Patient navigation: an update on the state of the science

The effects of navigation and types of neighborhoods on timely follow-up of abnormal mammogram among black women

BACKGROUND

Despite the availability of relatively simple and inexpensive screening tools, minority women are more often diagnosed at a late stage of breast cancer, in part due to delays in follow-up of abnormal screening result. One of the key factors for timely follow-up of abnormal mammogram may be neighborhood characteristics. Patient Navigation (PN) programs aim to diminish barriers, but its differential effects by neighborhood have not been fully examined. The current study examines the effect of types of neighborhoods on time to follow-up of abnormal mammogram, and the differential effects of PN by neighborhood characteristics.

METHODS

We examined data from a total of 1,696 randomized patients from a randomized controlled trial, "the Patient Navigation in Medically Underserved Areas" study that explored the effect of navigation on breast health outcomes. We categorized participants' neighborhoods into three categories and compared the effect of navigation between these neighborhood types.

RESULTS

Navigated women in mixed race neighborhoods had a shorter time to follow-up compared with non-navigated women in the neighborhoods. Black women living in mixed neighborhoods had a significant longer time to follow-up of abnormal mammogram, compared with black women living in middle class black neighborhoods.

CONCLUSION

Patient navigation interventions improve timely follow-up of abnormal mammogram. Patient navigation may be particularly beneficial for minority women who reside in racially heterogeneous neighborhoods which may be less likely to have access to affordable health clinics and social services. Health policies concerning breast cancer early detection for minority women need to pay further attention to those who might potentially be excluded from health services due to the characteristics of neighborhoods. Socioeconomic conditions of neighborhood may affect individual health through multiple interlinked mechanisms. Neighborhood characteristics, such as poverty, segregation, access to resources, and social cohesion, cannot be fully understood with simplistic measures of neighborhood disadvantage.

Racial and Ethnic Differences in Breast Cancer Survival: Mediating Effect of Tumor Characteristics and Sociodemographic and Treatment Factors

PURPOSE

To evaluate the relationship between race/ethnicity and breast cancer-specific survival according to subtype and explore mediating factors.

PATIENTS AND METHODS

Participants were women presenting with stage I to III breast cancer between January 2000 and December 2007 at National Comprehensive Cancer Network centers with survival follow-up through December 2009. Cox proportional hazards regression was used to compare breast cancer-specific survival among Asians (n = 533), Hispanics (n = 1,122), and blacks (n = 1,345) with that among whites (n = 14,268), overall and stratified by subtype (luminal A like, luminal B like, human epidermal growth factor receptor 2 type, and triple negative). Model estimates were used to derive mediation proportion and 95% CI for selected risk factors.

RESULTS

In multivariable adjusted models, overall, blacks had 21% higher risk of breast cancer-specific death (hazard ratio [HR], 1.21; 95% CI, 1.00 to 1.45). For estrogen receptor-positive tumors, black and white survival differences were greatest within 2 years of diagnosis (years 0 to 2: HR, 2.65; 95% CI, 1.34 to 5.24; year 2 to end of follow-up: HR, 1.50; 95% CI, 1.12 to 2.00). Blacks were 76% and 56% more likely to die as a result of luminal A-like and luminal B-like tumors, respectively. No disparities were observed for triple-negative or human epidermal growth factor receptor 2-type tumors. Asians and Hispanics were less likely to die as a result of breast cancer compared with whites (Asians: HR, 0.56; 95% CI, 0.37 to 0.85; Hispanics: HR, 0.74; 95% CI, 0.58 to 0.95). For blacks, tumor characteristics and stage at diagnosis were significant disparity mediators. Body mass index was an important mediator for blacks and Asians.

CONCLUSION

Racial disparities in breast cancer survival vary by tumor subtype. Interventions are needed to reduce disparities, particularly in the first 2 years after diagnosis among black women with estrogen receptor-positive tumors.

Underuse of surveillance colonoscopy in patients at increased risk of colorectal cancer

OBJECTIVES

Colorectal cancer incidence and mortality have declined over the past two decades, and much of this improvement is attributed to increased use of screening. Approximately 25% of patients who undergo screening colonoscopy have premalignant adenomas that require removal and follow-up colonoscopy. However, there are few studies of the use of surveillance colonoscopy in increased risk patients with previous adenomas.

METHODS

We conducted a cross-sectional study to examine factors associated with underuse of surveillance colonoscopy among patients who are at increased risk for colorectal cancer. The study population consisted of patients with previously identified adenomatous polyps and who were due for follow-up colonoscopy. Patients were categorized as attenders (n=100) or non-attenders (n=104) on the basis of completion of follow-up colonoscopy. Telephone surveys assessed the use of surveillance colonoscopy across domains of predisposing patient characteristics, enabling factors, and patient need. Mutlivariable logistic regression was used to identify factors associated with screening completion.

RESULTS

Perceived barriers, perceived benefits, social deprivation, and cancer worry were associated with attendance at colonoscopy. Higher benefits (odds ratio (OR) 2.37, 95% confidence interval (CI) 1.04-5.41) and cancer worry (OR 1.73, 95% CI 1.07-2.79) increased the odds of attendance at follow-up colonoscopy, whereas greater barriers (OR 0.49, 95% CI 0.28-0.88) and high social deprivation (≥2; OR 0.09, 95% CI 0.01-0.76) were associated with lower odds.

CONCLUSIONS

Our results suggest that multilevel factors contribute to the use of surveillance colonoscopy in higher risk populations, many of which are amenable to intervention. Interventions, such as patient navigation, may help facilitate appropriate use of surveillance colonoscopy.

Impact of depression on the intensity of patient navigation for women with abnormal cancer screenings

Patient navigation is increasingly being used to support vulnerable patients to receive timely and quality medical care. We sought to understand whether patients with depression utilize additional patient navigation services after abnormal cancer screening. We compared depressed and non-depressed women using three different measures of intensity of patient navigation: number of patient-navigator encounters, encounter time, and number of unique barriers to care. The study population consisted of 1,455 women who received navigation after abnormal screening for breast or cervical cancer at one of six community health centers in Boston. Navigators spent a median of 60-75 minutes over one or two encounters per participant, with 49% of participants having one or more documented barrier to care. Depressed women did not differ in total numbers of encounters, encounter time, or unique barriers compared with non-depressed women. Our findings suggest that pre-existing depression does not predict which women will utilize additional navigation services.

Apoyo con Cariño: a pilot randomized controlled trial of a patient navigator intervention to improve palliative care outcomes for Latinos with serious illness

CONTEXT

Latinos experience significant health disparities at the end of life compared with non-Latinos.

OBJECTIVES

To determine the feasibility of a patient navigator intervention to improve palliative care outcomes for Latino adults with serious illness.

METHODS

This was a pilot randomized controlled trial that included 64 Latino adults with life-limiting illness randomized to an intervention or a control group. All participants received a packet of linguistically matched materials on palliative care. In addition, intervention participants received up to five home visits from the bilingual, bicultural patient navigator. Visits focused on addressing barriers to palliative care through education, activation, and culturally tailored messaging. Outcomes included feasibility and advance care planning rates, documentation of pain management discussions in the medical record, and hospice utilization.

