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lupine-publishers-juns · 2 years ago

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Lupine Publishers | Private Health Insurance is a Favourable Prognostic Risk Factor in the Outcomes of Mortality Post Radical Cystectomy

Abstract

Objectives: There are well recognised differences in health outcomes generally in society due to a range of socio-economic factors. We have compared survival outcomes in patients undergoing radical cystectomy for aggressive bladder cancer in the national health service (NHS) and compared this with those with private health insurance (PHI).

Methods: This is retrospective study of 225 NHS and 32 PHI patients operated over 14 years by one surgeon. ASA scores were compared to approximate comorbidity status.

Results: There were significantly worse outcomes for all cause and disease specific mortality in the NHS group. There was no difference in ASA scores.

Conclusions: NHS patients fare worse than those with PHI. The reasons for this difference remain unclear. PHI patients have a more extensive lymphadenectomy and have fewer overall complications.

Keywords: NHS private insurance outcomes radical cystectomy bladder cancer

Introduction

We studied the outcome of patients with private health insurance (PHI) compared to national health service (NHS) patients. These patients had the same operation for muscle invasive cancer of the bladder, and we looked to see whether there were significant differences in both all-cause mortality and disease specific mortality. We have attempted to see whether we can propose any explanatory cause for such differences. There are barriers in society that delay detection and the treatment of cancers for those people with various social and economic disadvantages [1]. This imbalance creates health disparities such as differences in survival [2]. There are racial, gender, ethnic and socioeconomic components which are reflected in their insurance status [3]. Previous studies, mostly in the United States, although with some English and Danish studies, have looked at the effect of insurance status on outcomes of treatment for various cancers, including urological cancers of the prostate, kidney and bladder [4]. In the USA, the uninsured and those on Medicaid, have a worse stage at presentation [3-7]and a lower all cause survival than those with private insurance [2,1,8]. Worse disease specific mortality has also been shown to be an independent risk factor with worse outcomes for lower socio-economic status groups [9]. This finding, however, was not confirmed by a British study specifically looking at social deprivation [10]. Definitions of what constitutes adverse social groups are complex and may affect robustness of data [11]. A shift in classification of groups, pathological definitions and coding of cause of death may explain the lack of improvement in survival but not socioeconomic inequalities [11]. Many factors, including socio-demographic and clinical entities, form a complex network influencing survival. In the USA Insurance and socioeconomic status are predictors of mortality [1,8]. Uninsured patients are often treated at low volume centres[3]. Race and gender can also affect survival [12,13] as can communal poverty [14,15]. It has been suggested that poorer health generally, as demonstrated by more comorbidities and unhealthy lifestyle behaviours account for this phenomenon [2,15]. The affordable care act in the USA is an attempt to address the problem of the uninsured presenting with more advanced disease and their subsequent lower survival rates [16]. In addition, a negative association between income and prevalence of physicians for bladder and renal cancer mortality was found [17]. Those on Medicaid were less likely to receive definitive treatment [18]. Similar effects of socioeconomic status have been found in England [19]and Denmark [20]. These studies have all looked at the effect of all the range of treatments, both curative and palliative, for all types of cancer, including low- and high-grade disease which is of particular importance when discussing bladder cancer. For differences in outcomes after specific surgical treatments, research has focused on radical prostatectomy. Insurance status is associated with stage and cancer control [21]. Higher surgery rates and lower radiotherapy rates were observed in private patients who were more affluent [22]. We have shown previously that insurance status is a protective risk factor with radical prostatectomy, but wealth itself is not protective which may be due to different adverse lifestyle behaviour[23]. There are few published studies pertaining to insurance status and survival after a specific treatment for bladder cancer, particularly radical cystectomy [24].

