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

Engaging Community Health Workers in Primary Care Practices: Provider Understanding of Roles, Benefits, and Barriers

Community health workers (CHWs) are increasingly addressing health disparities in primary care settings; however, there is little information about how primary care practitioners (PCPs) interact with CHWs or perceive CHW roles. We examined PCP engagement with CHWs in adult primary care settings. Overall, 55% of 1504 PCPs reported working with CHWs; involvement with CHWs differed by some PCP demographic and practice-related factors. While PCPs perceived CHWs as engaging in most nationally endorsed CHW roles, they identified several barriers to integrating CHWs into care teams. Findings can inform ongoing efforts to advance health equity through integrating CHWs into primary care practices.

Patient navigation for perinatal substance use disorder treatment: A systematic review

BACKGROUND

Substance use during the perinatal period (i.e., pregnancy through the first year postpartum) can pose significant maternal and infant health risks. However, access to lifesaving medications and standard care remains low for perinatal persons who use substances. This lack of substance use disorder treatment access stems from fragmented services, stigma, and social determinants of health-related barriers that could be addressed using patient navigators. This systematic review describes patient navigation models of care for perinatal people who use substances and associated outcomes.

METHODS

We conducted a structured search of peer-reviewed, US-focused, English- or Spanish-language articles from 2000 to 2023 focused on 1) patient navigation, 2) prenatal and postpartum care, and 3) substance use treatment programs using PubMed, Scopus, PsycINFO, and CINAHL databases.

RESULTS

After meeting eligibility criteria, 17 studies were included in this review. The majority (n=8) described outpatient patient navigation programs, with notable hospital (n=4) and residential (n=3) programs. Patient navigation was associated with reduced maternal substance use, increased receipt of services, and improved maternal and neonatal health. Findings were mixed for engagement in substance use disorder treatment and child custody outcomes. Programs that co-located care, engaged patients across the perinatal period, and worked to build trust and communication with family members and service providers were particularly successful.

CONCLUSION

Patient navigation may be a promising strategy for improving maternal and infant health outcomes among perinatal persons who use substances. More experimental research is needed to test the effect of patient navigation programs for perinatal persons who use substances compared to other models of care.

Evaluating implementation of a community-focused patient navigation intervention at an NCI-designated cancer center using RE-AIM

BACKGROUND

Patient navigation is an evidence-based intervention that reduces cancer health disparities by directly addressing the barriers to care for underserved patients with cancer. Variability in design and integration of patient navigation programs within cancer care settings has limited this intervention's utility. The implementation science evaluation framework, RE-AIM, allows quantitative and qualitative examination of effective implementation of patient navigation programs into cancer care settings.

METHODS

The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework was used to evaluate implementation of a community-focused patient navigation intervention at an NCI-designated cancer center between June 2018 and October 2021. Using a 3-month longitudinal, non-comparative measurement period, univariate and bivariate analyses were conducted to examine associations between participant-level demographics and primary (i.e., barrier reduction) and secondary (i.e., patient-reported outcomes) effectiveness outcomes. Mixed methods analyses were used to examine adoption and delivery of the intervention into the cancer center setting. Process-level analyses were used to evaluate maintenance of the intervention.

RESULTS

Participants (n = 311) represented a largely underserved population, as defined by the National Cancer Institute, with the majority identifying as Hispanic/Latino, having a household income of $35,000 or less, and being enrolled in Medicaid. Participants were diagnosed with a variety of cancer types and most had advanced staged cancers. Pre-post-intervention analyses indicated significant reduction from pre-intervention assessments in the average number of reported barriers, F(1, 207) = 117.62, p < .001, as well as significant increases in patient-reported physical health, t(205) = - 6.004, p < .001, mental health, t(205) = - 3.810, p < .001, self-efficacy, t(205) = - 5.321, p < .001, and satisfaction with medical team communication, t(206) = - 2.03, p = .029. Referral patterns and qualitative data supported increased adoption and integration of the intervention into the target setting, and consistent intervention delivery metrics suggested high fidelity to intervention delivery over time. Process-level data outlined a successful transition from a grant-funded community-focused patient navigation intervention to an institution-funded program.

CONCLUSIONS

This study utilized the implementation science evaluation framework, RE-AIM, to evaluate implementation of a community-focused patient navigation program. Our analyses indicate successful implementation within a cancer care setting and provide a potential guide for other oncology settings who may be interested in implementing community-focused patient navigation programs.

Barriers and facilitators of colorectal cancer screening among East African men in Minnesota: a qualitative investigation

Objective: This study aimed to explore barriers and facilitators to colorectal cancer (CRC) screening among East African men in Minnesota.Design: Six focus groups were conducted in Minneapolis and St. Paul, MN, USA. Participants were asked to describe individual and structural barriers to CRC screening, and discuss strategies that would address individual and structural barriers to screening. Audio-recorded conversations were transcribed verbatim and translated to English. The transcriptions were analyzed using a thematic analysis. Major themes that emerged on individual barriers were lack of knowledge, fear, and privacy.Results: Themes that emerged on structural barriers were distrust in the medical system, lack of health care coverage, and access to the health care system. Education, client reminders, mass media, increased clarity in communication with the provider and translator, and increased access to health care were frequently mentioned strategies to increase CRC screening in the East African community. Participants expressed favorable views toward the concept of patient navigation.Conclusion: Our findings indicate the need to develop culturally appropriate, multi-faced, intervention programs that are aimed at eliminating personal, cultural, and structural barriers.

Improving Time to Diagnostic Resolution in the Breast Imaging Service: A Tertiary Center's Experience and Process of Improvement

OBJECTIVE

Breast imaging services often experience a significant degree of variability in patient flow, leading to delay in time to diagnostic resolution, commonly referred to as time to resolution (TTR). This study applies Lean Six Sigma Methodology (LSSM) to reduce TTR and enhance patient outcomes.

METHODS

This study was IRB-approved. A baseline audit was done using cases of mammographic recalls (BI-RADS 0) to measure baseline TTR. Multidisciplinary meetings with all members of the breast imaging service, alongside a study of patient complaint data, were utilized to identify issues that were causing prolonged TTR. Following that, possible solutions were proposed and implemented. A post-implementation audit was conducted, and the resulting TTRs were compared. Significant differences in TTR between the pre- and post-solution implementation were assessed using the Mann-Whitney U test.

RESULTS

During the baseline audit of 8 months, 589 cases of mammographic recalls (BI-RADS 0) were identified, and the resulting average TTR was 86.3 days. During the post-implementation period of 3 months, 370 mammographic recalls (BI-RADS 0) occurred, with a resulting average TTR of 36.0 days. After applying LSSM, TTR was reduced by 58.3% (P < 0.01). Some changes implemented included training the coordinators, establishing a rapid diagnostic clinic using previously underutilized equipment, and having radiologists assigned full-time to the breast imaging service.

CONCLUSION

Our team has successfully managed to identify various causes behind the prolonged TTR using LSSM. Team collaboration was essential to study and decide on a more achievable TTR.