RESULTS

Of the 32 patients randomized to the intervention arm, 81% had at least one home visit (range 1-5) with the patient navigator. Overall, advance care planning was higher in the intervention group (47% [n = 15] vs. 25% [n = 8], P = 0.06), and 79% of intervention participants had a discussion about pain management documented in their medical record vs. 54% of control patients (P = 0.05). Hospice enrollment between the two groups (n = 18 decedents) was similar (n = 7 intervention vs. n = 6 control); length of stay in the intervention group was 36.4 ± 51.6 vs. 19.7 ± 33.6 days for control patients (P = 0.39).

CONCLUSION

A culturally tailored patient navigator intervention was feasible and suggests improved palliative care outcomes for Latinos facing advanced medical illness, justifying a fully powered randomized controlled trial.

Disparities in barriers to follow-up care between African American and White breast cancer survivors

PURPOSE

Despite recommendations for breast cancer survivorship care, African American women are less likely to receive appropriate follow-up care, which is concerning due to their higher mortality rates. This study describes differences in barriers to follow-up care between African American and White breast cancer survivors.

METHODS

We conducted a mailed survey of women treated for non-metastatic breast cancer in 2009-2011, 6-24 months post-treatment (N = 203). Survivors were asked about 14 potential barriers to follow-up care. We used logistic regression to explore associations between barriers and race, adjusting for covariates.

RESULTS

Our participants included 31 African American and 160 White survivors. At least one barrier to follow-up care was reported by 62 %. Compared to White survivors, African Americans were more likely to identify barriers related to out-of-pocket costs (28 vs. 51.6 %, p = 0.01), other health care costs (21.3 vs. 45.2 %, p = 0.01), anxiety/worry (29.4 vs. 51.6 %, p = 0.02), and transportation (4.4 vs. 16.1 %, p = 0.03). After adjustment for covariates, African Americans were three times as likely to report at least one barrier to care (odds ratio (OR) = 3.3, 95 % confidence interval (CI) = 1.1-10.1).

CONCLUSIONS

Barriers to care are common among breast cancer survivors, especially African American women. Financial barriers to care may prevent minority and underserved survivors from accessing follow-up care. Enhancing insurance coverage or addressing out-of-pocket costs may help address financial barriers to follow-up care among breast cancer survivors. Psychosocial care aimed at reducing fear of recurrence may also be important to improve access among African American breast cancer survivors.

Patient navigators for people with chronic disease: protocol for a systematic review and meta-analysis

BACKGROUND

Individuals with chronic diseases may have difficulty optimizing their health and getting the care they need due to a combination of patient, provider, and health system level barriers. Patient navigator programs, in which trained personnel assess and assist patients in overcoming barriers to care, may improve care and outcomes for patients with chronic disease by providing an alternative approach to conventional information and support resources.

METHODS

This systematic review will evaluate the evidence for patient navigator programs, compared to usual care, in patients with chronic disease. We will include RCTs, cluster RCTs, and quasi-randomized RCTs that study the effects of patient navigator programs on clinical outcomes, patient experience, and markers of adherence to care. Studies will be identified by searching MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, PsycINFO, Social Work Abstracts, and the references of included studies. Two authors will screen titles and abstracts independently. Full texts will be reviewed for relevance and data extraction will be done independently by two authors. Studies will be included if they assess patients of any age with one or more chronic diseases. Outcomes will be categorized into groups characterized by their proximity to mechanism of action of the intervention: patient-level outcomes, intermediate outcomes, and process outcomes. Descriptive data about the elements of the patient navigator intervention will also be collected for potential subgroup analyses. Risk of bias will be assessed using the Effective Practice and Organisation of Care Group (EPOC) risk of bias tool. Data will be analyzed using random effects meta-analysis (relative risk for dichotomous data and mean difference for continuous data), if appropriate.

DISCUSSION

A comprehensive review of patient navigator programs, including a summary of the elements of programs that are associated with a successful intervention, does not yet exist. This systematic review will synthesize the evidence of the effect of patient navigator interventions on clinical and patient-oriented outcomes in populations across a comprehensive set of chronic diseases.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42013005857 .

Evaluating a bilingual patient navigation program for uninsured women with abnormal screening tests for breast and cervical cancer: implications for future navigator research

OBJECTIVES

The DuPage Patient Navigation Collaborative evaluated the Patient Navigation Research Program (PNRP) model for uninsured women receiving free breast or cervical cancer screening through the Illinois Breast and Cervical Cancer Program in DuPage County, Illinois.

METHODS

We used medical records review and patient surveys of 477 women to compare median follow-up times with external Illinois Breast and Cervical Cancer Program and Chicago PNRP benchmarks of performance. We examined the extent to which we mitigated community-defined timeliness risk factors for delayed follow-up, with a focus on Spanish-speaking participants.

RESULTS

Median follow-up time (29.0 days for breast and 56.5 days for cervical screening abnormalities) compared favorably to external benchmarks. Spanish-speaking patients had lower health literacy, lower patient activation, and more health care system distrust than did English-speaking patients, but despite the prevalence of timeliness risk factors, we observed no differences in likelihood of delayed (> 60 days) follow-up by language.

CONCLUSIONS

Our successful replication and scaling of the PNRP navigation model to DuPage County illustrates a promising approach for future navigator research.

Patient navigation based on predictive modeling decreases no-show rates in cancer care

BACKGROUND

Patient adherence to appointments is key to improving outcomes in health care. "No-show" appointments contribute to suboptimal resource use. Patient navigation and telephone reminders have been shown to improve cancer care and adherence, particularly in disadvantaged populations, but may not be cost-effective if not targeted at the appropriate patients.

METHODS

In 5 clinics within a large academic cancer center, patients who were considered to be likely (the top 20th percentile) to miss a scheduled appointment without contacting the clinic ahead of time ("no-shows") were identified using a predictive model and then randomized to an intervention versus a usual-care group. The intervention group received telephone calls from a bilingual patient navigator 7 days before and 1 day before the appointment.

RESULTS

Over a 5-month period, of the 40,075 appointments scheduled, 4425 patient appointments were deemed to be at high risk of a "no-show" event. After the patient navigation intervention, the no-show rate in the intervention group was 10.2% (167 of 1631), compared with 17.5% in the control group (280 of 1603) (P<.001). Reaching a patient or family member was associated with a significantly lower no-show rate (5.9% and 3.0%, respectively; P<.001 and .006, respectively) compared with leaving a message (14.7%: P = .117) or no contact (no-show rate, 21.6%: P = .857).

CONCLUSIONS

Telephone navigation targeted at those patients predicted to be at high risk of visit nonadherence was found to effectively and substantially improve patient adherence to cancer clinic appointments. Further studies are needed to determine the long-term impact on patient outcomes, but short-term gains in the optimization of resources can be recognized immediately.

Psychosocial correlates of appointment keeping in immigrant cancer patients

This study aims to determine the psychosocial correlates of self-reported adherence to cancer treatment appointments and treatment delays and interruptions. The sample included 622 immigrant cancer patients from New York City. Patients completed a survey that included sociodemographic and health-related questions, questions assessing missed appointments and delays/or interruptions, and quality of life and depression scales. After controlling for sociodemographic characteristics, having a positive depression screen and poor physical and emotional well-being were significant predictors of missed appointments and delays and/or interruptions of treatment. Non-adherence to treatment appointments in immigrant cancer patients is a complex outcome related to important modifiable or treatable factors.

