Cost analysis of a patient navigation system to increase screening colonoscopy adherence among urban minorities

Extending analytic methods for economic evaluation in implementation science

Background

Economic evaluations of the implementation of health-related evidence-based interventions (EBIs) are conducted infrequently and, when performed, often use a limited set of quantitative methods to estimate the cost and effectiveness of EBIs. These studies often underestimate the resources required to implement and sustain EBIs in diverse populations and settings, in part due to inadequate scoping of EBI boundaries and underutilization of methods designed to understand the local context. We call for increased use of diverse methods, especially the integration of quantitative and qualitative approaches, for conducting and better using economic evaluations and related insights across all phases of implementation.

Main body

We describe methodological opportunities by implementation phase to develop more comprehensive and context-specific estimates of implementation costs and downstream impacts of EBI implementation, using the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. We focus specifically on the implementation of complex interventions, which are often multi-level, resource-intensive, multicomponent, heterogeneous across sites and populations, involve many stakeholders and implementation agents, and change over time with respect to costs and outcomes. Using colorectal cancer (CRC) screening EBIs as examples, we outline several approaches to specifying the “boundaries” of EBI implementation and analyzing implementation costs by phase of implementation. We describe how systems mapping and stakeholder engagement methods can be used to clarify EBI implementation costs and guide data collection—particularly important when EBIs are complex. In addition, we discuss the use of simulation modeling with sensitivity/uncertainty analyses within implementation studies for projecting the health and economic impacts of investment in EBIs. Finally, we describe how these results, enhanced by careful data visualization, can inform selection, adoption, adaptation, and sustainment of EBIs.

Conclusion

Health economists and implementation scientists alike should draw from a larger menu of methods for estimating the costs and outcomes associated with complex EBI implementation and employ these methods across the EPIS phases. Our prior experiences using qualitative and systems approaches in addition to traditional quantitative methods provided rich data for informing decision-making about the value of investing in CRC screening EBIs and long-term planning for these health programs. Future work should consider additional opportunities for mixed-method approaches to economic evaluations.

Engaging Community Health Workers to Increase Cancer Screening: A Community Guide Systematic Economic Review

CONTEXT

The Community Preventive Services Task Force recommends engaging community health workers to increase breast, cervical, and colorectal cancer screenings on the basis of strong evidence of effectiveness. This systematic review examines the economic evidence of these interventions.

EVIDENCE ACQUISITION

A systematic literature search was performed with a search period through April 2019 to identify relevant economic evaluation studies. All monetary values were adjusted to 2018 U.S. dollars, and the analysis was completed in 2019.

EVIDENCE SYNTHESIS

A total of 19 studies were included in the final analysis with 3 on breast cancer, 5 on cervical cancer, 9 on colorectal cancer, and 2 that combined costs for breast and cervical cancers and for breast, cervical, and colorectal cancers. For cervical cancer screening, 2 U.S. studies reported incremental cost per quality-adjusted life year saved of $762 and $34,405. For colorectal cancer screening, 2 U.S. studies reported both a negative incremental cost and an increase in quality-adjusted life years saved with colonoscopy screening.

CONCLUSIONS

Engaging community health workers to increase cervical and colorectal cancer screenings is cost effective on the basis of estimated incremental cost-effectiveness ratios that were less than the conservative $50,000 per quality-adjusted life year threshold. In addition, quality-adjusted life years saved from colorectal screening with colonoscopy were associated with net healthcare cost savings.

Effectiveness and Cost of Organized Outreach for Colorectal Cancer Screening: A Randomized, Controlled Trial

BACKGROUND

Colorectal cancer (CRC) screening remains underused, especially in safety-net systems. The objective of this study was to determine the effectiveness, costs, and cost-effectiveness of organized outreach using fecal immunochemical tests (FITs) compared with usual care.

METHODS

Patients age 50-75 years eligible for CRC screening from eight participating primary care safety-net clinics were randomly assigned to outreach intervention with usual care vs usual care alone. The intervention included a mailed postcard and call, followed by a mailed FIT kit, and a reminder phone call if the FIT kit was not returned. The primary outcome was screening participation at 1 year and a microcosting analysis of the outreach activities with embedded long-term cost-effectiveness of outreach. All statistical tests were two-sided.

RESULTS

A total of 5386 patients were randomly assigned to the intervention group and 5434 to usual care. FIT screening was statistically significantly higher in the intervention group than in the control group (57.9% vs 37.4%, P < .001; difference = 20.5%, 95% confidence interval = 18.6% to 22.4%). In the intervention group, FIT completion rate was higher in patients who had previously completed a FIT vs those who had not (71.9% vs 35.7%, P < .001). There was evidence of effect modification of the intervention by language, and clinic. Outreach cost approximately $23 per patient and $112 per additional patient screened. Projecting long-term outcomes, outreach was estimated to cost $9200 per quality-adjusted life-year gained vs usual care.

CONCLUSION

Population-based management with organized FIT outreach statistically significantly increased CRC screening and was cost-effective in a safety-net system. The sustainability of the program and any impact of economies of scale remain to be determined.

Feasibility of Patient Navigation and Impact on Adherence to Screening Colonoscopy in a Large Diverse Urban Population

INTRODUCTION

Disparities observed in colorectal cancer (CRC) incidence and mortality among blacks and Hispanics compared with whites may be in part due to lower screening rates. The New York City (NYC) Department of Health and Mental Hygiene (DOHMH) has implemented a patient navigator (PN) program at NYC hospitals serving lower-income patients to promote high adherence by patients referred for screening colonoscopy. A prior study showed this PN program increased adherence at 3 public hospitals. The aim of this study was to determine the feasibility of expanding the PN program to 10 hospital sites by assessing the impact of the PN program on adherence to screening colonoscopy in a large, urban, lower-income population.

METHODS

Data were collected from 2007 through the first quarter of 2012 from PN sites. One site also contributed data from the pilot phase of the project, from 2005 to 2006. Adherence to scheduled screening colonoscopy among those ≥ 50 years was assessed among 10 hospital sites in NYC participating in the colonoscopy PN program.

RESULTS

Among the 37,077 asymptomatic adults ≥ 50 years who were scheduled for a screening colonoscopy from 2005 to the first quarter of 2012, 84.2% (83.2% of black, 84.9% of Hispanic, and 87.5% of white adults) were adherent to scheduled colonoscopy.

CONCLUSIONS

Expansion of PN programs to navigate all patients referred for a colonoscopy was feasible in a large, urban setting. This can be implemented resulting in high overall adherence rates to screening colonoscopies. The program likely did not result in large ethnic disparities.

