Adherence in the Cancer Care Setting: a Systematic Review of Patient Navigation to Traverse Barriers

Association Between Social Determinants of Health and Cancer Treatment Delay in an Urban Population

PURPOSE

Delays in oncologic time to treatment initiation (TTI) independently and adversely affect disease-specific mortality. Social Determinants of Health (SDoH) are increasingly recognized as significant contributors to patients' disease management and health outcomes. Our academic center has validated a 10-item SDoH screener, and we elucidated which specific needs may be predictive of delayed TTI.

METHODS

This is a retrospective cohort study at an urban academic center of patients with a SDoH screening and diagnosis of breast, colorectal, endocrine/neuroendocrine, GI, genitourinary, gynecologic, head and neck, hematologic, hepatobiliary, lung, or pancreatic cancer from 2018 to 2022. Variables of interest included household income, tumor stage, and emergency department (ED) or inpatient admission 30 days before diagnosis. Factors associated with delayed TTI ≥45 days were assessed using multivariable logistic regression.

RESULTS

Among 2,328 patients (mean [standard deviation] age, 64.0 (12.8) years; 66.6% female), having >1 unmet social need was associated with delayed TTI (odds ratio [OR], 1.68; 95% CI, 1.54 to 1.82). The disparities most associated with delay were legal help, transportation, housing stability, and needing to provide care for others. Those with ED (OR, 0.49; 95% CI, 0.44 to 0.54) or inpatient (OR, 0.54; 95% CI, 0.50 to 0.58) admission 30 days before diagnosis were less likely to experience delay.

CONCLUSION

Delays in oncologic TTI ≥45 days are independently associated with unmet social needs. ED or inpatient admissions before diagnosis increase care coordination, leading to improved TTI. Although limitations included the retrospective nature of the study and self-reporting bias, these findings more precisely identify targets for intervention that may more effectively decrease delay. Patients with SDoH barriers are at higher risk of treatment delay and could especially benefit from legal, transportation, caregiver, and housing assistance.

Creating safer cancer care with ethnic minority patients: A qualitative analysis of the experiences of cancer service staff

INTRODUCTION

Effective consumer engagement practices can enhance patient safety. This is important for consumers from ethnic minority backgrounds who are exposed to increased risk of patient safety events. Using the Systems Engineering Initiative for Patient Safety model, this study explored staff experiences of creating opportunities for engagement with consumers from ethnic minority backgrounds to contribute to their cancer care safety.

METHOD

A qualitative study was conducted using semistructured interviews with cancer service staff from four cancer services across two states in Australia. Purposive sampling was used to recruit healthcare staff from a diverse range of professions. Data were analysed using the Framework Analysis method.

RESULTS

Fifty-four interviews were conducted with healthcare staff. Analysis of the qualitative interview data identified enablers and associated challenges that contributed to creating a shared understanding between consumers and staff of the information, processes, expectations and problems arising in care. Enablers and challenges are reported in relation to four themes: (1) co-creating safety through shared understanding of care processes; (2) tools and technologies support planned communication; (3) organisational policy levers exist but lack implementation in direct care and (4) formal tasks incorporate consumer engagement more readily than informal interactions.

CONCLUSION

The availability of infrastructure and resources to support communication with consumers from ethnic minority backgrounds was limited to specific tasks across the cancer care continuum. Strategies implemented by health services to foster effective communication during formal interactions now require expansion to support and create conditions for effective consumer engagement during informal and everyday care tasks. The use of innovative language support tools and cultural considerations are required at the service and system level to support consumer engagement in all types of care interactions.

PUBLIC AND PATIENT INVOLVEMENT

The study was embedded within a larger project that included a consumer investigator and was guided by a consumer advisory group (CAG). These consumer team members have lived experience of cancer and are from diverse ethnic backgrounds. CAG members provided feedback on the draft interview guide and participant information for this study.

Rates of adherence to cancer treatment guidelines in Australia and the factors associated with adherence: A systematic review

Adherence to cancer treatment clinical practice guidelines (CPGs) varies enormously across Australia, despite being associated with improved patient outcomes. This systematic review aims to characterize adherence rates to active-cancer treatment CPGs in Australia and related factors to inform future implementation strategies. Five databases were systematically searched, abstracts were screened for eligibility, a full-text review and critical appraisal of eligible studies performed, and data extracted. A narrative synthesis of factors associated with adherence was conducted, and the median adherence rates within cancer streams calculated. A total of 21,031 abstracts were identified. After duplicates were removed, abstracts screened, and full texts reviewed, 20 studies focused on adherence to active-cancer treatment CPGs were included. Overall adherence rates ranged from 29% to 100%. Receipt of guideline recommended treatments was higher for patients who were younger (diffuse large B-cell lymphoma [DLBCL], colorectal, lung, and breast cancer); female (breast and lung cancer), and male (DLBCL and colorectal cancer); never smokers (DLBCL and lung cancer); non-Indigenous Australians (cervical and lung cancer); with less advanced stage disease (colorectal, lung, and cervical cancer), without comorbidities (DLBCL, colorectal, and lung cancer); with good-excellent Eastern Cooperative Oncology Group performance status (lung cancer); living in moderately accessible places (colon cancer); and; treated in metropolitan facilities (DLBLC, breast and colon cancer). This review characterized active-cancer treatment CPG adherence rates and associated factors in Australia. Future targeted CPG implementation strategies should account for these factors, to redress unwarranted variation particularly in vulnerable populations, and improve patient outcomes (Prospero number: CRD42020222962).