Quality of Care, Including Survivorship Care Plans

With the expectation of prolonged survival in the vast majority of women diagnosed with breast cancer, making initial treatment decisions that minimize or prevent late complications, and maximize the quality as well as quantity of life, is absolutely critical. Unfortunately, such care is not uniformly delivered. Patient, provider, and system barriers contribute to delays in cancer care, lower quality of care, and poorer outcomes in vulnerable populations, including low income, underinsured, and racial/ethnic minority populations. Covering the costs of cancer care is a major concern for many cancer survivors, and as a result, a major challenge will be to provide cost-effective follow-up care by reducing overuse of unnecessary tests and procedures so that access to effective medications can be preserved. One of the recently promoted means of improving the coordination of care for breast cancer survivors has been the use of survivorship care planning, as coordination of care will be absolutely essential to deliver high-quality care. Patient navigation is another approach to help overcome healthcare system barriers and facilitate timely access to quality medical care. Understanding the challenges and opportunities in delivering high-quality cancer care is one of the most critical issues of the day. With the large numbers of breast cancer patients and the tremendous advances in our understanding of the disease and treatments (leading to large numbers of survivors), breast cancer will likely be the focus of new models for the delivery of better and more efficient cancer care.

Experiences of women of color with a nurse patient navigation program for linkage and engagement in HIV care

Patient navigation, a patient-centered model of care coordination focused on reducing barriers to care, is an emerging strategy for linking patients to and retaining them in HIV care. The Guide to Healing Program (G2H), implemented at the Infectious Diseases Clinic at UNC Chapel Hill, provided patient navigation to women of color (WOC) new to or re-engaging in HIV care through a 'nurse guide' with mental health training and experience. The purpose of this study was to qualitatively explore patients' experiences working with the nurse guide. Twenty-one semi-structured telephone interviews with G2H participants were conducted. Interviews were transcribed and thematic analysis was utilized to identify patterns and themes in the data. Women's experiences with the nurse guide were overwhelmingly positive. They described the nurse guide teaching them critical information and skills, facilitating access to resources, and conveying authentic kindness and concern. The findings suggest that a properly trained nurse in this role can provide critical medical and psychosocial support in order to eliminate barriers to engagement in HIV care, and successfully facilitate patient HIV self-management. The nurse guide model represents a promising approach to patient navigation for WOC living with HIV.

Patient navigation to improve follow-up of abnormal mammograms among disadvantaged women

BACKGROUND

Patient navigation (PN) can improve breast cancer care among disadvantaged women. We evaluated the impact of a PN program on follow-up after an abnormal mammogram.

METHODS

Between 2007 and 2010, disadvantaged women with an abnormal mammogram (Breast Imaging-Reporting and Data System [BI-RADS] codes 0, 3, 4, 5) cared for in a community health center (CHC) with PN were compared to those receiving care in 11 network practices without PN. Multivariable logistic regression and Cox proportional hazards modeling were used to compare the percentages receiving appropriate follow-up and time to follow-up between the groups.

RESULTS

Abnormal mammography findings were reported for 132 women in the CHC with PN and 168 from practices without PN. The percentage of women with appropriate follow-up care was higher in the practice with PN than in non-PN practices (90.4% vs. 75.3%, adjusted p=0.006). RESULTS varied by BI-RADS score for women in PN and non-PN practices (BI-RADS 0, 93.7% vs. 90.2%, p=0.24; BI-RADS 3, 85.7% vs. 49.2%, p=0.003; BI-RADS 4/5, 95.1% vs. 82.8%, p=0.26). Time to follow-up was similar for BI-RADS 0 and occurred sooner for women in the PN practice than in non-PN practices for BI-RADS 3 and 4/5 (BI-RADS 3, adjusted hazard ratio [aHR], 95% confidence interval [CI]: 2.41 [1.36-4.27], BI-RADS 4/5, aHR [95% CI]: 1.41 [0.88-2.24]).

CONCLUSIONS

Disadvantaged women from a CHC with PN were more likely to receive appropriate follow-up after an abnormal mammogram than were those from practices without PN. Expanding PN to include all disadvantaged women within primary care networks could improve equity in cancer care.

Neighborhood factors associated with time to resolution following an abnormal breast or cervical cancer screening test

BACKGROUND

The effect of neighborhood and healthcare access factors on cancer outcomes among patients enrolled in navigator programs is not clearly understood. This study assessed associations between: (i) neighborhood factors and diagnostic time to resolution (TTR) and (ii) geographic access and TTR following an abnormal breast or cervical cancer screening test among women participating in the Ohio Patient Navigator Research Program (OPNRP).

METHODS

Patient (demographic, socioeconomic status, home-to-clinic distance) and neighborhood (deprivation, racial segregation) characteristics of 801 women living in one of 285 census tracts (CT) in greater Columbus, Ohio were examined. Randomization to receive navigation occurred at the clinic level. Multilevel Cox regression and spatial analysis were used to estimate effects of various factors on TTR and assess model assumptions, respectively.

RESULTS

TTR increased as neighborhood deprivation increased. After adjustment for age, friend social support, education, and healthcare status, the TTR among women living in a neighborhood with a moderate median household income (between $36,147 and $53,099) was shorter compared with women living in low median household income neighborhoods (<$36,147; P < 0.05). There is little evidence that unmeasured confounders are geographically patterned.

CONCLUSIONS

Increased neighborhood socioeconomic deprivation was associated with longer TTR following an abnormal breast or cervical cancer screening test.

IMPACT

These results highlight the need for addressing patient- and neighborhood-level factors to reduce cancer disparities among underserved populations.

Predictors of resolution in navigated patients with abnormal cancer screening tests

BACKGROUND

Patient navigation has been effective in improving cancer care, yet little is known about what predicts timely outcomes in navigated patients.

OBJECTIVE

To identify predictors of resolution of abnormal cancer screening tests in patients who received navigation.

METHODS

We examined data on patients with abnormal breast (n = 256) or cervical (n = 150) screening tests or symptoms who received navigation as part of the Ohio Patient Navigator Research Program during 2007-2010. We used multivariable Cox proportional hazards regression models to identify predictors of time to resolution (ie, when a patient's clinical abnormality or abnormal screening test was determined to be a benign condition or a cancer diagnosis).

RESULTS

The median time to resolution was 183 days for navigated patients with breast abnormalities and 172 days for navigated patients with cervical abnormalities. In patients with breast abnormalities, those who reported at least 1 barrier to care during navigation (HR, 0.66; 95% CI, 0.51-0.86) or higher perceived stress (HR, 0.90; 95% CI, 0.82-0.98) had slower resolution. Among patients with cervical abnormalities, those who reported at least 1 barrier to care during navigation had slower resolution (HR, 0.62; 95% CI, 0.42-0.91). Patients with cervical abnormalities had faster resolution if they had private health insurance, but this effect was present only in younger women (interaction 𝑃 = .003).

LIMITATIONS

Unknown generalizability of results because patients were female and from clinics in central Ohio.

CONCLUSIONS

Several variables predicted whether patient navigation led to faster resolution, and predictors differed somewhat by disease site. Results will be useful in improving current patient navigation programs and designing future programs.