Breast Cancer Management Timelines in a Tertiary Care Center During the COVID-19 Pandemic, Makkah City, Saudi Arabia: A Retrospective Study

BACKGROUND

Breast cancer (BC) is a prevalent form of cancer and a leading cause of death among women worldwide. In Saudi Arabia, it accounted for 31.8% among females of all new cancer cases reported in 2018. Following the declaration of COVID-19 as a global pandemic, there was a complete redistribution of healthcare resources to face this crisis, which caused a significant delay in the management of various diseases, including BC. There is currently a lack of research in our region on the facility time interval in BC management. Therefore, this study aimed to fill this gap by determining the timelines of diagnosis, management, and factors influencing the delay.

METHODS

This observational retrospective study included all female patients diagnosed with BC at or referred to King Abdullah Medical City (KAMC) in Makkah, Saudi Arabia, between January 2020 and August 2021. The data for this study were obtained from a centralized electronic chart review of all included patients at the KAMC center.

RESULTS

A total of 76 patients were included in the study, with a mean age of 50 ± 11 years. In terms of the disease management duration, 20 patients (26.3%) completed their management within 30 days, 28 patients (36.8%) had a management duration between 31 and 60 days, and the management duration of 28 patients (36.8%) exceeded 60 days. Patient deposition showed a significant association with delay (p = 0.033). A higher incidence of delays at the initiation of treatment was observed in patients who failed to attend appointments (p < 0.001). Among patients who skipped two or more appointments, 12 individuals (80%) experienced a delay of more than 60 days. Moreover, appointment cancellation was associated with delayed treatment initiation (p = 0.03). Patients' age and comorbidity showed no significant association (p = 0.49, p = 0.24, respectively).

CONCLUSION

Our findings highlight the significant impact of patient deposition and canceled or skipped appointments on delayed initiation of therapy for BC patients. Further research should be conducted to evaluate the impact of COVID-19 on other malignancies.

Predicting Social Determinants of Health in Patient Navigation: Case Study

BACKGROUND

Patient navigation (PN) programs have demonstrated efficacy in improving health outcomes for marginalized populations across a range of clinical contexts by addressing barriers to health care, including social determinants of health (SDoHs). However, it can be challenging for navigators to identify SDoHs by asking patients directly because of many factors, including patients' reluctance to disclose information, communication barriers, and the variable resources and experience levels of patient navigators. Navigators could benefit from strategies that augment their ability to gather SDoH data. Machine learning can be leveraged as one of these strategies to identify SDoH-related barriers. This could further improve health outcomes, particularly in underserved populations.

OBJECTIVE

In this formative study, we explored novel machine learning-based approaches to predict SDoHs in 2 Chicago area PN studies. In the first approach, we applied machine learning to data that include comments and interaction details between patients and navigators, whereas the second approach augmented patients' demographic information. This paper presents the results of these experiments and provides recommendations for data collection and the application of machine learning techniques more generally to the problem of predicting SDoHs.

METHODS

We conducted 2 experiments to explore the feasibility of using machine learning to predict patients' SDoHs using data collected from PN research. The machine learning algorithms were trained on data collected from 2 Chicago area PN studies. In the first experiment, we compared several machine learning algorithms (logistic regression, random forest, support vector machine, artificial neural network, and Gaussian naive Bayes) to predict SDoHs from both patient demographics and navigator's encounter data over time. In the second experiment, we used multiclass classification with augmented information, such as transportation time to a hospital, to predict multiple SDoHs for each patient.

RESULTS

In the first experiment, the random forest classifier achieved the highest accuracy among the classifiers tested. The overall accuracy to predict SDoHs was 71.3%. In the second experiment, multiclass classification effectively predicted a few patients' SDoHs based purely on demographic and augmented data. The best accuracy of these predictions overall was 73%. However, both experiments yielded high variability in individual SDoH predictions and correlations that become salient among SDoHs.

CONCLUSIONS

To our knowledge, this study is the first approach to applying PN encounter data and multiclass learning algorithms to predict SDoHs. The experiments discussed yielded valuable lessons, including the awareness of model limitations and bias, planning for standardization of data sources and measurement, and the need to identify and anticipate the intersectionality and clustering of SDoHs. Although our focus was on predicting patients' SDoHs, machine learning can have a broad range of applications in the field of PN, from tailoring intervention delivery (eg, supporting PN decision-making) to informing resource allocation for measurement, and PN supervision.

Implementation of postpartum navigation for low-income individuals at an urban academic medical center

BACKGROUND

Patient navigation, a patient-centered intervention to promote comprehensive health care, is an emerging innovation in obstetrics to optimize postpartum care. We aimed to evaluate the implementation of a novel postpartum patient navigation program at an urban academic medical center.

METHODS

This mixed-methods study analyzed the implementation of a postpartum patient navigation program within an ongoing randomized control trial. This study analyzed three navigators' logs of interactions with 50 patients, care team members, and community organizations throughout patients' first year postpartum. We categorized and quantified interactions by topic addressed, care team member interacted with, and communication mode used. We also conducted semi-structured interviews with each navigator every three months (5 interviews per navigator), emphasizing navigation experiences, relationships with patients and care teams, integration in the care team, and healthcare system gaps. Interview data were analyzed using the constant comparative method to identify themes using the constructs of the Consolidated Framework for Implementation Research (CFIR).

RESULTS

Analysis of navigator logs revealed a high patient need level, especially in the first 3 months postpartum. CFIR-guided analysis of intervention characteristics revealed positive perceptions of navigation's utility due to its adaptability. Navigation's complexity, however, posed an early obstacle to implementation that diminished over time. Outer setting analysis indicated navigators addressed patient needs through interactions with multiple systems. Despite clinicians' initial unfamiliarity with navigation, inner setting analysis suggested ongoing communication and electronic medical record use facilitated integration into the care team. Regarding individual and process characteristics, findings emphasized how navigator self-efficacy and confidence increased with experience (individual) and was facilitated by comprehensive training and reflection (process). Overall, barriers to implementation included unfamiliarity, varied patient engagement, and innovation complexity. Facilitators included high patient need, communication with outside organizations, medical record usage, navigator characteristics (self-efficacy, communication skills, and personal growth), a comprehensive training period, consistent reflection, high relative advantage, and high adaptability to patient need.

CONCLUSION

Patient navigation is a promising innovation to improve postpartum care coordination and support care team efforts. The successful implementation of navigation in this study indicates that, if shown to improve patient outcomes, obstetric navigation could be a component of patient-centered postpartum care.

Impact of COVID-19 Restrictions on Stage of Breast Cancer at Presentation and Time to Treatment at an Urban Safety-Net Hospital

Background

COVID-19 disrupted health systems across the country. Pre-pandemic, patients accessing our urban safety-net hospital presented with three-fold higher rates of late-stage breast cancer than other Commission-on-Cancer sites. We sought to determine the effect of the COVID-19 pandemic on stage of breast cancer presentation and time to first treatment at our urban safety-net hospital.

Methods

An Institutional Review Board-approved cohort study of newly diagnosed breast cancer patients was conducted at our safety-net hospital comparing a COVID cohort (March 2020–February 2021, n = 82) with a pre-COVID cohort (March 2018–February 2019, n = 90). Demographic information, stage at presentation, and time to first treatment—subdivided into time from symptom to diagnosis and diagnosis to treatment—were collected and analyzed for effect of COVID pandemic.

Results

Cohorts were similar in age, race, and payor. More patients had late-stage disease during COVID (32%) than pre-COVID (19%, p = 0.05). There was a significantly longer time to first treatment during COVID (p = 0.0001) explained by a significantly longer time from symptom to diagnosis (p = 0.0001), with no difference in time from diagnosis to treatment.