The impact of nurse navigation on timeliness to treatment for benign high-risk breast pathology

PURPOSE

High-risk breast pathology is a breast cancer risk factor for which timely treatment is crucial. Nurse navigation programs have been implemented to minimize delays in patient care. This study evaluated nurse navigation in terms of timeliness to surgery for patients with high-risk breast pathology.

METHODS

This was a single-institution, retrospective review of patients with identified high-risk breast pathology undergoing lumpectomy between January 2017 and June 2019. Patients were stratified into cohorts based on periods with and without nurse navigation. Preoperative and postoperative time to care as well as demographic and tumor characteristics were compared using univariate and multivariate analysis.

RESULTS

100 patients had assigned nurse navigators and 29 patients did not. Nurse navigation was associated with reduced time from referral to date of surgery (DOS) by 16.9 days (p = 0.003). Patients > 75 years had a shorter time to first appointment (p = 0.03), and patients with Medicare insurance had a reduced time from referral to DOS (p = 0.005). 20% of all patients were upstaged to cancer on final surgical pathology.

CONCLUSION

Nurse navigation was significantly associated with decreased time to care for patients with high-risk breast pathology undergoing lumpectomy. We recommend nurse navigation programs as part of a comprehensive approach for patients with high-risk breast pathology.

Feasibility of a patient-oriented navigation programme for patients with lung cancer or stroke in Germany: Protocol of the CoreNAVI study

BACKGROUND

Patient navigation programmes were introduced in the United States and recently gained interest in Germany, where the health care system is fragmented. Navigation programmes aim to decrease barriers to care for patients with age-associated diseases and complex care paths. Here we describe a feasibility study to evaluate a patient-oriented navigation model that was developed in a first project phase by integrating data about barriers to care, vulnerable patient populations and existing support services.

METHODS

We designed a mixed-methods feasibility study that consists of two two-arm randomized controlled trials aligned with observational cohorts. The intervention group of the RCTs gets support by personal navigators for 12 months. The control group receives a brochure with regional support offers for patients and caregivers. The feasibility of the patient-oriented navigation model for two prototypic age-associated diseases, lung cancer and stroke, is evaluated with regard to its acceptance, demand, practicality and efficacy. This investigation includes process evaluation measures with detailed documentation of the screening and recruitment process, questionnaires about satisfaction with navigation, observant participation and qualitative interviews. Estimates of efficacy for patient-reported outcomes are obtained at three follow-up time points including satisfaction with care and health-related quality of life. Furthermore, we analyze health insurance data from patients of the RCT insured at a large German health insurance (AOK Nordost) to investigate heath care utilization, costs and cost effectiveness.

TRIAL REGISTRATION

The study is registered at the German Clinical Trial Register (DRKS-ID: DRKS00025476).

Great Plains American Indians' Perspectives on Patient and Family Needs Throughout the Cancer Journey

PURPOSE

To explore the perspectives on patient and family needs during cancer treatment and survivorship of American Indian (AI) cancer survivors, caregivers, Tribal leaders, and healers.

PARTICIPANTS & SETTING

36 AI cancer survivors from three reservations in the Great Plains region.

METHODOLOGIC APPROACH

A community-based participatory research design was employed. Postcolonial Indigenous research techniques of talking circles and semistructured interviews were used to gather qualitative data. Data were analyzed using content analysis to identify themes.

FINDINGS

The overarching theme of accompaniment was identified. The following themes were intertwined with this theme: (a) the need for home health care, with the subthemes of family support and symptom management; and (b) patient and family education.

IMPLICATIONS FOR NURSING

To provide high-quality cancer care to AI patients in their home communities, oncology clinicians should collaborate with local care providers, relevant organizations, and the Indian Health Service to identify and develop essential services. Future efforts must emphasize culturally responsive interventions in which Tribal community health workers serve as navigators to accompany patients and families during treatment and in survivorship.

Predictive Factors for Cancer Treatment Delay in a Racially Diverse and Socioeconomically Disadvantaged Urban Population

PURPOSE

Incremental delays in time to treatment initiation (TTI) have been shown to cause a proportional, increased independent risk of disease-specific mortality for breast cancer, colorectal cancer (CRC), head and neck cancer (HNC), non–small-cell lung cancer (NSCLC), and pancreatic cancer. Studies suggest that delays are associated with racial and socioeconomic disparities. We evaluated associations between patient factors and TTI to identify those associated with delay.

