Predicting Colonoscopy Completion Among African American and Latino/a Participants in a Patient Navigation Program

Lung Cancer Mortality Racial/Ethnic Disparities in Patient Experiences with Care: a SEER-CAHPS Study

BACKGROUND

To determine whether there are racial/ethnic disparities in patient experiences with care among lung cancer survivors, whether they are associated with mortality.

METHODS

A retrospective cohort study of lung cancer survivors > 65 years old who completed a CAHPS survey > 6 months after the date of diagnosis. We used data from the SEER-Consumer Assessment of Healthcare Providers Systems (SEER-CAHPS®) database from 2000 to 2013 to assess racial/ethnic differences in patient experiences with care multivariable Cox proportional hazards models to assess the association between patient experience with care scores mortality in each racial/ethnic group.

RESULTS

Within our cohort of 2603 lung cancer patients, Hispanic patients reported lower adjusted mean score with their ability to get needed care compared to white patients (B: - 5.21, 95% CI: - 9.03, - 1.39). Asian patients reported lower adjusted mean scores with their ability to get care quickly (- 4.25 (- 8.19, - 0.31)), get needed care (- 7.06 (- 10.51, - 3.61)), get needed drugs (- 9.06 (- 13.04, - 5.08)). For Hispanic patients, a 1-unit score increase in their ability to get all needed care (HR: 1.02, 1.00-1.03) care coordination (1.06, 1.02-1.09) was associated with higher risk of mortality. Among black patients, a 1-unit score increase in their ability to get needed care (HR: 0.99, 95% CI 0.98-0.99) care coordination (0.97, 0.94-0.99) was associated with lower risk mortality.

CONCLUSIONS

There are racial/ethnic disparities in lung cancer patient experiences with care that may impact mortality. Patient experiences with care are important risk factors of mortality for certain racial/ethnic groups.

Adherence to surveillance colonoscopy guidelines in patients following curative-intent colorectal cancer resection

BACKGROUND

Current guidelines recommend that patients who have undergone curative-intent resection for colorectal cancer (CRC) should undergo colonoscopy one year following their surgery or at six months post-operatively if a pre-operative colonoscopy was not performed due to an obstructing lesion. We sought to determine adherence to postoperative surveillance colonoscopy guidelines in our National Cancer Institute designated comprehensive cancer center and potentially identify factors associated with non-adherence.

MATERIALS AND METHODS

A retrospective review of 100 patients who underwent curative-intent CRC resection was performed between 2013 and 2019. Patients were divided into two groups based upon adherence to surveillance colonoscopy guidelines. Demographic, tumor, and postoperative variables were analyzed.

RESULTS

The median age of all patients was 62. Fifty-seven percent of patients were male. Thirty-eight patients underwent surveillance colonoscopy in accordance with current guidelines. Sixty-two patients did not undergo surveillance colonoscopy postoperatively or did so outside of the National Comprehensive Cancer Network guidelines. Factors associated with non-adherence to surveillance colonoscopy included presence of comorbidities, albumin less than 3.5, and performance of a pre-operative colonoscopy.

CONCLUSIONS

Adherence to surveillance colonoscopy guidelines was low among our patients. Efforts should be directed toward patients at increased risk for non-adherence to surveillance colonoscopy guidelines.

Predictors of overall and test-specific colorectal Cancer screening adherence

This study investigated predictors of overall and test-specific colorectal cancer screening (CRCS). Stool blood test (SBT) and/or colonoscopy screening were offered to primary care patients in two randomized controlled trials which assessed the impact of behavioral interventions on screening. Data were obtained through surveys and electronic medical records. Among 1942 participants, 646 (33%) screened. Exposure to interventions was associated with higher overall CRCS by twofold to threefold; older age, African American race, being married, and having a higher screening decision stage were also associated with higher overall CRCS (odds ratios = 1.30, 1.31, 1.34, and 5.59, respectively). Intervention, older age, female gender, and being married were associated with higher SBT adherence, while preference for colonoscopy was associated with lower SBT adherence. Intervention and higher decision stage were associated with higher colonoscopy adherence, while preference for SBT was associated with lower colonoscopy adherence. Among older individuals, African Americans had higher overall CRCS than whites, but this was not true among younger individuals (interaction p = .041). The higher screening adherence of African Americans over whites was due to stronger screening with a non-preferred test, i.e., higher SBT adherence only among individuals who preferred colonoscopy and higher colonoscopy adherence only among individuals who preferred SBT. Intervention exposure, sociodemographic background, and screening decision stage predicted overall CRCS adherence. Gender and test preference also affected test-specific screening adherence. Interactions involving race and test preference suggest that it is important to provide both colonoscopy and SBT screening options to patients, particularly African Americans.