Cost-Effectiveness of Current Colorectal Cancer Screening Tests

Cost-effectiveness analysis compares benefits and costs of different interventions to inform decision makers. Alternatives are compared based on an incremental cost-effectiveness ratio reported in terms of cost per quality-adjusted life-year gained. Multiple cost-effectiveness analyses of colorectal cancer (CRC) screening have been performed. Although regional epidemiology of CRC, relevant screening strategies, regional health system, and applicable medical costs in local currencies differ by country and region, several overarching points emerge from literature on cost-effectiveness of CRC screening. Cost-effectiveness analysis informs decisions in ongoing debates, including preferred age to begin average-risk CRC screening, and implementation of CRC screening tailored to predicted CRC risk.

A survey on colonoscopy shows poor understanding of its protective value and widespread misconceptions across Europe

Background

Colonoscopy is a valuable screening tool for colorectal cancer. However, patients experience anxiety when faced with attending a first colonoscopy, and negative attitudes may contribute to non-attendance. Few studies in Europe have explored these attitudes, despite increasing colorectal cancer incidence.

Study aim

We conducted an online survey of the public in five European Union countries (France, Germany, Italy, Spain, and the UK), with the aim of understanding public knowledge of, perceptions of, and attitudes towards, colonoscopy and bowel preparation, amongst colonoscopy-naïve respondents. Attitudes towards colonoscopy were also gathered from colonoscopy-experienced patients.

Methods

Survey answers were gathered from 2,500 colonoscopy-naïve respondents and 500 colonoscopy-experienced patients, divided equally between countries.

Results

Across Europe, 72% of colonoscopy-naïve respondents showed receptiveness to colonoscopy if advised by their doctor to receive one, but only 45% understood its use to prevent colorectal cancer. Forty-three percent of colonoscopy-experienced respondents would still be embarrassed about having another colonoscopy, although 59% said that the experience had been better than expected. Colonoscopy-experienced respondents had greater aversion to bowel preparation than colonoscopy-naïve respondents (47% vs 26%), and 67% of colonoscopy-naïve respondents thought that only 1 litre of bowel preparation or less is required. Italians and the Spanish wanted more information than on average in Europe, while Germans had more realistic expectations of bowel preparation.

Discussion

There are perceptual gaps amongst the public around the purpose of colonoscopies, the subjective experience of the colonoscopy procedure, and the quantity of bowel preparation needed. These concerns could be mitigated by better education and using lower-volume bowel preparation techniques.

Conclusion

Europeans would have a colonoscopy, but its preventive medical purpose is poorly understood and there are misconceptions around the process. Further education about the procedure, its benefits and bowel preparation is vital to improve understanding and compliance.

Evolution of a longitudinal, multidisciplinary, and scalable patient navigation matrix model

This Longitudinal patient navigation Matrix Model was developed to overcome barriers across the cancer care continuum by offering prepatients, patients, and their families with support services. The extraordinary heterogeneity of patient needs during cancer screening, risk assessment, treatment, and survivorship as well as the vast heterogeneity of oncology care settings make it nearly impossible to follow a static navigation model. Our model of patient cancer navigation is unique as it enhances the traditional model by being highly adaptable based on both patient and family needs and scalable based on institutional needs and resources (eg, clinical volumes, financial resources, and community‐based resources). This relatively new operational model for system‐wide and systematic navigation incorporates a carefully cultivated supportive care program that evolved over the last decade from a bottom up approach that identified patient and family needs and developed appropriate resources. A core component of this model includes shifting away from department‐centric operations. This model does not require a patient to opt in or independently be able to report their needs or ask for services—it is an opt out model. The multidisciplinary “cross‐training” model can also facilitate reimbursement and sustainability by clarifying the differentiating actions that define navigation services: identification of barriers to quality care and specific actions taken to overcome those barriers, across the full continue of cancer care from community engagement to survivorship or end‐of‐life care.

The case for philanthropic investment to increase colorectal cancer screening rates: A novel paradigm to address a public health challenge

Background

Colorectal cancer (CRC) remains a leading cause of cancer‐related death despite being highly preventable. Efforts to increase participation in CRC screening have not met national goals. We developed a novel approach: building a business case for philanthropic investment in CRC screening.

Methods

A taskforce representing the public health community, professional societies, charitable foundations, academia, and industry was assembled to: (a) quantify the impact of improving CRC screening rates; (b) identify barriers to screening; (c) estimate the “activation cost” to overcome barriers and screen one additional person; (d) develop a holistic business case that is attractive to philanthropists; and (e) launch a demonstration project.

Results

We estimated that of 50 600 CRC deaths annually in the US, 55% occur in 50‐ to 85‐year‐olds and are potentially addressable by improvements in CRC screening. Barriers to screening were identified in all patient journey phases, including lack of awareness or insurance and logistical challenges in the pre‐physician phase. The cost to activate one person to undergo screening was $25‐175. This translated into a cost of $6000‐36 000 per CRC death averted by philanthropic investment. Based on this work, the Colorectal Cancer Alliance launched the effort “March Forth” to prevent 100 000 CRC deaths in the US over 10 years, with the first pilot in Philadelphia.

Conclusions

A holistic business plan can attract philanthropy to promote CRC screening. A simple message of “You can save a life from CRC with a $25 000 donation” can motivate demonstration projects in regions with high CRC rates and low screening participation.

Economics of Multicomponent Interventions to Increase Breast, Cervical, and Colorectal Cancer Screening: A Community Guide Systematic Review

CONTEXT

The Community Preventive Services Task Force recently recommended multicomponent interventions to increase breast, cervical, and colorectal cancer screening based on strong evidence of effectiveness. This systematic review examines the economic evidence to guide decisions on the implementation of these interventions.

EVIDENCE ACQUISITION

A systematic literature search for economic evidence was performed from January 2004 to January 2018. All monetary values were reported in 2016 US dollars, and the analysis was completed in 2018.

EVIDENCE SYNTHESIS

Fifty-three studies were included in the body of evidence from a literature search yield of 8,568 total articles. For multicomponent interventions to increase breast cancer screening, the median intervention cost per participant was $26.69 (interquartile interval [IQI]=$3.25, $113.72), and the median incremental cost per additional woman screened was $147.64 (IQI=$32.92, $924.98). For cervical cancer screening, the median costs per participant and per additional woman screened were $159.80 (IQI=$117.62, $214.73) and $159.49 (IQI=$64.74, $331.46), respectively. Two studies reported incremental cost per quality-adjusted life year gained of $748 and $33,433. For colorectal cancer screening, the median costs per participant and per additional person screened were $36.63 (IQI=$7.70, $139.23) and $582.44 (IQI=$91.10, $1,452.12), respectively. Two studies indicated a decline in incremental cost per quality-adjusted life year gained of $1,651 and $3,817.