MATERIALS AND METHODS

This is a retrospective cohort study at an urban community-based academic center of patients diagnosed with or referred for curative-intent treatment of breast cancer, CRC, HNC, NSCLC, and pancreatic cancer from January 2019 to December 2021. Variables of interest included Charlson Comorbidity Index (CCI) score, insurance type, language preference, and inpatient admission 30 days before diagnosis. Factors associated with TTI delay, defined as TTI ≥ 30 days, were assessed using multivariable logistic regression.

RESULTS

Among 2,543 patients (69% female), the mean age was 63.4 years and the median TTI was 25 days (IQR, 6-44). Within multivariable models, patients treated as outpatient and not admitted 30 days before diagnosis experienced statistically significant greater delay for CRC (odds ratio [OR], 2.82; 95% CI, 1.71 to 4.66) and NSCLC (OR, 2.11; 95% CI, 1.31 to 3.39). Higher CCI score was associated with delay for HNC (OR, 2.63; 95% CI, 1.04 to 6.66) and NSCLC (OR, 1.75; 95% CI, 1.14 to 2.71). For breast cancer, uninsured and Spanish-speaking patients (OR, 1.79; 95% CI, 1.21 to 2.67) experienced increased TTI.

CONCLUSION

Care coordination/compliance (eg, inpatient 30 days before diagnosis), clinical (eg, medical comorbidities), and socioeconomic (eg, uninsured status) predictors for delayed TTI were identified and may inform delay minimizing interventions. Our data support evidence that TTI delays are associated with demographic and socioeconomic disparities. Existing disparities are likely exacerbated by delays that disproportionately affect patients with care coordination/compliance issues, multiple comorbidities, and lower socioeconomic status.

Risk Factors for Operating Room No-Show in an Academic Otolaryngology Practice

OBJECTIVES/HYPOTHESIS

A no-show to the operating room date negatively impacts a hospital and can lead to increased costs for an institution in terms of time, materials, and manpower. Our objectives are to identify the factors associated with operating room no-shows in order to increase clinical efficiency, reduce hospital costs, and increase patient access to care.

STUDY DESIGN

Single institution retrospective chart review.

METHODS

A retrospective review was performed of all surgeries within the Otolaryngology department performed at a single tertiary academic center between 2006 and 2019. Demographic and surgical data were collected from the charts. Descriptive, univariate, and multivariate statistics were performed on the data.

RESULTS

There were a total of 1,752 no-shows and 46,440 patients who did show with an overall no-show rate of 3.63%. A multivariate logistic regression analysis was performed to compare patients who did not show for surgery to those who did. Analysis found multiple risk factors for not showing to surgery that were statistically significant (P < .05) and included decreasing age, planned outpatient case, head and neck oncology subspecialty, increasing distance from the facility, higher number of clinic no-shows, and not having private insurance. African-American race was more likely to show for surgery as scheduled.

CONCLUSIONS

Numerous factors may play a role on whether or not a patient attends a scheduled surgical date. Some of these factors may be preventable or modifiable to mitigate increased hospital costs associated with no-show to surgery and increase access to care.

LEVEL OF EVIDENCE

3 Laryngoscope, 132:1738-1742, 2022.

Quality of integrated female oncofertility care is suboptimal: A patient-reported measurement

BACKGROUND

Clinical practice guidelines recommend to inform female cancer patients about their infertility risks due to cancer treatment. Unfortunately, it seems that guideline adherence is suboptimal. In order to improve quality of integrated female oncofertility care, a systematic assessment of current practice is necessary.

METHODS

A multicenter cross-sectional survey study in which a set of systematically developed quality indicators was processed, was conducted among female cancer patients (diagnosed in 2016/2017). These indicators represented all domains in oncofertility care; risk communication, referral, counseling, and decision-making. Indicator scores were calculated, and determinants were assessed by multilevel multivariate analyses.

RESULTS

One hundred twenty-one out of 344 female cancer patients participated. Eight out of 11 indicators scored below 90% adherence. Of all patients, 72.7% was informed about their infertility, 51.2% was offered a referral, with 18.8% all aspects were discussed in counseling, and 35.5% received written and/or digital information. Patient's age, strength of wish to conceive, time before cancer treatment, and type of healthcare provider significantly influenced the scores of three indicators.

CONCLUSIONS

Current quality of female oncofertility care is far from optimal. Therefore, improvement is needed. To achieve this, improvement strategies that are tailored to the identified determinants and to guideline-specific barriers should be developed.

Comparing clinical and nonclinical cancer patient navigators: A national study in the United States

BACKGROUND

A nationwide survey was conducted to examine differences between clinical and nonclinical oncology navigators in their service provision, engagement in the cancer care continuum, personal characteristics, and program characteristics.

METHODS

Using convenience sampling, 527 oncology navigators participated and completed an online survey. Descriptive statistics, χ² statistics, and t tests were used to compare nonclinical (eg, community health worker) and clinical (eg, nurse navigators) navigators on the provision of various navigation services, personal characteristics, engagement in the cancer care continuum, and program characteristics.

