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Oncology Nursing Society
Oncology Nursing Society
Oncology Nursing Society
Oncology Nursing Society
Oncology Nursing Society
Oncology Nursing Society
Oncology Nursing Society
Oncology Nursing Society
Oncology Nursing Society
Oncology Nursing Society
Oncology Nursing Society
Oncology Nursing Society
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Oncology Nursing Society

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  • 1. Pennsylvania Department of Health – 2004-2005 Annual C.U.R.E. Report Annual Progress Report for Oncology Nursing Society – Page 1 Oncology Nursing Society Annual Progress Report: 2003 Formula Grant Reporting Period July 1, 2004 – April 30, 2005 Formula Grant Overview The Oncology Nursing Society received $33,420 in formula funds for the grant award period May 1, 2004 through April 30, 2005. The funds were used to support two research projects. Accomplishments for the reporting period are described below. Formula Grant Coordinator Gail Mallory, R.N., Ph.D., C.N.A.A. Director of Research Oncology Nursing Society 125 Enterprise Drive RIDC Park West Pittsburgh, PA 15275 (412) 859-6308 Research Project 1: Project Title and Purpose Nurse Assessments of Process and Outcomes for Hospitalized Cancer Patients - This project seeks to understand the role of process of nursing care on the outcomes for hospitalized cancer patients. Duration of Project 5/1/2004 - 4/30/2005 (extension to 6/30/2005 approved) Project Overview This study continues the successful collaboration between the Oncology Nursing Society and the research team at the Center for Health Outcomes and Policy Research at the University of Pennsylvania. The current work examines the role of organizational characteristics and nurse staffing on patient outcomes. This project expands the inquiry to examine the role of nursing process, defined as the specific activities of nursing care delivery, on outcomes for cancer patients following surgical hospitalizations. Two specific aims frame the work: 1) To assess the contributions of both the structure (nurse staffing) and process of nursing care on 30-day mortality, complications, and failure to rescue (FTR) for hospitalized surgical cancer patients; and 2) To determine if these
  • 2. Pennsylvania Department of Health – 2004-2005 Annual C.U.R.E. Report Annual Progress Report for Oncology Nursing Society – Page 2 nursing care process measures predict readmission to the hospital following surgery for cancer. The study employs an established research team and database of survey data from registered nurses and outcomes data on hospitalized patients in Pennsylvania during 1998 and 1999. Secondary analysis will complement the ongoing work to articulate the relationship between nurse staffing and cancer patient outcomes. After construction of hospital level indices of nursing care process, logistic regression models will estimate the effects of assessments of uncompleted nursing care and frequency of adverse patient events, and staffing levels on death, complications, and FTR, controlling for characteristics of patients and hospitals. Cox regression models will estimate the effects of nursing process measures on the likelihood of readmission after the first surgery, controlling for these patient and hospital characteristics. Principal Investigator Julie Sochalski, PhD, RN Associate Professor, School of Nursing University of Pennsylvania Philadelphia, PA Other Participating Researchers Christopher Friese, M.S., R.N., A.O.C.N. - employed by University of Pennsylvania School of Nursing served as oncology nursing consultant Expected Research Outcomes and Benefits The intersection of patient characteristics, organizational structure, and nursing process is all but absent from health services research. Given the complexity of cancer treatment, we believe the expansion of the prior study to explore the role of nursing process is vital to a more complete understanding of the determinants of patient outcomes. Findings from this study will aid managers and policymakers in defining the specific interventions needed to improve hospital care for the cancer patient. Two tangible products are envisioned from this research. First, this study will aid other prominent health services researchers studying cancer outcomes to incorporate measures of nursing care in their studies. To date, health services researchers have been reluctant to measure nursing variables in their study due to reliability and validity problems. A paper published in a leading health services research journal (i.e., Medical Care) which documents the reliability and validity of nurse-assessed process and outcome measures could prove useful in advancing the use of such measures in the broader outcomes research discipline. Second, this study will provide concrete details as to how specific nursing organizational features and processes are associated with patient outcomes. Such a paper would be prepared for Oncology Nursing Forum. These activities will increase the evidence base on the determinants of high-quality care for cancer patients, and ultimately lead to reformed organizations which allow nurses to perform the care activities required to reduce the risk of poor outcomes.
