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Reaves S, Hall KC, Stewart MW, Wentzensen N, Ferrell C, Risley C, Wells J, Rives R, Bobo F, Daniels J, Farrington K, Morgan JC, Clarke MA. Evaluation of follow-up colposcopy procedures after abnormal cervical screening result across a statewide study in Mississippi. Cancer Causes Control 2024:10.1007/s10552-024-01905-0. [PMID: 39152278 DOI: 10.1007/s10552-024-01905-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 08/07/2024] [Indexed: 08/19/2024]
Abstract
PURPOSE Cervical screening is used to detect and treat precancers to prevent invasive cancers. However, successful prevention also requires adequate follow-up and treatment of individuals with abnormal screening results. The aim was to investigate demographics, clinical characteristics, and follow-up status for individuals needing colposcopy after an abnormal screening result. METHODS The STRIDES (Studying Risk to Improve DisparitiES) cohort comprises individuals undergoing cervical cancer screening and management at a Mississippi Health Department or University of Mississippi clinic. Follow-up status, demographics, and clinical data were assessed from electronic health records and, if necessary, patient navigation on individuals identified as needing a colposcopy after an abnormal screening. RESULTS Of the 1,458 individuals requiring colposcopy, 43.0% had the procedure within 4 months, 16.4% had a delayed procedure, and 39.5% had no documented colposcopy follow-up, with significant predictors of follow-up identified as age and cytology diagnosis. Individuals 30 + were more likely to have follow up with a colposcopy compared to individuals < 30 years (49% and 38.7%, respectively; p < .001). Individuals with cytology diagnoses of LSIL (52.9%), ASC-H (51.4%), and HSIL (62.3%) had higher percentages of adherence to follow-up guidelines (p < .001). In total, we found that 78% of individuals had some type of follow-up, including a repeat screening visit. CONCLUSION Despite high cervical cancer screening rates among Mississippians, a substantial proportion did not have adequate next-step intervention. However, it is encouraging that highest risk individuals were more likely to have a colposcopy. Regardless, continuing to understand the underlying causes for incomplete follow-up is crucial for timely secondary targeted interventions to reduce cervical cancer burden, promote awareness, and improve health outcomes.
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Affiliation(s)
- Sydney Reaves
- School of Nursing, University of Mississippi Medical Center, 2500 N State St, Jackson, MS, 39216, USA.
| | - Katherine C Hall
- School of Nursing, University of Mississippi Medical Center, 2500 N State St, Jackson, MS, 39216, USA
| | - Mary W Stewart
- School of Nursing, Mississippi State University, Meridian, MS, USA
| | - Nicolas Wentzensen
- Division of Cancer Epidemiology & Genetics, Clinical Genetics Branch, National Cancer Institute, Rockville, MD, USA
| | - Christina Ferrell
- School of Nursing, University of Mississippi Medical Center, 2500 N State St, Jackson, MS, 39216, USA
| | - Carolann Risley
- School of Nursing, University of Mississippi Medical Center, 2500 N State St, Jackson, MS, 39216, USA
- Cancer Research Institute, University of Mississippi Medical Center, Jackson, MS, USA
- Department of Cell and Molecular Biology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Jimmie Wells
- School of Nursing, University of Mississippi Medical Center, 2500 N State St, Jackson, MS, 39216, USA
| | - Rhonda Rives
- Department of Pathology, Mississippi Baptist Medical Center, Jackson, MS, USA
| | - Fajada Bobo
- Department of Pathology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Jon Daniels
- Mississippi State Department of Health, Jackson, MS, USA
| | | | - Jody C Morgan
- School of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Megan A Clarke
- Division of Cancer Epidemiology & Genetics, Clinical Genetics Branch, National Cancer Institute, Rockville, MD, USA
