Access is an important concept in health policy and health services research, yet it is one which has not been defined or employed precisely. To some authors "access" refers to entry into or use of the health care system, while to others it characterizes factors influencing entry or use. The purpose of this article is to propose a taxonomic definition of "access." Access is presented here as a general concept that summarizes a set of more specific dimensions describing the fit between the patient and the health care system. The specific dimensions are availability, accessibility, accommodation, affordability and acceptability. Using interview data on patient satisfaction, the discriminant validity of these dimensions is investigated. Results provide strong support for the view that differentiation does exist among the five areas and that the measures do relate to the phenomena with which they are identified.

The concept of access: definition and relationship to consumer satisfaction.

Essentiality Toxicity Carcinogenicity Lead(Pb) Exposure Toxicokinetics Toxicity Neurologic, Neurobehavioral, and Developmental Effects in Children Mechanisms of Effects on the Developing Nervous System Peripheral Neuropathy Hematologic Effects Renal Toxicity Lead and Gout Effects on Cardiovascular System Immunotoxicity Bone Effects Reproductive Effects Birth Outcomes Carcinogenicity Other Effects Dose Response Treatment Organic Lead Compounds Mercury (Hg) Exposure Disposition and Toxicokinetics Metabolic Transformation Cellular Metabolism Toxicology Biological Indicators Treatment Nickel (Ni) Exposure Toxicokinetics Essentiality Toxicity Nickel Carbonyl Poisoning Dermatitis Indicators of Nickel Toxicity

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Toxic effects of metals

Immortal time is a span of cohort follow-up during which, because of exposure definition, the outcome under study could not occur. Bias from immortal time was first identified in the 1970s in epidemiology in the context of cohort studies of the survival benefit of heart transplantation. It recently resurfaced in pharmaco-epidemiology, with several observational studies reporting that various medications can be extremely effective at reducing morbidity and mortality. These studies, while using different cohort designs, all involved some form of immortal time and the corresponding bias. In this paper, the author describes various cohort study designs leading to this bias, quantifies its magnitude under different survival distributions, and illustrates it by using data from a cohort of lung cancer patients. The author shows that for time-based, event-based, and exposure-based cohort definitions, the bias in the rate ratio resulting from misclassified or excluded immortal time increases proportionately to the duration of immortal time. The bias is more pronounced with a decreasing hazard function for the outcome event, as illustrated with the Weibull distribution compared with a constant hazard from the exponential distribution. In conclusion, observational studies of drug benefit in which computerized databases are used must be designed and analyzed properly to avoid immortal time bias.

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Immortal Time Bias in Pharmacoepidemiology

Patient satisfaction in primary health care: a literature review and analysis.

Ingestion of arsenic, both from water supplies and medicinal preparations, is known to cause skin cancer. The evidence assessed here indicates that arsenic can also cause liver, lung, kidney, and bladder cancer and that the population cancer risks due to arsenic in U.S. water supplies may be comparable to those from environmental tobacco smoke and radon in homes. Large population studies in an area of Taiwan with high arsenic levels in well water (170-800 micrograms/L) were used to establish dose-response relationships between cancer risks and the concentration of inorganic arsenic naturally present in water supplies. It was estimated that at the current EPA standard of 50 micrograms/L, the lifetime risk of dying from cancer of the liver, lung, kidney, or bladder from drinking 1 L/day of water could be as high as 13 per 1000 persons. It has been estimated that more than 350,000 people in the United States may be supplied with water containing more than 50 micrograms/L arsenic, and more than 2.5 million people may be supplied with water with levels above 25 micrograms/L. For average arsenic levels and water consumption patterns in the United States, the risk estimate was around 1/1000. Although further research is needed to validate these findings, measures to reduce arsenic levels in water supplies should be considered.

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Cancer risks from arsenic in drinking water.

The mortality experience of 1074 white men who retired from a United States asbestos company during the period 1941-67 and who were exposed to asbestos working as production and maintenance employees for the company is reported to the end of 1980 when 88% of this cohort was known to be dead. As noted in earlier reports the mortality for respiratory and gastrointestinal cancer was raised. A more detailed examination of causes of death shows that the excess in gastrointestinal cancer was largely due to a statistically significant excess in stomach cancer. A statistically significant excess was also noted for kidney cancer, cancer of the eye, and non-malignant respiratory disease. Eight deaths from malignant mesothelioma were observed, two of which were peritoneal. Asbestos exposures for these mesothelioma cases were low relative to other members of the cohort. Continuing follow up of this cohort shows a dose response relation for respiratory cancer that has become increasingly linear. Standardised mortality ratios peaked 10 to 15 years after retirement and were relatively constant at around 250 in each five year interval starting in 1950. This excess might have been detected as early as 1960 but certainly by 1965. The mortality experience of this cohort reflects the ultimate effects of asbestos since nearly all of the cohort has now died.