  • 3. Pennsylvania Department of Health – 2004-2005 Annual C.U.R.E. Report Annual Progress Report for Oncology Nursing Society – Page 3 Summary of Research Completed The activities completed over the past year (7/1/2004 – 4/30/2005) in pursuit of the aims of this study comprise the following: (1) review and adapt the analytic approach employed in the prior study for use in the current project, and (2) refine and validate the risk adjustment model. 1. Adapting analytic approach: The analytic approach employed in the prior study assessed the effect of nurse staffing on 30-day mortality among surgical cancer patients who had one of nine solid-tumor types: head and neck, esophageal, colorectal, pancreas, lung, cervical, endometrial, ovarian, and prostate. We modified that approach for the current study in the following ways. First, further investigation revealed that cervical cancer patients had a negligible mortality rate and had hospital stays that were characteristically very different from the other cancer cases. Consequently these cases were excluded from the data set. Second, we identified additional cancer-related surgical procedures relevant to the study aims, matched them to their ICD-9-CM procedure codes, and added these cases. Third, we identified an additional hospital that had not been included in the prior data set (Magee Women’s Hospital) that had a substantial number of surgical cancer cases matching the criteria for our study. This hospital and all of its surgical cancer cases matching our sample criteria were added to the data set. These steps provided us with a modified data set containing 27,059 cases in 163 hospitals that were distributed across cancer types as follows: (1) head and neck, n= 1,595 (5.9%); (2) esophageal, n= 382 (1.4%); (3) colorectal, n= 11,963 (44.2%); (4) pancreas, n= 258 (1.0%); (5) lung, n= 706 (2.6%); (6) endometrial, n= 2,887 (10.7%); (7) ovarian, n= 1,836 (6.8%); (8) prostate, n= 7,432 (27.5%). In addition, we reviewed and refined the hospital characteristics variables for inclusion in the analysis. In particular, a refined measure of the accreditation status of each hospital’s cancer program by the American College of Surgeons was added to the data set to take into account the overall quality of cancer care at the hospital and its influence on the types of patients that it cared for, and to assess its relationship to the quality of nursing care. Over half of the hospitals in the sample (56%) did not have an ACS-accredited cancer program, and they provided cancer care to 34.4% of the patients in the sample. Conversely, 2.5% of the hospitals (n=4) were NCI comprehensive cancer care hospitals, and they treated 3.6% of the patients in the sample. 2. Risk adjustment model refinements: The risk adjustment model used in this study was derived from the work of our collaborator Dr. Jeffrey Silber. This model, originally designed for general surgical patients, was adapted for and used in the prior study for the first time with a cancer-specific population. Our work with that model led us to make several necessary modifications and enhancements in order to more fully adjust for severity of illness differences. We solicited surgical oncology experts to review the list of cancer-related surgical procedures and asked them to group these procedures on the basis of: (1) complexity, or the risk of short-term mortality or significant complications arising from the procedure, and/or (2) evidence of advanced cancer. These groups were then subsequently ranked from most to least severe or complex. This task led to the creation of
  • 4. Pennsylvania Department of Health – 2004-2005 Annual C.U.R.E. Report Annual Progress Report for Oncology Nursing Society – Page 4 43 expert-derived cancer-procedure risk groups among the eight cancer types that would be included in the analysis as risk adjustment variables. Our analysis of these groups showed that cancer-procedure risk group assignment was, unexpectedly, inversely associated with mortality. These findings suggested that patient selection is likely playing an important role in the likelihood of receiving and surviving a cancer surgical procedure: that is, physicians would be more likely to select healthier patients to undergo the more complex surgical procedures and these patients would thus be more likely to survive the procedure. These groups nonetheless captured important differences in severity of illness among patients and therefore these variables were retained as risk adjustment variables in the analytic model. In addition, we augmented the list of co-morbid conditions with eight cancer-specific co-morbidities (e.g., abdominal ascites) defined by the clinical oncology nursing experts collaborating on this project. The ICD-9-CM codes used to identify these cases were reviewed by cancer coding experts in medical records at the Hospital of the University of Pennsylvania. We also reviewed and modified the two cancer-specific risk adjustment variables that were afforded by merging the patient discharge data with the cancer registry data: length of disease (LOD)—the time between the initial cancer diagnosis and the hospital admission for cancer-related treatment—and cancer stage. Further review of LOD revealed that roughly one-third of the sample had an LOD of zero, meaning that the cancer diagnosis was first received during this hospital stay. In addition, LOD was significantly skewed (a relatively small number patients have extremely long LOD) and this skew