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Zumba EM, Watson KS, Torres P, Williams B, Mannan N, Green L, Owens B, Gastala N, Bueno R, Soto B, Carnahan L, Molina Y, Henderson V. Expanding Outcomes in Cancer Screening Safety Net Programs: Promoting Sustainability and Policy Reform. HEALTH EDUCATION & BEHAVIOR 2024; 51:352-358. [PMID: 38344982 DOI: 10.1177/10901981241231502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2024]
Abstract
Community-engaged patient navigation safety net programs are established as an evidence-based approach to address cancer prevention and early detection efforts, but barriers to expand and sustain such programs persist. In addition, few studies describe how these programs impact buy-in among communities and policy change within health care systems and government. We describe how we used the Capacity for Sustainability Framework to guide efforts for program sustainability and community, institutional, and policy level change in a breast cancer screening and patient navigation safety net program. The nine domains of the Capacity for Sustainability Framework were used to develop program logic models, to inform program implementation and quality improvement agendas, and to guide multi-level partner and stakeholder engagement, outreach, and dissemination of outcomes. The program is currently in its seventh year and continues to be annually funded by a city public health department. In 2021, additional 5-year renewable funding from a state public health department was secured. In addition, institutional program support was expanded for patients diagnosed with breast cancer. Program leaders worked with policymakers to draft legislation to support training certification and third-payor reimbursement for patient navigators and community health workers. The program is well-known and trusted among community members, community-based organizations, and providers. Community, organizational, and policy-level outcomes demonstrate that community-engaged patient navigation safety net programs can influence more than individual and interpersonal outcomes and can be sustained over time.
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Affiliation(s)
| | | | - Paola Torres
- University of Illinois Cancer Center, Chicago, IL, USA
| | | | | | - Lauren Green
- RUSH University Medical Center, Chicago, IL, USA
| | | | | | - Rocio Bueno
- University of Illinois Cancer Center, Chicago, IL, USA
| | - Brenda Soto
- University of Illinois Cancer Center, Chicago, IL, USA
| | - Leslie Carnahan
- University of Illinois Cancer Center, Chicago, IL, USA
- University of Illinois Chicago, IL, USA
| | - Yamile Molina
- University of Illinois Cancer Center, Chicago, IL, USA
- University of Illinois Chicago, IL, USA
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Spencer JC, Charlton BM, Pretsch PK, Schnarrs PW, Spees LP, Hudgens MG, Barclay L, Wheeler SB, Brewer NT, Smith JS. Barriers to Cervical Cancer Screening by Sexual Orientation Among Low-Income Women in North Carolina. ARCHIVES OF SEXUAL BEHAVIOR 2024; 53:1645-1652. [PMID: 38627295 PMCID: PMC11106100 DOI: 10.1007/s10508-024-02844-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 02/21/2024] [Accepted: 02/22/2024] [Indexed: 05/21/2024]
Abstract
We sought to examine cervical cancer screening barriers by sexual orientation among low-income women in North Carolina. The MyBodyMyTest-3 Trial recruited low-income women (< 250% of federal poverty level) aged 25-64 years who were 1+ year overdue for cervical cancer screening. We compared perceptions of cervical cancer screening among those who self-identified as lesbian, gay, bisexual, or queer (LGBQ; n = 70) to straight/heterosexual women (n = 683). For both LGBQ and straight respondents, the greatest barriers to screening were lack of health insurance (63% and 66%) and cost (49% and 50%). LGBQ respondents were more likely than straight respondents to report forgetting to screen (16% vs. 8%, p = .05), transportation barriers (10% vs. 2%, p = .001), and competing mental or physical health problems (39% vs. 27%, p = .10). Addressing access remains important for improving cervical cancer screening among those under-screened. For LGBQ women, additional attention may be needed for reminders, co-occurring health needs, and transportation barriers.