Conclusion

It was significantly more likely for patients to present to our safety-net hospital with late-stage breast cancer during COVID than pre-COVID. There was longer time to first treatment during COVID, driven by the increased time from symptom to diagnosis. Patients may have perceived that care was inaccessible during the pandemic or had competing priorities, driving delays. Efforts should be made to minimize disruption to safety-net hospitals during future shut-downs as these are among the most vulnerable patients.

Increased disparities associated with black women and abnormal cervical cancer screening follow-up

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Timely follow-up and treatment after abnormal cervical cancer screening is lacking in over half of all women.

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Black women have the lowest rate of follow-up after abnormal screening.

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One-fourth of Black and Hispanic women have delayed follow-up.

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Insurance status is also associated with timely follow-up with abnormal cervical cancer screening.

Background

To determine whether race and ethnicity impacts patient adherence to follow-up for colposcopy after abnormal cervical cancer screening.

Methods

This retrospective chart review included women that were randomly selected from patients presenting to our colposcopy clinic from 1/2019 to 12/2019. Inclusion criteria were females age ≥21 years-old and appropriate referral for colposcopy. Patients were grouped into three categories: (1) ADHERENT to follow-up if they came to their first scheduled appointment; (2) DELAYED if they presented more than three months from their original referral (usually missing 1–3 appointments); and (3) NOT ADHERENT if they did not show for their appointment after referral. Analysis was performed using SPSS v.26.

Results

284 women met inclusion criteria for the study. The majority of women were Black (65.2 %) followed by non-Hispanic Whites (20.0 %) and Latinx (14.8 %). Overall, 39.1 % were ADHERENT, 18.6 % were DELAYED, and 42.3 % were NOT ADHERENT. When compared with non-Hispanic White women, there was a significant difference between race/ethnicity and timing of follow-up (p = 0.03). Blacks were more likely to be NOT ADHERENT (45.9 %; p = 0.03), and Latinx and Blacks were the most likely to be DELAYED (35.7 % and 21.1 %; p = 0.03). Private insurance patients were more likely to be ADHERENT for care compared with un-/underinsured patients (78.9 vs 27.8 %, p = 0.0001).

Conclusion

There is inadequate follow-up after abnormal cervical cancer screening across all races/ethnicities; however, lack of adherence is higher in Black patients. Moreover, 25% of Hispanic and Black women present in a delayed fashion. Culturally relevant assessments and interventions are needed to understand and address these gaps.

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.

Barriers and facilitators affecting presentation in women with early versus advanced stage cervical cancer

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Structural and intrapersonal barriers to cervical cancer care persist but differ between early and advanced stage patients.

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Barriers in the early stage group were lack of knowledge, competing priorities, lack of insurance, and embarrassment.

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Barriers in the advanced stage group were lack of knowledge/risk, competing priorities, avoidance, fear of the healthcare system.

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Innovative methods to increase access to care and engagement with the healthcare system are needed.

Background

This study was performed to evaluate the barriers and facilitators associated with patient presentation for early stage (ES) versus advanced stage (AS) cervical cancer (CC).

Methods

A mixed-method approach was used to collect quantitative (i.e., demographics and medical/screening histories) and qualitative data (individual interviews assessing patients’ perceptions regarding their general health, HPV and CC screening, and barriers and facilitators to CC care). Two separate investigators coded the interviews for major themes that occurred with an agreement that 50% or more of the themes would be included.

Results

Twenty-five women agreed to participate in the study with 80% completing the interview. Patients with ES disease were classified as Stage IA1-Stage IB3; patients with Stage IIA-IVB disease were classified with AS disease. Frequent barriers in the ES group were lack of knowledge, competing priorities, feeling healthy, lack of time or health insurance, and being embarrassed/uncomfortable. Frequent barriers in the AS group were lack of knowledge, competing priorities, avoidance/procrastination, fear of the healthcare system or finding something wrong, and lack of perceived risk to CC. Facilitators for ES included understanding the importance of the Pap test, having an abnormal Pap test, and knowing someone with CC. Having abnormal symptoms was the only facilitator for AS patients.

Conclusions

Structural and intrapersonal barriers to CC care persist but differ between ES and AS patients. Multi-level interventions are needed to address the wide array of issues that women highlighted in this study including potential innovative methods to increase access to care and engagement with the healthcare system.

Addressing a critical need for caregiver support in neuro-oncology: development of a caregiver navigation intervention using eSNAP social resource visualization

Informal caregivers are key to oncology care, but often have unmet needs, leading to poor psychological and physical health outcomes. Comprehensive, proactive caregiver support programs are needed. We describe the development of a support intervention for caregivers of persons with brain tumors. The intervention uses a caregiver navigator to help participants identify and capitalize on existing social support resources captured using a web-based tool (eSNAP) and connects participants to existing formal services. We describe the iterative development process of the manualized intervention with particular focus on the caregiver navigator sessions. The process included review of the literature and published patient navigation programs, expert and stakeholder review, and study team member review. Quantitative and qualitative data were captured from the first 15 participants randomized to receive the intervention, enrolled from February 2020 to December 2020. Four participants dropped from the study, 9 completed at least 7 modules, and 8 participants completed all 8. Quantitative and qualitative data were collected primarily from those who completed the intervention; data suggest caregivers were satisfied with the intervention and found it helpful. Our intervention is one of the first theory-based caregiver support interventions to include caregiver navigation in neuro-oncology. We use best-practice guidelines for design, including extensive stakeholder feedback. COVID-19 may have impacted recruitment and participation, but some preliminary data suggest that those able to engage with the intervention find it helpful. Data collection is ongoing in a larger trial. If effective, caregiver navigation could be a model for future interventions to ensure caregiver support.

Pilot randomised controlled trial of a patient navigation intervention to enhance engagement in the PrEP continuum among young Latino MSM: a protocol paper

INTRODUCTION

Men who have sex with men (MSM) are one of the most at-risk group for contracting HIV in the USA. However, the HIV epidemic impacts some groups of MSM disproportionately. Latino MSM comprise 25.1% of new HIV infections among MSM between the ages of 13 and 29 years. The daily medication tenofovir/emtricitabine was approved by the Food and Drug Administration for pre-exposure prophylaxis (PrEP) in 2012 and has demonstrated strong efficacy in reducing HIV acquisition.

METHODS AND ANALYSIS

Through extensive formative research, this study uses a pilot randomised controlled trial design and will examine the feasibility and acceptability of a patient navigation intervention designed to address multiple barriers to improve engagement in the PrEP continuum among 60 Latino MSM between the ages of 18 and 29 years. The patient navigation intervention will be compared with usual care plus written information to evaluate the feasibility and acceptability of the intervention and study methods and the intervention's potential in improving PrEP continuum behaviours. The results will be reviewed for preparation for a future full-scale efficacy trial.

ETHICS AND DISSEMINATION

This study was approved by the institutional review board at San Diego State University and is registered at ClinicalTrials.gov. The intervention development process, plan and the results of this study will be shared through peer-reviewed journal publications, conference presentations and healthcare system and community presentations.