Effect of comorbidity and ASA score

Greater comorbidities as assessed by the ASA score, increase the likelihood of complications after radical cystectomy [25]. Patients with an ASA score of three or more have a greater complication rate [25]. Severe comorbidity is also associated with increased mortality [26,27]. The ASA score has been used to predict outcomes [28] and should be used for counselling and risk stratification [29,30]. In younger patients the ASA score can be useful despite EAU guidelines suggesting otherwise [31,32]. Neglect of comorbidities can cause misleading impressions of results [33] but the ASA score can be useful at to ascertain complication risk particularly with the type of urinary diversion and the time taken to do more complex surgery [34]. Comorbidity assessed using the Charlson score is useful for younger and older patients to predict toxicity of treatment and outcomes [35,36]. All-cause mortality has a stronger relation to comorbidity than disease specific mortality does [37].

Urinarydiversion

In general, the neobladder has a higher complication rate and longer stay in hospital [38] although it may be offered to most patients [39-41]. However, in practice, it still tends to be reserved for younger and fitter patients and thus may serve as a proxy for generally better health [42].

Methods

This is a retrospective study. The 257 radical cystectomy with bilateral lymphadenectomy (with ileal conduit or neobladder) operations were performed by one surgeon in both NHS and the private sector in the same county of the UK, operated from 1999 to 2013 and followed up to the present day. There were 225 patients from the NHS and 32 patients with private health insurance. These were sequential patients who underwent potentially curative operative and neoadjuvant/adjuvant treatments. We compared various patient characteristics from health records using Iqutopia for operation details, ICE, Bostwick laboratories and Masterlab for pathology and PACS for imaging. Medical statistics were done using Medcalc software for logistic regression analysis to determine significant predictors of mortality and progression. Fishers, Mann-Whitney, t tests and log rank tests to compare Kaplan Meier. P values less than 0.05 were considered significant. The ASA score was documented by the attending anaesthetist and retrieved from Iqutopia where available.

Results

(Table 1-4) (Graph1-6)

There is a significant difference between the ages of the two populations with NHS patients being older by four years. Private patients had a greater degree of nodal dissection and fewer complications. However, there was no difference in tumour volume, positive surgical margin status, advanced stage, carcinoma in situ, nodal involvement, nodal extracapsular extension. Further, there was no difference in rates of neo adjuvant or adjuvant treatment or the use of a neobladder. Logistic regression showed private health status to have highly significant negative coefficients which are protective in all cause and disease specific mortality as well as lower progression rates. All-cause mortality was associated with negative coefficients for neobladder and PHI. Locally advanced stage was predictive of a deleterious outcome. Disease specific mortality also showed adverse coefficients for additional treatments (adjuvant and neoadjuvant), complications and nodal density involvement. Progression was adversely affected by additional treatment and increasing stage. The ASA score was available in 169 of the 257 patients (66%). There was no difference in the distributions of healthy and unhealthy patients as measured by this score. (ASA1 and 2 were summated). Log rank tests showed significant differences between the two groups for mortality.

Discussion

This study has supported generally what is known about bladder cancer and the negative impact of lower socio-economic status. However former studies have looked at bladder cancer as a whole, which includes low grade and non-muscle invasive disease as well as advanced muscle invasive disease, inoperable cases, cases treated with radiotherapy and palliative cases all grouped together. This study looks at a subsection of these, those deemed appropriate for radical cystectomy. We have seen significant differences in both all-cause mortality and disease specific mortality. These differences have not been previously demonstrated. There are many gross and subtle differences that are difficult to detect with such a heterogenous disease in a heterogenous population. We propose that looking at a subgroup like this will decrease some of the obfuscating factors, by limiting geographical variation and the operation being performed by one surgeon only.

