Effect of Population Socioeconomic and Health System Factors on Medical Care of Childhood Cancer Survivors: A Report from the Childhood Cancer Survivor Study

Purpose: To determine the independent contribution of population socioeconomic and health system factors on childhood cancer survivors' medical care and screening. Methods: 7899 childhood cancer survivors in the United States and Canada enrolled in the Childhood Cancer Survivor Study (CCSS). Population-level factors were derived from U.S. Area Health Resource File or 201 Canadian Census. Health service utilization and individual-level factors were self-reported. Multivariable logistic regression was used to calculate the effect of population factors on medical care (any care vs. no care; risk-based care vs. general care) and indicated echocardiogram or mammogram, adjusting for individual sociodemographic and health status. Results: After adjusting for individual factors, population factors had a nominal impact on childhood cancer survivors' medical care and screening. Higher population median income was associated with risk-based survivor-focused care versus general care (odds ratio [OR] 1.05, 95% confidence interval [CI], 1.01-1.09) among all participants, but not among U.S. residents only (OR 1.03, 95% CI, 0.99-1.07). For U.S. residents, the number of CCSS centers within the geographic area was associated with greater odds of receiving risk-based survivor-focused medical care (OR 1.12, 95% CI, 1.04-1.20). Areas with higher median income had higher rates of echocardiogram screening among survivors at risk of cardiomyopathy (for every $10,000 increase in median income, there is a 12% increase in odds of echocardiogram screening; 95% CI 1.05-1.20). A positive relationship was identified between greater number of physicians and surgeons in the county of residence and recommended echocardiogram (for every additional 1000 physicians and surgeons: OR 1.12, 95% CI, 1.01-1.23). We found no association between population-level factors and mammography screening. Conclusions: Population socioeconomic disparities moderately affect childhood cancer survivors' risk-based medical care and screening after accounting for individual sociodemographic and health factors.