REGISTRATION DETAILS

Registered under the National Institutes of Health's ClinicalTrials.gov (NCT04048382) on 7 August 2019 and approved by the San Diego State University (HS-2017-0187) institutional review board. This study began on 5 August 2019 and is estimated to continue through 31 March 2021. The clinical trial is in the pre-results stage.

Immune-Based Cancer Treatment: Addressing Disparities in Access and Outcomes

Avoidable differences in the care and outcomes of patients with cancer (i.e., cancer care disparities) emerge or worsen with discoveries of new, more effective approaches to cancer diagnosis and treatment. The rapidly expanding use of immunotherapy for many different cancers across the spectrum from late to early stages has, predictably, been followed by emerging evidence of disparities in access to these highly effective but expensive treatments. The danger that these new treatments will further widen preexisting cancer care and outcome disparities requires urgent corrective intervention. Using a multilevel etiologic framework that categorizes the targets of intervention at the individual, provider, health care system, and social policy levels, we discuss options for a comprehensive approach to prevent and, where necessary, eliminate disparities in access to the clinical trials that are defining the optimal use of immunotherapy for cancer, as well as its safe use in routine care among appropriately diverse populations. We make the case that, contrary to the traditional focus on the individual level in descriptive reports of health care disparities, there is sequentially greater leverage at the provider, health care system, and social policy levels to overcome the challenge of cancer care and outcomes disparities, including access to immunotherapy. We also cite examples of effective government-sponsored and policy-level interventions, such as the National Cancer Institute Minority-Underserved Community Oncology Research Program and the Affordable Care Act, that have expanded clinical trial access and access to high-quality cancer care in general.

Problem-solving in technology-rich environments and cancer screening in later life

Routine cancer screening is widely recognized as an effective preventive strategy to reduce cancer mortality - the second leading cause of death in the US. However, cancer screening requires a complex array of tasks such as seeking up-to-date guidelines, making appointments, planning hospital visits, and communicating with health care professionals. Importantly, modern health care largely relies on technology to disseminate the latest information and administer the system. Yet, little is known about the technology-related skills that are relevant to regular cancer screening. This study examined the association between problem-solving skills in the technology-rich environment and cancer screening in later life. Using 2012/2014 Program for International Assessment of Adult Competencies data, binary logistic regressions with survey weights were used to estimate the association between problem-solving skills in the technology-rich environment and four cancer screening behaviors among the corresponding target populations aged between 45 and 74 years old (n = 1374 for cervical screening; n = 1373 for breast screening; n = 1166 for prostate screening; n = 2563 for colon screening). Results showed that greater problem-solving skills in the technology-rich environment scores (0-500 points) were significantly and positively associated with prostate cancer screening (odds ratio = 1.005, P < 0.05) among men, but not with colon (men and women) or cervical or breast (women) cancer screenings. Improvement in problem-solving skills in the technology-rich environment may promote specific cancer screening behaviors. Our findings inform future policy discussions and interventions that seek to improve cancer screening among a vulnerable section of older populations.

A conjoint analysis study on self-sampling for human papillomavirus (HPV) testing characteristics among black women in Indiana

Background

Self-sampling for HPV testing may be a method to increase overall cervical cancer screening rates among Black women, who are underscreened for cervical cancer in parts of the US. The purpose of this study was to assess preferred characteristics for delivery of HPV self-sampling kits, return of HPV self-sampling kits, and communication of HPV test results and explore sociodemographic factors (income, education, and marital status) associated with acceptability of self-sampling for HPV testing.

Methods

Survey data were gathered at an Indiana minority health fair. Participants evaluated 9 scenarios that varied along 3 dimensions: HPV self-sampling kit delivery (mail, pharmacy pick-up, or clinic pick-up), HPV self-sampling kit return (mail, pharmacy drop-off, or clinic drop-off), and HPV test results (mail, phone call, or text message). The 9 scenarios were produced from a fractional factorial design and rated on a 0 to 100 scale. Ratings-based conjoint analysis (RBCA) determined how each dimension influenced ratings. A measure for acceptability of self-sampling was obtained from the ratings of all 9 scenarios. The acceptability measure was regressed on sociodemographics.

Results

The 98 participants ranged in age from 21 to 65 (M = 45). Across the 9 scenarios, overall acceptability to self-sample had a mean of 60.9 (SD = 31.3). RBCA indicated that HPV self-sampling kit return had the most influence on ratings, followed by HPV self-sampling kit delivery, and finally, HPV test result communication. Thirty-six percent of participants rated all self-sampling scenarios the same. Sociodemographic characteristics were not associated with acceptability of self-sampling.

Conclusions

Self-sampling for HPV testing was found to be generally acceptable to Black women in this pilot survey study. This information could be used by researchers developing self-sampling interventions and the implementation of self-sampling among providers.

Increasing health service access by expanding disease coverage and adding patient navigation: challenges for patient satisfaction

BACKGROUND

Cancer control programs have added patient navigation to improve effectiveness in underserved populations, but research has yielded mixed results about their impact on patient satisfaction. This study focuses on three related research questions in a U.S. state cancer screening program before and after a redesign that added patient navigators and services for chronic illness: Did patient diversity increase; Did satisfaction levels improve; Did socioeconomic characteristics or perceived barriers explain improved satisfaction.

METHODS

Representative statewide patient samples were surveyed by phone both before and after the program design. Measures included satisfaction with overall health care and specific services, as well as experience of eleven barriers to accessing health care and self-reported health and sociodemographic characteristics. Multiple regression analysis is used to identify independent effects.

RESULTS

After the program redesign, the percentage of Hispanic and African American patients increased by more than 200% and satisfaction with overall health care quality rose significantly, but satisfaction with the program and with primary program staff declined. Sociodemographic characteristics explained the apparent program effects on overall satisfaction, but perceived barriers did not. Further analysis indicates that patients being seen for cancer risk were more satisfied if they had a patient navigator.

CONCLUSIONS

Health care access can be improved and patient diversity increased in public health programs by adding patient navigators and delivering more holistic care. Effects on patient satisfaction vary with patient health needs, with those being seen for chronic illness likely to be less satisfied with their health care than those being seen for cancer risk. It is important to use appropriate comparison groups when evaluating the effect of program changes on patient satisfaction and to consider establishing appropriate satisfaction benchmarks for patients being seen for chronic illness.

Mapping variation in intervention design: a systematic review to develop a program theory for patient navigator programs

BACKGROUND

There is a great deal of variation in the design and delivery of patient navigator (PN) programs, making it difficult to design or adopt these interventions in new contexts. We (1) systematically reviewed the literature to generate a preliminary program theory to describe how patient navigator interventions are designed and delivered; and (2) describe how the resulting program theory was applied in context to inform a prototype for a patient navigator program.

METHODS

The current study includes a secondary review of a larger systematic review. We reviewed studies included in the primary review to identify those that designed and evaluated programs to assist patients in accessing and/or adhering to care. We conducted a content analysis of included publications to describe the barriers targeted by PN interventions and the navigator activities addressing those barriers. A program theory was constructed by mapping patient navigator activities to corresponding constructs within the capability-opportunity-motivation model of behavior change (COM-B) model of behavior change. The program theory was then presented to individuals with chronic disease, healthcare providers, and system stakeholders, and refined iteratively based on feedback.