CONCLUSIONS

Multicomponent interventions to increase cervical and colorectal cancer screening were cost effective based on a very conservative threshold. Additionally, multicomponent interventions for colorectal cancer screening demonstrated net cost savings. Cost effectiveness for multicomponent interventions to increase breast cancer screening could not be determined owing to the lack of studies reporting incremental cost per quality-adjusted life year gained. Future studies estimating this outcome could assist implementers with decision making.

Electronic health record year and country of birth testing and patient navigation to increase diagnosis of chronic viral hepatitis

The United States Preventive Services Task Force recommends hepatitis C testing people born from 1945 to 1965, "birth cohort" as well as hepatitis C and hepatitis B testing people from countries of birth with endemic infection risk. We automated the hospital electronic health record system to test birth cohort and those born in countries with endemic infection risk. A script is launched searching the laboratory database upon registration for any hepatitis C antibody, hepatitis C RNA and/or hepatitis B surface antigen result. If no positive result was found, a hepatitis C antibody/reflex RNA and/or hepatitis B surface antigen were ordered. A patient navigator received weekly results and assisted patients with positive serology to schedule an appointment with their primary care provider or treatment specialist. A total of 10 726 participants were hepatitis C antibody tested, with 6.9% antibody positive. Monthly hepatitis C testing from January to July 2016 compared to August 2016-August 2017 increased 342% as a result of "birth cohort" testing. Following country of birth testing, monthly hepatitis B and hepatitis C testing increased 91%, and 44%, respectively, during June-August 2017 compared to September 2017-March 2018. 67% of hepatitis C-positive patients were linked to care. If the navigator contacted the patient, 92% were linked to care, and 32% were treated. Of hepatitis B surface antigen-positive patients, 43% were linked to care, 5% were on treatment, and 15% started treatment. Automated electronic health record ordering of hepatitis C and/or hepatitis B testing is feasible and increases testing. In the population tested, much improvement is needed with linkage to care and treatment.

Benefits, Cost, and Activities of Patient Navigation (PN) Program for Colorectal Cancer Screening at the Charles B. Wang Community Health Center (CBWCHC)

To evaluate the benefits of a PN program for colorectal cancer (CRC) screening at Charles B. Wang Community Health Center (CBWCHC) in New York City from June 2012 to May 2015, estimate the cost of implementation, and describe time allocation patterns of PN activities. Semi-structured interviews were conducted with key informants of the CBWCHC in 2015. The electronic PN database was used to evaluate the program's effectiveness. New York State Department of Health budgeting and cost data were used to estimate the implementation cost. Self-reported activities of PNs were used to analyze time allocation patterns. A total of 3723 screen-eligible patients were contacted by PNs and 2552 (68.5%) completed at least one CRC screening test. Of these, 266 (10.4%) patients were diagnosed with precancerous polyps and two patients were diagnosed with CRC. The CRC screening rate at CBWCHC increased from 56% to 60% during the program period. The total cost was estimated to be $295,296.51 (in 2014 dollar terms). Overall, this relatively inexpensive CRC screening PN program was effective in increasing CRC screening in a low-income Asian-American community.

The efficacy and cost-effectiveness of patient navigation programs across the cancer continuum: A systematic review

Published studies regarding patient navigation (PN) and cancer were reviewed to assess quality, determine gaps, and identify avenues for future research. The PubMed and EMBASE databases were searched for studies investigating the efficacy and cost-effectiveness of PN across the cancer continuum. Each included article was scored independently by 2 separate reviewers with the Quality Assessment Tool for Quantitative Studies. The current review identified 113 published articles that assessed PN and cancer care, between August 1, 2010, and February 1, 2018, 14 of which reported on the cost-effectiveness of PN programs. Most publications focused on the effectiveness of PN in screening (50%) and diagnosis (27%) along the continuum of cancer care. Many described the effectiveness of PN for breast cancer (52%) or colorectal cancer outcomes (51%). Most studies reported favorable outcomes for PN programs, including increased uptake of and adherence to cancer screenings, timely diagnostic resolution and follow-up, higher completion rates for cancer therapy, and higher rates of attending medical appointments. Cost-effectiveness studies showed that PN programs yielded financial benefits. Quality assessment showed that 75 of the 113 included articles (65%) had 2 or more weak components. In conclusion, this review indicates numerous gaps within the PN and cancer literature where improvement is needed. For example, more research is needed at other points along the continuum of cancer care outside of screening and diagnosis. In addition, future research into the effectiveness of PN for understudied cancers outside of breast and colorectal cancer is necessary along with an assessment of cost-effectiveness and more rigorous reporting of study designs and results in published articles.

Cost-effectiveness of a patient navigation intervention to increase colonoscopy screening among low-income adults in New Hampshire

BACKGROUND

Colonoscopy is the most widely used colorectal cancer (CRC) screening test in the United States. Through the detection and removal of potentially precancerous polyps, it can prevent CRC. However, CRC screening remains low among adults who are recommended for screening. The New Hampshire Colorectal Cancer Screening Program implemented a patient navigation (PN) intervention to increase colonoscopy screening among low-income patients in health centers in New Hampshire. In the current study, the authors examined the cost-effectiveness of this intervention.

METHODS

A decision tree model was constructed using Markov state transitions to calculate the costs and effectiveness associated with PN. Costs were calculated for the implementation of PN in a statewide public health program and in endoscopy centers. The main study outcome was colonoscopy screening completion. The main decision variable was the incremental cost-effectiveness ratio associated with the PN intervention compared with usual care.

RESULTS

The average cost per screening with PN was $1089 (95% confidence interval, $1075-$1103) compared with $894 with usual care (95% confidence interval, $886-$908). Among patients who were navigated, approximately 96.2% completed colonoscopy screening compared with 69.3% of those receiving usual care (odds ratio, 11.2; P <. 001). The incremental cost-effectiveness ratio indicated that 1 additional screening completion cost approximately $725 in a public health program and $548 in an endoscopy center with PN compared with usual care, both of which are less than the average Medicare reimbursement of $737 for a colonoscopy procedure.