All-causemortality

We have detected a significant difference in all-cause mortality (Graph 5) with NHS patients (Graph 2)faring far worse (log rank P = 0.025) and with an odds ratio 0.24 in favour of PP (Graph 1, Table 2). Overall survival at one year is 0.75 for NHS and 0.84 for PHI, and at five years it is 0.45 for NHS and 0.74 for PHI. Similarly, at ten years for NHS patients it is 0.34 compared to 0.53 for PP (Table 3). Numerous explanations have been proposed for the worse prognosis overall for bladder cancer in the uninsured [1- 12]. Overall worse health is the proposed principal reason for a worse all cause survival. We have tried to reflect potentially worse comorbidities with the ASA score as an approximation to overall health. There was, surprisingly, no significant difference detected between the two groups (P = 0.56) (Table 4). Private patients were four years younger on average and any chronic disease may not have reached a critical point to effect outcome (P =0.026) (Table 1). This was not a significant factor on regression analysis. We do see that having a neobladder is a significant (P = 0.0154) protective (negative coefficient -0.8) factor, perhaps standing as a proxy for overall health [38,39], but there was no significant difference in the use of this between the two groups (P=0.16) (Table 1). Locally advanced stage 3 and 4 were both significant as expected [43, 44] with increasingly worse odds ratios (Table 2). The five-year gold standard for radical cystectomy is about 50% [43-49], and our population in the NHS reflects this. The patients with PHI fare much better with a 5-year survival of 0.74.

Diseasespecificmortality

We found a significant protective coefficient and odds ratio of 0.33 in favour of private patients (Table2). There was a DSM of 0.87, 0.84 and 0.75 for PHI at one, five and ten years (Graph 3). This was superior to NHS patients with DSM of 0.82, 0.81 and 0.58 (Table 3, Graph 4). This compares favourably with other series (49). The log rank test comparing the two was significant (Graph 6, Table5). Interestingly, the NHS mass of tumour was twice that of PHI, yet there was no significant difference in tumour volume which one might expect if there were a longer time to diagnosis in NHS patients (11cc v 23cc P=0.18). Further, we did not detect a worse stage (NHS 56% localised, PHI 62% localised P=0.84) or a significantly greater positive surgical margin rate in NHS patients (14% NHS v 6% PHI P = 0.27). However, the trend was worse with all of these parameters for NHS patients. There was no difference in rates of CIS between the two. The use of neobladder was, once again, a protective risk factor (Table 2) which was used in 38% of PHI patients compared to 18% in NHS patients, however this did not reach significance (P=0.16) (Table 1). Additional treatments, neo-adjuvant and adjuvant therapies, were a significant detrimental risk factor (Table 2) but with no significant difference between the two groups (NHS 17% and PHI 13% P=0.79). The role of lymphadenectomy revealed no difference in severity of extracapsular invasion (Table 1)(P=1.0) or in nodal involvement with 19% of NHS patients having involved metastatic deposits within at least one node, compared to 22% of PHI patients (P=0.811). However, there was a significant difference in the number of nodes retrieved at lymphadenectomy, with an average of 9 for NHS and 13 for PHI patients (P=0.006). Node density is a significant predictor of DSM with an odds ratio of 9.67 (Table2). Complications, of all types, are a significant adverse predictor for DSM. With a significantly worse rate in NHS, 40% compared to PHI patients, 13% (P=0.002).

Progression

This also revealed PHI status to be protective and worse outcomes were associated with need for additional treatment and advancing stage. Time to diagnosis and time to treatment from diagnosis may be a factor, although studies are conflicting [50,51]. There is no lead time bias (perceived increased survival with no effect on course of cancer) as there is no screening protocol.

Conclusion

American studies have shown that insurance is important and that even Medicaid patients do worse than private patients. We concur that in the UK the NHS does not provide equal outcomes compared with PHI when comparing radical cystectomy. There may be social infrastructure issues involving hospital building capacity, education, prevention, detection and treatment. Assistance to patients to access and navigate healthcare systems and workplace policies to encourage overall better health is needed. National policies have been implemented to tackle this complex problem. The NHS cancer plan 2000 in the United Kingdom (http.//www.doh. gov.uk/cancer/pdfs/cancerplan.pdf) aims to reduce inequalities in survival between rich and poor with a 62-day target to treatment. The affordable care act in the USA highlights benefits of extending health coverage to the uninsured [1]. We have found significant differences in outcomes for all cause and disease specific mortality, yet the cause is elusive. We have shown a direct comparison of NHS and PHI to reveal these outcomes which can remain hidden in American studies as the SEER datebase does not include uninsured patients by definition. There is no difference in tumour volume, carcinoma in situ, advanced stage or not, nodal involvement, extracapsular involvement of nodes, rates of adjuvant and neo-adjuvant treatment. There are, however, differences in complication rates and extent of lymphadenectomy with favourable features pertaining to PHI. We need to look for other ways to measure overall health that include medical and lifestyle with socioeconomic components.