RESULTS

Twenty one publications describing 19 patient navigator interventions were included. A total of 17 unique patient navigator activities were reported. The most common included providing education, facilitating referrals, providing social and emotional support, and supporting self-management. The majority of navigator activities targeted barriers to physical opportunity, including facilitating insurance claims, assistance with scheduling, and providing transportation. Across all interventions, navigator activities were designed to target a total of 20 patient barriers. Among interventions reporting positive effects, over two thirds targeted knowledge barriers, problems with scheduling, proactive re-scheduling following a missed appointment, and insurance. The final program design included a total of 13 navigator activities-10 informed by the original program theory and 3 unique activities informed by stakeholders.

CONCLUSIONS

There is considerable heterogeneity in intervention content across patient navigator interventions. Our results provide a schema from which to develop PN interventions and illustrate how an evidence-based model was used to develop a real-world PN intervention. Our findings also highlight a critical need to improve the reporting of intervention components to facilitate translation.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42013005857.

An Exploration of Patient Navigation and Community Health Worker Activities Across National Comprehensive Cancer Control Programs

Purpose: Health disparities persist across the cancer care continuum. Patient navigator (PN) and community health worker (CHW) interventions are designed to increase health equity. National Comprehensive Cancer Control Program (NCCCP) awardees develop and implement plans to coordinate cancer prevention and control activities, including supporting PN and CHW interventions. This content analysis examined NCCCP action plans to assess the extent to which jurisdictions report engaging in PN and/or CHW activities.

Methods: We abstracted PN and CHW content from NCCCP action plans and coded content according to specific areas of PN and/or CHW intervention (e.g., screening, survivorship, and cancer type), used descriptive statistics to characterize overall results, and calculated chi-squares to determine whether programs engaged PNs and CHWs differently.

Results: Eighty-two percent (n=53) of 65 NCCCP action plans had content related to PN and/or CHW activities, with more PN language (83%) than CHW (58%). These action plans described engaging PNs and CHWs in activities across the cancer continuum, but particularly for screening (60%) and survivorship (55%). Eighty-one percent of these plans described activities related to workforce development, such as training and standardizing roles and competencies. Programs engaged CHWs more often than PNs for outreach and in community settings.

Conclusion: The majority of NCCCP awardees reported engaging in PN and/or CHW activities. Understanding how NCCCP awardees engage PNs and CHWs, including awardees' needs for workforce development in this area, can help Centers for Disease Control and Prevention provide more focused technical assistance as programs increase engagement of PNs and CHWs to improve health equity.

Gendered and racialized social expectations, barriers, and delayed breast cancer diagnosis

BACKGROUND

Black women are more likely to be diagnosed at a later stage of breast cancer in part due to barriers to timely screening mammography, resulting in poorer mortality and survival outcomes. Patient navigation that helps to overcome barriers to the early detection of breast cancer is an effective intervention for reducing breast cancer disparity. However, the ability to recognize and seek help to overcome barriers may be affected by gendered and racialized social expectations of women.

METHODS

Data from a randomized controlled trial, the Patient Navigation in Medically Underserved Areas study, were used. The likelihood of obtaining a follow-up screening mammogram was compared between women who identified ≥1 barriers and those who did not.

RESULTS

Of the 3754 women who received the Patient Navigation in Medically Underserved Areas navigation intervention, approximately 14% identified ≥ 1 barriers, which led to additional navigator contacts. Consequently, those women who reported barriers were more likely to obtain a subsequent screening mammogram. Black women, women living in poverty, and women with a higher level of distrust were less likely to report barriers.

CONCLUSIONS

Minority women living in poverty have always been the source of social support for others. However, gendered and racialized social expectations may affect the ways in which women seek help for their own health needs. A way to improve the effectiveness of navigation would be to recognize how minority women's gender images and expectations could shape how they seek help and support. A report of no barriers does not always translate into no problems. Proactive approaches to identify potential barriers may be beneficial.

Predictors of Adherence and Treatment Delays among African American Women Recommended to Receive Breast Cancer Chemotherapy

BACKGROUND

Recognition of potential explanations for nonadherence or treatment delays is crucial to improving survival, particularly among African American women, for whom there is limited research assessing patient factors that influence adherence to breast cancer chemotherapy.

OBJECTIVE

This study sought to examine the association of patient factors such as age, income, employment, and partner status with adherence (full dose/on time) to prescribed breast cancer adjuvant chemotherapy and delays in treatment among African American women.

METHODS

This observational, prospective study used baseline data from the Adherence, Communication, Treatment, and Support Intervention Study that included African American women with early stage breast cancer who were recommended to receive chemotherapy. Eleven baseline demographic variables measured by a sociodemographic questionnaire were analyzed against the outcome variables of 85% adherence to chemotherapy, dichotomized as yes or no, and chemotherapy treatment delays measured as number of days.

RESULTS

For the 121 African American women included in this study, only employment status and number of comorbidities were significant predictors for total treatment delays (incidence rate ratio [IRR] = 2.175 [p = .000]; IRR = 1.234 [p = .003]) in the adjusted models.

IMPLICATIONS

Employment status and number of comorbidities are predictors of the ability to receive timely breast cancer chemotherapy among African American women. This knowledge allows identification of patients in need of tailored supportive care to encourage adherence and prevent treatment delays.

Effects of program scale-up on time to resolution for patients with abnormal screening mammography results

PURPOSE

Effects of geographic program expansion to rural areas on screening program outcomes are understudied. We sought to determine whether time-to-resolution (TTR) varied significantly by service delivery time period, location, and participant characteristics across 19 North Texas counties.

METHODS

We calculated proportions undergoing diagnostic follow-up and resolved ≤ 60 days. We calculated median TTR for each time period and abnormal result BI-RADS 0, 4, 5. Cox proportional hazards regressions estimated time period and patient characteristic effects on TTR. Wilcoxon rank sum tests evaluated whether TTR differed between women who did or did not transfer between counties for services.

RESULTS

TTR ranged from 14 to 17 days for BI-RADs 0, 4, and 5; 12.4% transferred to a different county, resulting in longer median TTR (26 vs. 16 days; p < .001). Of those completing follow-up, 92% were resolved ≤ 60 days (median 15 days). For BI-RAD 3, TTR was 208 days (including required 180 day waiting period). Follow-up was significantly lower for women with BI-RAD 3 (59% vs. 96%; p < .0001).

CONCLUSION

Expansion maintained timely service delivery, increasing access to screening among rural, uninsured women. Policies adding a separate quality metric for BI-RAD 3 could encourage follow-up monitoring to address lower completion and longer TTR among women with this result.

A multi-site exploration of barriers faced by vulnerable patient populations: a qualitative analysis exploring the needs of patients for targeted interventions in new models of care delivery

AIM

To investigate which populations of patients are considered 'vulnerable' across varying clinical sites, and to identify the barriers encountered by these patient populations limiting optimal health.

BACKGROUND

Vulnerable patient populations encounter diverse barriers that limit their ability to successfully navigate the health system, potentially resulting in poor health outcomes. Little current-day work has described types of barriers encountered by vulnerable patient populations across numerous clinical sites and settings, which is necessary to ensure health systems can begin to improve quality and disparities for all patient populations.