RESULTS

Most participants were clinical navigators (76.1%). Compared to nonclinical navigators, clinical navigators were more likely to have a bachelor's degree or higher (88.6% vs 69.6%, P < .001), be funded by operational budgets (84.4% vs 35.7%, P < .001), and less likely to work at a community-based organization or nonprofit (2.0% vs 36.5%, P < .001). Clinical navigators were more likely to perform basic navigation (P < .001), care coordination (P < .001), treatment support (P < .001), and clinical trial/peer support (P = .005). Clinical navigators were more likely to engage in treatment (P < .001), end-of-life (P < .001), and palliative care (P = .001) navigation.

CONCLUSIONS

There is growing indication that clinical and nonclinical oncology navigators perform different functions and work in different settings. Nonclinical navigators may be more likely to face job insecurity because they work in nonprofit organizations and are primarily funded by grants.

Navigation programs relevant for African American men with prostate cancer: a scoping review protocol

BACKGROUND

The excess incidence and mortality due to prostate cancer that impacts African American men constitutes the largest of all cancer disparities. Patient navigation is a patient-centered healthcare system intervention to eliminate barriers to timely, high-quality care across the cancer continuum and improves health outcomes among vulnerable patients. However, little is known regarding the extent to which navigation programs include cultural humility to address prostate cancer disparities among African American men. We present a scoping review protocol of an in-depth examination of navigation programs in prostate cancer care-including navigation activities/procedures, training, and management-with a special focus on cultural context and humility for African American men to achieve health equity.

METHODS

We will conduct comprehensive searches of the literature in PubMed, Embase, Web of Science, and CINAHL Complete, using keywords and index terms (Mesh and Emtree) within the three main themes: prostate cancer, patient navigation, and African American men. We will also conduct a search of the gray literature, hand-searching, and reviewing references of included papers and conference abstracts. In a two-phase approach, two authors will independently screen titles and abstracts, and full-text based on inclusion/exclusion criteria. All study designs will be included that present detailed data about the elements of navigation programs, including intervention content, navigator training, and/or management. Data will be extracted from included studies, and review findings will be synthesized and summarized.

DISCUSSION

A scoping review focused on cultural humility in patient navigation within the context of eliminating disparities in PCa care among African American men does not yet exist. This review will synthesize existing evidence of patient navigation programs for African American prostate cancer patients and the inclusion of cultural humility. Results will inform the development and implementation of future programs to meet the unique needs of vulnerable prostate cancer patients in safety net settings.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 2021 CRD42021221412.

A Systematic Review of Head and Neck Cancer Health Disparities: A Call for Innovative Research

OBJECTIVE

(1) Describe the existing head and neck cancer health disparities literature. (2) Contextualize these studies by using the NIMHD research framework (National Institute on Minority Health and Health Disparities). (3) Explore innovative ideas for further study and intervention.

DATA SOURCES

Ovid MEDLINE, Embase, Web of Science, and Google Scholar.

REVIEW METHODS

Databases were systematically searched from inception to April 20, 2020. The PRISMA checklist was followed (Preferred Reporting Items for Systematic Reviews and Meta-analyses). Two authors reviewed all articles for inclusion. Extracted data included health disparity population and outcomes, study details, and main findings and recommendations. Articles were also classified per the NIMHD research framework.

RESULTS

There were 148 articles included for final review. The majority (n = 104) focused on health disparities related to at least race/ethnicity. Greater than two-thirds of studies (n = 105) identified health disparities specific to health behaviors or clinical outcomes. Interaction between the individual domain of influence and the health system level of influence was most discussed (n = 99, 66.9%). Less than half of studies (n = 61) offered specific recommendations or interventions.

CONCLUSIONS

There has been extensive study of health disparities for head and neck cancer, largely focusing on individual patient factors or health care access and quality. This review identifies gaps in this research, with large numbers of retrospective database studies and little discussion of potential contributors and explanations for these disparities. We recommend shifting research on disparities upstream toward a focus on community and societal factors, rather than individual, and an evaluation of interventions to promote health equity.

COVID-19 Disparities and Vaccine Hesitancy in Black Americans: What Ethical Lessons Can Be Learned?

OBJECTIVE

This state of the art review focuses on bioethical questions and considerations from research findings and methodological issues, including design and recruitment of participants, in studies related to COVID-19 vaccine hesitation in Black individuals. Ethical concerns identified were applied to otolaryngology with recommendations for improving health inequities within subspecialties.

DATA SOURCES

An internet search through PubMed, CINAHL, and socINDEX was conducted to identify articles on COVID-19 vaccine hesitation among the Black population between 2020 and 2021.

REVIEW METHODS

A systematic review approach was taken to search and analyze the research on this topic, which was coupled with expert analysis in identifying and classifying vital ethical considerations.

CONCLUSIONS

The most common COVID-19 vaccine hesitation factors were related to the development of the vaccine, mistrust toward government agencies, and misconceptions about safety and side effects. These findings raised bioethical concerns around mistrust of information, low health literacy, insufficient numbers of Black participants in medical research, and the unique positions of health professionals as trusted sources. These bioethical considerations can be applied in otolaryngology and other health-related areas to aid the public in making informed medical decisions regarding treatments, which may reduce health inequalities among Black Americans and other racial and ethnic minority groups.