Caregiving among American Indians and Alaska Natives with cancer

PURPOSE

Caregivers are an important source of support for oncology patients during cancer diagnosis and treatment, often helping patients manage barriers to care. Our study had three goals: to describe the characteristics of caregivers for American Indian and Alaska Native (AI/AN) oncology patients, to assess the similarities and differences between the perceptions of caregivers and patients regarding barriers to cancer care, and to compare AI/AN caregivers to non-AI/AN caregivers on perceived barriers to cancer care.

METHODS

We conducted a structured interview that assessed perceived barriers to cancer care with a paired sample of 98 adult caregivers and 98 AI/AN oncology patients and to assess the degree of agreement between these two groups. We also investigated whether AI/AN and non-AI/AN caregivers had differing perceptions of barriers to cancer care.

RESULTS

Caregivers reported that their role was very meaningful and not highly stressful. Caregivers and patients agreed 70 % of the time on specific barriers to cancer care. Both groups overwhelmingly reported financial and family or work issues as major barriers to care, whereas trust in providers was the least frequently endorsed barrier. A comparison of AI/AN and non-AI/AN caregivers revealed that AI/AN caregivers identified confidentiality among clinical staff as a significant barrier, whereas non-AI/AN caregivers perceived financial barriers as more significant.

CONCLUSIONS

Finances, family, and work are perceived as the largest barriers to the receipt of cancer care for AI/AN oncology patients. Both patients and caregivers trusted health-care providers. Assessing barriers to care early in the assessment process may result in better engagement with cancer treatment by patients and their caregivers.

Reducing inequities in colorectal cancer screening in North America

Colorectal cancer (CRC) is an important cause of mortality and morbidity in North America. Screening using a fecal occult blood test, flexible sigmoidoscopy, or colonoscopy reduces CRC mortality through the detection and treatment of precancerous polyps and early stage CRC. Although CRC screening participation has increased in recent years, large inequities still exist. Minorities, new immigrants, and those with lower levels of education or income are much less likely to be screened. This review provides an overview of the commonly used tests for CRC screening, disparities in CRC screening, and promising methods at the individual, provider, and system levels to reduce these disparities. Overall, to achieve high CRC participation rates and reduce the burden of CRC in the population, a multi-faceted approach that uses strategies at all levels to reduce CRC screening disparities is urgently required.

Racial and ethnic disparities in cancer survival by neighborhood socioeconomic status in Surveillance, Epidemiology, and End Results (SEER) Registries

INTRODUCTION

Reducing cancer disparities is a major public health objective. Disparities often are discussed in terms of either race and ethnicity or socioeconomic status (SES), without examining interactions between these variables.

METHODS

Surveillance, Epidemiology, and End Results (SEER)-18 data, excluding Alaska Native and Louisiana registries, from 2002 to 2008, were used to estimate five-year, cause-specific survival by race/ethnicity and census tract SES. Differences in survival between groups were used to assess absolute disparities. Hazard ratios were examined as a measure of relative disparity. Interactions between race/ethnicity and neighborhood SES were evaluated using proportional hazard models.

RESULTS

Survival increased with higher SES for all racial/ethnic groups and generally was higher among non-Hispanic white and Asian/Pacific Islander (API) than non-Hispanic black and Hispanic cases. Absolute disparity in breast cancer survival among non-Hispanic black vs non-Hispanic white cases was slightly larger in low-SES areas than in high-SES areas (7.1% and 6.8%, respectively). In contrast, after adjusting for stage, age, and treatment, risk of mortality among non-Hispanic black cases compared with non-Hispanic white cases was 21% higher in low-SES areas and 64% higher in high-SES areas. Similarly, patterns of absolute and relative disparity compared with non-Hispanic whites differed by SES for Hispanic breast cancer, non-Hispanic black colorectal cancer, and prostate cancer cases. Statistically significant interactions existed between race/ethnicity and SES for colorectal and female breast cancers.

DISCUSSION

In health disparities research, both relative and absolute measures provide context. A better understanding of the interactions between race/ethnicity and SES may be useful in directing screening and treatment resources toward at-risk populations.

Variations in coping stages for individuals with chronic kidney disease: Results from an exploratory study with patient navigators

Using a cross-sectional design, we examined coping stages (Kübler-Ross) among patients with end-stage renal disease at nephrology practices incorporating professional social workers as patient navigators, providing person-centered education and support (N = 420). We evaluated associations with behavioral counseling constructs (assess-advise-agree-assist-arrange). Coping stages comprised denial = 35.24 percent, acceptance = 24.05 percent, depression = 21.43 percent, bargaining = 12.86 percent, and anger = 6.43 percent. Compared to denial, other coping stages showed increased odds ratios for transplant referral agreement, transplant referral evaluations, understanding treatments, understanding donation procedures, plans to recruit donors, active donor recruitment, and potential living donor(s). Assessment of coping stages, and strategies to influence these, may be key factors in guiding patients to living donor kidney transplantation.

An assessment of patient navigator activities in breast cancer patient navigation programs using a nine-principle framework

OBJECTIVE

To determine how closely a published model of navigation reflects the practice of navigation in breast cancer patient navigation programs.

DATA SOURCE

Observational field notes describing patient navigator activities collected from 10 purposefully sampled, foundation-funded breast cancer navigation programs in 2008-2009.

STUDY DESIGN

An exploratory study evaluated a model framework for patient navigation published by Harold Freeman by using an a priori coding scheme based on model domains.

DATA COLLECTION

Field notes were compiled and coded. Inductive codes were added during analysis to characterize activities not included in the original model.

PRINCIPAL FINDINGS

Programs were consistent with individual-level principles representing tasks focused on individual patients. There was variation with respect to program-level principles that related to program organization and structure. Program characteristics such as the use of volunteer or clinical navigators were identified as contributors to patterns of model concordance.

CONCLUSIONS

This research provides a framework for defining the navigator role as focused on eliminating barriers through the provision of individual-level interventions. The diversity observed at the program level in these programs was a reflection of implementation according to target population. Further guidance may be required to assist patient navigation programs to define and tailor goals and measurement to community needs.

Can patient navigation improve receipt of recommended breast cancer care? Evidence from the National Patient Navigation Research Program

PURPOSE

Poor and underserved women face barriers in receiving timely and appropriate breast cancer care. Patient navigators help individuals overcome these barriers, but little is known about whether patient navigation improves quality of care. The purpose of this study is to examine whether navigated women with breast cancer are more likely to receive recommended standard breast cancer care.

PATIENTS AND METHODS

Women with breast cancer who participated in the national Patient Navigation Research Program were examined to determine whether the care they received included the following: initiation of antiestrogen therapy in patients with hormone receptor-positive breast cancer; initiation of postlumpectomy radiation therapy; and initiation of chemotherapy in women younger than age 70 years with triple-negative tumors more than 1 cm. This is a secondary analysis of a multicenter quasi-experimental study funded by the National Cancer Institute to evaluate patient navigation. Multiple logistic regression was performed to compare differences in receipt of care between navigated and non-navigated participants.

RESULTS

Among participants eligible for antiestrogen therapy, navigated participants (n = 380) had a statistically significant higher likelihood of receiving antiestrogen therapy compared with non-navigated controls (n = 381; odds ratio [OR], 1.73; P = .004) in a multivariable analysis. Among the participants eligible for radiation therapy after lumpectomy, navigated participants (n = 255) were no more likely to receive radiation (OR, 1.42; P = .22) than control participants (n = 297).