CONCLUSIONS

PN was found to be cost-effective in increasing colonoscopy screening among low-income adults in the New Hampshire Colorectal Cancer Screening Program, even at the threshold of current Medicare reimbursement rates for colonoscopy. The results of the current study support the implementation of PN in statewide public health programs and endoscopy centers.

Economic assessment of patient navigation to colonoscopy-based colorectal cancer screening in the real-world setting at the University of Chicago Medical Center

BACKGROUND

This report details the cost effectiveness of a non-nurse patient navigation (PN) program that was implemented at the University of Chicago Medical Center to increase colonoscopy-based colorectal cancer (CRC) screening.

METHODS

The authors investigated the impact of the PN intervention by collecting process measures. Individuals who received navigation were compared with a historic cohort of non-navigated patients. In addition, a previously validated data-collection instrument was tailored and used to collect all costs related to developing, implementing, and administering the program; and the incremental cost per patient successfully navigated (the cost of the intervention divided by the change in the number who complete screening) was calculated.

RESULTS

The screening colonoscopy completion rate was 85.1% among those who were selected to receive PN compared with 74.3% when no navigation was implemented. With navigation, the proportion of no-shows was 8.2% compared with 15.4% of a historic cohort of non-navigated patients. Because the perceived risk of noncompletion was greater among those who received PN (previous no-show or cancellation, poor bowel preparation) than that in the historic cohort, a scenario analysis was performed. Assuming no-show rates between 0% and 50% and using a navigated rate of 85%, the total incremental program cost per patient successfully navigated ranged from $148 to $359, whereas the incremental intervention-only implementation cost ranged from $88 to $215.

CONCLUSIONS

The current findings indicate that non-nurse PN can increase colonoscopy completion, and this can be achieved at a minimal incremental cost for an insured population at an urban academic medical center.

Economic evaluation of patient navigation programs in colorectal cancer care, a systematic review

Patient navigation has expanded as a promising approach to improve cancer care coordination and patient adherence. This paper addresses the need to identify the evidence on the economic impact of patient navigation in colorectal cancer, following the Health Economic Evaluation Publication Guidelines. Articles indexed in Medline, Cochrane, CINAHL, and Web of Science between January 2000 and March 2017 were analyzed. We conducted a systematic review of the literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The quality assessment of the included studies was based on the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. Inclusion criteria indicated that the paper's subject had to explicitly address patient navigation in colorectal cancer and the study had to be an economic evaluation. The search yielded 243 papers, 9 of which were finally included within this review. Seven out of the nine studies included met standards for high-quality based on CHEERS criteria. Eight concluded that patient navigation programs were unequivocally cost-effective for the health outcomes of interest. Six studies were cost-effectiveness analyses. All studies computed the direct costs of the program, which were defined a minima as the program costs. Eight of the reviewed studies adopted the healthcare system perspective. Direct medical costs were usually divided into outpatient and inpatient visits, tests, and diagnostics. Effectiveness outcomes were mainly assessed through screening adherence, quality of life and time to diagnostic resolution. Given these outcomes, more economic research is needed for patient navigation during cancer treatment and survivorship as well as for patient navigation for other cancer types so that decision makers better understand costs and benefits for heterogeneous patient navigation programs.

The Role of Patient Navigation on Colorectal Cancer Screening Completion and Education: a Review of the Literature

Although the general assumption is that patient navigation helps patients adhere to CRC screening recommendations, concrete evidence for its effectiveness is still currently under investigation. The present literature review was conducted to explore effectiveness of patient navigation and education on colorectal cancer (CRC) screening completion in medically underserved populations. Data collection included PubMed, Google Scholar, and Cochrane reviews searches. Study inclusion criteria included randomized controlled trials and prospective investigations that included an intervention and control group. Case series, brief communications, commentaries, case reports, and uncontrolled studies were excluded. Twenty-seven of the 36 studies screened for relevance were selected for inclusion. Most studies explored the utility of lay and clinic-based patient navigation. Others implemented interventions that included tailored messaging, and culturally and linguistically appropriate outreach and education efforts to meet CRC screening needs of medically underserved individuals. More recent studies have begun to conduct cost-effectiveness analyses of patient navigation programs that impacted CRC screening and completion. Peer-reviewed publications consistently indicate a positive impact of patient navigation programs on CRC screening completion, as well have provided preliminary evidence for their cost-effectiveness.

Audio-computer-assisted survey interview and patient navigation to increase chronic viral hepatitis diagnosis and linkage to care in urban health clinics

Intravenous drug use and sexual practices account for 60% of hepatitis C (HCV) and B (HBV) infection. Disclosing these activities can be embarrassing and reduce risk reporting, blood testing and diagnosis. In diagnosed patients, linkage to care remains a challenge. Audio-computer-assisted survey interview (Audio-CASI) was used to guide HCV and HBV infection testing in urban clinics. Risk reporting, blood testing and serology results were compared to historical controls. A patient navigator (PN) followed up blood test results and provided patients with positive serology linkage to care (LTC). Of 1932 patients surveyed, 574 (30%) were at risk for chronic viral hepatitis. A total of 254 (44.3%) patients were tested, 34 (13.5%) had serology warranting treatment evaluation, and 64% required HBV vaccination. Of 16 patients with infection, seven HCV and three HBV patients started treatment following patient LTC. Of 146 HBV-naïve patients, 70 completed vaccination. About 75% and 49% of HCV antibody and HBV surface antigen-positive patients were born between 1945 and 1965. Subsequently, automated HCV testing of patients born between 1945 and 1965 was built into our hospital electronic medical records. Average monthly HCV antibody testing increased from 245 (January-June) to 1187 (July-October). Patient navigator directed LTC for HCV antibody-positive patients was 61.6%. In conclusion, audio-CASI can identify patients at risk for HCV or HBV infection and those in need of HBV vaccination in urban medical clinics. Although blood testing once a patient is identified at risk for infection needs to increase, a PN is useful to provide LTC of newly diagnosed patients.

Impact of Resected Colon Site on Quality of Bowel Preparation in Patients Who Underwent Prior Colorectal Resection

BACKGROUND AND AIM

Various factors are known to be associated with quality of bowel preparation (QBP), but have rarely been investigated in patients with prior colorectal resection. The aim of this study was to investigate variables associated with bowel preparation in patients with prior colorectal resection.

MATERIALS AND METHODS

A total of 247 patients with prior colorectal resection and undergone surveillance colonoscopy were consecutively chosen. One clinician performed endoscopy for all patients. QBP was rated using Aronchick grade and was categorized as either satisfactory (Aronchick grades, 1 to 3) or unsatisfactory (Aronchick grades, 4 and 5). Factors associated with QBP were analyzed.