Limitations

The PHI cohort is small. We have not measured the time to diagnosis and to treatment. We have not been able to document the Charlson comorbidity score. We have not documented types of complications.

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mindfulnutritionsblog · 3 months ago

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Why Reducing Sodium and Fluid Intake is Crucial for Kids with Nephrotic Syndrome

Did you know that about 12 in every 100,000 children in India are affected by nephrotic syndrome each year? Nephrotic syndrome is a kidney disorder that can cause significant health problems if not managed properly. One of the most important steps in managing this condition is reducing sodium and fluid intake. This might sound simple, but it can make a big difference in a child's health. Additionally, consulting with the best nephrologists in India can provide expert guidance and tailored treatment plans to ensure the best possible outcomes for affected children.

Engaging Stat:

Approximately 12 in 100,000 children in India are diagnosed with nephrotic syndrome annually, highlighting the importance of dietary management for better health outcomes.

The Importance of Dietary Changes:

Nephrotic syndrome causes the kidneys to leak protein into the urine, leading to swelling, especially in the legs and around the eyes. High sodium intake can worsen this swelling, making the condition harder to manage. Excess fluid intake can also increase swelling and blood pressure, putting extra strain on the kidneys. By reducing sodium and fluid intake, children with nephrotic syndrome can prevent these complications and improve their overall health.

Understanding the Benefits:

Lowering sodium and fluid intake helps control swelling and blood pressure, reducing the burden on the kidneys. This can lead to fewer hospital visits and a better quality of life for children. Parents might worry about how to limit these elements in their child's diet. However, many resources and recipes are available to make this transition easier. Choosing fresh fruits and vegetables over processed foods can significantly reduce sodium intake.

Making Healthier Choices:

Parents and children must work together to choose healthier options. Reducing sodium and fluid doesn't mean bland food or constant thirst. Many delicious, low-sodium recipes can be both satisfying and nutritious. It's also essential to teach children about the importance of these dietary changes. By making them part of the decision-making process, kids are more likely to stick to the guidelines.

Five Steps for a healthier you:

Start by gradually reducing the amount of salt in your child's diet. Replace high-sodium snacks with fruits, vegetables, and homemade treats. Encourage your child to drink water instead of sugary drinks and limit their intake of soups and sauces that are often high in sodium. Regularly check food labels to make informed choices.

Gradually Reduce Salt: Start by slowly decreasing the amount of salt in your child's diet. This helps their taste buds adjust to less salty flavors over time.

Choose Healthy Snacks: Replace high-sodium snacks like chips and processed foods with healthier options such as fresh fruits, vegetables, and homemade treats.

Encourage Water Consumption: Promote drinking water instead of sugary drinks, which can contain hidden sodium and extra calories.

Limit High-Sodium Foods: Reduce your child's intake of foods like soups and sauces, which are often high in sodium. Opt for low-sodium or homemade versions whenever possible.

Check Food Labels: Regularly read food labels to identify and avoid high-sodium products. Look for items labeled as "low sodium" or "no added salt."

Conclusion:

In India, managing nephrotic syndrome is a significant challenge, but with the right dietary changes, children can lead healthier lives. Reducing sodium and fluid intake plays a crucial role in controlling symptoms and preventing complications. About 12 in every 100,000 children in India struggle with this condition each year. By making simple yet effective changes to their diet, families can help their children feel better and avoid hospital visits. Have you considered how these dietary adjustments could benefit your child? With the right approach, managing nephrotic syndrome becomes much more manageable. Additionally, seeking advice from the best doctors for nephrotic syndrome treatment in India can provide valuable guidance and ensure that your child receives the most effective care.

FAQ’s:

Q1: What is nephrotic syndrome?Nephrotic syndrome is a kidney disorder that causes the body to excrete too much protein in the urine, leading to swelling, especially in the legs and around the eyes.