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Affiliation(s)
- Jennifer C Spencer
- Department of Population Health, Dell Medical School, University of Texas at Austin, 1601 Trinity St., Bldg. A, Austin, TX, 78712, USA.
| | - Brittany M Charlton
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Peyton K Pretsch
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Phillip W Schnarrs
- Department of Population Health, Dell Medical School, University of Texas at Austin, 1601 Trinity St., Bldg. A, Austin, TX, 78712, USA
| | - Lisa P Spees
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Michael G Hudgens
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Lynn Barclay
- American Sexual Health Association, Research Triangle Park, Durham, NC, USA
| | - Stephanie B Wheeler
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Noel T Brewer
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Jennifer S Smith
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Varon ML, Geng Y, Fellman BM, Troisi C, Fernandez ME, Li R, Reininger B, Schmeler KM, Allanson E. Interventions to increase follow-up of abnormal cervical cancer screening results: A systematic literature review and meta-analysis. PLoS One 2024; 19:e0291931. [PMID: 38381754 PMCID: PMC10880967 DOI: 10.1371/journal.pone.0291931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 09/10/2023] [Indexed: 02/23/2024] Open
Abstract
INTRODUCTION Ensuring timely follow-up of abnormal screening results is essential for eliminating cervical cancer. OBJECTIVE The purpose of the study was to review single and multicomponent interventions designed to improve follow-up of women with abnormal cervical cancer screening results. We report on effectiveness across studies, and describe what aspects of these interventions might be more impactful. METHODS Publications were searched between January 2000 and December 2022. The search included observational, quasi-experimental (pre-post studies) and randomized controlled studies describing at least one intervention to increase follow-up of women with abnormal cervical cancer screening results. Outcomes of studies included completion of any follow-up (i.e., attending a follow-up appointment), timely diagnosis (i.e., colposcopy results within 90 days of screening) and time to diagnostic resolution (i.e., days between screening and final diagnosis). We assessed risk of bias for observational and quasi-experimental studies using the Newcastle-Ottawa Scale (NOS) tool and the Cochrane collaboration tool for randomized studies. We conducted a meta-analysis using studies where data were provided to estimate a summary average effect of the interventions on follow-up of patients and to identify characteristics of studies associated with an increased effectiveness of interventions. We extracted the comparison and intervention proportions of women with follow-up before and after the intervention (control and intervention) and plotted the odds ratios (ORs) of completing follow-up along with the 95% confidence intervals (CIs) using forest plots for the interventions vs. controls when data were available. FINDINGS From 7,457 identified studies, 28 met the inclusion criteria. Eleven (39%) of the included studies had used a randomized design. Most studies (63%) assessed completion of any follow-up visit as the primary outcome, whereas others measured time to definite diagnosis (15%) or diagnostic resolution (22%). Navigation was used as a type of intervention in 63% of the included studies. Most interventions utilized behavioral approaches to improve outcomes. The overall estimate of the OR for completion of follow-up for all interventions was 1.81 (1.36-2.42). The highest impact was for programs using more than one approach (multicomponent interventions) to improve outcomes with OR = 3.01 (2.03-4.46), compared with studies with single intervention approaches with OR = 1.56 (1.14-2.14). No statistical risks were noted from publication bias or small-study effects in the studies reviewed. CONCLUSION Our findings revealed large heterogeneity in how follow-up of abnormal cervical cancer screening results was defined. Our results suggest that multicomponent interventions were more effective than single component interventions and should be used to improve follow-up after abnormal cervical cancer screening results. Navigation appears to be an important tool for improving follow-up. We also provide recommendations for future studies and implications for policy in terms of better defining outcomes for these interventions.