Predicting Colonoscopy Screening Behavior and Future Screening Intentions for African Americans Older than 50 Years

African Americans experience a disproportionate burden of morbidity and mortality from colorectal cancer, which may be due to low adherence to screening recommendations. Previous studies have found relationships between decision-making factors and screening behavior, but few have looked at both cognitive and affective factors or within a specifically African American sample. To better understand determinants that drive screening behavior, this study examines affective, cognitive, and social variables as predictors of colonoscopy in an age-eligible African American population. Participants completed surveys assessing affective associations with colonoscopy, perceived benefits and barriers, self-efficacy, knowledge, fear of colonoscopy, perceived risk, and colorectal cancer worry and fear. Regression analysis was used to model decision-making constructs as predictors of screening behavior/intentions. Affective, cognitive, and health care experience variables predicted colonoscopy completion and intentions. Provider-level factors and previous cancer screenings predicted prior screening only, but not intentions. Affective and cognitive components of perceived risk were associated with decreased likelihood of colonoscopy behavior, but increased likelihood of colonoscopy intentions. These findings suggest that colonoscopy decision making involves a complex array of both cognitive and affective determinants. This work extends our knowledge of colorectal cancer screening decision making by evaluating the effects of these multiple determinants on screening behavior in an African American sample. Future work exploring the interplay of affect and cognitions as influences on colonoscopy decision making and how health care experiences may moderate this effect is needed to develop effective intervention approaches and reduce screening disparities.

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

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

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

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

Disparities in Cancer Screening Practices among Minority and Underrepresented Populations

OBJECTIVES

To review current evidence about cancer screening challenges that lead to cancer health disparities in minority populations.

DATA SOURCES

Research reports, published journal articles, web sites, and clinical practice observations.

CONCLUSION

There are significant disparities that exist in cancer screening practices among racial and ethnic minority and underrepresented populations, resulting in disproportionately higher cancer mortality rates in these populations.

IMPLICATIONS FOR NURSING PRACTICE

Nurses are positioned to lead in educating, promoting, and bringing awareness to cancer screening recommendationsand current cancer prevention guidelines for at-risk individuals, and help them to implement these guidelines to reduce incidence and mortality.

Knowledge of Polyp History and Recommended Follow-Up Among a Predominately African American Patient Population and the Impact of Patient Navigation

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Colonoscopy-specific fears in African Americans and Hispanics

Although fears of colonoscopy may deter African Americans and Hispanics from having a screening colonoscopy, little is known about these fears. This study examined the proportion of African Americans and Hispanics who experience colonoscopy-specific fears and identified factors associated with these fears. Data were collected at an academic hospital in New York City between 2008-2010. African Americans (N = 383) and Hispanics (N = 407) who received a recommendation for a screening colonoscopy completed a questionnaire that assessed: colonoscopy-specific fears, demographics, and psychological variables. Presence of colonoscopy-specific fears was endorsed by 79.5% of participants. Being female (p < 0.001), speaking English (p < 0.001), having greater perceived risk of colorectal cancer (CRC) (p < 0.01), greater worry about risk of CRC (p < 0.01), greater fear of CRC (p < 0.001) and lower levels of self-efficacy of having a colonoscopy (p < 0.01) were associated with greater colonoscopy-specific fears. Results can inform interventions designed to assuage fears in African Americans and Hispanics.