IMPLICATIONS FOR PRACTICE

Addressing ethical questions by decreasing mistrust, tailoring information for specific populations, increasing minority representation in research, and using health professionals as primary sources for communicating health information and recommendations may improve relationships with Black communities and increase acceptance of new knowledge and therapies such as COVID-19 vaccination.

Effects of Nurse Navigators During the Transition from Cancer Screening to the First Treatment Phase: A Systematic Review and Meta-analysis

PURPOSE

Implementation of nurse navigators during cancer screening to the first treatment visit may facilitate early diagnosis and treatment. This study aims to demonstrate the evidence of the effects of nurse navigators during cancer screening in the first treatment phase.

METHODS

Eleven electronic databases were searched, including PubMed, CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, Web of Science, ScienceDirect, PsycINFO, KoreaMed, KISS, RISS, and DBPIA. The final search was completed in August 2021. Two reviewers independently screened and selected studies, extracted data, and conducted a quality assessment. Data to evaluate the effects of nurse navigators was analyzed through meta-analysis and narrative summary. Subgroup analyses were performed.

RESULTS

A total of 16 studies was included. With low to moderate quality of evidence, nurse navigators had favorable effects on improving the timeliness of care during screening during the first treatment visits (MD = 20.42, 95% CI = 8.74 to 32.10, p = .001). Additionally, 13.0% to 45.0% of nurse navigated patients were more likely to complete cancer care services, although insignificant effects were observed. Study participants from individual studies reported a high satisfaction to the nurse navigators. Subgroup analyses indicated that nurse navigators working as key members in multidisciplinary programs had the greatest effect on reducing waiting times.

CONCLUSION

Nurse navigators improve cancer patient outcomes by providing more timely care. Additionally, nurse navigators have the substantial potential to increase completion rates to cancer care services and patient satisfaction. For facilitating multidisciplinary care, the use of nurse navigators is highly recommended in the future.

The role of patient navigators in ambulatory care: overview of systematic reviews

BACKGROUND

Patient navigators have been introduced across various countries to enable timely access to healthcare services and to ensure completion of diagnosis and follow-up of care. There is an increasing evidence on the the role of patient navigation for patients and healthcare systems. The aim of this study was to analyse the evidence on patient navigation interventions in ambulatory care and to evaluate their effects on individuals and health system outcomes.

METHODS

An overview of reviews was conducted, following a prespecified protocol. All patients in ambulatory care or transitional care setting were included in this review as long as it was related to the role of patient navigators. The study analysed patient navigators covering a wide range of health professionals such as physicians, nurses, pharmacists, social workers and lay health workers or community-based workers with no or very limited training. Studies including patient-related measures and health system-related outcomes were eligible for inclusion. A rigorous search was performed in multiple data bases. After reaching a high inter-rater agreement of 0.86, title and abstract screening was independently performed. Of an initial 14,248 search results and an additional 62 articles identified through the snowballing approach, a total of 7159 hits were eligible for title/abstract screening. 679  articles were included for full-text screening.

RESULTS

Eleven systematic reviews were included covering various patient navigation intervention in cancer care, disease screening, transitional care and for various chronic conditions and multimorbidity. Nine systematic reviews primarily tailored services to ethnic minorities or other disadvantaged groups. Patient navigators performed tasks such as providing education and counselling, translations, home visits, outreach, scheduling of appointments and follow-up. Eight reviews identified positive outcomes in expanding access to care, in particular for vulnerable patient groups. Two reviews on patient navigation in transitional care reported improved patient outcomes, hospital readmission rates and mixed evidence on quality of life and emergency department visits. Two reviews demonstrated improved patient outcomes for persons with various chronic conditions and multimorbidity.

CONCLUSIONS

Patient navigators were shown to expand access to screenings and health services for vulnerable patients or population groups with chronic conditions who tend to underuse health services.

'There's nothing you can do … it's like that in Chinatown': Chinese immigrant women's perceptions of experiences in Chicago Chinatown healthcare settings

Objectives: Chinese American women living in linguistically isolated communities are among the least likely to utilize healthcare services. Qualitative research methods can help identify health system vulnerability points to improve local healthcare delivery for this population.Design: We conducted 6 focus groups among 56 Chinese-speaking adult women in Chicago's Chinatown between July and August 2014 to explore their perceptions of experiences receiving medical care and interacting with healthcare providers in Chinatown healthcare settings.Results: Health system/clinic infrastructure and patient-provider communications were perceived barriers to care at Chinatown healthcare settings. Chinese participants reported long wait times, difficulty scheduling appointments, and poor front desk customer service. Communication difficulties at Chinatown healthcare settings involved language barriers with non-Chinese-speaking providers, but consideration for healthcare providers, provider demeanor, and reliance on provider recommendation also hindered patient-provider communications.Conclusions: Findings improve understanding of barriers to care experienced by Chinese immigrant women in one urban Chinatown community.