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Affiliation(s)
- Melissa Lopez Varon
- Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
- Health Promotion & Behavioral Sciences, The University of Texas Health Science Center at Houston School of Public Health, Houston, Texas, United States of America
| | - Yimin Geng
- Research Medical Library, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Bryan M. Fellman
- Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Catherine Troisi
- Management, Policy & Community Health, The University of Texas Health Science Center at Houston School of Public Health, Houston, Texas, United States of America
| | - Maria E. Fernandez
- Health Promotion & Behavioral Sciences, The University of Texas Health Science Center at Houston School of Public Health, Houston, Texas, United States of America
| | - Ruosha Li
- Biostatistics, The University of Texas Health Science Center at Houston School of Public Health, Houston, Texas, United States of America
| | - Belinda Reininger
- Health Promotion & Behavioral Sciences, The University of Texas Health Science Center at Houston School of Public Health, Brownsville Regional Campus, Brownsville, Texas, United States of America
| | - Kathleen M. Schmeler
- Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Emma Allanson
- The Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia
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Reaves S, Hall KC, Stewart MW, Wentzensen N, Ferrell C, Risley C, Wells J, Rives R, Bobo F, Daniels J, Farrington K, Morgan JC, Clarke MA. Evaluation of Follow-up Colposcopy Procedures After Abnormal Cervical Screening Result Across a Statewide Study in Mississippi. RESEARCH SQUARE 2024:rs.3.rs-3943646. [PMID: 38410464 PMCID: PMC10896379 DOI: 10.21203/rs.3.rs-3943646/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
Purpose Cervical screening is used to detect and treat precancers to prevent invasive cancers. However, successful prevention also requires adequate follow-up and treatment of individuals with abnormal screening results. The aim was to investigate demographics, clinical characteristics, and follow-up status for individuals needing colposcopy after an abnormal screening result. Methods The STRIDES (Studying Risk to Improve DisparitiES) cohort comprises individuals undergoing cervical cancer screening and management at a Mississippi Health Department or University of Mississippi clinic. Follow-up status, demographics, and clinical data were assessed from electronic health records and, if necessary, patient navigation on individuals identified as needing a colposcopy after an abnormal screening. Results Of the 1,458 individuals requiring colposcopy, 43.0% had the procedure within 4 months, 16.4% had a delayed procedure, and 39.5% had no documented follow-up, with significant predictors of follow-up identified as age and cytology diagnosis. Based on age, individuals 30 + were more likely to follow up with a colposcopy compared to individuals < 30 years (49% and 38.7%, respectively; p < .001). Individuals with cytology diagnoses of LSIL (52.9%), ASC-H (51.4%), and HSIL (62.3%) had higher percentages of adherence to follow-up colposcopy guidelines (p < .001). Conclusion Despite high cervical cancer screening rates among Mississippians, a substantial portion did not have adequate next-step intervention. However, it is encouraging that highest risk individuals were more likely to have a colposcopy. Regardless, continuing to understand the underlying causes for incomplete follow-up is crucial for timely secondary targeted interventions to reduce cervical cancer burden, promote awareness, and improve health outcomes.
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Affiliation(s)
- Sydney Reaves
- University of Mississippi Medical Center, School of Nursing
| | | | | | | | | | - Carolann Risley
- University of Mississippi Medical Center, Cancer Research Institute
| | - Jimmie Wells
- University of Mississippi Medical Center, School of Nursing
| | - Rhonda Rives
- Mississippi Baptist Medical Center, Department of Pathology
| | - Fajada Bobo
- University of Mississippi Medical Center, Department of Pathology
| | | | | | - Jody C Morgan
- University of Mississippi Medical Center, School of Medicine
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Graboyes EM, Chappell M, Duckett KA, Sterba K, Halbert CH, Hill EG, Chera B, McCay J, Puram SV, Ramadan S, Sandulache VC, Kahmke R, Nussenbaum B, Alberg AJ, Paskett ED, Calhoun E. Patient Navigation for Timely, Guideline-Adherent Adjuvant Therapy for Head and Neck Cancer: A National Landscape Analysis. J Natl Compr Canc Netw 2023; 21:1251-1259.e5. [PMID: 38081134 PMCID: PMC10846494 DOI: 10.6004/jnccn.2023.7061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 07/24/2023] [Indexed: 12/18/2023]
