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Thompson JH, Rivelli JS, Schneider JL, Kenzie ES, Myers E, Coury J, Davis M, Gautom P, Coronado GD. Adaptations to a patient navigation program for follow-up colonoscopy in rural primary care practices. J Eval Clin Pract 2024. [PMID: 38935862 DOI: 10.1111/jep.14068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 06/09/2024] [Indexed: 06/29/2024]
Abstract
PURPOSE Patient navigation is a recommended practice to improve cancer screenings among underserved populations including those residing in rural areas with care access barriers. We report on patient navigation programme adaptations to increase follow-up colonoscopy rates after abnormal fecal testing in rural primary care practices. METHODS Participating clinics delivered a patient navigation programme to eligible patients from 28 affiliated clinics serving rural communities in Oregon clustered within 3 Medicaid health plans. Patient navigation adaptations were tracked using data sources including patient navigation training programme reflections, qualitative interviews, clinic meetings, and periodic reflections with practice facilitators. FINDINGS Initial, planned (proactive) adaptations were made to address the rural context; later, unplanned (reactive) adaptations were implemented to address the impact of the COVID-19 global pandemic. Initial planned adaptations to the patient navigation programme were made before the main trial to address the needs of the rural context, including provider shortages and geographic dispersion limiting both patient access to care and training opportunities for providers. Later unplanned adaptations were made primarily in response to COVID-19 care suspension and staff redeployments and shortages that occurred during implementation. CONCLUSION While unplanned adaptations were implemented to address the contextual impact of the COVID-19 pandemic on care access patterns and staffing, the changes to training content and context were beneficial to the rural setting overall and should be sustained. Our findings can guide future efforts to optimise the success of such programmes in other rural settings and highlight the important role of adaptations in implementation projects.
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Affiliation(s)
- Jamie H Thompson
- Science Programs Department, Kaiser Permanente Center for Health Research, Portland, Oregon, USA
| | - Jennifer S Rivelli
- Science Programs Department, Kaiser Permanente Center for Health Research, Portland, Oregon, USA
| | - Jennifer L Schneider
- Science Programs Department, Kaiser Permanente Center for Health Research, Portland, Oregon, USA
| | - Erin S Kenzie
- Oregon Rural Practice-based Research Network, Oregon Health & Science University, Portland, Oregon, USA
- OHSU-PSU School of Public Health Division, Oregon Health & Science University, Portland, Oregon, USA
| | - Emily Myers
- Oregon Rural Practice-based Research Network, Oregon Health & Science University, Portland, Oregon, USA
| | - Jennifer Coury
- Oregon Rural Practice-based Research Network, Oregon Health & Science University, Portland, Oregon, USA
| | - Melinda Davis
- Oregon Rural Practice-based Research Network, Oregon Health & Science University, Portland, Oregon, USA
- OHSU-PSU School of Public Health Division, Oregon Health & Science University, Portland, Oregon, USA
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Priyanka Gautom
- Science Programs Department, Kaiser Permanente Center for Health Research, Portland, Oregon, USA
- OHSU-PSU School of Public Health Division, Oregon Health & Science University, Portland, Oregon, USA
| | - Gloria D Coronado
- Science Programs Department, Kaiser Permanente Center for Health Research, Portland, Oregon, USA
- Department of Population Sciences, University of Arizona Cancer Center, Tucson, Arizona, USA
- Department of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, USA
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Korn AR, Walsh-Bailey C, Correa-Mendez M, DelNero P, Pilar M, Sandler B, Brownson RC, Emmons KM, Oh AY. Social determinants of health and US cancer screening interventions: A systematic review. CA Cancer J Clin 2023; 73:461-479. [PMID: 37329257 PMCID: PMC10529377 DOI: 10.3322/caac.21801] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 04/05/2023] [Accepted: 05/08/2023] [Indexed: 06/19/2023] Open
Abstract
There remains a need to synthesize linkages between social determinants of health (SDOH) and cancer screening to reduce persistent inequities contributing to the US cancer burden. The authors conducted a systematic review of US-based breast, cervical, colorectal, and lung cancer screening intervention studies to summarize how SDOH have been considered in interventions and relationships between SDOH and screening. Five databases were searched for peer-reviewed research articles published in English between 2010 and 2021. The Covidence software platform was used to screen articles and extract data using a standardized template. Data items included study and intervention characteristics, SDOH intervention components and measures, and screening outcomes. The findings were summarized using descriptive statistics and narratives. The review included 144 studies among diverse population groups. SDOH interventions increased screening rates overall by a median of 8.4 percentage points (interquartile interval, 1.8-18.8 percentage points). The objective of most interventions was to increase community demand (90.3%) and access (84.0%) to screening. SDOH interventions related to health care access and quality were most prevalent (227 unique intervention components). Other SDOH, including educational, social/community, environmental, and economic factors, were less common (90, 52, 21, and zero intervention components, respectively). Studies that included analyses of health policy, access to care, and lower costs yielded the largest proportions of favorable associations with screening outcomes. SDOH were predominantly measured at the individual level. This review describes how SDOH have been considered in the design and evaluation of cancer screening interventions and effect sizes for SDOH interventions. Findings may guide future intervention and implementation research aiming to reduce US screening inequities.
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Affiliation(s)
- Ariella R. Korn
- Cancer Prevention Fellowship Program, Implementation Science Team, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD
- Behavioral and Policy Sciences Department, RAND Corporation, Boston, MA
| | - Callie Walsh-Bailey
- Prevention Research Center, Brown School at Washington University in St. Louis, St. Louis, MO
| | - Margarita Correa-Mendez
- Cancer Prevention Fellowship Program, Implementation Science Team, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD
| | - Peter DelNero
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Meagan Pilar
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO
| | - Brittney Sandler
- Bernard Becker Medical Library, Washington University School of Medicine, St. Louis, MO
| | - Ross C. Brownson
- Prevention Research Center, Brown School at Washington University in St. Louis, St. Louis, MO
- Department of Surgery, Division of Public Health Sciences, and Alvin J. Siteman Cancer Center, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO
| | - Karen M. Emmons
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA
| | - April Y. Oh
- Implementation Science Team, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD
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Mosquera I, Todd A, Balaj M, Zhang L, Benitez Majano S, Mensah K, Eikemo TA, Basu P, Carvalho AL. Components and effectiveness of patient navigation programmes to increase participation to breast, cervical and colorectal cancer screening: A systematic review. Cancer Med 2023; 12:14584-14611. [PMID: 37245225 PMCID: PMC10358261 DOI: 10.1002/cam4.6050] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 04/03/2023] [Accepted: 04/26/2023] [Indexed: 05/30/2023] Open
Abstract
BACKGROUND Inequalities in cancer incidence and mortality can be partly explained by unequal access to high-quality health services, including cancer screening. Several interventions have been described to increase access to cancer screening, among them patient navigation (PN), a barrier-focused intervention. This systematic review aimed to identify the reported components of PN and to assess the effectiveness of PN to promote breast, cervical and colorectal cancer screening. METHODS We searched Embase, PubMed and Web of Science Core Collection databases. The components of PN programmes were identified, including the types of barriers addressed by navigators. The percentage change in screening participation was calculated. RESULTS The 44 studies included were mainly on colorectal cancer and were conducted in the USA. All described their goals and community characteristics, and the majority reported the setting (97.7%), monitoring and evaluation (97.7%), navigator background and qualifications (81.4%) and training (79.1%). Supervision was only referred to in 16 studies (36.4%). Programmes addressed mainly barriers at the educational (63.6%) and health system level (61.4%), while only 25.0% reported providing social and emotional support. PN increased cancer screening participation when compared with usual care (0.4% to 250.6% higher) and educational interventions (3.3% to 3558.0% higher). CONCLUSION Patient navigation programmes are effective at increasing participation to breast, cervical and colorectal cancer screening. A standardized reporting of the components of PN programmes would allow their replication and a better measure of their impact. Understanding the local context and needs is essential to design a successful PN programme.
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Affiliation(s)
- Isabel Mosquera
- Early Detection, Prevention & Infections Branch, International Agency for Research on CancerLyonFrance
| | - Adam Todd
- School of PharmacyNewcastle University, Newcastle upon TyneUK
| | - Mirza Balaj
- Centre for Global Health Inequalities Research (CHAIN), Department of Sociology and Political ScienceNorwegian University of Science and Technology (NTNU)TrondheimNorway
| | - Li Zhang
- Early Detection, Prevention & Infections Branch, International Agency for Research on CancerLyonFrance
| | - Sara Benitez Majano
- Noncommunicable Diseases, Violence and Injuries Prevention Unit, Pan American Health OrganizationWashingtonDCUSA
- Inequalities in Cancer Outcomes Network, London School of Hygiene and Tropical MedicineLondonUK
| | - Keitly Mensah
- Early Detection, Prevention & Infections Branch, International Agency for Research on CancerLyonFrance
| | - Terje Andreas Eikemo
- Centre for Global Health Inequalities Research (CHAIN), Department of Sociology and Political ScienceNorwegian University of Science and Technology (NTNU)TrondheimNorway
| | - Partha Basu
- Early Detection, Prevention & Infections Branch, International Agency for Research on CancerLyonFrance
| | - Andre L. Carvalho
- Early Detection, Prevention & Infections Branch, International Agency for Research on CancerLyonFrance
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Champion VL, Paskett ED, Stump TE, Biederman EB, Vachon E, Katz ML, Rawl SM, Baltic RD, Kettler CD, Seiber EE, Xu WY, Monahan PO. Comparative Effectiveness of 2 Interventions to Increase Breast, Cervical, and Colorectal Cancer Screening Among Women in the Rural US: A Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2311004. [PMID: 37115541 PMCID: PMC10148202 DOI: 10.1001/jamanetworkopen.2023.11004] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 03/19/2023] [Indexed: 04/29/2023] Open
Abstract
Importance Women living in rural areas have lower rates of breast, cervical, and colorectal cancer screening compared with women living in urban settings. Objective To assess the comparative effectiveness of (1) a mailed, tailored digital video disc (DVD) intervention; (2) a DVD intervention plus telephonic patient navigation (DVD/PN); and (3) usual care with simultaneously increased adherence to any breast, cervical, and colorectal cancer screening that was not up to date at baseline and to assess cost-effectiveness. Design, Setting, and Participants This randomized clinical trial recruited and followed up women from rural Indiana and Ohio (community based) who were not up to date on any or all recommended cancer screenings. Participants were randomly assigned between November 28, 2016, and July 1, 2019, to 1 of 3 study groups (DVD, DVD/PN, or usual care). Statistical analyses were completed between August and December 2021 and between March and September 2022. Intervention The DVD interactively assessed and provided messages for health beliefs, including risk of developing the targeted cancers and barriers, benefits, and self-efficacy for obtaining the needed screenings. Patient navigators counseled women on barriers to obtaining screenings. The intervention simultaneously supported obtaining screening for all or any tests outside of guidelines at baseline. Main Outcomes and Measures Receipt of any or all needed cancer screenings from baseline through 12 months, including breast, cervical, and colorectal cancer, and cost-effectiveness of the intervention. Binary logistic regression was used to compare the randomized groups on being up to date for all and any screenings at 12 months. Results The sample included 963 women aged 50 to 74 years (mean [SD] age, 58.6 [6.3] years). The DVD group had nearly twice the odds of those in the usual care group of obtaining all needed screenings (odds ratio [OR], 1.84; 95% CI, 1.02-3.43; P = .048), and the odds were nearly 6 times greater for DVD/PN vs usual care (OR, 5.69; 95% CI, 3.24-10.5; P < .001). The DVD/PN intervention (but not DVD alone) was significantly more effective than usual care (OR, 4.01; 95% CI, 2.60-6.28; P < .001) for promoting at least 1 (ie, any) of the needed screenings at 12 months. Cost-effectiveness per woman who was up to date was $14 462 in the DVD group and $10 638 in the DVD/PN group. Conclusions and Relevance In this randomized clinical trial of rural women who were not up to date with at least 1 of the recommended cancer screenings (breast, cervical, or colorectal), an intervention designed to simultaneously increase adherence to any or all of the 3 cancer screening tests was more effective than usual care, available at relatively modest costs, and able to be remotely delivered, demonstrating great potential for implementing an evidence-based intervention in remote areas of the midwestern US. Trial Registration ClinicalTrials.gov Identifier: NCT02795104.