RESULTS

Unsatisfactory bowel preparation was detected in 49 patients (19.8%). There was no difference in QBP on the basis of sex, age, body mass index, hypertension history, diabetes mellitus history, smoking habits, time after surgery, resected colon length, or bowel preparation method. Operation method was marginally associated with QBP (P=0.056). When we dichotomized patients into right-side colon preservation or not, the right colon preservation group showed a significant association with poor QBP on univariate (22.3% vs. 7.5%, P=0.028) and multivariate analysis (odds ratio, 3.6; 95% confidence interval, 1.0-12.3; P=0.038).

CONCLUSION

Patients with a preserved right colon were associated with poor bowel preparations compared with patients who underwent right-side colon resection. When preparing patients with history of colorectal resection for colonoscopy, these differences should be considered for better bowel preparation.

The effectiveness of patient navigation to improve healthcare utilization outcomes: A meta-analysis of randomized controlled trials

OBJECTIVE

To determine the effects of patient navigation (PN) on healthcare utilization outcomes using meta-analysis and the quality of evidence.

METHODS

Medical and social science databases were searched for randomized controlled trials published in English between 1989 and May 2015. The review process was guided by PRISMA. Included studies were assessed for quality using the Downs and Black tool. Data were extracted to assess the effect of navigation on: health screening rates, diagnostic resolution, cancer care follow-up treatment adherence, and attendance of care events. Random-effects models were used to compute risk ratios and I² statistics determined the impact of heterogeneity.

RESULTS

Of 3985 articles screened, 25 articles met inclusion criteria. Compared to usual care, patients who received PN were significantly more likely to access health screening (OR 2.48, 95% CI, 1.93-3.18, P<0.00001) and attend a recommended care event (OR 2.55, 95% CI, 1.27-5.10, P<0.01). PN was favoured to increase adherence to cancer care follow-up treatment and obtain diagnoses. Most studies involved trained lay navigators (n=12) compared to health professionals (n=9).

CONCLUSION

PN is effective to increase screening rates and complete care events.

PRACTICE IMPLICATIONS

PN is an effective intervention for use in healthcare.

Predictors of Suboptimal Bowel Preparation Using 3-l of Polyethylene Glycol for an Outpatient Colonoscopy: A Prospective Observational Study

BACKGROUND

A 3-l polyethylene glycol (PEG) solution provided better bowel cleansing quality than a 2-l solution for outpatient colonoscopy. Predictors of suboptimal preparation using a 3-l PEG have not been previously reported.

AIMS

To investigate the possible predictors of suboptimal bowel preparation using 3-l of PEG.

METHODS

We analyzed a database of 1404 consecutive colonoscopies during a 27-month period at a community hospital. A split-dose PEG regimen was provided for morning colonoscopies, and a same-day PEG regimen was provided for afternoon colonoscopies. The level of bowel cleansing was prospectively scored according to the Boston Bowel Preparation Scale (BBPS). Possible predictors of suboptimal colon preparation, defined as a BBPS score <7, were analyzed using univariate statistics and multivariate logistic regression models.

RESULTS

The mean age of the study population (46.7 % men) was 52.5 years (range 20-80 years, SD 11.1 years), and the majority of patients (77.6 %) underwent morning colonoscopies. A suboptimal bowel preparation was reported in 17.2 % of the observed colonoscopies. In the multivariate regression analysis, constipation (odds ratio [OR] 1.60, 95 % confidence interval [CI] 1.15-2.22), male gender (OR 1.68, 95 % CI 1.25-2.25), obesity (OR 1.76, 95 % CI 1.29-2.41), and inadequate (<80 %) PEG consumption (OR 5.4, 95 % CI 2.67-10.89) were independent predictors of a suboptimal colon preparation.

CONCLUSIONS

This prospective study identified that constipation, male gender, obesity, and inadequate intake of PEG were significant risk factors for suboptimal bowel preparation using a 3-l PEG solution for outpatient colonoscopy. Interventions of optimized colonoscopy preparation should be targeted at these patient populations.

Why Wait Until Our Community Gets Cancer?: Exploring CRC Screening Barriers and Facilitators in the Spanish-Speaking Community in North Carolina

Colorectal cancer (CRC) is a leading cause of death among Hispanics in the United States. Despite the benefits of CRC screening, many Hispanics are not being screened. Using a combined methodology of focus groups and discrete choice experiment (DCE) surveys, the objectives for this research were as follows: (1) to improve understanding of preferences regarding potential CRC screening program characteristics, and (2) to improve understanding of the barriers and facilitators around CRC screening with the Hispanic, immigrant community in North Carolina. Four gender-stratified focus groups were conducted and DCE surveys were administered to 38 Spanish-speaking individuals across four counties in North Carolina. In-depth content analysis was used to examine the focus group data; descriptive analyses and mean attribute importance scores for cost of screening and follow-up care, travel time, and test options were calculated from DCE data. Data analyses showed that this population has a strong interest in CRC screening but experience barriers such as lack of access to resources, cost uncertainty, and stigma. Some of these barriers are unique to their cultural experiences in the United States, such as an expressed lack of tailored CRC information. Based on the DCE, cost variables were more important than testing options or travel time. This study suggests that Hispanics may have a general awareness of and interest in CRC screening, but multiple barriers prevent them from getting screened. Special attention should be given to designing culturally and linguistically appropriate programs to improve access to healthcare resources, insurance, and associated costs among Hispanics.

Unmet basic needs and health intervention effectiveness in low-income populations

In the face of unmet basic needs, low SES adults are less likely to obtain needed preventive health services. The study objective was to understand how these hardships may cluster and how the effectiveness of different health-focused interventions might vary across vulnerable population sub-groups with different basic needs profiles. From June 2010-2012, a random sample of low-income adult callers to Missouri 2-1-1 completed a cancer risk assessment and received up to 3 health referrals for needed services (mammography, pap testing, colonoscopy, HPV vaccination, smoking cessation and smoke-free home policies). Participants received either a verbal referral only (N=365), verbal referral+tailored print reminder (N=372), or verbal referral+navigator (N=353). Participants reported their unmet basic needs at baseline and contacts with health referrals at 1-month post-intervention. We examined latent classes of unmet basic needs using SAS. Logistic regression examined the association between latent classes and contacting a health referral, by intervention condition. A 3 class solution best fit the data. For participants with relatively more unmet needs (C2) and those with money needs (C3), the navigator intervention was more effective than the tailored or verbal referral only conditions in leading to health referrals contacts. For participants with fewer unmet basic needs (C1), the tailored intervention was as effective as the navigator intervention. The distribution and nature of unmet basic needs in this sample of low-income adults was heterogeneous, and those with the greatest needs benefitted most from a more intensive navigator intervention in helping them seek needed preventive health services.