Q2: Why is reducing sodium important for children with nephrotic syndrome?Reducing sodium helps to control swelling and lower blood pressure, making it easier for the kidneys to function properly.

Q3: How can I reduce sodium in my child’s diet?You can reduce sodium by avoiding processed and packaged foods, using fresh ingredients, and seasoning foods with herbs and spices instead of salt.

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nuhospitals24 · 6 months ago

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General Nephrology | NU Hospitals

General Nephrology deals with the treatment and management of Nephrotic Syndrome, Acute Nephritic Syndrome, Acute Renal Failure, and Chronic Renal Failure.

#Best Nephrology Hospital in Bangalore #Top Nephrology Hospital in Bangalore #Nephrology Specialist in Bangalore #Nephrology speciality Hospital in Bangalore #Nephrotic Syndrome Hospitals in Bangalore

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pediatric-nephrology-india · 8 months ago

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Child Kidney Doctor in India

Dr Sethi at Medanta, The Medicity is the leading Pediatric Nephrologist providing diagnostic and treatment services for children with conditions of the kidney, especially Nephrotic syndrome, Glomerular disorders, rare tubular disorders and Chronic Kidney disease. Our team is the leading dialysis and renal transplant service center for children.

Dr Sethi & team believes in personalized care that focuses on individual patient and family needs. Our team understands the challenges many of our families face when trying to access the care they need. Our caring goes beyond diagnostics and treatment. Our team is nationally recognized for their innovation, experience, dedication and expertise. We have the newest dialysis technology and provides comprehensive kidney transplant care to children of all ages.

To schedule an appointment With Child Kidney Doctor in India, please contact: Name: Pediatric Nephrology India Address: Division of Pediatric Nephrology, Kidney Institute, Medanta, The Medicity, Gurgaon, Haryana, India, 122001 Phone: 0124–4141414 Website: www.pediatricnephrologyindia.com

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dailyupdatednews · 1 year ago

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Nephrotic Syndrome in children is a kidney disorder that can have a variety of causes and symptoms. In children, the most prevalent reason is idiopathic, which implies that the exact cause is unknown. It can, however, be linked to other health conditions such as infections, drugs, or underlying kidney disease. In children, there are two types of Nephrotic Syndrome in children: minimal change disease and focal segmental glomerulosclerosis (FSGS). FSGS, on the other hand, is a more complex disorder for which treatment may be less effective. Understanding the precise cause and kind is critical for accurate diagnosis and targeted therapy, which may include medications or dietary changes.

#Nephrotic Syndrome in children #Nephrotic Syndrome in children symptoms #types of Nephrotic Syndrome in children #syndrome in children #signs of Nephrotic Syndrome in children

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nephorology · 1 year ago

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Nephrotic syndrome treatment

Nephrotic syndrome is a kidney disorder characterized by increased protein levels in the urine, low blood protein levels, high cholesterol levels, and swelling (edema) in various parts of the body. The treatment of nephrotic syndrome aims to reduce proteinuria, manage symptoms, and prevent complications. Here are common treatment approaches:

Medications:

Corticosteroids: The first-line treatment for nephrotic syndrome is usually corticosteroids, such as prednisone. They help reduce inflammation in the kidneys and decrease protein leakage into the urine. A high dose may be prescribed initially, followed by a gradually decreasing maintenance dose.

Immunosuppressive drugs: If corticosteroids alone are ineffective or not well-tolerated, additional immunosuppressive medications like cyclophosphamide, mycophenolate mofetil, or rituximab may be prescribed to further suppress the immune system and reduce proteinuria.

Diuretics: Diuretic medications like furosemide or spironolactone may be used to manage edema by increasing urine output and reducing fluid retention.

Dietary and lifestyle modifications:

Sodium restriction: Limiting sodium intake can help manage edema by reducing fluid retention. This often involves avoiding processed foods and adding less salt to meals.

Low-fat, low-cholesterol diet: A diet low in saturated fats and cholesterol may be recommended to control high cholesterol levels often seen in nephrotic syndrome.