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Affiliation(s)
- Victoria L. Champion
- School of Nursing, Indiana University, Indianapolis
- Indiana University Melvin and Bren Simon Comprehensive Cancer Center, Indianapolis
| | - Electra D. Paskett
- Comprehensive Cancer Center, The Ohio State University, Columbus
- Division of Cancer Prevention and Control, Department of Medicine, College of Medicine, The Ohio State University, Columbus
| | - Timothy E. Stump
- Indiana University Melvin and Bren Simon Comprehensive Cancer Center, Indianapolis
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis
| | | | - Eric Vachon
- School of Nursing, Indiana University, Indianapolis
- Indiana University Melvin and Bren Simon Comprehensive Cancer Center, Indianapolis
- Center for Health Services Research, Regenstrief Institute, Indianapolis, Indiana
| | - Mira L. Katz
- Comprehensive Cancer Center, The Ohio State University, Columbus
- Division of Health Behavior and Health Promotion, College of Public Health, The Ohio State University, Columbus
| | - Susan M. Rawl
- School of Nursing, Indiana University, Indianapolis
- Indiana University Melvin and Bren Simon Comprehensive Cancer Center, Indianapolis
| | - Ryan D. Baltic
- Comprehensive Cancer Center, The Ohio State University, Columbus
| | - Carla D. Kettler
- Indiana University Melvin and Bren Simon Comprehensive Cancer Center, Indianapolis
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis
| | - Eric E. Seiber
- Division of Health Services Management and Policy, The Ohio State University, Columbus
| | - Wendy Y. Xu
- Division of Health Services Management and Policy, The Ohio State University, Columbus
| | - Patrick O. Monahan
- Indiana University Melvin and Bren Simon Comprehensive Cancer Center, Indianapolis
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis
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D’Apice C, Ghirotto L, Bassi MC, Artioli G, Sarli L. A realist synthesis of staff-based primary health care interventions addressing universal health coverage. J Glob Health 2022; 12:04035. [PMID: 35569053 PMCID: PMC9107778 DOI: 10.7189/jogh.12.04035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Methods Results Conclusions
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Affiliation(s)
- Clelia D’Apice
- University of Parma, Department of Medicine and Surgery, Parma, Italy
| | - Luca Ghirotto
- Qualitative Research Unit, Azienda USL – IRCCS, Reggio Emilia, Italy
| | - Maria C Bassi
- Medical Library, Azienda USL – IRCCS, Reggio Emilia, Italy
| | - Giovanna Artioli
- University of Parma, Department of Medicine and Surgery, Parma, Italy
| | - Leopoldo Sarli
- University of Parma, Department of Medicine and Surgery, Parma, Italy
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Baggett TP, Barbosa Teixeira J, Rodriguez EC, Anandakugan N, Sporn N, Chang Y, Percac-Lima S, Park ER, Rigotti NA. Patient navigation to promote lung cancer screening in a community health center for people experiencing homelessness: Protocol for a pragmatic randomized controlled trial. Contemp Clin Trials 2022; 113:106666. [PMID: 34971796 DOI: 10.1016/j.cct.2021.106666] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 12/13/2021] [Accepted: 12/23/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Lung cancer is a major cause of death among people experiencing homelessness, with mortality rates more than double those in the general population. Lung cancer screening (LCS) with low-dose computed tomography (LDCT) could reduce lung cancer deaths in this population, although the circumstances of homelessness present multiple barriers to LCS LDCT completion. Patient navigation is a promising strategy for overcoming these barriers. METHODS The Investigating Navigation to Help Advance Lung Equity (INHALE) Study is a pragmatic randomized controlled trial of patient navigation for LCS among individuals receiving primary care at Boston Health Care for the Homeless Program (BHCHP). Three hundred BHCHP patients who meet Medicare/Medicaid criteria for LCS will be randomized 2:1 to usual care with (n = 200) or without (n = 100) LCS navigation. Following a structured, theory-based protocol, the patient navigator assists with each step in the LCS process, providing lung cancer education, facilitating shared decision-making visits with primary care providers (PCPs), assisting in making and attending LCS LDCT appointments, arranging follow-up when needed, and offering tobacco cessation support for smokers. The primary outcome is receipt of LCS LDCT at 6 months. Using a sequential explanatory mixed methods approach, qualitative interviews with participants and PCPs will aid in interpreting and contextualizing the trial results. DISCUSSION This trial will produce the first experimental evidence on patient navigation for cancer screening in a homeless health care setting. Results could inform cancer health equity efforts at the 299 Health Care for the Homeless programs that serve over 900,000 patients annually in the US.
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Affiliation(s)
- Travis P Baggett
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America; Mongan Institute, Massachusetts General Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America; Institute for Research, Quality & Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, MA, United States of America.
| | - Joana Barbosa Teixeira
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Elijah C Rodriguez
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America; New York University Grossman School of Medicine, New York, NY, United States of America
| | - Nillani Anandakugan
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Nora Sporn
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Yuchiao Chang
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America; Mongan Institute, Massachusetts General Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
| | - Sanja Percac-Lima
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America; Mongan Institute, Massachusetts General Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
| | - Elyse R Park
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America; Mongan Institute, Massachusetts General Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
| | - Nancy A Rigotti
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America; Mongan Institute, Massachusetts General Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
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The Feasibility of a Primary Care Based Navigation Service to Support Access to Health and Social Resources: The Access to Resources in the Community (ARC) Model. Int J Integr Care 2022; 22:13. [PMID: 36474646 PMCID: PMC9695153 DOI: 10.5334/ijic.6500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 10/28/2022] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION We established a patient centric navigation model embedded in primary care (PC) to support access to the broad range of health and social resources; the Access to Resources in the Community (ARC) model. METHODS We evaluated the feasibility of ARC using the rapid cycle evaluations of the intervention processes, patient and PC provider surveys, and navigator log data. PC providers enrolled were asked to refer patients in whom they identified a health and/or social need to the ARC navigator. RESULTS Participants: 26 family physicians in four practices, and 82 of the 131 patients they referred. ARC was easily integrated in PC practices and was especially valued in the non-interprofessional practices. Patient overall satisfaction was very high (89%). Sixty patients completed the post-intervention surveys, and 33 reported accessing one or more service(s). CONCLUSION The ARC Model is an innovative approach to reach and support a broad range of patients access needed resources. The Model is feasible and acceptable to PC providers and patients, and has demonstrated potential for improving patients' access to health and social resources. This study has informed a pragmatic randomized controlled trial to evaluate the ARC navigation to an existing web and telephone navigation service (Ontario 211).
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Hyams T, Mueller N, Curbow B, King-Marshall E, Sultan S. Screening for colorectal cancer in people ages 45-49: research gaps, challenges and future directions for research and practice. Transl Behav Med 2021; 12:198-202. [PMID: 34184736 DOI: 10.1093/tbm/ibab079] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Travis Hyams
- National Cancer Institute, Division of Cancer Control and Population Sciences, Office of the Director, Rockville, MD, USA.,Department of Behavioral and Community Health, University of Maryland, College Park, School of Public Health, College Park, MD USA
| | - Nora Mueller
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Barbara Curbow
- Department of Behavioral and Community Health, University of Maryland, College Park, School of Public Health, College Park, MD USA
| | - Evelyn King-Marshall
- Department of Behavioral and Community Health, University of Maryland, College Park, School of Public Health, College Park, MD USA
| | - Shahnaz Sultan
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, MN, USA
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Castro S, Sosa E, Lozano V, Akhtar A, Love K, Duffels J, Raz DJ, Kim JY, Sun V, Erhunmwunsee L. The impact of income and education on lung cancer screening utilization, eligibility, and outcomes: a narrative review of socioeconomic disparities in lung cancer screening. J Thorac Dis 2021; 13:3745-3757. [PMID: 34277066 PMCID: PMC8264678 DOI: 10.21037/jtd-20-3281] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 03/04/2021] [Indexed: 12/12/2022]
Abstract
Non-small cell lung cancer (NSCLC) is the leading cause of cancer deaths in the US and worldwide. In particular, vulnerable populations such as those of low socioeconomic status (SES) are at the highest risk for and suffer the highest mortality from NSCLC. Although lung cancer screening (LCS) has been demonstrated to be a powerful tool to lower NSCLC mortality, it is underutilized by eligible smokers, and disparities in screening are likely to contribute to inequities in NSCLC outcomes. It is imperative that we collect and analyze LCS data focused on individuals of low socioeconomic position to identify and address barriers to LCS utilization and help close the gaps in NSCLC mortality along socioeconomic lines. Toward this end, this review aims to examine published studies that have evaluated the impact of income and education on LCS utilization, eligibility, and outcomes. We searched the PubMed, Ovid MEDLINE, and CINAHL Plus databases for all studies published from January 1, 2010, to October 21, 2020, that discussed socioeconomic-based LCS outcomes. The review reveals that income and education have impact on LCS utilization, eligibility, false positive rates and smoking cessation attempts; however, there is a lack of studies evaluating the impact of SES on LCS follow-up, stage at diagnosis, and treatment. We recommend the intentional inclusion of lower SES participants in LCS studies in order to clarify appropriate eligibility criteria, risk-based metrics and outcomes in this high-risk group. We also anticipate that low SES smokers and their providers will require increased support and education regarding smoking cessation and shared decision-making efforts.
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Affiliation(s)
- Samuel Castro
- Department of Surgery, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Ernesto Sosa
- Department of Populations Sciences, City of Hope National Medical Center, Duarte, CA, USA
| | - Vanessa Lozano
- Department of Populations Sciences, City of Hope National Medical Center, Duarte, CA, USA
| | - Aamna Akhtar
- Department of Surgery, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Kyra Love
- Library Services, City of Hope National Medical Center, Duarte, CA, USA
| | - Jeanette Duffels
- Library Services, City of Hope National Medical Center, Duarte, CA, USA
| | - Dan J Raz
- Department of Surgery, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Jae Y Kim
- Department of Surgery, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Virginia Sun
- Department of Surgery, City of Hope Comprehensive Cancer Center, Duarte, CA, USA.,Department of Populations Sciences, City of Hope National Medical Center, Duarte, CA, USA
| | - Loretta Erhunmwunsee
- Department of Surgery, City of Hope Comprehensive Cancer Center, Duarte, CA, USA.,Department of Populations Sciences, City of Hope National Medical Center, Duarte, CA, USA
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Rivera MP, Katki HA, Tanner NT, Triplette M, Sakoda LC, Wiener RS, Cardarelli R, Carter-Harris L, Crothers K, Fathi JT, Ford ME, Smith R, Winn RA, Wisnivesky JP, Henderson LM, Aldrich MC. Addressing Disparities in Lung Cancer Screening Eligibility and Healthcare Access. An Official American Thoracic Society Statement. Am J Respir Crit Care Med 2020; 202:e95-e112. [PMID: 33000953 PMCID: PMC7528802 DOI: 10.1164/rccm.202008-3053st] [Citation(s) in RCA: 116] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: There are well-documented disparities in lung cancer outcomes across populations. Lung cancer screening (LCS) has the potential to reduce lung cancer mortality, but for this benefit to be realized by all high-risk groups, there must be careful attention to ensuring equitable access to this lifesaving preventive health measure.Objectives: To outline current knowledge on disparities in eligibility criteria for, access to, and implementation of LCS, and to develop an official American Thoracic Society statement to propose strategies to optimize current screening guidelines and resource allocation for equitable LCS implementation and dissemination.Methods: A multidisciplinary panel with expertise in LCS, implementation science, primary care, pulmonology, health behavior, smoking cessation, epidemiology, and disparities research was convened. Participants reviewed available literature on historical disparities in cancer screening and emerging evidence of disparities in LCS.Results: Existing LCS guidelines do not consider racial, ethnic, socioeconomic, and sex-based differences in smoking behaviors or lung cancer risk. Multiple barriers, including access to screening and cost, further contribute to the inequities in implementation and dissemination of LCS.Conclusions: This statement identifies the impact of LCS eligibility criteria on vulnerable populations who are at increased risk of lung cancer but do not meet eligibility criteria for screening, as well as multiple barriers that contribute to disparities in LCS implementation. Strategies to improve the selection and dissemination of LCS in vulnerable groups are described.