Patient-Reported Attributions for Missed Colonoscopy Appointments in Two Large Healthcare Systems

BACKGROUND

Missed colonoscopy appointments (no-shows) can lead to wasted resources and delays in colorectal cancer diagnosis, an area of special concern in public health systems that often provide care for vulnerable patients. Our objective was to identify reasons for missed colonoscopy appointments in patients seeking care at two large public health systems in Houston, TX.

METHODS

We conducted a telephone survey of patients who missed their colonoscopy appointments at two tertiary care health systems. Using a structured survey instrument, we collected information on patient-specific and health services barriers. Patient-specific barriers included perceived procedural-related factors (e.g., difficulty in preparation), cognitive-emotional factors (e.g., fear or concern about modesty), and changes in health status (e.g., improvement or worsening of health). Health services barriers included logistical factors (e.g., travel-related difficulties) and appointment scheduling problems (inconvenient date or time). We examined differences in attributions for missed appointments between the two study sites.

RESULTS

Of 160 unique patients (102 Site A and 58 Site B) who missed their appointment during the study period, 153 (95.6 %) attributed their no-show to at least one of the listed barriers. Most respondents (125; 78.1 %) cited travel-related issues or scheduling problems as reasons for their missed appointment. Not having a ride or a travel companion was the most commonly reported travel-related issue. We also found significant differences for barriers between the two sites.

CONCLUSIONS

Most missed colonoscopy appointments resulted from potentially preventable travel- and scheduling-related issues. Because barriers to keeping colonoscopy appointments are different across health systems, each health system might need to develop unique interventions to reduce missed colonoscopy appointments.

Screening Colonoscopy among Uninsured and Underinsured Urban Minorities

Background/Aims

Uninsured individuals have lower rates of screening colonoscopy (SC), and little is known regarding the pathology results obtained when they undergo colonoscopies. Since 2004, we have participated in a program that offers SC to uninsured New Yorkers; herein, we report our findings.

Methods

Uninsured, average-risk patients who were at least 50 years of age underwent SC at our institution between April 2004 and June 2011. We analyzed polyp pathology, location, size, incidence of adenomas, and incidence of adenomas with advanced pathology (AAP) with respect to ethnicity, gender, and age.

Results

Out of 493 referrals, 222 patients completed the colonoscopies. Polyps were identified in 21.2% of all patients; 14% had adenomas, and 4.5% had AAP. The rates of adenomas among African-Americans, Hispanics, and Whites were 24.3%, 12.1%, and 11.6%, respectively, and the corresponding rates of AAP were 10.8%, 3.5%, and 2.3%. Differences in the polyp type, location, and AAP did not reach statistical significance with respect to ethnicity or gender. Patients aged 60 and older were found to have a higher rate of advanced adenomas compared with younger patients (8.6% vs 2.6%, p=0.047).

Conclusions

Further efforts to fund screening colonoscopies for uninsured individuals will likely result in the identification of advanced lesions of the colon before they progress to colorectal cancer.

Use of Evidence-Based Interventions to Address Disparities in Colorectal Cancer Screening

Colorectal cancer (CRC) is the second leading cause of cancer death among cancers that affect both men and women. Despite strong evidence of their effectiveness, CRC screening tests are underused. Racial/ethnic minority groups, persons without insurance, those with lower educational attainment, and those with lower household income levels have lower rates of CRC screening. Since 2009, CDC's Colorectal Cancer Control Program (CRCCP) has supported state health departments and tribal organizations in implementing evidence-based interventions (EBIs) to increase use of CRC screening tests among their populations. This report highlights the successful implementation of EBIs to address disparities by two CRCCP grantees: the Alaska Native Tribal Health Consortium (ANTHC) and Washington State's Breast, Cervical, and Colon Health Program (BCCHP). ANTHC partnered with regional tribal health organizations in the Alaska Tribal Health System to implement provider and client reminders and use patient navigators to increase CRC screening rates among Alaska Native populations. BCCHP identified patient care coordinators in each clinic who coordinated staff training on CRC screening and integrated client and provider reminder systems. In both the Alaska and Washington programs, instituting provider reminder systems, client reminder systems, or both was facilitated by use of electronic health record systems. Using multicomponent interventions in a single clinical site or facility can support more organized screening programs and potentially result in greater increases in screening rates than relying on a single strategy. Organized screening systems have an explicit policy for screening, a defined target population, a team responsible for implementation of the screening program, and a quality assurance structure. Although CRC screening rates in the United States have increased steadily over the past decade, this increase has not been seen equally across all populations. Increasing the use of EBIs, such as those described in this report, in health care clinics and systems that serve populations with lower CRC screening rates could substantially increase CRC screening rates.

Training in Patient Navigation: A Review of the Research Literature

Despite the proliferation of patient navigation programs designed to increase timely receipt of health care, little is known about the content and delivery of patient navigation training, or best practices in this arena. The current study begins to address these gaps in understanding, as it is the first study to comprehensively review descriptions of patient navigation training in the peer-reviewed research literature. Seventy-five patient navigation efficacy studies published since 1995, identified through PubMed and by the authors, were included in this narrative review. Fifty-nine of the included studies (79%) mentioned patient navigation training, and 55 of these studies additionally provided a description of training. Most studies did not thoroughly document patient navigation training practices. Additionally, several topics integral to the role of patient navigators, as well as components of training central to successful adult learning, were not commonly described in the research literature. Descriptions of training also varied widely across studies in terms of duration, location, format, learning strategies employed, occupation of trainer, and content. These findings demonstrate the need for established standards of navigator training as well as for future research on the optimal delivery and content of patient navigation training.

New York Citywide Colon Cancer Control Coalition: A public health effort to increase colon cancer screening and address health disparities

BACKGROUND

Although screening for colorectal cancer (CRC) is a widely accepted concept nationally and screening rates are increasing, there are differences in screening rates between states and within states.

METHODS

In an effort to increase screening rates and ensure equal access with respect to race/ethnicity, the New York City Department of Health and Mental Hygiene formed a coalition of stakeholders in 2003, with its primary focus on colonoscopy, to develop and implement strategies across the city to achieve this goal.