CONCLUSION

We demonstrate that navigated participants were more likely than non-navigated participants to receive antiestrogen therapy. Future studies are required to determine the full impact patient navigation may have on ensuring that vulnerable populations receive quality care.

Lay navigator model for impacting cancer health disparities

This paper recounts experiences, challenges, and lessons learned when implementing a lay patient navigator program to improve cancer care among medically underserved patients who presented in a primary care clinic with a breast or colorectal cancer abnormality. The program employed five lay navigators to navigate 588 patients. Central programmatic elements were the following: (1) use of bilingual lay navigators with familiarity of communities they served; (2) provision of training, education, and supportive activities; (3) multidisciplinary clinical oversight that factored in caseload intensity; and (4) well-developed partnerships with community clinics and social service entities. Deconstruction of healthcare system information was fundamental to navigation processes. We conclude that a lay model of navigation is well suited to assist patients through complex healthcare systems; however, a stepped care model that includes both lay and professional navigation may be optimal to help patients across the entire continuum.

Can patient navigation improve receipt of recommended breast cancer care? Evidence from the National Patient Navigation Research Program

PURPOSE

Poor and underserved women face barriers in receiving timely and appropriate breast cancer care. Patient navigators help individuals overcome these barriers, but little is known about whether patient navigation improves quality of care. The purpose of this study is to examine whether navigated women with breast cancer are more likely to receive recommended standard breast cancer care.

PATIENTS AND METHODS

Women with breast cancer who participated in the national Patient Navigation Research Program were examined to determine whether the care they received included the following: initiation of antiestrogen therapy in patients with hormone receptor-positive breast cancer; initiation of postlumpectomy radiation therapy; and initiation of chemotherapy in women younger than age 70 years with triple-negative tumors more than 1 cm. This is a secondary analysis of a multicenter quasi-experimental study funded by the National Cancer Institute to evaluate patient navigation. Multiple logistic regression was performed to compare differences in receipt of care between navigated and non-navigated participants.

RESULTS

Among participants eligible for antiestrogen therapy, navigated participants (n = 380) had a statistically significant higher likelihood of receiving antiestrogen therapy compared with non-navigated controls (n = 381; odds ratio [OR], 1.73; P = .004) in a multivariable analysis. Among the participants eligible for radiation therapy after lumpectomy, navigated participants (n = 255) were no more likely to receive radiation (OR, 1.42; P = .22) than control participants (n = 297).

CONCLUSION

We demonstrate that navigated participants were more likely than non-navigated participants to receive antiestrogen therapy. Future studies are required to determine the full impact patient navigation may have on ensuring that vulnerable populations receive quality care.

A cost analysis of a community health worker program in rural Vermont

Studies have shown that community health workers (CHWs) can improve the effectiveness of health care systems; however, little has been reported about CHW program costs. We examined the costs of a program staffed by three CHWs associated with a small, rural hospital in Vermont. We used a standardized data collection tool to compile cost information from administrative data and personal interviews. We analyzed personnel and operational costs from October 2010 to September 2011. The estimated total program cost was $420,348, a figure comprised of $281,063 (67%) for personnel and $139,285 (33%) for operations. CHW salaries and office space were the major cost components. Our cost analysis approach may be adapted by others to conduct cost analyses of their CHW program. Our cost estimates can help inform future economic studies of CHW programs and resource allocation decisions.

Comparing the effect of a decision aid plus patient navigation with usual care on colorectal cancer screening completion in vulnerable populations: study protocol for a randomized controlled trial

BACKGROUND

Screening can reduce colorectal cancer (CRC) incidence and mortality. However, screening is underutilized in vulnerable patient populations, particularly among Latinos. Patient-directed decision aids can increase CRC screening knowledge, self-efficacy, and intent; however, their effect on actual screening test completion tends to be modest. This is probably because decision aids do not address some of the patient-specific barriers that prevent successful completion of CRC screening in these populations. These individual barriers might be addressed though patient navigation interventions. This study will test a combined decision aid and patient navigator intervention on screening completion in diverse populations of vulnerable primary care patients.

METHODS/DESIGN

We will conduct a multisite, randomized controlled trial with patient-level randomization. Planned enrollment is 300 patients aged 50 to 75 years at average CRC risk presenting for appointments at two primary clinics in North Carolina and New Mexico. Intervention participants will view a video decision aid immediately before the clinic visit. The 14 to 16 minute video presents information about fecal occult blood tests and colonoscopy and will be viewed on a portable computer tablet in English or Spanish. Clinic-based patient navigators are bilingual and bicultural and will provide both face-to-face and telephone-based navigation. Control participants will view an unrelated food safety video and receive usual care. The primary outcome is completion of a CRC screening test at six months. Planned subgroup analyses include examining intervention effectiveness in Latinos, who will be oversampled. Secondarily, the trial will evaluate the intervention effects on knowledge of CRC screening, self-efficacy, intent, and patient-provider communication. The study will also examine whether patient ethnicity, acculturation, language preference, or health insurance status moderate the intervention effect on CRC screening.

DISCUSSION

This pragmatic randomized controlled trial will test a combined decision aid and patient navigator intervention targeting CRC screening completion. Findings from this trial may inform future interventions and implementation policies designed to promote CRC screening in vulnerable patient populations and to reduce screening disparities.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov NCT02054598.

Survivorship care plans: a work in progress

BACKGROUND

Health agencies across the world have echoed the recommendation of the U.S. Institute of Medicine (iom) that survivorship care plans (scps) should be provided to patients upon completion of treatment. To date, reviews of scps have been limited to the United States. The present review offers an expanded scope and describes how scps are being designed, delivered, and evaluated in various countries.

METHODS

We collected scps from Canada, the United States, Europe, the United Kingdom, Australia, and New Zealand. We selected for analysis the scps for which we could obtain the actual scp, information about the delivery approach, and evaluation data. We conducted a content analysis and compared the scps with the iom guidelines.

RESULTS

Of 47 scps initially identified, 16 were analyzed. The scps incorporated several of the iom's guidelines, but many did not include psychosocial services, identification of a key point of contact, genetic testing, and financial concerns. The model of delivery instituted by the U.K. National Cancer Survivorship Initiative stands out because of its unique approach that initiates care planning at diagnosis and stratifies patients into a follow-up program based on self-management capacities.

SUMMARY

There is considerable variation in the approach to delivery and the extent to which scps follow the original recommendations from the iom. We discuss the implications of this review for future care-planning programs and prospective research. A holistic approach to care that goes beyond the iom recommendations and that incorporates care planning from the point of diagnosis to beyond completion of treatment might improve people's experience of cancer care.