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Rutter CM, Knudsen AB, Lin JS, Bouskill KE. Black and White Differences in Colorectal Cancer Screening and Screening Outcomes: A Narrative Review. Cancer Epidemiol Biomarkers Prev 2020; 30:3-12. [PMID: 33144285 DOI: 10.1158/1055-9965.epi-19-1537] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 05/06/2020] [Accepted: 10/21/2020] [Indexed: 11/16/2022] Open
Abstract
Racial disparities in colorectal cancer incidence are widely documented. There are two potential mechanisms for these disparities: differences in access to screening, including screening follow-up, and differences in underlying risk of colorectal cancer. We reviewed the literature for evidence of these two mechanisms. We show that higher colorectal cancer incidence in blacks relative to whites emerged only after the dissemination of screening and describe evidence of racial disparities in screening rates. In contrast to the strong evidence for differences in colorectal cancer screening utilization, there is limited evidence for racial differences in adenoma prevalence. In general, black and white patients who are screened have similar adenoma prevalence, though there is some evidence that advanced adenomas and adenomas in the proximal colon are somewhat more likely in black than white patients. We conclude that higher rates of colorectal cancer incidence among black patients are primarily driven by lower rates of colorectal cancer screening. Our findings highlight the need to increase black patients' access to quality screening to reduce colorectal cancer incidence and mortality.
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Affiliation(s)
| | - Amy B Knudsen
- Institute for Technology Assessment, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jennifer S Lin
- Kaiser Permanente Center for Health Research, Portland, Oregon
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Abuelo C, Ashburner JM, Atlas SJ, Knudsen A, Morrill J, Corona P, Shtasel D, Percac-Lima S. Colorectal Cancer Screening Patient Navigation for Patients with Mental Illness and/or Substance Use Disorder: Pilot Randomized Control Trial. J Dual Diagn 2020; 16:438-446. [PMID: 32762637 DOI: 10.1080/15504263.2020.1802542] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Colorectal cancer (CRC) is the second leading cause of cancer death in the US. Screening has decreased CRC mortality. However, disadvantaged patients, particularly those with mental illness or substance use disorder (SUD), are less likely to be screened. The aim of this trial was to evaluate the impact of a patient navigation program on CRC screening in patients with mental illness and/or SUD. METHODS A pilot randomized nonblinded controlled trial was conducted from January to June 2017 in an urban community health center serving a low-income population. We randomized 251 patients aged 50-74 years with mental illness and/or SUD diagnosis overdue for CRC screening to intervention (n = 126) or usual care (n = 125) stratified by mental illness, SUD, or dual diagnosis. Intervention group patients received a letter followed by a phone call from patient navigators. Navigators helped patients overcome their individual barriers to CRC screening including: education, scheduling, explanation of bowel preparation, lack of transportation or accompaniment to appointments. If patient refused colonoscopy, navigators offered fecal occult blood testing. The main measure was proportion of patients completing CRC screening in intervention and usual care groups. RESULTS Navigators contacted 85 patients (67%) in the intervention group and 26 declined to participate. In intention-to treat analysis, more patients in the intervention group received CRC screening than in the usual care group, 19% versus 10.4% (p = .04). Among 56 intervention patients who received navigation, 19 completed screening (33.9% versus 10.4% in the control group, p = .001). In the subgroup of patients with SUD, 20% in the intervention group were screened compared to none in the usual care group (p = .05). CONCLUSIONS A patient navigation program improved CRC screening rates in patients with mental illness and/or SUD. Larger studies in diverse care settings are needed to demonstrate generalizability and explore which modality of CRC screening is most acceptable and which navigator activities are most effective for this vulnerable population. TRIALS REGISTRATION NUMBER 2016P001322.
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Affiliation(s)
- Carolina Abuelo
- Massachusetts General Hospital, Division of General Internal Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeffrey M Ashburner
- Massachusetts General Hospital, Division of General Internal Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Steven J Atlas
- Massachusetts General Hospital, Division of General Internal Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Amy Knudsen
- Massachusetts General Hospital Institute for Technology Assessment, Harvard Medical School, Boston, Massachusetts, USA
| | - James Morrill
- Massachusetts General Hospital, Division of General Internal Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Derri Shtasel
- Massachusetts General Hospital, Division of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Sanja Percac-Lima
- Massachusetts General Hospital, Division of General Internal Medicine, Harvard Medical School, Boston, Massachusetts, USA
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13
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Nelson HD, Cantor A, Wagner J, Jungbauer R, Fu R, Kondo K, Stillman L, Quiñones A. Effectiveness of Patient Navigation to Increase Cancer Screening in Populations Adversely Affected by Health Disparities: a Meta-analysis. J Gen Intern Med 2020; 35:3026-3035. [PMID: 32700218 PMCID: PMC7573022 DOI: 10.1007/s11606-020-06020-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 06/30/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND This study evaluates the effectiveness of patient navigation to increase screening for colorectal, breast, and cervical cancer in populations adversely affected by health care disparities. METHODS Eligible studies were identified through English-language searches of Ovid® MEDLINE®, PsycINFO®, SocINDEX, and Veterans Affairs Health Services database (January 1, 1996, to July 5, 2019) and manual review of reference lists. Randomized trials and observational studies of relevant populations that evaluated the effectiveness of patient navigation on screening rates for colorectal, breast, or cervical cancer compared with usual or alternative care comparison groups were included. Two investigators independently abstracted study data and assessed study quality and applicability using criteria adapted from the U.S. Preventive Services Task Force. Discrepancies were resolved by consensus with a third reviewer. Results were combined using profile likelihood random effects models. RESULTS Thirty-seven studies met inclusion criteria (28 colorectal, 11 breast, 4 cervical cancers including 3 trials with multiple cancer types). Screening rates were higher with patient navigation for colorectal cancer overall (risk ratio [RR] 1.64; 95% confidence interval [CI] 1.42 to 1.92; I2 = 93.7%; 22 trials) and by type of test (fecal occult blood or immunohistochemistry testing [RR 1.69; 95% CI 1.33 to 2.15; I2 = 80.5%; 6 trials]; colonoscopy/endoscopy [RR 2.08; 95% CI 1.08 to 4.56; I2 = 94.6%; 6 trials]). Screening was also higher with navigation for breast cancer (RR 1.50; 95% CI 1.22 to 1.91; I2 = 98.6%; 10 trials) and cervical cancer (RR 1.11; 95% CI 1.05 to 1.19; based on the largest trial). The high heterogeneity of cervical cancer studies prohibited meta-analysis. Results were similar for colorectal and breast cancer regardless of prior adherence to screening guidelines, follow-up time, and study quality. CONCLUSIONS In populations adversely affected by disparities, colorectal, breast, and cervical cancer screening rates were higher in patients provided navigation services. Registration: PROSPERO: CRD42018109263.
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Affiliation(s)
- Heidi D Nelson
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA. .,Department of Medicine, Oregon Health & Science University, Portland, OR, USA.
| | - Amy Cantor
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA.,Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Jesse Wagner
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA
| | - Rebecca Jungbauer
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA
| | - Rongwei Fu
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA.,School of Public Health, Oregon Health & Science University-Portland State University, Portland, OR, USA
| | - Karli Kondo
- Evidence-based Synthesis Program, Portland VA Health Care System, Portland, OR, USA.,Office of Research Integrity, Oregon Health & Science University, Portland, OR, USA
| | - Lucy Stillman
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA
| | - Ana Quiñones
- School of Public Health, Oregon Health & Science University-Portland State University, Portland, OR, USA
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Freije SL, Holmes JA, Rachidi S, Ellsworth SG, Zellars RC, Lautenschlaeger T. Demographic factors associated with missed follow-up among solid tumor patients treated at a large multi-site academic institution. Future Oncol 2020; 16:2635-2643. [PMID: 32976060 DOI: 10.2217/fon-2020-0425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To identify demographic predictors of patients who miss oncology follow-up, considering that missed follow-up has not been well studies in cancer patients. Methods: Patients with solid tumors diagnosed from 2007 to 2016 were analyzed (n = 16,080). Univariate and multivariable logistic regression models were constructed to examine predictors of missed follow-up. Results: Our study revealed that 21.2% of patients missed ≥1 follow-up appointment. African-American race (odds ratio [OR] 1.33; 95% CI: 1.17-1.51), Medicaid insurance (OR 1.59; 1.36-1.87), no insurance (OR 1.66; 1.32-2.10) and rural residence (OR 1.78; 1.49-2.13) were associated with missed follow-up. Conclusion: Many cancer patients miss follow-up, and inadequate follow-up may influence cancer outcomes. Further research is needed on how to address disparities in follow-up care in high-risk patients.
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Affiliation(s)
- Samantha L Freije
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Jordan A Holmes
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Saleh Rachidi
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.,Department of Dermatology, Johns Hopkins Medicine, Baltimore, MD 21287, USA
| | - Susannah G Ellsworth
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Richard C Zellars
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Tim Lautenschlaeger
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
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15
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Nelson HD, Cantor A, Wagner J, Jungbauer R, Quiñones A, Stillman L, Kondo K. Achieving Health Equity in Preventive Services: A Systematic Review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med 2020; 172:258-271. [PMID: 31931527 DOI: 10.7326/m19-3199] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Disadvantaged populations in the United States experience disparities in the use of preventive health services. PURPOSE To examine effects of barriers that create health disparities in 10 recommended preventive services for adults, and to evaluate the effectiveness of interventions to reduce them. DATA SOURCES English-language searches of Ovid MEDLINE, PsycINFO, SocINDEX, and the Veterans Affairs Health Services database (1 January 1996 to 5 July 2019); reference lists. STUDY SELECTION Trials, observational studies with comparison groups, and systematic reviews of populations adversely affected by disparities that reported effects of barriers on use of any of the 10 selected preventive services or that reported the effectiveness of interventions to reduce disparities in use of a preventive service by improving intermediate or clinical outcomes. DATA EXTRACTION Dual extraction and assessment of study quality, strength of evidence, and evidence applicability. DATA SYNTHESIS No studies reported effects of provider-specific barriers on preventive service use. Eighteen studies reporting effects of patient barriers, such as insurance coverage or lack of a regular provider, on preventive service use had mixed and inconclusive findings. Studies of patient-provider interventions (n = 12), health information technologies (n = 11), and health system interventions (n = 88) indicated higher cancer screening rates with patient navigation; telephone calls, prompts, and other outreach methods; reminders involving lay health workers; patient education; risk assessment, counseling, and decision aids; screening checklists; community engagement; and provider training. Single studies showed that clinician-delivered and technology-assisted interventions improved rates of smoking cessation and weight loss, respectively. LIMITATION Insufficient or low strength of evidence and applicability for most interventions except patient navigation, telephone calls and prompts, and reminders involving lay health workers. CONCLUSION In populations adversely affected by disparities, patient navigation, telephone calls and prompts, and reminders involving lay health workers increase cancer screening. PRIMARY FUNDING SOURCE National Institutes of Health Office of Disease Prevention through an interagency agreement with the Agency for Healthcare Research and Quality. (PROSPERO: CRD42018109263).
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Affiliation(s)
- Heidi D Nelson
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland, Oregon (H.D.N., A.C., J.W., R.J., L.S.)
| | - Amy Cantor
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland, Oregon (H.D.N., A.C., J.W., R.J., L.S.)
| | - Jesse Wagner
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland, Oregon (H.D.N., A.C., J.W., R.J., L.S.)
| | - Rebecca Jungbauer
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland, Oregon (H.D.N., A.C., J.W., R.J., L.S.)
| | - Ana Quiñones
- Oregon Health & Science University-Portland State University, Portland, Oregon (A.Q.)
| | - Lucy Stillman
- Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland, Oregon (H.D.N., A.C., J.W., R.J., L.S.)
| | - Karli Kondo
- Portland VA Health Care System and Oregon Health & Science University, Portland, Oregon (K.K.)