"This Graft-vs.-Host Disease Determines My Life. That's It."-A Qualitative Analysis of the Experiences and Needs of Allogenic Hematopoietic Stem Cells Transplantation Survivors in Germany

Background: Allogeneic hematopoietic stem cell transplantation (alloHSCT) is the only curative treatment modality for many patients affected by hematologic malignancies. However, it can cause debilitating long-term effects. Understanding the impact of alloHSCT on all aspects of the patients' life is required for optimal survivorship management. Aim: To explore in-depth HSCT-survivors' experiences and needs post-transplant. Partners were included to provide further information on survivors' needs and how care could be improved in this area. Methods: We conducted semi-structured face-to-face and phone interviews with alloHSCT-survivors and their partners referred to a survivorship clinic in Germany. Theoretical sampling was used to recruit participants. Data were analyzed using framework analysis. Results: Thirty-two survivors (consent rate: 100%, response rate: 100%) and eighteen partners (consent rate: 84%, response rate: 72%) participated. Survivors were aged between 25 and 68 years (Median: 48, IQR: 25.3) and partners were aged between 26 and 64 years (Median: 54, IQR: 16, SD: 12.8). The themes emerging from the data involved survivors' needs included (i) the diversity of long-term treatment side-effects; and (ii) time post discharge as a dynamic process with individual peaks of burden. Survivors and their partners also suggested strategies for mitigating these unmet needs, i.e., (iii) transparent communication and patient empowerment; and (iv) improvement in continuity of care system and help with claiming social benefits as cornerstones of optimal survivorship care. Conclusion: To our knowledge, this is one of the first qualitative studies focused on the views of German alloHSCT-survivors on the long-term effects of alloHSCT and the first study integrating the view of their partners. Healthcare providers could better support survivors with managing their symptoms and adhering to their prescribed care by ensuring comprehensive, transparent communication that helps increase survivors' understanding and involvement in their care. Further efforts should be made to provide patient-centered, continuous survivorship care that involves additional support with navigating the healthcare and social service system. Intervention studies are required to test the effectiveness of the suggested strategies.

How is the COVID-19 pandemic shaping transportation access to health care?

The Coronavirus disease 19 (COVID-19) pandemic has disrupted both transportation and health systems. While about 40% of Americans have delayed seeking medical care during the pandemic, it remains unclear to what extent transportation is contributing to missed care. To understand the relationship between transportation and unmet health care needs during the pandemic, this paper synthesizes existing knowledge on transportation patterns and barriers across five types of health care needs. While the literature is limited by the absence of detailed data for trips to health care, key themes emerged across populations and settings. We find that some patients, many of whom already experience transportation disadvantage, likely need extra support during the pandemic to overcome new travel barriers related to changes in public transit or the inability to rely on others for rides. Telemedicine is working as a partial substitute for some visits but cannot fulfill all health care needs, especially for vulnerable groups. Structural inequality during the pandemic has likely compounded health care access barriers for low-income individuals and people of color, who face not only disproportionate health risks, but also greater difficulty in transportation access and heightened economic hardship due to COVID-19. Partnerships between health and transportation systems hold promise for jointly addressing disparities in health- and transportation-related challenges but are largely limited to Medicaid-enrolled patients. Our findings suggest that transportation and health care providers should look for additional strategies to ensure that transportation access is not a reason for delayed medical care during and after the COVID-19 pandemic.

Is nurse-led case management effective in improving treatment outcomes for cancer patients? A systematic review and meta-analysis

AIMS

To identify and synthesize the outcomes of nurse-led case management interventions for improving cancer treatment.

DESIGN

Systematic review with meta-analysis.

DATA SOURCES

PubMed, MEDLINE, CINAHL, EMBASE, Cochrane Library and CEPS were searched for articles published from inception till June 2019, and search was finalized in January 2020.

REVIEW METHODS

The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines. The quality of evidence was assessed using Joanna Briggs Institute Critical Appraisal Tools. Outcomes were analysed by using a pool of data of 95% confidence intervals (CIs), p value and fitting model based on heterogeneity of test results.

RESULTS

Eleven articles were included in the meta-analysis. When compared with the regular care group, the nurse-led case management group had: 1) shorter time from diagnosis to treatment by 9.07 days, 2) an improved treatment completion rates (OR = 2.45) and 3) more number of patients received hormone therapy.

CONCLUSION

The synthesized results presented that nurse-led case management is more effective than regular care in improving treatment timeliness, treatment completion rates and hormone therapy rates.

Patient and Provider Perceptions of a Patient Navigation Program to Improve Postpartum Care Among Publicly Insured Women

OBJECTIVE

This study was aimed to assess patient and provider perceptions of a postpartum patient navigation program.

STUDY DESIGN

This was a mixed-method assessment of a postpartum patient navigation program. Navigating New Motherhood (NNM) participants completed a follow-up survey including the Patient Satisfaction with Interpersonal Relationship with Navigator (PSN-I) scale and an open-ended question. PSN-I scores were analyzed descriptively. Eighteen provider stakeholders underwent in-depth interviews to gauge program satisfaction, perceived outcomes, and ideas for improvement. Qualitative data were analyzed by the constant comparative method.