Patient navigators' reflections on the navigator-patient relationship

Patient navigation emerged as a strategy to reduce cancer disparities among low-income and minority patients and has demonstrated efficacy in improving clinical outcomes. Observational studies have contributed valuable evaluations of navigation processes and tasks; however, few have offered in-depth reflections about the relationship between patient and navigator from the navigators' perspective. These approaches have addressed the emotional and relational components of patient navigation through the lens of process factors, relegating the navigator-patient relationship to a siloed, compartmentalized functionality. To expand upon existing task-oriented definitions of navigation, we conducted qualitative interviews among community-based patient navigators who coordinated care for uninsured, predominantly Hispanic, women receiving cancer screening and follow-up care in a county outside Chicago. Interviews were recorded, transcribed, and analyzed for themes within the navigator-patient relationship domain. The main themes that emerged centered on relational roles, relational boundaries, and ideal navigator relational qualities. While patient navigators described engaging with patients in a manner similar to a friend, they stressed the importance of maintaining professional boundaries. Navigators' support assisted patients in bridging their hospital and community lives, a result of navigators' investment in both hemispheres. We conclude that the navigator-patient relationship is not a self-contained utility, but rather the medium through which all other navigator functions are enabled. These insights further characterize the navigator-patient relationship, which will help shape the development of future navigation programs and support the need for further research on the impact of relationship factors on clinical and psychosocial outcome measures.

The association of self-leadership, health behaviors, and posttraumatic growth with health-related quality of life in patients with cancer

PURPOSE

We tried to evaluate the association of self-leadership, effective health behaviors, and posttraumatic growth with health-related quality of life (HRQOL).

METHODS

We recruited survivors of cancer from seven hospitals in Korea between 2011 and 2012. The patients completed the Seven Habits Profile (7HP) to evaluate leadership competency, the 10 rules for highly effective health behavior to evaluate health behavior, the Posttraumatic Growth Inventory (PTGI) to evaluate posttraumatic growth, the Short Form 36 (SF-36) to evaluate HRQOL, and the Hospital Anxiety and Depression Scale (HADS) to evaluate anxiety and depression. We performed multiple logistic regressions to identify significant associations.

RESULTS

A total of 668 patients with cancer participated in the study. Patients who scored high on the leadership subscales of Be Proactive, Begin with the End in Mind, Put First Things First, Think Win-Win, Synergize, and Sharpen the Saw in 7HP tried to practice and keep their health behaviors more. The Begin with the End in Mind, Put First Things First, Synergize, and Sharpen the Saw subscales of the 7HP were also significantly correlated with subscales on the PTGI. Patients who scored high on the leadership subscales of Life Balance, Be Proactive, Begin with the End in Mind, Think Win-Win, and Sharpen the Saw had higher physical and mental component scale scores on the SF-36 and lower anxiety and depression subscale scores on the HADS.

CONCLUSION

Self-leadership, health behaviors, and posttraumatic growth are associated with QOL in survivors of cancer.

Reducing barriers to breast cancer care through Avon patient navigation programs

CONTEXT

Avon Foundation for Women grantees provide breast cancer services through patient navigation (PN) in an effort to alleviate barriers to care among underserved women.

OBJECTIVE

To gain a better understanding of how PN programs function, this study explores variations in the use of navigators, types of services offered, description of clients they serve, tracking of treatment completion, and evaluation mechanisms.

PARTICIPANTS

Fifty-six Avon PN programs funded since 2008 throughout the United States were contacted.

DESIGN

An online survey was distributed to the grantees of which 44 (81%) complete responses were collected and analyzed.

RESULTS

Clients were racially and ethnically diverse, mostly in the 40- to 64-year old age range (64%) and 91.6% with an average income of less than $30 000. Women were either uninsured (50.7%) or receiving Medicaid (32.4%). PN programs were both community and hospital-based (22.5%); many hospitals (35.2%) were described as safety nets (eg, provide a significant level of care to low-income, uninsured, vulnerable populations). On-site services included breast screening (eg, mammography and breast ultrasound) and treatment (eg, breast surgery and radiation therapy). Some barriers to care identified by the programs included transportation, access to appointments, language, and financial issues (eg, cost of screening and treatment specifically for those uninsured). More than 39% of programs provided care across the cancer continuum.

CONCLUSIONS

Many Avon PN programs incorporated navigation services that span the cancer care continuum. They addressed disparities by offering navigation and on-site medical services to reduce multiple systems barriers and social issues related to breast care.

Patient perceptions of a comprehensive cancer navigation service

OBJECTIVE

Our aim was to determine the extent to which comprehensive navigation augments the provincial health system for meeting the needs of newly-diagnosed cancer patients (clients). We also assessed reactions of attending physicians to comprehensive navigation.

METHODS

Clients who completed navigation as an employee benefit or through membership in an insurance organization were polled to determine whether they needed help beyond that provided by the provincial health system and the extent to which that help was provided by navigation. Exit interviews were analyzed for perceptions of the clients about reactions by their attending physicians to navigation.

RESULTS

Of eligible clients, 72% responded. They reported needing help beyond that which the provincial system could provide in 64%-98% of specified areas. Navigation provided help in more than 90% of those cases. Almost all respondents (98%) appreciated having a designated oncology nurse navigator. Family doctors were perceived to be positive or neutral about navigation in 100% of exit interviews. Oncologists were positive or neutral in 92% (p < 0.001 for difference from family doctors).

CONCLUSIONS

In many areas, cancer patients need additional help beyond that which the provincial health system can provide. Comprehensive cancer navigation provides that help to a considerable extent. Clients perceived the reactions of attending physicians to comprehensive navigation to be generally supportive or neutral.

Psychosocial barriers to follow-up adherence after an abnormal cervical cytology test result among low-income, inner-city women

OBJECTIVES

Low-income, inner-city women bear a disproportionate burden of cervical cancer in both incidence and mortality rates in the United States, largely because of low adherence to follow-up recommendations after an abnormal cervical cytology result in the primary care setting. The goals of the present study were to delineate the theory-based psychosocial barriers underlying these persistent low follow-up rates and their sociodemographic correlates.

METHODS

Guided by a well-validated psychosocial theory of health behaviors, this cross-sectional, correlational study assessed the barriers to follow-up adherence among underserved women (N = 210) who received an abnormal cervical cytology result. Participants were recruited through an inner-city hospital colposcopy clinic, and were assessed by telephone prior to the colposcopy appointment.

RESULTS

Participants were largely of African American race (82.2%), lower than high school completion education (58.7%), single, never married (67.3%), and without full-time employment (64.1%). Knowledge barriers were most often endorsed (68%, M = 3.22), followed by distress barriers (64%, M = 3.09), and coping barriers (36%, M = 2.36). Forty-six percent reported more than one barrier category. Less education and being unemployed were correlated with higher knowledge barriers (P < .0001 and P < .01, respectively) and more coping barriers (P < .05 and P < .05, respectively). Women who were younger than 30 years displayed greater distress barriers (P < .05).

CONCLUSION

In the primary care setting, assessing and addressing knowledge and distress barriers after feedback of an abnormal cervical cytology result may improve adherence to follow-up recommendations. The use of structured counseling protocols and referral to navigational and other resources may facilitate this process and thereby reduce disparities in cervical cancer.

Time and Motion Study of a Community Patient Navigator

Research on patient navigation has focused on validating the utility of navigators by defining their roles and analyzing their effects on patient outcomes, patient satisfaction, and cost effectiveness. Patient navigators are increasingly used outside the research context, and their roles without research responsibilities may look very different. This pilot study captured the activities of a community patient navigator for uninsured women with a positive screening test for breast cancer, using a time and motion approach over a period of three days. We followed the actions of this navigator minute by minute to assess the relative ratios of actions performed and to identify areas for time efficiency improvement to increase direct time with patients. This novel approach depicts the duties of a community patient navigator no longer fettered by navigation logs, research team meetings, surveys, and the consent process. We found that the community patient navigator was able to spend more time with patients in the clinical context relative to performing paperwork or logging communication with patients as a result of her lack of research responsibilities. By illuminating how community patient navigation functions as separate from the research setting, our results will inform future hiring and training of community patient navigators, system design and operations for improving the efficiency and efficacy of navigators, and our understanding of what community patient navigators do in the absence of research responsibilities.