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16
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Sharma N, Harris E, Lloyd J, Mistry SK, Harris M. Community health workers involvement in preventative care in primary healthcare: a systematic scoping review. BMJ Open 2019; 9:e031666. [PMID: 31852698 PMCID: PMC6937114 DOI: 10.1136/bmjopen-2019-031666] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 11/04/2019] [Accepted: 11/25/2019] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES To review effective models of community health worker (CHW) involvement in preventive care for disadvantaged culturally and linguistically diverse (CALD) patients in primary healthcare (PHC) that may be applicable to the Australian context. DESIGN Systematic scoping review. DATA SOURCES The studies were gathered through searching Medline, EMBASE, EMCARE, PsycINFO, CINAHL and online portals of relevant organisations. ELIGIBILITY CRITERIA All selected studies were original research studies which essentially evaluated preventive intervention undertake by CHWs in PHC. The intervened population were adults with or without diagnosed chronic health disease, culturally and linguistically diverse, or vulnerable due to geographic, economic and/or cultural characteristics that impede or compromise their access to healthcare. DATA EXTRACTION AND SYNTHESIS Data extraction was undertaken systematically in an excel spreadsheet while the findings were synthesised in a narrative manner. The quality appraisal of the selected studies was performed using effective public health practice project quality assessment tool. RESULTS A total of 1066 articles were identified during the initial search of six bibliographic databases. After screening the title, abstract and full text, 37 articles met the selection and methodological criteria and underwent data extraction. A high-quality evidence-base supporting the positive impact of CHWs supporting patients' access to healthcare and influencing positive behaviour change was found. Positive impacts of CHW interventions included improvements in clinical disease indicators, screening rates and behavioural change. Education-focused interventions were more effective in improving patient behaviour, whereas navigation interventions were most effective in improving access to services. Implementation was enhanced by cultural and linguistic congruence and specific training of CHWs in the intervention but reduced by short duration interventions, dropouts and poor adherence of patients. CONCLUSION The evidence generated from this systematic scoping review demonstrates the contribution of CHWs to improving access to preventive care for patients from CALD and disadvantaged backgrounds by providing both education and navigational interventions. More research is needed on CHW training and the incorporation of CHWs into primary health care (PHC) teams.
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Affiliation(s)
- Nila Sharma
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, New South Wales, Australia
| | - Elizabeth Harris
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, New South Wales, Australia
| | - Jane Lloyd
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, New South Wales, Australia
| | - Sabuj Kanti Mistry
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, New South Wales, Australia
| | - Mark Harris
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, New South Wales, Australia
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17
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Lopez D, Pratt-Chapman ML, Rohan EA, Sheldon LK, Basen-Engquist K, Kline R, Shulman LN, Flores EJ. Establishing effective patient navigation programs in oncology. Support Care Cancer 2019; 27:1985-1996. [PMID: 30887125 PMCID: PMC8811719 DOI: 10.1007/s00520-019-04739-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 03/07/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE Recent advances in cancer treatment have resulted in greatly improved survival, and yet many patients in the USA have not benefited due to poor access to healthcare and difficulty accessing timely care across the cancer care continuum. Recognizing these issues and the need to facilitate discussions on how to improve navigation services for patients with cancer, the National Cancer Policy Forum of the National Academies of Sciences, Engineering, and Medicine (NASEM) held a workshop entitled, "Establishing Effective Patient Navigation Programs in Oncology. The purpose of this manuscript is to disseminate the conclusions of this workshop while providing a clinically relevant review of patient navigation in oncology. DESIGN Narrative literature review and summary of workshop discussions RESULTS: Patient navigation has been shown to be effective at improving outcomes throughout the spectrum of cancer care. Work remains to develop consensus on scope of practice and evaluation criteria and to align payment incentives and policy. CONCLUSION Patient navigation plays an essential role in overcoming patient- and system-level barriers to improve access to cancer care and outcomes for those most in need.
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Affiliation(s)
| | | | | | | | | | - Ron Kline
- Centers for Medicare & Medicaid Innovation, Baltimore, MD, USA
| | - Lawrence N Shulman
- University of Pennsylvania Abramson Cancer Center, Philadelphia, PA, USA
| | - Efren J Flores
- Massachusetts General Hospital, 55 Fruit St, Boston, MA, USA.
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18
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Patient Satisfaction with Navigator Interpersonal Relationship (PSN-I): item-level psychometrics using IRT analysis. Support Care Cancer 2019; 28:541-550. [PMID: 31076896 DOI: 10.1007/s00520-019-04833-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 04/23/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Patient navigation (PN) is a promising intervention to eliminate cancer health inequities. Patient navigators play a critical role in the navigation process. Patients' satisfaction with navigators is important in determining the effectiveness of PN programs. We applied item response theory (IRT) analysis to establish item-level psychometric properties for the Patient Satisfaction with Interpersonal Relationship with Navigators (PSN-I). METHODS We conducted a confirmatory factor analysis (CFA) to establish unidimensionality of the 9-item PSN-I in 751 cancer patients (68% female) between 18 and 86 years old. We fitted unidimensional IRT models-unconstrained graded response model (GRM) and Rasch model-to PSN-I data, and compared model fit using likelihood ratio (LR) test and information criteria. We obtained item parameter estimates (IPEs), item category/operating characteristic curves, and item/test information curves for the better fitting model. RESULTS CFA with diagonally weighted least squares confirmed that the one-factor model fit the data (RMSEA = 0.047, 95% CI = 0.033-0.060, and CFI ≈ 1). Responses to PSN-I items clustered into the 4th and 5th categories. We aggregated the first three response categories to provide stable parameter estimates for both IRT models. The GRM fit the data significantly better than the Rasch model (LR = 80.659, df = 8, p < 0.001). Akaike's information coefficient (6384.978 vs. 6320.319) and Bayesian information coefficient (6471.851 vs. 6443.771) were lower for the GRM. IPEs showed substantial variation in items' discriminating power (1.80-3.35) for GRM. CONCLUSIONS This IRT analysis confirms the latent structure of the PSN-I and supports its use as a valid and reliable measure of latent satisfaction with PN.
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19
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Bernardo BM, Zhang X, Beverly Hery CM, Meadows RJ, Paskett ED. The efficacy and cost-effectiveness of patient navigation programs across the cancer continuum: A systematic review. Cancer 2019; 125:2747-2761. [PMID: 31034604 DOI: 10.1002/cncr.32147] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 03/04/2019] [Accepted: 03/27/2019] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Brittany M Bernardo
- Division of Population Sciences, Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio
| | - Xiaochen Zhang
- Division of Population Sciences, Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio
| | - Chloe M Beverly Hery
- Division of Population Sciences, Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio
| | - Rachel J Meadows
- Division of Population Sciences, Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio.,Division of Epidemiology, College of Public Health, Ohio State University, Columbus, Ohio
| | - Electra D Paskett
- Division of Population Sciences, Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio.,Division of Epidemiology, College of Public Health, Ohio State University, Columbus, Ohio.,Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio.,Division of Cancer Prevention and Control, Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, Ohio
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20
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A Multi-Level Fit-Based Quality Improvement Initiative to Improve Colorectal Cancer Screening in a Managed Care Population. Clin Transl Gastroenterol 2018; 9:177. [PMID: 30177700 PMCID: PMC6120887 DOI: 10.1038/s41424-018-0046-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 07/19/2018] [Indexed: 12/28/2022] Open
Abstract
Introduction Colorectal cancer (CRC) is a common but largely preventable disease with suboptimal screening rates despite national guidelines to screen individuals age 50–75. Single-component interventions aimed to improve screening uptake only modestly improve rates; data suggest that multi-modal approaches may be more effective. Methods We designed, implemented, and evaluated the impact of a multi-modal intervention on CRC screening uptake among unscreened patients in a large managed care population. Patient-level components included a mailed letter with education about screening options and pre-colonoscopy telephone counseling. For providers, we facilitated communication of screening test results and work-flow for abnormal results. System-level modifications included establishment of a patient navigator, expedited work-up for abnormal results, and stream-lined colonoscopy scheduling. We measured the rate of screening uptake overall, screening uptake by modality, change in the proportion of the population screened, and positive fecal immunochemical test (FIT) follow-up rates in the 1-year study period. Results There were 5093 patients in the intervention cohort. Of these, 33.2% participated in FIT or colonoscopy screening within 1 year of the mailing. A total of 1078 (21.2%) participants completed a FIT and 611 (12.0%) completed a screening colonoscopy. The screening rate in the managed care population increased from 65.1 to 76.6%. Fifty-nine patients (5.5%) had a positive FIT, of which 30 (50.8%) completed a diagnostic colonoscopy. Conclusion Multi-modal interventions can result in substantial improvement in CRC screening uptake in large and diverse managed care populations. Translational Impact Health systems should shift their focus from single-level to multi-level interventions when addressing barriers to CRC screening.
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21
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Katz ML, Young GS, Zimmermann BJ, Tatum CM, Paskett ED. Assessing Colorectal Cancer Screening Barriers by Two Methods. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2018; 33:536-543. [PMID: 27933460 PMCID: PMC7076560 DOI: 10.1007/s13187-016-1148-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Colorectal cancer (CRC) is commonly diagnosed in the USA despite screening tests that have decreased CRC incidence and mortality. Finding the best method to identify patient-level screening barriers is important to improve CRC screening rates. A group-randomized trial was conducted among ten primary-care clinics. Clinics were randomized to a multi-level (clinic, provider, patient) CRC screening intervention or usual care (2007-2013). Subsequent to clinic- and provider-level interventions, a three-step, patient-level intervention was conducted. One step of the patient-level intervention was a CRC screening barriers counseling call conducted by a lay health advisor (LHA). During the call, two methods were used to identify CRC screening barriers. An open-ended question was used first to determine why participants had not completed screening (without probes). Subsequently, the LHA read a list of additional potential screening barriers and asked participants whether each barrier was applicable (with probes). A generalized estimating equation approach was used to compare the two methods. Participants (n = 109) were female (59%), had a mean age of 57.2 years, and were white (67%) or black (31%). Most participants had some college education or a college degree (79%), annual household income $30,000+ (60%), and health insurance (80%). The number of CRC screening barriers increased with probing compared to the open-ended question format (OR 2.10, 95% CI 1.92-2.31; p < 0.01). The ranking of reported CRC screening barriers did not vary by assessment method. However, the methodology used to document CRC screening barriers may influence the content of patient-directed interventions.
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Affiliation(s)
- Mira L Katz
- College of Public Health, The Ohio State University, Suite 525 1590 North High Street, Columbus, OH, 43201, USA.
- Comprehensive Cancer Center, The Ohio State University, Suite 525 1590 North High Street, Columbus, OH, 43201, USA.
- College of Medicine, The Ohio State University, Suite 525 1590 North High Street, Columbus, OH, 43201, USA.
| | - Gregory S Young
- Comprehensive Cancer Center, The Ohio State University, Suite 525 1590 North High Street, Columbus, OH, 43201, USA
| | - Barret J Zimmermann
- College of Public Health, The Ohio State University, Suite 525 1590 North High Street, Columbus, OH, 43201, USA
- Comprehensive Cancer Center, The Ohio State University, Suite 525 1590 North High Street, Columbus, OH, 43201, USA
| | - Cathy M Tatum
- Comprehensive Cancer Center, The Ohio State University, Suite 525 1590 North High Street, Columbus, OH, 43201, USA
| | - Electra D Paskett
- College of Public Health, The Ohio State University, Suite 525 1590 North High Street, Columbus, OH, 43201, USA
- Comprehensive Cancer Center, The Ohio State University, Suite 525 1590 North High Street, Columbus, OH, 43201, USA
- College of Medicine, The Ohio State University, Suite 525 1590 North High Street, Columbus, OH, 43201, USA
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22
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Hartzler AL, Tuzzio L, Hsu C, Wagner EH. Roles and Functions of Community Health Workers in Primary Care. Ann Fam Med 2018; 16:240-245. [PMID: 29760028 PMCID: PMC5951253 DOI: 10.1370/afm.2208] [Citation(s) in RCA: 115] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 12/13/2017] [Accepted: 01/11/2017] [Indexed: 11/09/2022] Open
Abstract
Community health workers have potential to enhance primary care access and quality, but remain underutilized. To provide guidance on their integration, we characterized roles and functions of community health workers in primary care through a literature review and synthesis. Analysis of 30 studies identified 12 functions (ie, care coordination, health coaching, social support, health assessment, resource linking, case management, medication management, remote care, follow-up, administration, health education, and literacy support) and 3 prominent roles representing clusters of functions: clinical services, community resource connections, and health education and coaching. We discuss implications for community health worker training and clinical support in primary care.