RESULTS

From a screening colonoscopy rate of only 42% in 2003, these concerted efforts contributed to achieving a screening rate of 62% by 2007 and a screening rate of almost 70% in 2014 with the elimination of racial and ethnic disparities.

CONCLUSIONS

This article provides details of how this program was successfully conceived, implemented, and sustained in the large urban population of New York City. The authors hope that by sharing the many elements involved and the lessons learned, they may help other communities to adapt these experiences to their own environments so that CRC screening rates can be maximized. Cancer 2016;122:269-277. © 2015 American Cancer Society.

Patient Non-adherence and Cancellations Are Higher for Screening Colonoscopy Compared with Surveillance Colonoscopy

BACKGROUND

A significant proportion of the eligible population is non-adherent to colonoscopy for colorectal cancer (CRC) screening.

AIMS

To define the demographic and clinical variables associated with non-adherence and multiple cancellations to scheduled colonoscopy within 1 year in a CRC screening and adenomatous polyp surveillance population.

METHODS

This was an observational cohort study of 617 consecutive patients scheduled to undergo colonoscopy at an outpatient academic tertiary care center for CRC screening or adenomatous polyp surveillance from January 2012 to September 2012.

RESULTS

Overall, 551 patients (89.3%) were adherent and 66 (10.7%) were non-adherent to scheduled colonoscopy at 1 year. The relative risk for non-adherence was 5.42 [95% confidence interval (CI) 2.74-10.75] in patients undergoing colonoscopy for screening compared to those for surveillance (16.7 vs. 3.5% non-adherence, respectively, P < 0.001). An indication of screening in comparison with surveillance was associated with non-adherence [odds ratio (OR) 12.69, 95% CI 4.18-38.51] and multiple cancellations (OR 2.33, 95% CI 1.27-4.31) by multiple regression analysis.

CONCLUSIONS

Patients undergoing colonoscopy for CRC screening are significantly less likely to attend their scheduled procedure within a year and have more procedure cancellations than those undergoing surveillance colonoscopy.

Cost-effectiveness analysis of a colonoscopy screening navigator program designed for Hispanic men

Although Hispanic men are at higher risk of developing colon cancer compared to non-Hispanic white men, colonoscopy screening among Hispanic men is much lower than among non-Hispanic white men. University Health System (UHS) in San Antonio, Texas, instituted a Colorectal Cancer Male Navigation (CCMN) Program in 2011 specifically designed for Hispanic men. The CCMN Program contacted 461 Hispanic men 50 years of age and older to participate over a 2-year period. Of these age-eligible men, 370 were screened for CRC after being contacted by the navigator. Using participant and program data, a Markov model was constructed to determine the cost-effectiveness of the CCMN Program. An average 50-year-old Hispanic male who participates in the CCMN Program will have 0.3 more quality-adjusted life-years (QALYs) compared to a similar male receiving usual care. Life expectancy is also predicted to increase by 6 months for participants compared to non-participants. The program results in net health care savings of $1,148 per participant ($424,760 for the 370 CCMN Program participants). The incremental cost-effectiveness ratio is estimated at $3,765 per QALY in favor of the navigation program. Interventions to reduce disparities in CRC screening across ethnic groups are needed, and this is one of the first studies to evaluate the economic benefit of a patient navigator program specifically designed for an urban population of Hispanic men. A colorectal cancer screening intervention which relies on patient navigators trained to address the unique needs of the targeted population (language barriers, transportation and scheduling assistance, colon cancer, and screening knowledge) can substantially increase the likelihood of screening and improve quality of life in a cost-effective manner.

Cost-effectiveness of patient navigation to increase adherence with screening colonoscopy among minority individuals

BACKGROUND

Colorectal cancer (CRC) screening is underused by minority populations, and patient navigation increases adherence with screening colonoscopy. In this study, the authors estimated the cost-effectiveness of navigation for screening colonoscopy from the perspective of a payer seeking to improve population health.

METHODS

A validated model of CRC screening was informed with inputs from navigation studies in New York City (population: 43% African American, 49% Hispanic, 4% white, 4% other; base-case screening: 40% without navigation, 65% with navigation; navigation costs: $29 per colonoscopy completer, $21 per noncompleter, $3 per non-navigated individual). Two analyses compared: 1) navigation versus no navigation for 1-time screening colonoscopy in unscreened individuals aged ≥ 50 years; and 2) programs of colonoscopy with versus without navigation versus fecal occult blood testing (FOBT) or fecal immunochemical testing (FIT) for individuals ages 50 to 80 years.

RESULTS

In the base case: 1) 1-time navigation gained quality-adjusted life-years (QALYs) and decreased costs; 2) longitudinal navigation cost $9800 per QALY gained versus no navigation, and, assuming comparable uptake rates, it cost $118,700 per QALY gained versus FOBT but was less effective and more costly than FIT. The results were most dependent on screening participation rates and navigation costs: 1) assuming a 5% increase in screening uptake with navigation, and a navigation cost of $150 per completer, 1-time navigation cost $26,400 per QALY gained; and 2) longitudinal navigation with 75% colonoscopy uptake cost <$25,000 per QALY gained versus FIT when FIT uptake was <50%. Probabilistic sensitivity analyses did not alter the conclusions.

CONCLUSIONS

Navigation for screening colonoscopy appears to be cost-effective, and 1-time navigation may be cost-saving. In emerging health care models that reward outcomes, payers should consider covering the costs of navigation for screening colonoscopy.

Intraprocedural cleansing work during colonoscopy and achievable rates of adequate preparation in an open-access endoscopy unit

BACKGROUND

Rates of adequate bowel preparation in the 60% to 80% range continue to be reported for colonoscopy.

OBJECTIVE

To describe the rate of adequate bowel preparation and intraprocedural work needed to achieve this rate in an open-access endoscopy unit. Universal split dosing and regimens tailored to medical predictors of inadequate preparation were used.

DESIGN

Prospective observational study.

SETTING

Academic hospital outpatient endoscopy unit and ambulatory surgery center.

PATIENTS

Outpatients undergoing colonoscopy.

INTERVENTIONS

Prospective assessment of preparation quality for colonoscopy during insertion and after intraprocedural cleansing in 525 patients.

MAIN OUTCOME MEASUREMENTS

Rates of adequate preparation and work required to improve cleansing quality. Work time for cleaning was measured with a stopwatch.

RESULTS

Adequate preparation to allow recommendation of standard screening or surveillance intervals was achieved in 96% of patients, including 6% for whom preparation was adequate only after intraprocedural cleansing work. The mean time for intraprocedural cleaning was 4.1 minutes and constituted 17% of total procedure time. Work time for cleaning and fluid volume injected increased when worse preparation grades were identified before cleaning.