State-of-the-science of patient navigation as a strategy for enhancing minority clinical trial accrual

BACKGROUND

Patient navigation programs are emerging that aim to address disparities in clinical trial participation among medically underserved populations, including racial/ethnic minorities. However, there is a lack of consensus on the role of patient navigators within the clinical trial process as well as outcome measures to evaluate program effectiveness.

METHODS

A review of the literature was conducted of PubMed, Medline, CINHAL, and other sources to identify qualitative and quantitative studies on patient navigation in clinical trials. The search yielded 212 studies, of which only 12 were eligible for this review.

RESULTS

The eligible studies reported on the development of programs for patient navigation in cancer clinical trials, including training and implementation among African Americans, American Indians, and Native Hawaiians. A low rate of clinical trial refusal (range, 4%-6%) was reported among patients enrolled in patient navigation programs. However, few studies reported on the efficacy of patient navigation in increasing clinical treatment trial enrollment.

CONCLUSIONS

Outcome measures are proposed to assist in developing and evaluating the efficacy and/or effectiveness of patient navigation programs that aim to increase participation in cancer clinical trials. Future research is needed to evaluate the efficacy of patient navigators in addressing barriers to clinical trial participation and increasing enrollment among medically underserved cancer patients.

Reducing time-to-treatment in underserved Latinas with breast cancer: the Six Cities Study

BACKGROUND

The interaction of clinical and patient-level challenges following a breast cancer diagnosis can be a significant source of health care disparities. Failure to address specific cultural features that create or exacerbate barriers can lead to less-than optimal navigation results, specifically in Hispanic/Latino women.

METHODS

To address these disparities, the study leaders in San Antonio, Texas, and 5 other regional partners of the federally-funded Redes En Acción: The National Latino Cancer Research Network developed a culturally-tailored patient navigation intervention model for Latinas with breast cancer.

RESULTS

Compared with control patients, a higher percentage of navigated subjects initiated treatment within 30 days (69.0% versus 46.3%, P = .029) and 60 days (97.6% versus 73.1%, P = .001) following their cancer diagnosis. Time from cancer diagnosis to first treatment was lower in the navigated group (mean, 22.22 days; median, 23.00 days) than controls (mean, 48.30 days; median, 33.00 days). These results were independent of cancer stage at diagnosis and numerous characteristics of cancer clinics and individual participants.

CONCLUSIONS

Successful application of patient navigation increased the percentage of Latinas initiating breast cancer treatment within 30 and 60 days of diagnosis. This was achieved through navigator provision of services such as accompaniment to appointments, transportation arrangements, patient telephone support, patient-family telephone support, Spanish-English language translation, and assistance with insurance paperwork.

Reducing time-to-treatment in underserved Latinas with breast cancer: the Six Cities Study

BACKGROUND

The interaction of clinical and patient-level challenges following a breast cancer diagnosis can be a significant source of health care disparities. Failure to address specific cultural features that create or exacerbate barriers can lead to less-than optimal navigation results, specifically in Hispanic/Latino women.

METHODS

To address these disparities, the study leaders in San Antonio, Texas, and 5 other regional partners of the federally-funded Redes En Acción: The National Latino Cancer Research Network developed a culturally-tailored patient navigation intervention model for Latinas with breast cancer.

RESULTS

Compared with control patients, a higher percentage of navigated subjects initiated treatment within 30 days (69.0% versus 46.3%, P = .029) and 60 days (97.6% versus 73.1%, P = .001) following their cancer diagnosis. Time from cancer diagnosis to first treatment was lower in the navigated group (mean, 22.22 days; median, 23.00 days) than controls (mean, 48.30 days; median, 33.00 days). These results were independent of cancer stage at diagnosis and numerous characteristics of cancer clinics and individual participants.

CONCLUSIONS

Successful application of patient navigation increased the percentage of Latinas initiating breast cancer treatment within 30 and 60 days of diagnosis. This was achieved through navigator provision of services such as accompaniment to appointments, transportation arrangements, patient telephone support, patient-family telephone support, Spanish-English language translation, and assistance with insurance paperwork.

Creating a patient navigation model to address cervical cancer disparities in a rural Hispanic farmworker community

This report describes the implementation of a pilot patient navigation (PN) program created to address cervical cancer disparities in a predominantly Hispanic agricultural community. Since November 2009, a patient navigator has provided services to patients of Catholic Mobile Medical Services (CMMS). The PN program has resulted in the need for additional clinic sessions to accommodate the demand for preventive care at CMMS.

Acceptance of a community-based navigator program for cancer control among urban African Americans

Patient navigation is now a standard component of cancer care in many oncology facilities, but a fundamental question for navigator programs, especially in medically underserved populations, is whether or not individuals will use this service. In this study, we evaluated acceptance of a community-based navigator program for cancer control and identified factors having significant independent associations with navigation acceptance in an urban sample of African Americans. Participants were African American men and women ages 50-75 who were residents in an urban metropolitan city who were referred for navigation. Of 240 participants, 76% completed navigation. Age and perceived risk of developing cancer had a significant independent association with navigation acceptance. Participants who believed that they were at high risk for developing cancer had a lower likelihood of completing navigation compared with those who believed that they had a low risk for developing this disease. The likelihood of completing navigation increased with increases in age. None of the socioeconomic factors or health care variables had a significant association with navigation acceptance. There are few barriers to using community-based navigation for cancer control among urban African Americans. Continued efforts are needed to develop and implement community-based programs for cancer control that are easy to use and address the needs of medically underserved populations.

Health literacy and cancer screening: a systematic review

OBJECTIVE

To evaluate published evidence about health literacy and cancer screening.

METHODS

Seven databases were searched for English language articles measuring health literacy and cancer screening published in 1990-2011. Articles meeting inclusion criteria were independently reviewed by two investigators using a standardized data abstraction form. Abstracts (n=932) were reviewed and full text retrieved for 83 articles. Ten articles with 14 comparisons of health literacy and cancer screening according to recommended medical guidelines were included in the analysis.

RESULTS

Most articles measured health literacy using the S-TOFHLA instrument and documented cancer screening by self-report. There is a trend for an association of inadequate health literacy and lower cancer screening rates, however, the evidence is mixed and limited by study design and measurement issues.

CONCLUSION

A patient's health literacy may be a contributing factor to being within recommended cancer screening guidelines.

PRACTICE IMPLICATIONS

Future research should: be conducted using validated health literacy instruments; describe the population included in the study; document cancer screening test completion according to recommended guidelines; verify the completion of cancer screening tests by medical record review; adjust for confounding factors; and report effect size of the association of health literacy and cancer screening.