varied across cancer types. After testing different types of variable conversion, we categorized LOD into five groups: those with an LOD of zero, and the remaining patients divided into quartiles. This categorization was done specifically for each of the eight cancer types, as the distribution of LOD varied tremendously across these groups. We also reviewed cancer stage, which was obtained from the cancer registry record, and tested different grouping methods. Cancer stage was ultimately grouped into five categories: stage 0 (in situ), stage 1 (local disease), stage 2-5 (regional disease), stage 7 (metastases), and stage 9 (unstaged). We further examined these groups and verified that they were ordered according to risk (e.g., stage 0 comprised patients with the lowest risk of mortality). These steps, and the work from the prior study, produced 88 main effects variables that would comprise the risk model. We undertook a systematic and rigorous examination of all possible interactions between these 88 variables and found that none of the interaction terms met the empirical threshold (Bonferroni p value). Consequently the final risk model contained the 88 main effects variables. All of our development and testing of these variables was undertaken on a 50% sample of the data set. The model was then rigorously evaluated on the second half of the data set, and each validation test confirmed the integrity of the model we developed and indicated its appropriateness for use. Research Project 2: Project Title and Purpose Oncology Nurses’ Perceptions of Cancer Patients’ Outcomes - This survey research project will determine the perception of oncology nurses, nurse administrators, and nurse educators in Pennsylvania and the United States regarding the impact, value, use, and education needs related to oncology nursing sensitive patient outcomes.
  • 5. Pennsylvania Department of Health – 2004-2005 Annual C.U.R.E. Report Annual Progress Report for Oncology Nursing Society – Page 5 Duration of Project 5/1/2004 - 6/30/2005 Project Overview This study is designed as a survey research project to gather basic descriptive information regarding oncology nurses’ perceptions of oncology nursing sensitive patient outcomes. The proposed work is to distribute (via the Internet and U.S Mail), analyze, and summarize the “Oncology Nursing Society (ONS) Patient Outcomes Survey”. The ONS Patient Outcomes Survey was designed to gather information regarding the impact, value, use, and education needs of oncology nurses related to oncology nursing sensitive patient outcomes. Oncology nursing patient outcomes are defined as “the consequences or effects of nursing interventions that result in changes in patients’ health status, behavior, and problem resolution. The focus is on symptoms, functional status, safety/preventable adverse events, psychological distress, and economic outcomes.” Secondary aims include to (a) determine similarities and differences in responses to the ONS Patient Outcomes Survey of ONS members from Pennsylvania and a national sample of ONS members and (b) determine similarities and differences in responses to the ONS Patient Outcomes Survey of ONS members with e-mail (Internet) access and ONS members without e-mail (Internet) access (do ONS members with e-mail access respond differently than ONS members without e-mail access?). The ONS Patient Outcomes Survey will be distributed to a random sample of Pennsylvania and national oncology nurses (ONS members) via a web-based survey program or via the U.S. Mail. The data will be entered into a database and analyzed using descriptive and Chi-square and the Mann-Whitney statistical tests to summarize the results from the survey in relationship to the overall purpose and the secondary aims of the survey. Principal Investigator Gail Mallory, R.N., Ph.D., C.N.A.A. Director of Research Oncology Nursing Society 125 Enterprise Drive RIDC Park West Pittsburgh, PA 15275 Other Participating Researchers None Expected Research Outcomes and Benefits The results from this survey, combined with the results from other health services research projects regarding cancer patients’ outcomes of care, can be used to design research to test the impact of specific oncology nursing interventions on oncology
  • 6. Pennsylvania Department of Health – 2004-2005 Annual C.U.R.E. Report Annual Progress Report for Oncology Nursing Society – Page 6 patients’ outcomes. Oncology nursing interventions have been shown to reduce health risks related to cancer treatment in clinical studies. The results from this survey can be used to plan future large scale studies of the delivery of health services (specifically oncology nursing interventions) to people with cancer. The mission of the Oncology Nursing Society is to promote excellence in oncology nursing and quality cancer care. One of the strategic goals of the Oncology Nursing Society is to generate public awareness of the specific contributions that oncology nurses and oncology nursing research make to patient outcomes. The results from this survey of oncology nurses will add to hospital level information on cancer patient outcomes currently being studied and provide direction for the Oncology Nursing Society’s education and research efforts regarding the quality of care provided to people with cancer. Summary of Research Completed The ONS Patient Outcomes Survey was conducted from October 2004 - December 1, 2004 using both web-based technology via Zoomerang.com and the