RESULTS

In this population of low-income, minority women, participants (n = 166) were highly satisfied with NNM. The median PSN-I score was 45 out of 45 (interquartile range [IQR]: 43-45), where a higher score corresponds to higher satisfaction. Patient feedback was also highly positive, though a small number desired more navigator support. Provider stakeholders offered consistently positive program feedback, expressing satisfaction with NNM execution and outcomes. Provider stakeholders noted that navigators avoided inhibiting clinic workflow and eased clinic administrative burden. They perceived NNM improved multiple clinical and satisfaction outcomes. All provider stakeholders believed that NNM should be sustained long-term; suggestions for improvement were offered.

CONCLUSION

A postpartum patient navigation program can perceivably improve patient satisfaction, clinical care, and clinic workflow without burden to clinic providers.

Fertility navigators in female oncofertility care in an academic medical center: a qualitative evaluation

PURPOSE

To explore patients' and professionals' experiences with fertility navigators in female oncofertility care.

METHODS

Semi-structured in-depth interviews were conducted with nine female cancer patients and six healthcare professionals to explore their experiences. They were recruited from an academic medical center (referral clinic for female fertility preservation care). Data were analyzed using the concepts of grounded theory.

RESULTS

Patients were satisfied about the supportive role of the fertility navigator in their fertility preservation process: fertility navigators added value as they became "familiar faces" and provided information, emotional support, personal care, and served as patients' primary contact person. The fertility navigators had a pleasant collaboration with professionals and supported professionals by taking over tasks. To improve the role of fertility navigators, it was suggested that they should always be present in fertility preservation counseling, and attention should be paid to their availability to improve continuity of care.

CONCLUSION

Fertility navigators provide personal care, improve satisfaction in patients in their oncofertility process, and support professionals. The overview of issues that need to be addressed when assigning fertility navigators in female oncofertility care combined with the improvement suggestions could be used by other centers when considering implementing fertility navigators.

Quality of life outcomes from a randomized controlled trial of patient navigation in Latina breast cancer survivors

INTRODUCTION

Breast cancer survivorship is a life-long process involving challenges to health-care communities and individuals, especially Latinas. Patient Navigation has shown some success in meeting these challenges. The purpose of this study was to compare the effects of an enhanced Patient Navigation program (Intervention; PN+) vs Control (PN) over time on general cancer and breast cancer-specific quality of life (QoL) in Latina breast cancer survivors (BCS).

METHODS

We conducted a 2-year, two-arm randomized controlled trial of the "Staying Healthy" program among Latina BCS. The design compared PN+ vs PN over time. We recruited 60 patients into each study arm and randomized them by sequential numerical assignment. PN+ participants received culturally tailored educational materials and active, personalized Patient Navigation services, including phone calls, transportation, and care coordination. PN participants were navigated only upon request. Primary outcomes included general cancer (Functional Assessments of Cancer Therapy [FACTS]-G) and breast cancer-specific (FACT-B) QoL.

RESULTS

PN+ participants had significantly improved QoL measures compared to PN at 6-month follow-up on all subscales (P-values .007-.04) except physical well-being (PWB; P = .11). Intervention effect size coefficient (standard error) for FACT-G overall was 7.9 (3.1); P = .01. For FACT-B, it was 10.9 (3.9); P = .006. Again, all subscales showed significant effects [range 1.7-3.1 (0.8-1.2); P-values .006-.04], except for PWB [1.5 (1.0); P = .16] and social/family well-being (SWB) [2.1 (1.1); P = .06]. There were no differences between groups at baseline.

DISCUSSION

Multiple cultural, psychosocial, and socioeconomic variables contributing to these intervention effects will be addressed in future studies. As the national BCS population continues to increase, more Patient Navigation-focused partnerships among patients, health-care professionals, research groups, and community organizations are needed to improve BCS experiences. The Staying Healthy program has the potential to serve as a national survivorship care model for improving Latina BCS QoL.

Systematic Patient Navigation Strategies to Scale Breast Cancer Disparity Reduction by Improved Cancer Prevention and Care Delivery Processes

PURPOSE

Patient navigation uses trained personnel to eliminate barriers to timely care across all phases of the health care continuum, thereby reducing health disparities. However, patient navigation has yet to be systematized in implementation models to improve processes of care at scale rather than remain a band-aid approach focused solely on improving care for the individual patient. The 4R systems engineering approach (right information and right treatment to the right patient at the right time) uses project management discipline principles to develop care sequence templates that serve as patient-centered project plans guiding patients and their care team.

METHODS

A case-study approach focused on the underserved patient shows how facilitators to timely breast cancer screening and care pragmatically identified as emergent data by patient navigators can be actionized by iteratively revising 4R care sequence templates to incorporate new insights as they emerge.

