer in women. By contrast, untreatable cancer mortality was not significantly linked with changes in unemployment. Lag analyses showed significant associations remained 5 years after unemployment increases for the treatable cancer class. Rerunning analyses, while accounting for UHC status, removed the significant associations. All-cancer, treatable cancer, and specific cancer mortalities significantly decreased as PEH increased. Time-series analysis provided an estimate of more than 40 000 excess deaths due to a subset of treatable cancers from 2008 to 2010, on the basis of 2000-07 trends. Most of these deaths were in non-UHC countries.Interpretation Unemployment increases are associated with rises in cancer mortality; UHC seems to protect against this effect. PEH increases are associated with reduced cancer mortality. Access to health care could underlie these associations. We estimate that the 2008-10 economic crisis was associated with about 260 000 excess cancer-related deaths in the Organisation for Economic Co-operation and Development alone.