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Affiliation(s)
- Andrea L Hartzler
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, Washington
| | - Leah Tuzzio
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Clarissa Hsu
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Edward H Wagner
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
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23
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Percac-Lima S, Pace LE, Nguyen KH, Crofton CN, Normandin KA, Singer SJ, Rosenthal MB, Chien AT. Diagnostic Evaluation of Patients Presenting to Primary Care with Rectal Bleeding. J Gen Intern Med 2018; 33:415-422. [PMID: 29302885 PMCID: PMC5880768 DOI: 10.1007/s11606-017-4273-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 10/31/2017] [Accepted: 12/05/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND Rectal bleeding is a common, frequently benign problem that can also be an early sign of colorectal cancer. Diagnostic evaluation for rectal bleeding is complex, and clinical practice may deviate from available guidelines. OBJECTIVE To assess the degree to which primary care physicians document risk factors for colorectal cancer among patients with rectal bleeding and order colonoscopies when indicated, and the likelihood of physicians ordering and patients receiving recommended colonoscopies based on demographic characteristics, visit patterns, and clinical presentations. DESIGN Cross-sectional study using explicit chart abstraction methods. PARTICIPANTS Three hundred adults, 40-80 years of age, presenting with rectal bleeding to 15 academically affiliated primary care practices between 2012 and 2016. MAIN MEASURES 1) The frequency at which colorectal cancer risk factors were documented in patients' charts, 2) the frequency at which physicians ordered colonoscopies and patients received them, and 3) the odds of ordering and patients receiving recommended colonoscopies based on patient demographic characteristics, visit patterns, and clinical presentations. KEY RESULTS Risk factors for colorectal cancer were documented between 9% and 66% of the time. Most patients (89%) with rectal bleeding needed a colonoscopy according to a clinical guideline. Physicians placed colonoscopy orders for 74% of these patients, and 56% completed the colonoscopy within a year (36% within 60 days). The odds of physicians ordering recommended colonoscopies were significantly higher in patients aged 50-64 years of age than in those aged 40-50 years (OR = 2.23, 95% CI: 1.04, 4.80), and for patients whose most recent colonoscopy was 5 or more years ago (OR = 4.04, 95% CI: 1.50, 10.83). The odds of physicians ordering and patients receiving recommended colonoscopies were significantly lower for each primary care visit unrelated to rectal bleeding (OR = 0.85, 95% CI: 0.75, 0.96). CONCLUSIONS Diagnostic evaluation of patients presenting to primary care with rectal bleeding may be suboptimal because of inadequate risk factor assessment and prioritization of patients' other concurrent medical problems.
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Affiliation(s)
- Sanja Percac-Lima
- Harvard Medical School, Boston, MA, USA.
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.
| | - Lydia E Pace
- Harvard Medical School, Boston, MA, USA
- Division of Women's Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Kevin H Nguyen
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Charis N Crofton
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Katharine A Normandin
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Sara J Singer
- Harvard Medical School, Boston, MA, USA
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Mongan Institute, Massachusetts General Hospital, Boston, MA, USA
| | - Meredith B Rosenthal
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Alyna T Chien
- Harvard Medical School, Boston, MA, USA
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
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24
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Sunny A, Rustveld L. The Role of Patient Navigation on Colorectal Cancer Screening Completion and Education: a Review of the Literature. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2018; 33:251-259. [PMID: 27878766 DOI: 10.1007/s13187-016-1140-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
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.
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Affiliation(s)
- Ajeesh Sunny
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Luis Rustveld
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA.
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25
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Percac-Lima S, Ashburner JM, Rigotti NA, Park ER, Chang Y, Kuchukhidze S, Atlas SJ. Patient navigation for lung cancer screening among current smokers in community health centers a randomized controlled trial. Cancer Med 2018; 7:894-902. [PMID: 29464877 PMCID: PMC5852345 DOI: 10.1002/cam4.1297] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 11/22/2017] [Accepted: 11/26/2017] [Indexed: 12/14/2022] Open
Abstract
Annual chest computed tomography (CT) can decrease lung cancer mortality in high-risk individuals. Patient navigation improves cancer screening rates in underserved populations. Randomized controlled trial was conducted from February 2016 to January 2017 to evaluate the impact of a patient navigation program on lung cancer screening (LCS) among current smokers in five community health centers (CHCs) affiliated with an academic primary care network. We randomized 1200 smokers aged 55-77 years to intervention (n = 400) or usual care (n = 800). Navigators contacted patients to determine LCS eligibility, introduce shared decision making about screening, schedule appointments with primary care physicians (PCPs), and help overcome barriers to obtaining screening and follow-up. Control patients received usual care. The main outcome was the proportion of patients who had any chest CT. Secondary outcomes were the proportion of patients contacted, proportion receiving LCS CTs, screening results and number of lung cancers diagnosed. Of the 400 intervention patients, 335 were contacted and 76 refused participation. Of the 259 participants, 124 (48%) were ineligible for screening; 119 had smoked <30 pack-years, and five had competing comorbidities. Among the 135 eligible participants in the intervention group, 124 (92%) had any chest CT performed. In intention-to-treat analyses, 124 intervention patients (31%) had any chest CT versus 138 control patients (17.3%, P < 0.001). LCS CTs were performed in 94 intervention patients (23.5%) versus 69 controls (8.6%, P < 0.001). A total of 20% of screened patients required follow-up. Lung cancer was diagnosed in eight intervention (2%) and four control (0.5%) patients. A patient navigation program implemented in CHCs significantly increased LCS among high-risk current smokers.
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Affiliation(s)
- Sanja Percac-Lima
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Massachusetts General Hospital Cancer Center, Boston, Massachusetts
| | - Jeffrey M Ashburner
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Nancy A Rigotti
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Elyse R Park
- Mongan Institute for Health Policy, Massachusetts General Hospital, Boston, Massachusetts
| | - Yuchiao Chang
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Steven J Atlas
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
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26
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Improving cancer patient emergency room utilization: A New Jersey state assessment. Cancer Epidemiol 2017; 51:15-22. [DOI: 10.1016/j.canep.2017.09.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 09/20/2017] [Accepted: 09/27/2017] [Indexed: 01/07/2023]
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27
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Molina Y, Kim SJ, Berrios N, Glassgow AE, San Miguel Y, Darnell JS, Pauls H, Vijayasiri G, Warnecke RB, Calhoun EA. Patient Navigation Improves Subsequent Breast Cancer Screening After a Noncancerous Result: Evidence from the Patient Navigation in Medically Underserved Areas Study. J Womens Health (Larchmt) 2017; 27:317-323. [PMID: 28933653 DOI: 10.1089/jwh.2016.6120] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Past efforts to assess patient navigation on cancer screening utilization have focused on one-time uptake, which may not be sufficient in the long term. This is partially due to limited resources for in-person, longitudinal patient navigation. We examine the effectiveness of a low-intensity phone- and mail-based navigation on multiple screening episodes with a focus on screening uptake after receiving noncancerous results during a previous screening episode. METHODS The is a secondary analysis of patients who participated in a randomized controlled patient navigation trial in Chicago. Participants include women referred for a screening mammogram, aged 50-74 years, and with a history of benign/normal screening results. Navigation services focused on identification of barriers and intervention via shared decision-making processes. A multivariable logistic regression intent-to-treat model was used to examine differences in odds of obtaining a screening mammogram within 2 years of the initial mammogram (yes/no) between navigated and non-navigated women. Sensitivity analyses were conducted to explore patterns across subsets of participants (e.g., navigated women successfully contacted before the initial appointment; women receiving care at Hospital C). RESULTS The final sample included 2,536 women (741 navigated, 1,795 non-navigated). Navigated women exhibited greater odds of obtaining subsequent screenings relative to women in the standard care group in adjusted models and analyses including women who received navigation before the initial appointment. CONCLUSIONS Our findings suggest that low-intensity navigation services can improve follow-up screening among women who receive a noncancerous result. Further investigation is needed to confirm navigation's impacts on longitudinal screening.
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Affiliation(s)
- Yamile Molina
- 1 School of Public Health, Cancer Center, Center for Research on Women and Gender, University of Illinois at Chicago , Chicago, Illinois
| | - Sage J Kim
- 2 School of Public Health, University of Illinois at Chicago , Chicago, Illinois
| | - Nerida Berrios
- 2 School of Public Health, University of Illinois at Chicago , Chicago, Illinois
| | | | - Yazmin San Miguel
- 4 Department of Epidemiology, University of California San Diego, San Diego State University , San Diego, California
| | - Julie S Darnell
- 5 Health Sciences Division, Loyola University , Chicago, Illinois
| | - Heather Pauls
- 6 College of Nursing, University of Illinois at Chicago , Chicago, Illinois
| | - Ganga Vijayasiri
- 7 Institute for Health Research and Policy, University of Illinois at Chicago , Chicago, Illinois
| | - Richard B Warnecke
- 7 Institute for Health Research and Policy, University of Illinois at Chicago , Chicago, Illinois
| | - Elizabeth A Calhoun
- 2 School of Public Health, University of Illinois at Chicago , Chicago, Illinois
- 8 University of Arizona , Tucson, Arizona
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28
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Thomas K, Martin T, Gao A, Ahn C, Wilhelm H, Schwartz DL. Interruptions of Head and Neck Radiotherapy Across Insured and Indigent Patient Populations. J Oncol Pract 2017; 13:e319-e328. [PMID: 28267393 DOI: 10.1200/jop.2016.017863] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose: Radiotherapy for head and neck cancer is a cornerstone of care, requiring 30 to 35 days of treatment over 6 to 7 weeks. Diligent patient compliance is crucial, and unplanned treatment interruptions reduce cure rates. We studied interruption rates in private carrier–insured and Medicare-insured populations versus indigent populations served by a single academic health system. Materials and Methods: A retrospective cohort study of electronic medical and billing records was performed analyzing treatment interruptions between January 2011 and December 2014. The study included 564 patients with head and neck cancer prescribed radiotherapy and referred from clinics run by University of Texas Southwestern Medical Center (UTSW) and the Parkland Health and Hospital System (PHHS), which provides indigent care to Dallas County, Texas. Results: Three-hundred sixteen patients (56%) had a treatment break; 114 patients missed a single session, and 202 patients missed multiple treatments. Seventy percent of PHHS patients had treatment delays compared with 47% of UTSW patients ( P < .001). The number of interrupted days in the PHHS population was nearly twice that observed in UTSW patients. PHHS patients most commonly missed treatment for nonmedical or logistical reasons. Delay was predictive for local recurrence ( P < .001) and overall survival ( P < .001). In compliant patients, there was no significant difference in local recurrence ( P = .43) or overall survival ( P = .27) across referral sites. However, among noncompliant patients, there was a higher likelihood for local recurrence in the PHHS cohort ( P = .016). Multivariable modeling suggested treatment interruption to be a key driver of outcome differences across referral sites. Conclusion: Survival outcomes in our at-risk population were inferior to those in patients insured by commercial carriers or Medicare. Treatment interruption predicted for poor outcome across all patients but was disproportionately experienced by at-risk patients. These results highlight cancer control needs specific to disadvantaged communities at risk for poor treatment compliance.
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Affiliation(s)
- Kimberly Thomas
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX; and University of Tennessee Health Sciences Center-West Cancer Center, Methodist University Hospital, Memphis, TN
| | - Travis Martin
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX; and University of Tennessee Health Sciences Center-West Cancer Center, Methodist University Hospital, Memphis, TN
| | - Ang Gao
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX; and University of Tennessee Health Sciences Center-West Cancer Center, Methodist University Hospital, Memphis, TN
| | - Chul Ahn
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX; and University of Tennessee Health Sciences Center-West Cancer Center, Methodist University Hospital, Memphis, TN
| | - Holly Wilhelm
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX; and University of Tennessee Health Sciences Center-West Cancer Center, Methodist University Hospital, Memphis, TN
| | - David L. Schwartz
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX; and University of Tennessee Health Sciences Center-West Cancer Center, Methodist University Hospital, Memphis, TN
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29
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Pennell NA, Dicker AP, Tran C, Jim HSL, Schwartz DL, Stepanski EJ. mHealth: Mobile Technologies to Virtually Bring the Patient Into an Oncology Practice. Am Soc Clin Oncol Educ Book 2017; 37:144-154. [PMID: 28561720 DOI: 10.1200/edbk_176093] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Accompanied by the change in the traditional medical landscape, advances in wireless technology have led to the development of telehealth or mobile health (mHealth), which offers an unparalleled opportunity for health care providers to continually deliver high-quality care. This revolutionary shift makes the patient the consumer of health care and empowers patients to be the driving force of management of their own health through mobile devices and wearable technology. This article presents an overview of technology as it pertains to clinical practice considerations. Telemedicine is changing the way clinical care is delivered without regard for proximity to the patient, whereas nonclinical telehealth applications affect distance education for consumers or clinicians, meetings, research, continuing medical education, and health care management. Technology has the potential to reduce administrative burdens and improve both efficiency and quality of care delivery in the clinic. Finally, the potential for telehealth approaches as cost-effective ways to improve adherence to treatment is explored. As telehealth advances, health care providers must understand the fundamental framework for applying telehealth strategies to incorporate into successful clinical practice.