RESULTS

Using a case study of breast cancer screening of a low-income patient, we illustrate how 4R care sequence templates can be revised to incorporate emergent facilitators to care identified through patient navigation.

CONCLUSION

Use of care sequence templates can inform the care team to optimize a particular patient's care, while functioning as a learning health care system for process improvement of patient care and patient navigation scaling. A learning health care system approach that systematically integrates data patterns emerging from multiple patient navigation experiences through in-person navigators and 4R care sequence templates may improve processes of care and allow patient navigation scaling to reduce cancer disparities.

The use of mobile technology and peer navigation to promote adolescent and young adult (AYA) cancer survivorship care: results of a randomized controlled trial

PURPOSE

Adolescent and young adult (AYA) cancer survivors experience unique barriers that compromise receipt of survivorship care; therefore, development of innovative educational interventions to improve rates of AYA survivorship care is needed. The efficacy of text-messaging and peer navigation interventions was compared to standard-of-care survivorship educational materials to increase AYAs' (1) late effects knowledge and (2) knowledge, attitudes, and self-efficacy towards seeking survivor-focused care.

METHODS

This was a three-armed, prospective, randomized controlled trial with one control group and two intervention groups. The control group received current standard-of-care educational materials. One intervention group participated in a text-messaging program, and the second participated in a peer navigator program. Participants completed pre- and post-intervention questionnaires. Study outcome variables were quantified using Fisher exact tests, two-sample t tests, exact McNemar tests, conditional logistic regression models, and analysis of covariance.

RESULTS

Seventy-one survivors completed the study (control n = 24; text-messaging n = 23; peer navigation n = 24). Late effects knowledge was high at baseline for all groups. The text-messaging group had increased survivorship care knowledge compared to the control group (p < 0.05); the peer navigation group had increased survivorship care self-efficacy compared to the control group; p < 0.05. Both intervention groups showed increased attitudes towards seeking survivor-focused care compared to the control group (text-messaging p < 0.05; peer navigation p < 0.05).

CONCLUSIONS

Each intervention demonstrated significant benefits compared to the control group.

IMPLICATIONS FOR CANCER SURVIVORS

Given the preliminary effectiveness of both interventions, each can potentially be used in the future by AYA cancer survivors to educate and empower them to obtain needed survivorship care.

The Chinatown Patient Navigation Program: Adaptation and Implementation of Breast and Cervical Cancer Patient Navigation in Chicago's Chinatown

Background

As health care reform continues within the United States, navigators may play increasingly diverse and vital roles across the health care continuum. The growing interest in patient navigation programs for underserved populations calls for detailed descriptions of intervention components to facilitate implementation and dissemination efforts.

Methods

In Chicago's Chinatown, Chinese immigrant women face language, cultural, and access barriers in obtaining breast and cervical cancer screening and follow-up. These barriers spurred the research partnership between Northwestern University, the Chinese American Service League, Mercy Hospital & Medical Center, and Rush University Medical Center to formalize the Chinatown Patient Navigation Collaborative for adapting and implementing previously developed patient navigation models.

Results

In this report, we describe the adaptation of patient navigation to build the Chinatown Patient Navigation Collaborative's community-based patient navigation program for breast and cervical cancer. We offer insights into the roles of community patient navigators in safety net hospital and underserved Chinese immigrant communities, and describe implications for patient navigation initiatives to maximize community benefits by improving access to health care for vulnerable populations.

Conclusions

Our adaptation and implementation of a patient navigation intervention in Chicago's Chinatown illustrates promising approaches for future navigator research.

Chinese Immigrant Women's Attitudes and Beliefs About Family Involvement in Women's Health and Healthcare: A Qualitative Study in Chicago's Chinatown

Purpose: Healthcare utilization and health-seeking behaviors of Chinese American immigrant women may be influenced by longstanding cultural perspectives of family roles and relationships. An understanding of Chinese immigrant women's perceptions of family social support in health and how these beliefs manifest in healthcare utilization and help-seeking behaviors is critical to the development of culturally appropriate health interventions. Focusing on a sample of Chinese women in Chicago's Chinatown, this qualitative study seeks to describe women's attitudes and beliefs about spouse and adult children's involvement in women's health and healthcare.

Methods: We conducted six focus groups among 56 Chinese-speaking adult women in Chicago's Chinatown between July and August 2014. Focus groups were transcribed, coded, and analyzed for emergent themes.

Results: Women reported that their adult children supported their health and healthcare utilization by helping them overcome language and transportation barriers, making and supporting decisions, and providing informational and instrumental support related to diet and nutrition. Women viewed these supports with mixed expectations of filial piety, alongside preferences to limit dependency and help-seeking because of concern and emotional distress regarding burdening adult children. Women's expectations of the spouse involvement in their healthcare were low and were shaped by avoidance of family conflict.

Conclusion: Findings inform opportunities for the development of culturally appropriate interventions to enhance Chinese immigrant women's health and healthcare. These include patient navigation/community health worker programs to promote self-management of healthcare and family-centered strategies for enhancing family social support structures and reducing family conflict.