METHODS

An inductive content analysis was performed based on field-site notes and digitally recorded telephone interviews with providers/leadership at clinics/programs related to patient- and clinic-needs from January 2014 through May 2015. Using thematic analysis with grounded theory techniques, authors identified categories and themes. In total, 30 diverse clinical sites/programs including inpatient- and outpatient-based clinics providing medicine and surgery-based services were assessed through both site visits and follow-up telephone interviews. Follow-up interviews were conducted with one individual in various positions within sites/programs, including physicians (n=15), registered nurses (n=8), clinic managers/coordinators (n=2), clinical program coordinator (n=1), and care coordinator (n=1); one participant represented three clinical sites.

FINDINGS

In total, 30 sites/programs (n=30) received both a site visit and follow-up interview. Commonly reported vulnerable patient populations included those with multiple chronic conditions, lower socioeconomic status, patients in a specific stage in the continuum of care, and patients with over- and under-utilization of resources without a clear etiology. Themes related to barriers included systems barriers (eg, insufficiencies of care processes), clinic barriers (eg, lack of resources), patient-related barriers (eg, housing, transportation), and provider-related barriers (eg, inadequate time and knowledge).

CONCLUSIONS

These results provide a framework to identify systems- and clinic-related barriers that can be used in population health management strategies aimed at improving health disparities within clinically diverse sites.

Health Beliefs Associated with the Follow-Up of Pap Smear Abnormalities Among Low-Income Women in Medellín, Colombia

The purpose of the study was to explore variables of the health belief model in relation to the follow-up of abnormal Pap smear among low-income women in Medellín, Colombia. Eight focus groups (62 women) were conducted according to age groups (25-45 and 46-69 years). The data were analyzed using content analysis. The participants perceived themselves as vulnerable, recognized the severity of the disease in terms of both its emotional and physical consequences, perceived the benefits of the follow-up, and mentioned cues to action, such as social support and the support of health entities. Perceived self-efficacy was compromised by health system barriers and by personal barriers, such as placing the needs of their children ahead of their own, fear, neglect, and the pain caused by the diagnostic and therapeutic procedures. Health education activities aimed at increasing the follow-up of abnormal Pap smears should consider psychological factors.

Insurance-Based Differences in Time to Diagnostic Follow-up after Positive Screening Mammography

BACKGROUND

Insurance may lengthen or inhibit time to follow-up after positive screening mammography. We assessed the association between insurance status and time to initial diagnostic follow-up after a positive screening mammogram.

METHODS

Using 1995-2010 data from a North Carolina population-based registry of breast imaging and cancer outcomes, we identified women with a positive screening mammogram. We compared receipt of follow-up within 60 days of screening using logistic regression and evaluated time to follow-up initiation using Cox proportional hazards regression.

RESULTS

Among 43,026 women included in the study, 73% were <65 years and 27% were 65+ years. Median time until initial diagnostic follow-up was similar by age group and insurance status. In the adjusted model for women <65, uninsured women experienced a longer time to initiation of diagnostic follow-up [HR, 0.47; 95% confidence interval (CI), 0.25-0.89] versus women with private insurance. There were increased odds of these uninsured women not meeting the Centers for Disease Control and Prevention guideline for follow-up within 60 days (OR, 1.59; 95% CI, 1.31-1.94). Among women ages 65+, women with private insurance experienced a faster time to follow-up (adjusted HR, 2.09; 95% CI, 1.27-3.44) than women with Medicare and private insurance. Approximately 10% of women had no follow-up by 365 days.

CONCLUSIONS

We found differences in time to initial diagnostic follow-up after a positive screening mammogram by insurance status and age group. Uninsured women younger than 65 years at a positive screening event had delayed follow-up.

IMPACT

Replication of these findings and examination of their clinical significance warrant additional investigation. Cancer Epidemiol Biomarkers Prev; 25(11); 1474-82. ©2016 AACR.

Examining care navigation: librarian participation in a team-based approach?

OBJECTIVE

This study investigated responsibilities, skill sets, degrees, and certifications required of health care navigators in order to identify areas of potential overlap with health sciences librarianship.

METHOD

The authors conducted a content analysis of health care navigator position announcements and developed and assigned forty-eight category terms to represent the sample's responsibilities and skill sets.

RESULTS

Coordination of patient care and a bachelor's degree were the most common responsibility and degree requirements, respectively. Results also suggest that managing and providing health information resources is an area of overlap between health care navigators and health sciences librarians, and that librarians are well suited to serve on navigation teams.

CONCLUSION

Such overlap may provide an avenue for collaboration between navigators and health sciences librarians.

Care for a Patient With Cancer As a Project: Management of Complex Task Interdependence in Cancer Care Delivery

Cancer care is highly complex and suffers from fragmentation and lack of coordination across provider specialties and clinical domains. As a result, patients often find that they must coordinate care on their own. Coordinated delivery teams may address these challenges and improve quality of cancer care. Task interdependence is a core principle of rigorous teamwork and is essential to addressing the complexity of cancer care, which is highly interdependent across specialties and modalities. We examined challenges faced by a patient with early-stage breast cancer that resulted from difficulties in understanding and managing task interdependence across clinical domains involved in this patient's care. We used team science supported by the project management discipline to discuss how various task interdependence aspects can be recognized, deliberately designed, and systematically managed to prevent care breakdowns. This case highlights how effective task interdependence management facilitated by project management methods could markedly improve the course of a patient's care. This work informs efforts of cancer centers and practices to redesign cancer care delivery through innovative, practical, and patient-centered approaches to management of task interdependence in cancer care. Future patient-reported outcomes research will help to determine optimal ways to engage patients, including those who are medically underserved, in managing task interdependence in their own care.

Time from Screening Mammography to Biopsy and from Biopsy to Breast Cancer Treatment among Black and White, Women Medicare Beneficiaries Not Participating in a Health Maintenance Organization

PURPOSE

There is a breast cancer mortality gap adversely affecting Black women in the United States. This study assessed the relationship between number of days between abnormal mammogram, biopsy, and treatment among Medicare (Part B) beneficiaries ages 65 to 74 and 75 to 84 years, accounting for race and comorbidity.

METHODS

A cohort of non-Hispanic Black and non-Hispanic White women residing in the continental United States and receiving no services from a health maintenance organization was randomly selected from the Center for Medicare and Medicaid Services denominator file. The cohort was followed from 2005 to 2008 using Center for Medicare and Medicaid Services claims data. The sample included 4,476 women (weighted n = 70,731) with a diagnosis of breast cancer. Cox proportional hazard modeling was used to identify predictors of waiting times.

FINDINGS

Black women had a mean of 16.7 more days between biopsy and treatment (p < .001) and 15.7 more days from mammogram to treatment (p = .003) than White women. Median duration from abnormal mammogram to treatment exceeded National Quality Measures for Breast Centers medians regardless of race, age, or number of comorbidities (overall 43 days vs. the National Quality Measures for Breast Centers value of 28 days).

CONCLUSIONS

Medical care delays may contribute, in part, to the widening breast cancer mortality gap between Black women and White women. Further study, with additional clinical and social information, is needed to broaden scientific understanding of racial determinants and assess the clinical significance of mammogram to treatment times among Medicare beneficiaries.

Relation of comorbidities and patient navigation with the time to diagnostic resolution after abnormal cancer screening

BACKGROUND

Whether patient navigation improves outcomes for patients with comorbidities is unknown. The aims of this study were to determine the effect of comorbidities on the time to diagnostic resolution after an abnormal cancer screening test and to examine whether patient navigation improves the timeliness and likelihood of diagnostic resolution for patients with comorbidities in comparison with no navigation.