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Affiliation(s)
- Nathan A Pennell
- From the Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH; Department of Radiation Oncology, The Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, PA; Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL; Department of Radiation Oncology, University of Tennessee Health Sciences Center West Cancer Clinic; University of Tennessee Health Sciences Center, Vector Oncology, Memphis, TN
| | - Adam P Dicker
- From the Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH; Department of Radiation Oncology, The Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, PA; Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL; Department of Radiation Oncology, University of Tennessee Health Sciences Center West Cancer Clinic; University of Tennessee Health Sciences Center, Vector Oncology, Memphis, TN
| | - Christine Tran
- From the Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH; Department of Radiation Oncology, The Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, PA; Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL; Department of Radiation Oncology, University of Tennessee Health Sciences Center West Cancer Clinic; University of Tennessee Health Sciences Center, Vector Oncology, Memphis, TN
| | - Heather S L Jim
- From the Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH; Department of Radiation Oncology, The Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, PA; Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL; Department of Radiation Oncology, University of Tennessee Health Sciences Center West Cancer Clinic; University of Tennessee Health Sciences Center, Vector Oncology, Memphis, TN
| | - David L Schwartz
- From the Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH; Department of Radiation Oncology, The Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, PA; Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL; Department of Radiation Oncology, University of Tennessee Health Sciences Center West Cancer Clinic; University of Tennessee Health Sciences Center, Vector Oncology, Memphis, TN
| | - Edward J Stepanski
- From the Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH; Department of Radiation Oncology, The Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, PA; Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL; Department of Radiation Oncology, University of Tennessee Health Sciences Center West Cancer Clinic; University of Tennessee Health Sciences Center, Vector Oncology, Memphis, TN
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Naylor K, Fritz C, Polite B, Kim K. Evaluating screening colonoscopy quality in an uninsured urban population following patient navigation. Prev Med Rep 2016; 5:194-199. [PMID: 28070476 PMCID: PMC5219647 DOI: 10.1016/j.pmedr.2016.12.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 12/20/2016] [Accepted: 12/26/2016] [Indexed: 12/22/2022] Open
Abstract
Patient navigation (PN) increases screening colonoscopy completion in minority and uninsured populations. However, colonoscopy quality is under-reported in the setting of PN and quality indicators have often failed to meet benchmark standards. This study investigated screening colonoscopy quality indicators after year-one of a PN initiative targeting the medically uninsured. This was a retrospective analysis of 296 outpatient screening colonoscopies. Patients were 45 to 75 years of age with no history of bowel cancer, inflammatory bowel disease, or colorectal surgery. The screening colonoscopy quality indicators: adenoma detection rate (ADR), cecal intubation rate (CIR), and bowel preparation quality were compared in 89 uninsured Federally Qualified Health Center (FQHC) patients who received PN and 207 University Hospital patients who received usual care. The FQHC PN and University Hospital cohorts were similar in female sex (69% vs. 70%; p = 0.861) and African American race (61% vs. 61%; p = 0.920). The FQHC PN cohort was younger (57 years vs. 60 years; p < 0.001). There was no difference in ADR (33% vs. 32%; p = 0.971) or CIR (96% vs. 95%; p = 0.900) comparing the FQHC PN and University Hospital cohorts. The FQHC PN patients had a greater likelihood of an optimal bowel preparation on multivariate logistic regression (odds ratio 4.17; 95% confidence interval 1.07 to 16.20). Uninsured FQHC patients who received PN were observed to have intra-procedure quality indicators that exceeded bench-mark standards for high-quality screening colonoscopy and were equivalent to those observed in an insured University Hospital patient population.
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Affiliation(s)
- Keith Naylor
- Section of Gastroenterology, Hepatology, and Nutrition, the University of Chicago Medicine, Chicago, IL, United States
| | - Cassandra Fritz
- Pritzker School of Medicine, the University of Chicago, Chicago, IL, United States
| | - Blase Polite
- Section of Hematology/Oncology, the University of Chicago Medicine, Chicago, IL, United States
| | - Karen Kim
- Section of Gastroenterology, Hepatology, and Nutrition, the University of Chicago Medicine, Chicago, IL, United States
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31
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Bukowski A, Gioia S, Chavarri-Guerra Y, Soto-Perez-de-Celis E, St Louis J, Paulino E, Nogueira-Rodrigues A, Goss PE. Patient Navigation to Improve Access to Breast Cancer Care in Brazil. J Glob Oncol 2016; 3:433-437. [PMID: 29094079 PMCID: PMC5646893 DOI: 10.1200/jgo.2016.006726] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
- Alexandra Bukowski
- , , and , Avon International Breast Cancer Research Program, Massachusetts General Hospital; , , , , , , , and , The Global Cancer Institute, Boston, MA; and , Instituto Nacional de Câncer José Alencar Gomes da Silva; Rio de Janeiro; , Federal University of Minas Gerais, Belo Horizonte, Brazil; and and , Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Sandra Gioia
- , , and , Avon International Breast Cancer Research Program, Massachusetts General Hospital; , , , , , , , and , The Global Cancer Institute, Boston, MA; and , Instituto Nacional de Câncer José Alencar Gomes da Silva; Rio de Janeiro; , Federal University of Minas Gerais, Belo Horizonte, Brazil; and and , Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Yanin Chavarri-Guerra
- , , and , Avon International Breast Cancer Research Program, Massachusetts General Hospital; , , , , , , , and , The Global Cancer Institute, Boston, MA; and , Instituto Nacional de Câncer José Alencar Gomes da Silva; Rio de Janeiro; , Federal University of Minas Gerais, Belo Horizonte, Brazil; and and , Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Enrique Soto-Perez-de-Celis
- , , and , Avon International Breast Cancer Research Program, Massachusetts General Hospital; , , , , , , , and , The Global Cancer Institute, Boston, MA; and , Instituto Nacional de Câncer José Alencar Gomes da Silva; Rio de Janeiro; , Federal University of Minas Gerais, Belo Horizonte, Brazil; and and , Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Jessica St Louis
- , , and , Avon International Breast Cancer Research Program, Massachusetts General Hospital; , , , , , , , and , The Global Cancer Institute, Boston, MA; and , Instituto Nacional de Câncer José Alencar Gomes da Silva; Rio de Janeiro; , Federal University of Minas Gerais, Belo Horizonte, Brazil; and and , Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Eduardo Paulino
- , , and , Avon International Breast Cancer Research Program, Massachusetts General Hospital; , , , , , , , and , The Global Cancer Institute, Boston, MA; and , Instituto Nacional de Câncer José Alencar Gomes da Silva; Rio de Janeiro; , Federal University of Minas Gerais, Belo Horizonte, Brazil; and and , Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Angelica Nogueira-Rodrigues
- , , and , Avon International Breast Cancer Research Program, Massachusetts General Hospital; , , , , , , , and , The Global Cancer Institute, Boston, MA; and , Instituto Nacional de Câncer José Alencar Gomes da Silva; Rio de Janeiro; , Federal University of Minas Gerais, Belo Horizonte, Brazil; and and , Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Paul E Goss
- , , and , Avon International Breast Cancer Research Program, Massachusetts General Hospital; , , , , , , , and , The Global Cancer Institute, Boston, MA; and , Instituto Nacional de Câncer José Alencar Gomes da Silva; Rio de Janeiro; , Federal University of Minas Gerais, Belo Horizonte, Brazil; and and , Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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Rohan EA, Slotman B, DeGroff A, Morrissey KG, Murillo J, Schroy P. Refining the Patient Navigation Role in a Colorectal Cancer Screening Program: Results From an Intervention Study. J Natl Compr Canc Netw 2016; 14:1371-1378. [PMID: 27799508 DOI: 10.6004/jnccn.2016.0147] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 07/13/2016] [Indexed: 01/16/2023]
Abstract
BACKGROUND Oncology patient navigators help individuals overcome barriers to increase access to cancer screening, diagnosis, and timely treatment. This study, part of a randomized intervention trial investigating the efficacy of patient navigation in increasing colonoscopy completion, examined navigators' activities to ameliorate barriers to colonoscopy screening in a medically disadvantaged population. METHODS This study was conducted from 2012 through 2014 at Boston Medical Center. We analyzed navigator service delivery and survey data collected on 420 participants who were navigated for colonoscopy screening after randomization to this intervention. Key variables under investigation included barriers to colonoscopy, activities navigators undertook to reduce barriers, time navigators spent on each activity and per contact, and patient satisfaction with navigation services. Descriptive analysis assessed how navigators spent their time and examined what aspects of patient navigation were most valued by patients. RESULTS Navigators spent the most time assessing patient barriers/needs; facilitating appointment scheduling; reminding patients of appointments; educating patients about colorectal cancer, the importance of screening, and the colonoscopy preparation and procedures; and arranging transportation. Navigators spent an average of 44 minutes per patient. Patients valued the navigators, especially for providing emotional/peer support and explaining screening procedures and bowel preparation clearly. CONCLUSIONS Our findings help clarify the role of the navigator in colonoscopy screening within a medically disadvantaged community. These findings may help further refine the navigator role in cancer screening and treatment programs as facilities strive to effectively and efficiently integrate navigation into their services.
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Affiliation(s)
- Elizabeth A Rohan
- From Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia; Westat, Rockville, Maryland; and Boston Medical Center, Department of Gastroenterology, Boston, Massachusetts
| | - Beth Slotman
- From Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia; Westat, Rockville, Maryland; and Boston Medical Center, Department of Gastroenterology, Boston, Massachusetts
| | - Amy DeGroff
- From Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia; Westat, Rockville, Maryland; and Boston Medical Center, Department of Gastroenterology, Boston, Massachusetts
| | - Kerry Grace Morrissey
- From Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia; Westat, Rockville, Maryland; and Boston Medical Center, Department of Gastroenterology, Boston, Massachusetts
| | - Jennifer Murillo
- From Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia; Westat, Rockville, Maryland; and Boston Medical Center, Department of Gastroenterology, Boston, Massachusetts
| | - Paul Schroy
- From Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia; Westat, Rockville, Maryland; and Boston Medical Center, Department of Gastroenterology, Boston, Massachusetts
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Diagnostic colonoscopy following a positive fecal occult blood test in community health center patients. Cancer Causes Control 2016; 27:881-7. [PMID: 27228991 DOI: 10.1007/s10552-016-0763-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 05/13/2016] [Indexed: 01/07/2023]
Abstract
PURPOSE Fecal occult blood testing (FOBT) is a pragmatic screening option for many community health centers (CHCs), but FOBT screening programs will not reduce mortality if patients with positive results do not undergo diagnostic colonoscopy (DC). This study was conducted to investigate DC completion among CHC patients. METHODS This retrospective cohort study used data from three CHCs in the Midwest and Southwest. The primary study outcome was DC completion within 6 months of positive FOBT among adults age 50-75. Patient data was collected using automated electronic queries. Manual chart reviews were conducted if queries produced no evidence of DC. Poisson regression models described adjusted relative risks (RRs) of DC completion. RESULTS The study included 308 patients; 63.3 % were female, 48.7 % were Spanish speakers and 35.7 % were uninsured. Based on combined query and chart review findings, 51.5 % completed DC. Spanish speakers were more likely than English speakers to complete DC [RR 1.19; 95 % confidence interval (CI) 1.04-1.36; P = 0.009], and DC completion was lower among patients with 0 visits than those with 1-2 visits (RR 2.81; 95% CI 1.83-4.33; P < 0.001) or ≥3 visits (RR 3.06; 95% CI 1.57-5.95; P = 0.001). CONCLUSIONS DC completion was low overall, which raises concerns about whether FOBT can reduce CRC mortality in practice. Further research is needed to understand whether CHC navigator programs can achieve very high DC rates. If organizations use FOBT as their primary CRC screening approach and a substantial number of patients receive positive results, both screening rates and DC rates should be measured.