Adequate protein intake: In some cases, protein intake may need to be adjusted to ensure a balance between maintaining protein levels and minimizing proteinuria. This is best determined by a healthcare professional or registered dietitian.

Blood pressure control:

Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs): These medications are often prescribed to control blood pressure and reduce proteinuria in nephrotic syndrome.

Management of complications:

Blood clot prevention: Nephrotic syndrome increases the risk of blood clots. Medications like anticoagulants (blood thinners) may be prescribed to prevent clot formation.

Vaccinations: It is important for individuals with nephrotic syndrome to stay up to date with vaccinations, particularly for pneumococcal infections and influenza, as they are more susceptible to infections.

Regular follow-up appointments with a healthcare provider are essential to monitor the response to treatment, adjust medication dosages, and address any emerging complications. In some cases, if the underlying cause of nephrotic syndrome is a specific kidney disease, additional treatments such as immunosuppressive therapies or plasmapheresis may be considered.

#nephrotic syndrome treatment

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ayurvedayogashram · 2 years ago

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In this article, we will explore the various Ayurvedic Nephrotic Syndrome treatment and their effectiveness. We will also discuss how these cures work.

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bestpediatricnephrologistindelhi · 2 years ago

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Best Pediatric Nephrologist in Delhi

Child Kidney Specialist in India

A Glimpse On Chronic Kidney Disease

CKD (chronic kidney disease) is a lifelong condition in which the kidney function slowly declines over many years. It is common in adults but extremely rare in children. It can be caused by a number of conditions affecting the kidney and can present at birth or later on during childhood. All kidney conditions do not cause CKD and all kids with CKD do not always progress to the end stage. It is a complicated disease with a wide spectrum from which full recovery is not possible but timely specialist care can help your child live a long, healthy and wholesome life.

How Severe Is My Child’s Disease?

CKD is divided into 5 stages based on GFR [glomerular filtration rate- tells how well the tiny filters (glomeruli) inside your child’s kidney are cleaning the blood].

How Would My Child Be Treated?

Your child will require specialized medical care from a pediatric nephrologist. It is important that you regularly visit the clinic for follow-up appointments even if your child feels well. At each of these visits, the growth(height,weight) and kidney function of your child would be monitored to avoid any future complications. The medical treatment aims at-

Reducing blood pressure [by low salt diet and medicines]

Slowing protein loss in the urine [by medicines like ACE-I(angiotensin converting enzyme inhibitor) or ARB(angiotensin receptor blocker)]

Avoiding bone disease [by calcium and vitamin D supplements]

Controlling anemia [by erythropoietin supplements or blood transfusion]

Healthful living-

Ensure that your child eats at least five servings of fruits and vegetables a day. Cut down on his/her sugar and fat intake.

Get him/her plenty of exercise.

Avoid taking common medicines like ibuprofen/diclofenac without higher supervision as they cause further kidney damage.

Many children with progressive disease who develop ESRD would ultimately need dialysis, which uses special equipment to remove waste products and extra water from their body. The best treatment is a kidney transplant, in which a healthy kidney from another person is transplanted into the child. After a successful kidney transplant, the child can live a healthy life, but will need to take medicines to look after the new kidney.

What To Anticipate About My Kid’s Future?

CKD can take a heavy emotional toll not just on the kid but the entire household. Speaking with families of other children with CKD can be a huge support. Your child will need to take care of his or her health throughout life. As an adult, he/she will be supported by a new team. Due to the current medical advancements, children with CKD can reach their adulthood with better kidney outcomes. They should be encouraged to live a full and fulfilling life, pursue higher education, work and have a family.For any queries or concerns, please visit this website/contact Dr. Sethi today.

TAG : Child Kidney Specialist in Delhi, Child Kidney Doctor in Gurgaon, Pediatric Nephrology India

#Dr. Sidharth Kumar Sethi #Best Pediatric Nephrologist in Delhi #Nephrotic syndrome Specialist in India #Child Kidney Doctor in Delhi

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