METHODS

A secondary analysis of comorbidity data collected by Patient Navigation Research Program sites using the Charlson Comorbidity Index (CCI) was conducted. The participants were 6,349 patients with abnormal breast, cervical, colon, or prostate cancer screening tests between 2007 and 2011. The intervention was patient navigation or usual care. The CCI data were highly skewed across projects and cancer sites, and the CCI scores were categorized as 0 (CCI score of 0 or no comorbidities identified; 76% of cases); 1 (CCI score of 1; 16% of cases), or 2 (CCI score ≥ 2; 8% of cases). Separate adjusted hazard ratios for each site and cancer type were obtained, and then they were pooled with a meta-analysis random effects methodology.

RESULTS

Patients with a CCI score ≥ 2 had delayed diagnostic resolution after an abnormal cancer screening test in comparison with those with no comorbidities. Patient navigation reduced delays in diagnostic resolution, with the greatest benefits seen for those with a CCI score ≥ 2.

CONCLUSIONS

Persons with a CCI score ≥ 2 experienced significant delays in timely diagnostic care in comparison with patients without comorbidities. Patient navigation was effective in reducing delays in diagnostic resolution among those with CCI scores > 1. Cancer 2017;123:312-318. © 2016 American Cancer Society.

Racial and ethnic differences in patient navigation: Results from the Patient Navigation Research Program

BACKGROUND

Patient navigation was developed to address barriers to timely care and reduce cancer disparities. The current study explored navigation and racial and ethnic differences in time to the diagnostic resolution of a cancer screening abnormality.

METHODS

The authors conducted an analysis of the multisite Patient Navigation Research Program. Participants with an abnormal cancer screening test were allocated to either navigation or control. The unadjusted median time to resolution was calculated for each racial and ethnic group by navigation and control. Multivariable Cox proportional hazards models were fit, adjusting for sex, age, cancer abnormality type, and health insurance and stratifying by center of care.

RESULTS

Among a sample of 7514 participants, 29% were non-Hispanic white, 43% were Hispanic, and 28% were black. In the control group, black individuals were found to have a longer median time to diagnostic resolution (108 days) compared with non-Hispanic white individuals (65 days) or Hispanic individuals (68 days) (P<.0001). In the navigated groups, black individuals had a reduction in the median time to diagnostic resolution (97 days) (P<.0001). In the multivariable models, among controls, black race was found to be associated with an increased delay to diagnostic resolution (hazard ratio, 0.77; 95% confidence interval, 0.69-0.84) compared with non-Hispanic white individuals, which was reduced in the navigated arm (hazard ratio, 0.85; 95% confidence interval, 0.77-0.94).

CONCLUSIONS

Patient navigation appears to have the greatest impact among black patients, who had the greatest delays in care. Cancer 2016. © 2016 American Cancer Society. Cancer 2016;122:2715-2722. © 2016 American Cancer Society.

Patient Navigation As a Model to Increase Participation of African Americans in Cancer Clinical Trials

PURPOSE

Less than 10% of patients enrolled in clinical trials are minorities. The patient navigation model has been used to improve access to medical care but has not been evaluated as a tool to increase the participation of minorities in clinical trials. The Increasing Minority Participation in Clinical Trials project used patient navigators (PNs) to enhance the recruitment of African Americans for and their retention in therapeutic cancer clinical trials in a National Cancer Institute-designated comprehensive cancer center.

METHODS

Lay individuals were hired and trained to serve as PNs for clinical trials. African American patients potentially eligible for clinical trials were identified through chart review or referrals by clinic nurses, physicians, and social workers. PNs provided two levels of services: education about clinical trials and tailored support for patients who enrolled in clinical trials.

RESULTS

Between 2007 and 2014, 424 African American patients with cancer were referred to the Increasing Minority Participation in Clinical Trials project. Of those eligible for a clinical trial (N = 378), 304 (80.4%) enrolled in a trial and 272 (72%) consented to receive patient navigation support. Of those receiving patient navigation support, 74.5% completed the trial, compared with 37.5% of those not receiving patient navigation support. The difference in retention rates between the two groups was statistically significant (P < .001). Participation of African Americans in therapeutic cancer clinical trials increased from 9% to 16%.

CONCLUSION

Patient navigation for clinical trials successfully retained African Americans in therapeutic trials compared with non-patient navigation trial participation. The model holds promise as a strategy to reduce disparities in cancer clinical trial participation. Future studies should evaluate it with racial/ethnic minorities across cancer centers.

Cancer Care Delivery and Women's Health: The Role of Patient Navigation

Background

Patient navigation (PN) is a patient-centered health-care service delivery model that assists individuals, particularly the medically underserved, in overcoming barriers (e.g., personal, logistical, and system) to care across the cancer care continuum. In 2012, the American College of Surgeons Commission on Cancer (CoC) announced that health-care facilities seeking CoC-accreditation must have PN processes in place starting January 1, 2015. The CoC mandate, in light of the recent findings from centers within the Patient Navigation Research Program and the influx of PN interventions, warrants the present literature review.

Methods

PubMed and Medline were searched for studies published from January 2010 to October 2015, particularly those recent articles within the past 2 years, addressing PN for breast and gynecological cancers, and written in English. Search terms included patient navigation, navigation, navigator, cancer screening, clinical trials, cancer patient, cancer survivor, breast cancer, gynecological cancer, ovarian cancer, uterine cancer, vaginal cancer, and vulvar cancer.

Results

Consistent with prior reviews, PN was shown to be effective in helping women who receive cancer screenings, receive more timely diagnostic resolution after a breast and cervical cancer screening abnormality, initiate treatment sooner, receive proper treatment, and improve quality of life after cancer diagnosis. However, several limitations were observed. The majority of PN interventions focused on cancer screening and diagnostic resolution for breast cancer. As observed in prior reviews, methodological rigor (e.g., randomized controlled trial design) was lacking.

Conclusion

Future research opportunities include testing PN interventions in the post-treatment settings and among gynecological cancer patient populations, age-related barriers to effective PN, and collaborative efforts between community health workers and patient navigators as care goes across segments of the cancer control continuum. As PN programs continue to develop and become a standard of care, further research will be required to determine the effectiveness of cancer PN across the cancer care continuum, and in different patient populations.

Comparison of anal cancer outcomes in public and private hospital patients treated at a single radiation oncology center

OBJECTIVE

To compare clinical and treatment characteristics and outcomes in locally advanced anal cancer, a potentially curable disease, in patients referred from a public or private hospital.

METHODS

We retrospectively reviewed 112 anal cancer patients from a public and a private hospital who received definitive chemoradiotherapy at the same cancer center between 2004 and 2013. Tumor stage, radiotherapy delay, radiotherapy duration, and unplanned treatment breaks ≥10 days were compared using t-test and χ(2) test. Overall survival (OS), disease free survival (DFS), and colostomy free survival (CFS) were examined using the Kaplan-Meier method and compared with the log-rank test. Cox proportional hazard models for OS and DFS were developed.