LIMITATIONS

Single-center study with low percentage (4%) of patients receiving Medicaid.

CONCLUSION

An open-access unit using split-dose bowel cleansing preparations can achieve high rates of adequate bowel preparation for colonoscopy. Intraprocedural cleansing accounts for a substantial fraction of the total procedure time in colonoscopy and is an important contributor to high rates of adequate preparation.

Optimal bowel preparation--a practical guide for clinicians

High-quality bowel preparation is essential for effective colonoscopy. Bowel preparations are judged by their safety, efficacy and tolerability. Between efficacy and tolerability, efficacy is the clinical priority because inadequate preparations are disruptive and costly. Achieving high rates of adequate preparation depends first on using split-dose or same-day dosing. Patients who have medical predictors of inadequate preparation quality (for example chronic constipation) should be prescribed more aggressive preparations and patients who have factors that predict they are less likely to follow the instructions (such as English not being their first language) should receive intensified education. On the day of the procedure, patients with persistent brown effluent should be considered for large-volume enemas or additional oral preparation before proceeding with colonoscopy. During the procedure, preparation quality should be graded after the clean-up has been completed.

Challenges and possible solutions to colorectal cancer screening for the underserved

Colorectal cancer (CRC) is a leading cause of cancer mortality worldwide. CRC incidence and mortality can be reduced through screening. However, in the United States, screening participation remains suboptimal, particularly among underserved populations such as the uninsured, recent immigrants, and racial/ethnic minority groups. Increasing screening rates among underserved populations will reduce the US burden of CRC. In this commentary focusing on underserved populations, we highlight the public health impact of CRC screening, list key challenges to screening the underserved, and review promising approaches to boost screening rates. We identify four key policy and research priorities to increase screening among underserved populations: 1) actively promote the message, "the best test is the one that gets done"; 2) develop and implement methods to identify unscreened individuals within underserved population groups for screening interventions; 3) develop and implement approaches for organized screening delivery; and 4) fund and enhance programs and policies that provide access to screening, diagnostic follow-up, and CRC treatment for underserved populations. This commentary represents the consensus of a diverse group of experts in cancer control and prevention, epidemiology, gastroenterology, and primary care from across the country who formed the Coalition to Boost Screening among the Underserved in the United States. The group was organized and held its first annual working group meeting in conjunction with the World Endoscopy Organization's annual Colorectal Cancer Screening Committee meeting during Digestive Disease Week 2012 in San Diego, California.

Effect of patient navigation on time to diagnostic resolution among patients with colorectal cancer-related abnormalities

The objective of this study is to evaluate whether a patient navigation (PN) program is effective in reducing delay in diagnostic resolution among medically underserved patients with colorectal cancer (CRC)-related abnormalities in Tampa Bay, Florida. This study involved ten primary care clinics randomized either to receive navigation or to serve as controls (five clinics per arm). Each clinic identified all subjects with CRC-related abnormalities in the year prior to the clinic beginning participation in the Moffitt Patient Navigator Research Program. Patients with CRC-related abnormalities were navigated from the time of a colorectal abnormality to diagnostic resolution. Control patients received usual care, and outcome information was obtained from medical record abstraction. Using a frailty Cox proportional hazard model, we examined the length of time between colorectal abnormality and definitive diagnosis. One hundred ninety-three patients were eligible for the study because of a CRC-related abnormality (75 navigated and 118 controls). Analysis of PN effect by two time periods of resolution (0-4 and >4 months) showed a lagged effect of PN. The adjusted time-varying PN effect on diagnostic resolution compared to the controls was marginally significant (adjusted hazard ratio [aHR] = 1.15, 95% confidence interval = 1.02-1.29) after controlling for insurance status. The predicted aHR at 4 months was 1.2, but showed no significant effect until 12 months. For patients having an abnormal symptom of CRC, PN appeared to have a positive effect over time and sped diagnostic resolution after 4 months. However, the small sample size limits drawing a definitive conclusion regarding the positive PN effect.

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.

Trial to examine text message-based mHealth in emergency department patients with diabetes (TExT-MED): a randomized controlled trial

STUDY OBJECTIVE

Increasingly, low-income inner-city patients with diabetes utilize emergency departments (EDs) for acute and chronic care. We seek to determine whether a scalable, low-cost, unidirectional, text message-based mobile health intervention (TExT-MED) improves clinical outcomes, increases healthy behaviors, and decreases ED utilization in a safety net population.

METHODS

We conducted an randomized controlled trial of 128 adult patients with poorly controlled diabetes (glycosylated hemoglobin [Hb A1C] level ≥8%) in an urban, public ED. The TExT-MED group received 2 daily text messages for 6 months in English or Spanish. The primary outcome was change in Hb A1C level. Secondary outcomes included changes in medication adherence, self-efficacy, performance of self-care tasks, quality of life, diabetes-specific knowledge, ED utilization, and patient satisfaction.

RESULTS

Hb A1C level decreased by 1.05% in the TExT-MED group compared with 0.60% in the controls (Δ0.45; 95% confidence interval [CI] -0.27 to 1.17) at 6 months. Secondary outcomes favored the TExT-MED group, with the most sizable change observed in self-reported medication adherence (as measured by the Morisky Medication Adherence Scale, an 8-point validated scale with higher scores representing better adherence), which improved from 4.5 to 5.4 in the TExT-MED group compared with a net decrease of -0.1 in the controls (Δ1.1 [95% CI 0.1 to 2.1]). Effects were larger among Spanish speakers for both medication adherence (1.1 versus -0.3; Δ1.4; 95% CI 0.2 to 2.7) and Hb A1C (-1.2% versus -0.4%) in the TExT-MED group. The proportion of patients who used emergency services trended lower in the TExT-MED group (35.9% versus 51.6%; Δ15.7%; 95% CI 9.4% to 22%). Overall, 93.6% of respondents enjoyed TExT-MED and 100% would recommend it to family/friends.

CONCLUSION

The TExT-MED program did not result in a statistically significant improvement in Hb A1C. However, trends toward improvement in the primary outcome of Hb A1C and other secondary outcomes, including quality of life, were observed, the most pronounced being improved medication adherence. TExT-MED also decreased ED utilization. These findings were magnified in the Spanish-speaking subgroup. Technologies such as TExT-MED represent highly scalable, low-cost, and widely accessible solutions for safety-net ED populations.