U.S. Mail. The survey instrument “Oncology Nursing Society (ONS) Patient Outcomes Survey” was developed utilizing the ONSPO and issues related to outcomes utilization identified in the literature and by the 2003 ONSPO Project Team. The questionnaire was designed to provide descriptive information from the subject regarding the impact, value, use, and education needs related to ONSPO, along with demographic information about the subject’s professional role. In October 2004, there were 30,629 ONS members who met the selected membership categories of employed full-or part-time; patient, administration or education functional area; primary position of staff nurse, manager, clinical nurse specialist, nurse practitioner, educator, clinical trials nurse, or case manager; and worked in medical oncology, radiation oncology, surgical oncology or bone marrow transplant. Of these, 24,263 had e- mail addresses in the membership database. There were a total of 1,590 ONS members with PA addresses (1,178 with e-mail addresses and 412 without e-mail). A random sample of ONS members (7,500) with e-mail was selected. A random sample of 1,000 ONS members without e-mail was selected with the goal of a response rate of 30% or 300 responses, which is the modal response rate to complex ONS U.S. Mail surveys. All of the PA members with e-mail and 100 randomly selected PA members without e-mail were included in the sample prior to the random selection of the national ONS members. The PA sample size was based on the goal of achieving a large enough sample from the PA ONS members to conduct statistical analyses to answer aim two. Two e-mail messages were sent to the sample with e-mail addresses (n = 8,678). The U.S. Mail distribution occurred to the sample without e-mail addresses (n = 1,100) in early October 2004 and a postcard reminder was sent two weeks later. The computer-based web surveys were entered directly by the study respondent. The mail surveys covered the same content as online survey. Once the mail surveys were received in the research office, an office staff member entered the questionnaire responses into the online questionnaire. The data files from both the online surveys and the entered mail surveys were combined into a single data file with a variable included to specify route of
  • 7. Pennsylvania Department of Health – 2004-2005 Annual C.U.R.E. Report Annual Progress Report for Oncology Nursing Society – Page 7 response (e-mail or U.S. mail). Over eight in every ten (81.5%) who did reply, used the online survey option. All of the data were screened for accuracy and completeness of entries and the open- ended responses were tabulated. As appropriate, open-ended responses were classified into categories for summary response tables. The data were initially tabulated for the complete sample. No weightings were applied, so the base frequencies represent the relative proportions among those who chose to respond. After generating the base descriptive frequencies from these data, we analyzed potential association with select characteristics by computing cross-tabulations using chi-square tests of significance. Associations are reported as significant if the p value for the chi-square test of the test of statistical independence is .05 or below. An incentive of an Oncology Nurse’s Month pin was sent to the first ONS members to respond to the survey and submit their name/address separate from the survey (in order to maintain the anonymity of the subject) to the ONS Research Team. The first 200 nurses who responded to the survey using the Zoomerang® website and sent their name and address via e-mail to the ONS Research Team received a pin and the first 100 nurses who responded to the survey using the U.S. Mail and called the ONS Research Team using a toll-free number with their name and address received a pin. Summary of Key Findings All of the aims of this survey were met. The demographics of the respondents were similar to the overall characteristics of ONS members except for a larger number of respondents from hospital-based clinics and medical oncology settings and more respondents with greater than 20 years of experience in nursing and in oncology nursing. The respondents reported that they have a positive impact on cancer patients’ symptoms, functional status, safety, psychological distress and economic values. The respondents value ONSPO, and want additional information about them. However, while the respondents indicated that they understood the importance of outcomes, the manner in which they measured and documented the outcomes varied. The Numeric Pain Scale was the most used tool, which is not surprising as both the American Pain Society and the Joint Commission and Association on Health Care have been encouraging this use since 2000. There were also inconsistencies in the nursing language used for documentation. While less than a third of the respondents used the North American Nursing Diagnosis Association Classification (NANDA), almost half of the respondents were not able to state what nursing language (if any) their employers used. This could be for future research in nursing-sensitive patient outcomes, as it would be important to use the same language when comparing the impact of nursing interventions on outcomes patient tools. Nurses indicated that they desired additional education in the areas of psychological distress, functional status and safety outcomes, along with support in symptom management outcomes and economic outcomes.