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Genoff MC, Zaballa A, Gany F, Gonzalez J, Ramirez J, Jewell ST, Diamond LC. Navigating Language Barriers: A Systematic Review of Patient Navigators' Impact on Cancer Screening for Limited English Proficient Patients. J Gen Intern Med 2016; 31:426-34. [PMID: 26786875 PMCID: PMC4803699 DOI: 10.1007/s11606-015-3572-3] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 06/18/2015] [Accepted: 12/14/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To systematically review the literature on the impact of patient navigators on cancer screening for limited English proficient (LEP) patients. DATA SOURCES Electronic databases (PubMed, PsycINFO via OVID, Web of Science, Cochrane, EMBASE, and Scopus) through 8 May 2015. ELIGIBILITY CRITERIA Articles in this review had: (1) a study population of LEP patients eligible for breast, cervical or colorectal cancer screenings, (2) a patient navigator intervention to provide services prior to or during cancer screening, (3) a comparison of the patient navigator intervention to either a control group or another intervention, and (4) language-specific outcomes related to the patient navigator intervention. STUDY APPRAISAL We assessed the quality of the articles using the Downs and Black Scale. RESULTS Fifteen studies met the inclusion criteria and evaluated the screening rates for breast, colorectal, and cervical cancer in 15 language populations. Fourteen studies resulted in improved screening rates for LEP patients between 7 and 60%. There was great variability in the patient navigation interventions evaluated. Training received by navigators was not reported in nine of the studies and no studies assessed the language skills of the patient navigators in English or the target language. LIMITATIONS This study is limited by the variability in study designs and limited reporting on patient navigator interventions, which reduces the ability to draw conclusions on the full effect of patient navigators. CONCLUSIONS Overall, we found evidence that navigators improved screening rates for breast, cervical and colorectal cancer screening for LEP patients. Future studies should systematically collect data on the training curricula for navigators and assess their English and non-English language skills in order to identify ways to reduce disparities for LEP patients.
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Affiliation(s)
- Margaux C Genoff
- Department of Psychiatry and Behavioral Sciences, Immigrant Health and Cancer Disparities Service, Memorial Sloan-Kettering Cancer Center, New York City, NY, USA
- Department of Psychology, New School for Social Research, New York, NY, USA
| | | | - Francesca Gany
- Department of Psychiatry and Behavioral Sciences, Immigrant Health and Cancer Disparities Service, Memorial Sloan-Kettering Cancer Center, New York City, NY, USA
| | - Javier Gonzalez
- Department of Psychiatry and Behavioral Sciences, Immigrant Health and Cancer Disparities Service, Memorial Sloan-Kettering Cancer Center, New York City, NY, USA
| | - Julia Ramirez
- Department of Psychiatry and Behavioral Sciences, Immigrant Health and Cancer Disparities Service, Memorial Sloan-Kettering Cancer Center, New York City, NY, USA
| | - Sarah T Jewell
- Medical Library, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Lisa C Diamond
- Department of Psychiatry and Behavioral Sciences, Immigrant Health and Cancer Disparities Service, Memorial Sloan-Kettering Cancer Center, New York City, NY, USA.
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Cruz-Correa M, Cordero F, Betancourt JP, Diaz-Algorri Y, Lopez SM, Rivera M, Mosquera R, Carlo-Chevere V, Rodriguez-Quilichini S. Implementation and Outcomes of a Community-Based Educational Program for Colorectal Cancer Prevention in Hispanics. JOURNAL OF FAMILY MEDICINE AND DISEASE PREVENTION 2016; 2. [PMID: 30288455 DOI: 10.23937/2469-5793/1510042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Objectives Colorectal cancer (CRC) is the 2nd most diagnosed cancer and leading cause of cancer death in Puerto Rico. However, CRC screening rates remain low. The aim of this study was to test the effectiveness of a Train-the-Trainers' (TTT) program to develop trainers capable of educating others within their communities about CRC prevention. Methods The TTT program consisted of didactics and seminars to capacitate participants to become trainers in CRC prevention. This project was evaluated using three components: (1) training workshops; (2) community educational sessions; and (3) the participant's experience as a trainer. Pre - and post-tests on CRC screening knowledge were given to TTT participants. Program effectiveness was determined by the pre- and post-tests, number of workshop participants completing a community educational session within three months of training and the number of community members reached. Results Among the 115 total participants, 97 participants took the pre- and post-test. There was a significant difference in the scores for the pre-test (M = 10.56, SD = 2.57) and the post-test (M = 11.43, SD = 1.83) given; t (96) = -4.68, p < 0.001. A total of 955 community members were reached. Participants from the community educational sessions (n = 680) evaluated the program. 77.7% of those participants expressed intent to undergo colonoscopy screening in the future. Conclusions TTT was effective in preparing trainers in CRC prevention. Participants increased their knowledge about CRC prevention and successfully reached members of their community. Utilization of community trainers is an effective alternative to increase CRC education and awareness in Hispanic communities, which may positively impact CRC screening rates in this population.
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Affiliation(s)
- Marcia Cruz-Correa
- University of Puerto Rico Comprehensive Cancer Center, USA.,University of Puerto Rico School of Medicine, USA.,Puerto Rico Colorectal Cancer Coalition, USA
| | | | | | | | - Sofia M Lopez
- University of Puerto Rico Comprehensive Cancer Center, USA
| | - Mirza Rivera
- University of Puerto Rico Comprehensive Cancer Center, USA.,Graduate School of Public Health, University of Puerto Rico, USA
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Liang PS, Wheat CL, Abhat A, Brenner AT, Fagerlin A, Hayward RA, Thomas JP, Vijan S, Inadomi JM. Adherence to Competing Strategies for Colorectal Cancer Screening Over 3 Years. Am J Gastroenterol 2016; 111:105-14. [PMID: 26526080 PMCID: PMC4887132 DOI: 10.1038/ajg.2015.367] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 09/03/2015] [Accepted: 10/01/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVES We have shown that, in a randomized trial comparing adherence to different colorectal cancer (CRC) screening strategies, participants assigned to either fecal occult blood testing (FOBT) or given a choice between FOBT and colonoscopy had significantly higher adherence than those assigned to colonoscopy during the first year. However, how adherence to screening changes over time is unknown. METHODS In this trial, 997 participants were cluster randomized to one of the three screening strategies: (i) FOBT, (ii) colonoscopy, or (iii) a choice between FOBT and colonoscopy. Research assistants helped participants to complete testing only in the first year. Adherence to screening was defined as completion of three FOBT cards in each of 3 years after enrollment or completion of colonoscopy within the first year of enrollment. The primary outcome was adherence to assigned strategy over 3 years. Additional outcomes included identification of sociodemographic factors associated with adherence. RESULTS Participants assigned to annual FOBT completed screening at a significantly lower rate over 3 years (14%) than those assigned to colonoscopy (38%, P<0.001) or choice (42%, P<0.001); however, completion of any screening test fell precipitously, indicating the strong effect of patient navigation. In multivariable logistic regression analysis, being randomized to the choice or colonoscopy group, Chinese language, homosexuality, being married/partnered, and having a non-nurse practitioner primary care provider were independently associated with greater adherence to screening (P<0.01). CONCLUSIONS In a 3-year follow-up of a randomized trial comparing competing CRC screening strategies, participants offered a choice between FOBT and colonoscopy continued to have relatively high adherence, whereas adherence in the FOBT group fell significantly below that of the choice and colonoscopy groups. Patient navigation is crucial to achieving adherence to CRC screening, and FOBT is especially vulnerable because of the need for annual testing.
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Affiliation(s)
- Peter S. Liang
- Department of Medicine, Division of Gastroenterology, University of Washington, Seattle, Washington, USA
| | - Chelle L. Wheat
- Department of Health Services, School of Public Health, University of Washington, Seattle, Washington, USA
| | - Anshu Abhat
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Alison T. Brenner
- Cecil Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Angela Fagerlin
- Veteran Affairs Center for Clinical Management Research, Ann Arbor, Michigan, USA
- Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Rodney A. Hayward
- Veteran Affairs Center for Clinical Management Research, Ann Arbor, Michigan, USA
- Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jennifer P. Thomas
- Department of Medicine, University of California, San Francisco, California, USA
| | - Sandeep Vijan
- Veteran Affairs Center for Clinical Management Research, Ann Arbor, Michigan, USA
- Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - John M. Inadomi
- Department of Medicine, Division of Gastroenterology, University of Washington, Seattle, Washington, USA
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Ustjanauskas AE, Bredice M, Nuhaily S, Kath L, Wells KJ. Training in Patient Navigation: A Review of the Research Literature. Health Promot Pract 2015; 17:373-81. [PMID: 26656600 DOI: 10.1177/1524839915616362] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- Amy E Ustjanauskas
- University of California, San Diego Moores Cancer Center, San Diego, CA, USA San Diego State University/University of California, San Diego Joint Doctoral Program in Clinical Psychology, San Diego, CA, USA
| | | | | | - Lisa Kath
- San Diego State University, San Diego, CA, USA
| | - Kristen J Wells
- University of California, San Diego Moores Cancer Center, San Diego, CA, USA San Diego State University/University of California, San Diego Joint Doctoral Program in Clinical Psychology, San Diego, CA, USA San Diego State University, San Diego, CA, USA
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The Family Value of Information, Community Support, and Experience Study: Rationale, Design, and Methods of a "Family-Centered" Research Study. J Nerv Ment Dis 2015; 203:896-900. [PMID: 26524515 DOI: 10.1097/nmd.0000000000000393] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The Patient Protection and Affordable Care Act focuses on improving consumer engagement and patient-centered care. This article describes the design and rationale of a study targeting family engagement in pediatric mental health services. The study is a 90-day randomized trial of a telephone-delivered Family Navigator services versus usual care for parents of Medicaid-insured youth younger than 13 years with serious mental illness. Youth are identified through a pediatric antipsychotic medication preauthorization program. Family Navigators offer peer support to empower and engage parents in their child's recovery. Outcomes include parent report of empowerment, social support, satisfaction with child mental health services, and child functioning as well as claims-based measures of psychotherapy service utilization and antipsychotic medication dosage. The focus on "family-centered" care in this study is strongly supported by the active role of consumers in study design and implementation.
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Knowledge of Polyp History and Recommended Follow-Up Among a Predominately African American Patient Population and the Impact of Patient Navigation. J Racial Ethn Health Disparities 2015; 3:403-12. [PMID: 27294735 DOI: 10.1007/s40615-015-0152-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 07/10/2015] [Accepted: 08/06/2015] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND AIMS Colorectal screening (CRS) rates in minority and uninsured populations have increased through patient navigation (PN) interventions. However, patient knowledge of colonoscopy results and follow-up recommendations has not been described in an African American (AA) population or following PN. Our objectives were to determine patient knowledge of colonoscopy results and follow-up recommendations within an AA patient population and to compare post-colonoscopy knowledge among patients who received either PN or usual care. METHODS This is a prospective observational study of patients who completed a screening colonoscopy in 2014. A semi-structured telephone survey was completed by 96 participants (69 % AA, 78 % female, and mean age 63 years). The survey assessed patient recall of polyp results and follow-up recommendations. Responses were compared with the medical record. RESULTS Of 96 patients surveyed (response rate, 68 %), 83 % accurately reported if polyps were detected and 66 % accurately reported their recommended follow-up. The identification of adenomatous polyps on colonoscopy was a predictor of accurate recall of colonoscopy results and follow-up recommendations. Uninsured patients who completed PN (18 of 96) were more likely to accurately report polyp results (100 vs. 80 %; P = 0.036), but the rates of accurate follow-up recall were not statistically significant (44 vs. 71 %; P = 0.053) when compared to usual care patients. CONCLUSIONS In an AA population, post-colonoscopy polyp recall rates were similar to those described in white populations. Uninsured patients who completed PN were more likely than insured usual care patients to accurately report the presence of polyps on colonoscopy.