https://oem.bmj.com/content/oemed/44/6/396.full.pdf

Asbestos and cancer: a cohort followed up to death

A study of the mortality experience of 2802 men who worked one year or more during the period 1940-4964 at a copper smelter in Tacoma, Washington, where arsenic exposure occurred showed a twofold excess in respiratory cancer deaths. Using a time-weighted measure of exposure, a life table method for accumulating dose, and a 10-year lag period, the excess ranged from 1.5 in the lowest exposure category to 2.5 in the highest exposure category. Neither duration of exposure nor time since first exposure contributed strongly to the respiratory cancer excess. The twofold excess in respiratory cancer deaths held for workers with relatively short exposures (less than 10 years) and with a relatively short latency period (less than 20 years) as well as for those with longer exposure and latent periods. This appeared to be because the respiratory cancer excess tended to disappear with time for workers who terminated employment alive, and because workers in high-exposure jobs tended to terminate more quickly than workers in low-exposure jobs. A somewhat unorthodox analytic method showed a weak relationship between the respiratory cancer excess and exposure duration when exposure intensity was held constant. Here, arsenic exposure intensity made an independent contribution to the respiratory cancer excess.

Cancer among workers exposed to arsenic and other substances in a copper smelter

OBJECTIVE--This is an update of an earlier study on the relation between exposure to arsenic in air and deaths from respiratory cancer. The purpose was to verify earlier findings of a supralinear dose response relation and to examine relations with other cancers, particularly those reported in studies on drinking water. METHODS--An earlier study of 2802 men who worked at a copper smelter for a year or more during the period 1940-64 and who were followed up for deaths during the period 1941-76 was updated until 1986. Estimates of exposure for the period 1977-1984 were added. RESULTS AND CONCLUSIONS--The additional follow up confirms the earlier finding that at low doses the increments in death rates for respiratory cancer for a given increment in dose are greater than at high doses. The additional follow up also shows significant increases in cancer of the large intestine and bone, and SMRs > 150 for cancer of the buccal cavity and pharynx, rectal cancer, and kidney cancer. There was a positive relation between exposure to arsenic in air and kidney and bone cancer, but none for the other cancers, except respiratory.

https://oem.bmj.com/content/oemed/52/1/28.full.pdf

Cancers related to exposure to arsenic at a copper smelter.

This paper is a reanalysis of data on the respiratory cancer mortality experience of 2,802 men who worked one year or more during the period 1940-1964 at a copper smelter in Tacoma, Washington. Exposure estimates presented earlier have been recalculated and perhaps improved. While the previous analysis showed only a weak relation between respiratory cancer and arsenic exposure, use of new data shows a much stronger relation--but one that is concave downward and not ordinarily considered for environmental exposure and cancer. This new analysis indicates that arsenic is probably more potent as a carcinogen than indicated by other studies. It also demonstrates the distinction between airborne arsenic and the bioavailability of arsenic, and the importance of this distinction for risk assessment. When a dose-response relation is based on airborne concentrations of arsenic, it is clearly concave downward, but when based on urine concentrations, it appears to be linear.

Exposure to arsenic and respiratory cancer: a reanalysis

Household interviews were conducted before and after the introduction in Quebec of a government-sponsored compulsory insurance program covering physician services. Physician visits per person per year remained constant at about five but were markedly shifted from persons in higher to lower income groups. The percentage of selected medical symptoms for which a doctor was consulted increased from 62 per cent to 73 per cent, with all the increase in lower income groups. Average waiting time for a doctor's appointment increased from 6.0 to 11.0 days, with the largest increases in the higher income groups. Waiting time in the doctor's office also increased, again with the largest increase in higher income groups. Eight per cent of the population considered the quality of medical care improved whereas 30 per cent thought it worse. For those who saw a doctor in the previous year, however, about 90 per cent were satisfied with the services received — the same proportion as before Medicare. (N Engl J Med ...

Philip E. Enterline

Papers

Asbestos and cancer: a cohort followed up to death

Cancer among workers exposed to arsenic and other substances in a copper smelter

Cancers related to exposure to arsenic at a copper smelter.

Exposure to arsenic and respiratory cancer: a reanalysis

The distribution of medical services before and after "free" medical care--the Quebec experience.