  • 8. Pennsylvania Department of Health – 2004-2005 Annual C.U.R.E. Report Annual Progress Report for Oncology Nursing Society – Page 8 Oncology nurses who reside in PA responded similarly to those who do not reside in PA. The only significant differences were with some of the measurement tools used (sleep and patient satisfaction). The similarity of responses of nurses who reside in PA to a national sample of nurses is important in analyzing the results of larger studies using PA nurses as a representative sample of nurses in the United States. There were significant differences found in the response mode (email versus US mail), in role category (most of the nurses who responded by mail were staff nurses, whereas most non-staff nurses responded by e-mail) as well as values. Despite the differences found in use of e-mail, 92% of the respondents indicated that they felt that information about nursing-sensitive patient outcomes should be available on the ONS Website. This may indicate that while some nurses still prefer not to use e-mail for correspondence, they are comfortable accessing the ONS Website for information.
  • 9. Pennsylvania Department of Health – 2004-2005 Annual C.U.R.E. Report Annual Progress Report for Oncology Nursing Society – Page 9 Oncology Nursing Society Annual Progress Report: 2004 Formula Grant Reporting Period July 1, 2004 – June 30, 2005 Formula Grant Overview The Oncology Nursing Society received $31,527 in formula funds for the grant award period January 1, 2005 through June 30, 2006. The funds were used to support one research project. Accomplishments for the reporting period are described below. Formula Grant Coordinator Gail A. Mallory, Ph.D., R.N., C.N.A.A. Director of Research Oncology Nursing Society 125 Enterprise Drive Pittsburgh, PA 15275-1214 (412) 859-6308 Research Project 1: Project Title and Purpose Symptom Clusters in Patients with Chronic Disease and Cancer as a Comorbidity - A symptom cluster is three or more concurrent symptoms that are related to and influence one another. As the number of cancer survivors increases, it is important to know how a past diagnosis of cancer influences the symptom clusters experienced with other chronic health problems. To date, no studies have documented symptom clusters in patients with chronic health problems who have cancer as a comorbid condition. The purpose of this exploratory, secondary analysis is to identify and compare symptom clusters in individuals with chronic health problems with cancer as a comorbidity versus individuals with chronic health problems who do not have cancer as a comorbidity. Duration of Project 1/1/2005 - 6/30/2006 Project Overview This behavioral study represents a collaboration between the University of Pittsburgh School of Nursing and the Oncology Nursing Society. The specific aims of this study are to explore: 1) the symptom clusters in individuals with chronic health problems who have cancer as a comorbidity; 2) whether there are differences in symptom clusters between
  • 10. Pennsylvania Department of Health – 2004-2005 Annual C.U.R.E. Report Annual Progress Report for Oncology Nursing Society – Page 10 individuals with chronic health problems who have cancer as a comorbidity versus individuals with chronic health problems who do not have cancer as a comorbidity; 3) whether there are differences in the number and type of comorbidities between individuals with chronic health problems who have cancer as a comorbidity versus those who do not have cancer as a comorbidity; and 4) whether there are differences in symptom clusters, depending upon the number and type of comorbidities, in individuals with chronic health problems who have cancer as a comorbidity versus those who do not have cancer as a comorbidity. The design of this exploratory study is a secondary analysis of existing comorbidity and symptom data collected at the baseline assessment from two independent studies of subjects with chronic health problems who do and do not have cancer as a comorbid condition. Study 1 is an investigation of the efficacy of an intervention to improve medication adherence in patients with rheumatoid arthritis. Study 2 is an investigation of the efficacy of an intervention to decrease relapse rates following pelvic floor muscle training for urinary incontinence in the elderly. Data from two measures, used in both studies, will be analyzed. The Co-Morbidity Questionnaire is a self-report measure of comorbid conditions and symptom assessment. The Center for Research in Chronic Disorders Sociodemographic Questionnaire assesses sociodemographic and socioeconomic attributes of subjects. Merged, de-identified data from both studies will be analyzed to identify symptom clusters and to compare symptom clusters between subjects with a comorbidity of cancer and subjects without a comorbidity of cancer. Principal Investigator Catherine M. Bender, Ph.D., R.N. University of Pittsburgh School of Nursing 3500 Victoria Street, Suite 415 Pittsburgh, PA 15261 Other Participating Researchers Heidi Donovan, Ph.D., R.N., Susan Sereika, Ph.D., Margaret Rosenzweig, Ph.D., R.N., Susan Cohen, Ph.D, R.N., Janet Stewart, Ph.D., R.N., Julius Kitutu, ME.d., MS.c., Ph.D.