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Steffen LE, Boucher KM, Damron BH, Pappas LM, Walters ST, Flores KG, Boonyasiriwat W, Vernon SW, Stroup AM, Schwartz MD, Edwards SL, Kohlmann WK, Lowery JT, Wiggins CL, Hill DA, Higginbotham JC, Burt R, Simmons RG, Kinney AY. Efficacy of a Telehealth Intervention on Colonoscopy Uptake When Cost Is a Barrier: The Family CARE Cluster Randomized Controlled Trial. Cancer Epidemiol Biomarkers Prev 2015; 24:1311-8. [PMID: 26101306 PMCID: PMC4734378 DOI: 10.1158/1055-9965.epi-15-0150] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 06/02/2015] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND We tested the efficacy of a remote tailored intervention Tele-Cancer Risk Assessment and Evaluation (TeleCARE) compared with a mailed educational brochure for improving colonoscopy uptake among at-risk relatives of colorectal cancer patients and examined subgroup differences based on participant reported cost barriers. METHODS Family members of colorectal cancer patients who were not up-to-date with colonoscopy were randomly assigned as family units to TeleCARE (N = 232) or an educational brochure (N = 249). At the 9-month follow-up, a cost resource letter listing resources for free or reduced-cost colonoscopy was mailed to participants who had reported cost barriers and remained nonadherent. Rates of medically verified colonoscopy at the 15-month follow-up were compared on the basis of group assignment and within group stratification by cost barriers. RESULTS In intent-to-treat analysis, 42.7% of participants in TeleCARE and 24.1% of participants in the educational brochure group had a medically verified colonoscopy [OR, 2.37; 95% confidence interval (CI) 1.59-3.52]. Cost was identified as a barrier in both groups (TeleCARE = 62.5%; educational brochure = 57.0%). When cost was not a barrier, the TeleCARE group was almost four times as likely as the comparison to have a colonoscopy (OR, 3.66; 95% CI, 1.85-7.24). The intervention was efficacious among those who reported cost barriers; the TeleCARE group was nearly twice as likely to have a colonoscopy (OR, 1.99; 95% CI, 1.12-3.52). CONCLUSIONS TeleCARE increased colonoscopy regardless of cost barriers. IMPACT Remote interventions may bolster screening colonoscopy regardless of cost barriers and be more efficacious when cost barriers are absent.
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Affiliation(s)
- Laurie E Steffen
- University of New Mexico Cancer Center, Albuquerque, New Mexico. Department of Psychology, University of New Mexico, Albuquerque, New Mexico
| | - Kenneth M Boucher
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah. Department of Oncologic Sciences, University of Utah, Salt Lake City, Utah
| | | | - Lisa M Pappas
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Scott T Walters
- Department of School of Public Health Behavioral and Community Health, University of North Texas Health Science Center, Fort Worth, Texas
| | - Kristina G Flores
- University of New Mexico Cancer Center, Albuquerque, New Mexico. Division of Epidemiology, Biostatistics, and Prevention, Department of Internal Medicine, School of Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | | | - Sally W Vernon
- Division of Health Promotion and Behavioral Sciences, The University of Texas School of Public Health, Houston, Texas
| | - Antoinette M Stroup
- Department of Epidemiology, Rutgers School of Public Health, Piscataway Township, New Jersey. Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Marc D Schwartz
- Department of Oncology, Georgetown University, Washington, DC. Lombardi Comprehensive Cancer Center, Washington, DC
| | - Sandra L Edwards
- Division of Epidemiology, Department of Medicine, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Wendy K Kohlmann
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Jan T Lowery
- Department of Epidemiology, University of Colorado School of Public Health, Aurora, Colorado
| | - Charles L Wiggins
- University of New Mexico Cancer Center, Albuquerque, New Mexico. Division of Epidemiology, Biostatistics, and Prevention, Department of Internal Medicine, School of Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Deirdre A Hill
- University of New Mexico Cancer Center, Albuquerque, New Mexico. Division of Epidemiology, Biostatistics, and Prevention, Department of Internal Medicine, School of Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - John C Higginbotham
- Community and Rural Medicine Institute for Rural Health Research, College of Community Health Sciences, University of Alabama, Tuscaloosa, Alabama
| | - Randall Burt
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | | | - Anita Y Kinney
- University of New Mexico Cancer Center, Albuquerque, New Mexico. Division of Epidemiology, Biostatistics, and Prevention, Department of Internal Medicine, School of Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico.
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Fedewa SA, Ma J, Sauer AG, Siegel RL, Smith RA, Wender RC, Doroshenk MK, Brawley OW, Ward EM, Jemal A. How many individuals will need to be screened to increase colorectal cancer screening prevalence to 80% by 2018? Cancer 2015; 121:4258-65. [PMID: 26308967 DOI: 10.1002/cncr.29659] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 07/20/2015] [Accepted: 07/21/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND A recent study estimates that 277,000 colorectal cancer (CRC) cases and 203,000 CRC deaths will be averted between 2013 and 2030 if the National Colorectal Cancer Roundtable goal of increasing CRC screening prevalence to 80% by 2018 is reached. However, the number of individuals who need to be screened (NNS) to achieve this goal is unknown. In this communication, the authors estimate the NNS to achieve 80% by 2018 nationwide and by state. METHODS The authors estimated the NNS by subtracting adults aged 50 to 75 years who would need to be screened to achieve an 80% CRC screening prevalence from the number who are currently guideline-compliant from population estimates for this age group. The 2013 National Health Interview Survey and the 2012 Behavioral Risk Factor Surveillance System were used to estimate CRC screening prevalence and data from the US Census Bureau were used to estimate population projections. The NNS were age-standardized and sex-standardized. RESULTS Nationwide, 24.39 million individuals (95% confidence interval, 24.37-24.41 million) aged 50 to 75 years will need to be screened to achieve 80% by 2018. By state, the NNS ranged from 45,400 in Vermont to 2.72 million in California. The majority of individuals who need to be screened are aged 50 to 64 years and the largest subgroup is privately insured. CONCLUSIONS The authors estimated that at least 24.4 million additional individuals in the United States will need to be screened to achieve the National Colorectal Cancer Roundtable goal of increasing CRC screening prevalence to 80% by 2018. To reach this goal, improving facilitators of CRC screening, including physician recommendation and patient awareness, is needed.
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Affiliation(s)
- Stacey A Fedewa
- Surveillance and Health Services Research, American Cancer Society, Atlanta, Georgia.,Department of Epidemiology, Emory University, Atlanta, Georgia
| | - Jiemin Ma
- Surveillance and Health Services Research, American Cancer Society, Atlanta, Georgia
| | - Ann Goding Sauer
- Surveillance and Health Services Research, American Cancer Society, Atlanta, Georgia
| | - Rebecca L Siegel
- Surveillance and Health Services Research, American Cancer Society, Atlanta, Georgia
| | - Robert A Smith
- Cancer Control Science, American Cancer Society, Atlanta, Georgia
| | - Richard C Wender
- Cancer Control Science, American Cancer Society, Atlanta, Georgia
| | - Mary K Doroshenk
- Cancer Control Science, American Cancer Society, Atlanta, Georgia
| | - Otis W Brawley
- Office of the Chief Medical Officer, American Cancer Society, Atlanta, Georgia
| | - Elizabeth M Ward
- Surveillance and Health Services Research, American Cancer Society, Atlanta, Georgia
| | - Ahmedin Jemal
- Surveillance and Health Services Research, American Cancer Society, Atlanta, Georgia
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Berkowitz SA, Percac-Lima S, Ashburner JM, Chang Y, Zai AH, He W, Grant RW, Atlas SJ. Building Equity Improvement into Quality Improvement: Reducing Socioeconomic Disparities in Colorectal Cancer Screening as Part of Population Health Management. J Gen Intern Med 2015; 30:942-9. [PMID: 25678378 PMCID: PMC4471039 DOI: 10.1007/s11606-015-3227-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Revised: 01/07/2015] [Accepted: 01/26/2015] [Indexed: 01/05/2023]
Abstract
BACKGROUND Improving colorectal cancer (CRC) screening rates for patients from socioeconomically disadvantaged backgrounds is a recognized public health priority. OBJECTIVE Our aim was to determine if implementation of a system-wide screening intervention could reduce disparities in the setting of improved overall screening rates. DESIGN This was an interrupted time series (ITS) analysis before and after a population management intervention. PARTICIPANTS Patients eligible for CRC screening (age 52-75 years without prior total colectomy) in an 18-practice research network from 15 June 2009 to 15 June 2012 participated in the study. INTERVENTION The Technology for Optimizing Population Care (TopCare) intervention electronically identified patients overdue for screening and facilitated contact by letter or telephone scheduler, with or without physician involvement. Patients identified by algorithm as high risk for non-completion entered into intensive patient navigation. MAIN MEASURES Patients were dichotomized as ≤ high school diploma (≤ HS), an indicator of socioeconomic disadvantage, vs. >HS diploma (> HS). The monthly disparity between ≤ HS and > HS with regard to CRC screening completion was examined. KEY RESULTS At baseline, 72% of 47,447 eligible patients had completed screening, compared with 75% of 51,442 eligible patients at the end of follow-up (p < 0.001). CRC screening completion was lower in ≤ HS vs. >HS patients in June 2009 (65.7% vs. 74.5%, p < 0.001) and remained lower in June 2012 (69.4% vs. 76.7%, p < 0.001). In the ITS analysis, which accounts for secular trends, TopCare was associated with a significant decrease in the CRC screening disparity (0.7%, p < 0.001). The effect of TopCare represents approximately 99 additional ≤ HS patients screened above prevailing trends, or 26 life-years gained had these patients remained unscreened. CONCLUSIONS A multifaceted population management intervention sensitive to the needs of vulnerable patients modestly narrowed disparities in CRC screening, while also increasing overall screening rates. Embedding interventions for vulnerable patients within larger population management systems represents an effective approach to increasing overall quality of care while also decreasing disparities.
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Affiliation(s)
- Seth A Berkowitz
- Division of General Internal Medicine, Medical Services, Massachusetts General Hospital, Boston, MA, USA,
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Wolf HJ, Dwyer A, Ahnen DJ, Pray SL, Rein SM, Morwood KD, Lowery JT, Masias A, Collins NJ, Brown CE, DeMaio Goheen CA, McAbee KE, Sauaia A, Byers TE. Colon cancer screening for Colorado's underserved: a community clinic/academic partnership. Am J Prev Med 2015; 48:264-70. [PMID: 25547926 DOI: 10.1016/j.amepre.2014.09.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Revised: 08/25/2014] [Accepted: 09/18/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND Colorectal cancer (CRC) is largely preventable by finding and removing adenomas, but many people have not been screened, especially the uninsured with low income. PURPOSE To establish a statewide infrastructure to ensure that low-income Coloradans receive colonoscopy for CRC screening and diagnostic evaluation. DESIGN In 2006, a statewide program to provide free colonoscopy to uninsured Coloradans was developed as a partnership between the University of Colorado Cancer Center and Colorado safety-net clinics. Funded by excise tax revenues, the Colorado Colorectal Screening Program (CCSP) successfully embedded screening into primary care, providing patient navigation support and reimbursement that allowed primary care providers to refer patients for colonoscopy. SETTING/PARTICIPANTS More than 50 safety-net clinics joined the CCSP to provide colonoscopies to uninsured Coloradans with low income, aged ≥50 years or <50 years at elevated risk, lawfully present and needing CRC screening by American Cancer Society consensus guidelines. MAIN OUTCOME MEASURES Process and clinical outcomes included people screened, show rates, patient satisfaction, and quality measures, such as adenoma detection rate, bowel cleansing quality, and timeliness of care. Program costs and benefits were estimated. The 2013 analysis was completed using 2006-2012 data on 13,252 of 13,774 people receiving colonoscopy. RESULTS In 2006-2012, the CCSP screened 13,774 people, with 38% minorities and 39% men. Patient navigators ensured >90% of those referred attended their colonoscopy. Adenomas were removed from 27% of patients and 1% had cancers diagnosed. Total direct medical services cost was $998/person receiving colonoscopy. About 325 fewer future incident CRCs were predicted due to adenoma removal, projecting substantial future cost savings. CONCLUSIONS The CCSP, a successful community clinic/academic partnership provides cost-effective CRC screening and prevention services to low-income uninsured Coloradans and establishes the infrastructure to support screening low-income Coloradans as Affordable Care Act reforms provide payer coverage for them.
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Affiliation(s)
- Holly J Wolf
- Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
| | - Andrea Dwyer
- Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Dennis J Ahnen
- Division of Gastroenterology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Shannon L Pray
- University of Colorado Cancer Center, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Susan M Rein
- Division of Gastroenterology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Krystal D Morwood
- Preventive Services Division, Colorado Department of Public Health and Environment, Denver, Colorado
| | - Jan T Lowery
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Andrea Masias
- Colorado Access, Colorado Department of Public Health and Environment, Denver, Colorado
| | - Nicole J Collins
- Preventive Services Division, Colorado Department of Public Health and Environment, Denver, Colorado
| | - Carol E Brown
- Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Carol-Ann DeMaio Goheen
- Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Keavy E McAbee
- Department of Community and Behavioral Health, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Angela Sauaia
- Department of Health Systems, Management, and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Tim E Byers
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado; University of Colorado Cancer Center, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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