RESULTS

The follow-up was 14.9 months (range, 0.7-94.8 months). Public hospital patients presented with significantly higher clinical T stage (P<0.05) and clinical stage group (P<0.05), had significantly longer radiotherapy delays (P<0.05) and radiotherapy duration (P<0.05), and had more frequent radiation therapy (RT) breaks ≥10 days (P<0.05). Three-year OS showed a marked trend in favor of private hospital patients for 3-year OS (72.8% vs. 48.9%; P=0.171), 3-year DFS (66.3% vs. 42.7%, P=0.352), and 3-year CFS (86.4% vs. 68.9%, P=0.299). Referral hospital was not predictive of OS or DFS on multivariate analysis.

CONCLUSIONS

Public hospital patients presented at later stage and experienced more delays in initiating and completing radiotherapy, which may contribute to the trend in poorer DFS and OS. These findings emphasize the need for identifying clinical and treatment factors that contribute to decreased survival in low socioeconomic status (SES) populations.

Impact of patient navigation in eliminating economic disparities in cancer care

BACKGROUND

Patient navigation may reduce cancer disparities associated with socioeconomic status (SES) and household factors. This study examined whether these factors were associated with delays in diagnostic resolution among patients with cancer screening abnormalities and whether patient navigation ameliorated these delays.

METHODS

This study analyzed data from 5 of 10 centers of the National Cancer Institute's Patient Navigation Research Program, which collected SES and household data on employment, income, education, housing, marital status, and household composition. The primary outcome was the time to diagnostic resolution after a cancer screening abnormality. Separate adjusted Cox proportional hazard models were fit for each SES and household factor, and an interaction between that factor and the intervention status was included.

RESULTS

Among the 3777 participants (1968 in the control arm and 1809 in the navigation intervention arm), 91% were women, and the mean age was 44 years; 43% were Hispanic, 28% were white, and 27% were African American. Within the control arm, the unemployed experienced a longer time to resolution than those employed full-time (hazard ratio [HR], 0.85; P = .02). Renters (HR, 0.81; P = .02) and those with other (ie, unstable) housing (HR, 0.60; P < .001) had delays in comparison with homeowners. Never married (HR, 0.70; P < .001) and previously married participants (HR, 0.85; P = .03) had a longer time to care than married participants. There were no differences in the time to diagnostic resolution with any of these variables within the navigation intervention arm.

CONCLUSIONS

Delays in diagnostic resolution exist by employment, housing type, and marital status. Patient navigation eliminated these disparities in the study sample. These findings demonstrate the value of providing patient navigation to patients at high risk for delays in cancer care.

Unifying screening processes within the PROSPR consortium: a conceptual model for breast, cervical, and colorectal cancer screening

General frameworks of the cancer screening process are available, but none directly compare the process in detail across different organ sites. This limits the ability of medical and public health professionals to develop and evaluate coordinated screening programs that apply resources and population management strategies available for one cancer site to other sites. We present a trans-organ conceptual model that incorporates a single screening episode for breast, cervical, and colorectal cancers into a unified framework based on clinical guidelines and protocols; the model concepts could be expanded to other organ sites. The model covers four types of care in the screening process: risk assessment, detection, diagnosis, and treatment. Interfaces between different provider teams (eg, primary care and specialty care), including communication and transfer of responsibility, may occur when transitioning between types of care. Our model highlights across each organ site similarities and differences in steps, interfaces, and transitions in the screening process and documents the conclusion of a screening episode. This model was developed within the National Cancer Institute-funded consortium Population-based Research Optimizing Screening through Personalized Regimens (PROSPR). PROSPR aims to optimize the screening process for breast, cervical, and colorectal cancer and includes seven research centers and a statistical coordinating center. Given current health care reform initiatives in the United States, this conceptual model can facilitate the development of comprehensive quality metrics for cancer screening and promote trans-organ comparative cancer screening research. PROSPR findings will support the design of interventions that improve screening outcomes across multiple cancer sites.

Improving breast cancer survivors' knowledge using a patient-centered intervention

BACKGROUND

Low-income, minority women with breast cancer experience a range of barriers to receiving survivorship information. Our objective was to test a novel, patient-centered intervention aimed at improving communication about survivorship care.

METHODS

We developed a wallet card to provide oncologic and follow-up care survivorship information to breast cancer patients. We used a prospective, pre-post design to assess the intervention at a safety net hospital. The intervention was given by a patient navigator or community health worker.

RESULTS

Patient knowledge (n = 130) of personal cancer history improved from baseline pretest to 1 week after the intervention for stage (66-93%; P < .05), treatment (79-92%; P < .05), and symptoms of recurrence (48-89%; P < .05), which was retained at 3 months. The intervention reduced the number of patients who were unsure when their mammogram was due (15-5% at 1 week and 6% at 3 months; P < .05). Nearly 90% reported they would be likely to share their survivorship card with their providers.

CONCLUSION

A patient-centered survivorship card improved short-term recall of key survivorship care knowledge and seems to be effective at reducing communication barriers for this population. Further studies are warranted to assess long-term retention and the impact on receipt of appropriate survivorship follow-up care.

Multiple barriers delay care among women with abnormal cancer screening despite patient navigation

BACKGROUND

While there is widespread dissemination of patient navigation programs in an effort to reduce delays in cancer care, little is known about the impact of barriers to care on timely outcomes.

METHODS

We conducted a secondary analysis of the Boston Patient Navigation Research Program (PNRP) to examine the effect that the presence of barriers had on time to diagnostic resolution of abnormal breast or cervical cancer screening tests. We used multivariable Cox proportional hazards regression with time to diagnostic resolution as the outcome to examine the effect of the number of barriers, controlling for demographic covariates and clustered by patients' primary navigator.

RESULTS

There were 1481 women who received navigation; mean age was 39 years; 32% were White, 27% Black, and 31% Hispanic; 28% had private health insurance; and 38% did not speak English. Overall, half (n=745, 50%) had documentation of one or more barriers to care. Women with barriers were more likely to be older, non-White, non-English language speakers, and on public or no health insurance compared with women without barriers. In multivariable analyses, we found less timely diagnostic resolution as the number of barriers increased (one barrier, adjusted hazard ratio [aHR] 0.81 [95% CI 0.56-1.17], p=0.26; two barriers, aHR 0.55 [95% CI 0.37-0.81], p=0.0025; three or more barriers, aHR 0.31 [95% CI 0.21-0.46], p<0.0001)].

CONCLUSION

Within a patient navigation program proven to reduce delays in care, we found that navigated patients with documented barriers to care experience less timely resolution of abnormal cancer screening tests.

Predictors of resolution in navigated patients with abnormal cancer screening tests

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

Acceptability of self-collected human papillomavirus specimens in cervical cancer screening: A review

Cervical cancer morbidity and mortality is an important public health problem around the world. Some of the barriers to cervical cancer screening include the embarrassment, discomfort, lack of privacy and time and cost associated with clinician-collected, clinic-based screening with cytology or human papillomavirus tests. Self-collection of a human papillomavirus (HPV) test has been found to be generally more acceptable, less embarrassing, more comfortable, more private and easy to do and preferred to pelvic examination for cervical cytology by many women worldwide. The most commonly reported limitation to self-collection is a woman’s lack of confidence in her ability to perform it correctly. Self-collected human papillomavirus tests have been shown to be as or more sensitive than cytology or clinician-collected HPV tests. With confidence-building education about self-collection, it is likely a viable method to extend the reach of screening in high and low-resource areas around the world.