- employed by University of Pittsburgh School of Nursing Gail A. Mallory, Ph.D., R.N. - Oncology Nursing Society Expected Research Outcomes and Benefits With the number of cancer survivors increasing every year, it is important to understand the influence of cancer as a comorbidity with other chronic health problems. In particular, being able to predict the influence of a cancer history on symptom clusters could help promote optimal symptom management for patients with chronic illnesses. Symptoms within a symptom cluster can influence one another and knowledge of this influence may direct interventions for the prevention and management of symptoms. This is an important area of research because patients with chronic health problems tend to experience multiple concurrent symptoms. Symptom clusters have a negative effect
  • 11. Pennsylvania Department of Health – 2004-2005 Annual C.U.R.E. Report Annual Progress Report for Oncology Nursing Society – Page 11 on patient outcomes such as functional status and quality of life. Management of single symptoms may have unintended implications for the management of related symptoms. It is important to identify and describe symptom clusters to insure accurate and well- timed symptom identification and to develop and test interventions to prevent and manage symptom clusters in patients with chronic health problems who do and do not have cancer as a comorbidity. Summary of Research Completed We have completed the following work in this project during the reporting period: 1) The honest broker was given password-protected access to the Center for Research in Chronic Disorders (CRCD) server to retrieve data from the study measures: Comorbidity Scale CRCD Sociodemographic Scale 2) Retrieved and abstracted de-identified data from the two projects. 3) Merged the files from the two studies: Adherence in rheumatoid arthritis: Intervention strategies Homebound elderly: Maintaining post-treatment continence 4) A preliminary descriptive analysis of the sociodemographic data and comorbidity data (whether or not subjects have ever had a cancer diagnosis) has been conducted. See Table 1 for a summary of these analyses.
  • 12. Pennsylvania Department of Health – 2004-2005 Annual C.U.R.E. Report Annual Progress Report for Oncology Nursing Society – Page 12 5) Table 1. Characteristics of subjects with rheumatoid arthritis and urinary incontinence. Rheumatoid Arthritis Urinary Incontinence Characteristic N/Mean (SD) N/Mean (SD) df t p Age 637/59.53 (11.92) 406/76.83 (8.18) 1044 -25.69 .000* Education (years) 637/13.41 (2.43) 406/13.02 (3.06) 1042 2.27 .023* n (%) n (%) df χ2 p Gender Male Female 123 (60.0) 516 (61.2) 80 (39.4) 327 (38.8) 1 0.03 .87 Race White Black American Indian Eskimo Asian Unknown Other 608 (61.0) 27 (61.4) 12 (100) 3 (100) 5 (83.3) 4 (80.0) 4 (66.7) 388 (39.0) 17 (38.6) 0 0 1 (16.7) 1 (20.0) 2 (33.3) 1 1 1 1 1 1 1 0.02 .001 7.73 1.92 1.26 0.76 0.08 .89 .97 .005* .17 .26 .38 .78 Marital status Never married Currently married Living with partner/ significant other Widowed Separated Divorced 61 (74.4) 418 (74.5) 13 (92.9) 86 (30.1) 9 (56.3) 52 (8.10) 21 (31.9) 143 (25.5) 1 (7.1) 200 (69.9) 7 (43.8) 35 (40.2) 5 170.55 .000* Employment status Full time employment Part time employment Laid off/unemployed (looking for work) Laid off/unemployed (not looking for work) Retired (not working at all) Retired (working part or full time) Disabled/Unable to work Full time homemaker Student Other 137 (92.6) 58 (90.6) 5 (100) 3 (100) 186 (33.6) 21 (65.6) 123 (96.9) 90 (92.8) 1 (100) 12 (100) 11 (7.4) 6 (9.4) 0 0 368 (66.4) 11 (34.4) 4 (3.1) 7 (7.2) 0 0 9 384.20 .000* Health care insurance Yes No 637 (61.1) 1 (50.0) 406 (38.9) 1 (50.0) 1 0.10 .75 Ever had cancer? Yes No 56 (36.4) 583 (65.4) 98 (63.6) 309 (34.6) 1 46.42 .000*

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