Enhancing the care navigation model: potential roles for health sciences librarians

This study analyzed the overlap between roles and activities that health care navigators perform and competencies identified by the Medical Library Association’s (MLA’s) educational policy statement.Roles and activities that health care navigators perform were gleaned from published literature. Once common roles and activities that health care navigators perform were identified, MLA competencies were mapped against those roles and activities to identify areas of overlap. The greatest extent of correspondence occurred in patient empowerment and support. Further research is warranted to determine the extent to which health sciences librarians might assume responsibility for roles and activities that health care navigators perform

Community cancer center administration and support for navigation services

OBJECTIVES

To address the value of patient navigation (PN) to a community cancer center and suggest ways to measure PN outcomes to justify it as a critical component of cancer care.

DATA SOURCES

Literature review and unpublished data from the DC Citywide Patient Navigation Network.

CONCLUSION

Economic challenges in health care necessitate justification and appropriate utilization of all specialties and roles in cancer care. Demonstrating the value of PN programs is critical for sustaining these programs in community cancer centers. Having a clear business plan helps to define appropriate return-on-investment measures and an evaluation plan is important to assess program impact.

IMPLICATIONS FOR NURSING PRACTICE

Nurses play a key role in working with administrators to define value metrics, track these measures, and report the results. Nurses should also seek out training and resources to enhance knowledge and skills for navigating patients.

An mHealth model to increase clinic attendance for breast symptoms in rural Bangladesh: can bridging the digital divide help close the cancer divide?

OBJECTIVE

To demonstrate proof of concept for a smart phone-empowered community health worker (CHW) model of care for breast health promotion, clinical breast examination (CBE), and patient navigation in rural Bangladesh.

METHODS

This study was a randomized controlled trial; July 1 to October 31, 2012, 30 CHWs conducted door-to-door interviews of women aged 25 and older in Khulna Division. Only women who disclosed a breast symptom were offered CBE. Arm A: smart phone with applications to guide interview, report data, show motivational video, and offer appointment for women with an abnormal CBE. Arm B: smart phone/applications identical to Arm A plus CHW had training in "patient navigation" to address potential barriers to seeking care. Arm C: control arm (no smart phone; same interview recorded on paper). Outcomes are presented as the "adherence" (to advice regarding a clinic appointment) for women with an abnormal CBE. This study was approved by Women's College Hospital Research Ethics Board (Toronto, Ontario, Canada) and district government officials (Khulna, Bangladesh). Funded by Grand Challenges Canada.

RESULTS

In 4 months, 22,337 women were interviewed; <1% declined participation, and 556 women had an abnormal CBE. Control group CHWs completed fewer interviews, had inferior data quality, and identified significantly fewer women with abnormal breast exams compared with CHWs in arms A and B. Arm B had the highest adherence.

CONCLUSION

CHWs guided by our smart phone applications were more efficient and effective in breast health promotion compared with the control group. CHW "navigators" were most effective in encouraging women with an abnormal breast examination to adhere to advice regarding clinic attendance.

Nurse navigators in early cancer care: a randomized, controlled trial

PURPOSE

To determine whether a nurse navigator intervention improves quality of life and patient experience with care for people recently given a diagnosis of breast, colorectal, or lung cancer.

PATIENTS AND METHODS

Adults with recently diagnosed primary breast, colorectal, or lung cancer (n = 251) received either enhanced usual care (n = 118) or nurse navigator support for 4 months (n = 133) in a two-group cluster randomized, controlled trial with primary care physicians as the units of randomization. Patient-reported measures included the Functional Assessment of Cancer Therapy-General (FACT-G) Quality of Life scale, three subscales of the Patient Assessment of Chronic Illness Care (PACIC), and selected subscales from a cancer adaptation of the Picker Institute's patient experience survey. Self-report measures were collected at baseline, 4 months, and 12 months. Automated administrative data were used to assess time to treatment and total health care costs.

RESULTS

There were no significant differences between groups in FACT-G scores. Nurse navigator patients reported significantly higher scores on the PACIC and reported significantly fewer problems with care, especially psychosocial care, care coordination, and information, as measured by the Picker instrument. Cumulative costs after diagnosis did not differ significantly between groups, but lung cancer costs were $6,852 less among nurse navigator patients.

CONCLUSION

Compared with enhanced usual care, nurse navigator support for patients with cancer early in their course improves patient experience and reduces problems in care, but did not differentially affect quality of life.

Barriers reported among patients with breast and cervical abnormalities in the patient navigation research program: impact on timely care

BACKGROUND

Patient navigation (PN) is a system-level strategy to decrease cancer mortality rates by reducing barriers to cancer care. Barriers to resolution among participants in the PN intervention arm with a breast or cervical abnormality in the Patient Navigation Research Program and navigators' actions to address those barriers were examined.

METHODS

Data from seven institutions (2005-2010) included 1,995 breast and 1,194 cervical patients. A stratified Cox proportional hazards regression model was used to examine the effects of barriers on time to resolution of an abnormal screening test or clinical finding.

FINDINGS

The range of unique barriers was 0 to 12 and 0 to 7 among participants with breast and cervical abnormalities, respectively. About two thirds of breast and one half of cervical participants had at least one barrier resulting in longer time to diagnostic resolution among breast (adjusted hazard ratio [HR], 0.744; p < .001) and cervical (adjusted HR, 0.792; p < .001) participants. Patient- and system-level barriers were most common. Frequent navigator actions were making arrangements, scheduling appointments, referrals, and education.

CONCLUSIONS

Having a barrier resulted in a delay in diagnostic resolution of an abnormal screening test or clinical finding. Health care systems can use these findings to improve existing PN programs or when developing new programs.

Evaluating a De-Centralized Regional Delivery System for Breast Cancer Screening and Patient Navigation for the Rural Underserved

Providing breast cancer screening services in rural areas is challenging due to the fractured nature of healthcare delivery systems and complex reimbursement mechanisms that create barriers to access for the under- and uninsured. Interventions that reduce structural barriers to mammography, like patient navigation programs, are effective and recommended, especially for minority and underserved women. Although the literature on rural healthcare is significant, the field lacks studies of adaptive service delivery models and rigorous evaluation of evidence-based programs that facilitate routine screening and appropriate follow-up across large geographic areas.

OBJECTIVES

To better understand how to implement a decentralized regional delivery "hub & spoke" model for rural breast cancer screening and patient navigation, we have designed a rigorous, structured, multi-level and mixed-methods evaluation based on Glasgow's RE-AIM model (Reach, Effectiveness, Adoption, Implementation, and Maintenance).

METHODS AND DESIGN

The program is comprised of three core components: 1) Outreach to underserved women by partnering with county organizations; 2) Navigation to guide patients through screening and appropriate follow-up; and 3) Centralized Reimbursement to coordinate funding for screening services through a central contract with Medicaid Breast and Cervical Cancer Services (BCCS). Using Glasgow's RE-AIM model, we will: 1) assess which counties have the resources and capacity to implement outreach and/or navigation components, 2) train partners in each county on how to implement components, and 3) monitor process and outcome measures in each county at regular intervals, providing booster training when needed.

DISCUSSION

This evaluation strategy will elucidate how the heterogeneity of rural county infrastructure impacts decentralized service delivery as a navigation program expands. In addition to increasing breast cancer screening access, our model improves and maintains time to diagnostic resolution and facilitates timely referral to local cancer treatment services. We offer this evaluation approach as an exemplar for scientific methods to evaluate the translation of evidence-based federal policy into sustainable health services delivery in a rural setting.