Abstract
BACKGROUND Aligned with the NCCN Clinical Practice Guidelines in Oncology for Head and Neck Cancers, in November 2021 the Commission on Cancer approved initiation of postoperative radiation therapy (PORT) within 6 weeks of surgery for head and neck cancer (HNC) as its first and only HNC quality metric. Unfortunately, >50% of patients do not commence PORT within 6 weeks, and delays disproportionately burden racial and ethnic minority groups. Although patient navigation (PN) is a potential strategy to improve the delivery of timely, equitable, guideline-adherent PORT, the national landscape of PN for this aspect of care is unknown. MATERIALS AND METHODS From September through November 2022, we conducted a survey of health care organizations that participate in the American Cancer Society National Navigation Roundtable to understand the scope of PN for delivering timely, guideline-adherent PORT for patients with HNC. RESULTS Of the 94 institutions that completed the survey, 89.4% (n=84) reported that at least part of their practice was dedicated to navigating patients with HNC. Sixty-eight percent of the institutions who reported navigating patients with HNC along the continuum (56/83) reported helping them begin PORT. One-third of HNC navigators (32.5%; 27/83) reported tracking the metric for time-to-PORT at their facility. When estimating the timeframe in which the NCCN and Commission on Cancer guidelines recommend commencing PORT, 44.0% (37/84) of HNC navigators correctly stated ≤6 weeks; 71.4% (60/84) reported that they did not know the frequency of delays starting PORT among patients with HNC nationally, and 63.1% (53/84) did not know the frequency of delays at their institution. CONCLUSIONS In this national landscape survey, we identified that PN is already widely used in clinical practice to help patients with HNC start timely, guideline-adherent PORT. To enhance and scale PN within this area and improve the quality and equity of HNC care delivery, organizations could focus on providing better education and support for their navigators as well as specialization in HNC.
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Affiliation(s)
- Evan M. Graboyes
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina
| | - Michelle Chappell
- American Cancer Society National Navigation Roundtable, Cincinnati, Ohio
| | - Kelsey A. Duckett
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Katherine Sterba
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina
| | - Chanita Hughes Halbert
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, California
| | - Elizabeth G. Hill
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina
| | - Bhishamjit Chera
- Department of Radiation Oncology, Hollings Cancer Center, Medical University of South Carolina, Charleston, South Carolina
| | - Jessica McCay
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Sidharth V. Puram
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri
- Department of Genetics, Washington University School of Medicine, St. Louis, Missouri
| | - Salma Ramadan
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Vlad C. Sandulache
- Bobby R. Alford Department of Otolaryngology Head and Neck Surgery, Baylor College of Medicine, Houston, Texas
- ENT Section, Operative Care Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Russel Kahmke
- Department of Head and Neck Surgery and Communication Sciences, Duke University, Durham, North Carolina
| | - Brian Nussenbaum
- American Board of Otolaryngology - Head and Neck Surgery, Houston, Texas
| | - Anthony J. Alberg
- Department of Epidemiology and Biostatistics, University of South Carolina Arnold School of Public Health, Columbia, South Carolina
| | - Electra D. Paskett
- Division of Population Sciences, Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, Ohio
- Division of Cancer Prevention Control, Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, Ohio
| | - Elizabeth Calhoun
- Department of Population Health, University of Illinois Chicago, Chicago, Illinois
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Atlas SJ, Tosteson ANA, Wright A, Orav EJ, Burdick TE, Zhao W, Hort SJ, Wint AJ, Smith RE, Chang FY, Aman DG, Thillaiyapillai M, Diamond CJ, Zhou L, Haas JS. A Multilevel Primary Care Intervention to Improve Follow-Up of Overdue Abnormal Cancer Screening Test Results: A Cluster Randomized Clinical Trial. JAMA 2023; 330:1348-1358. [PMID: 37815566 PMCID: PMC10565610 DOI: 10.1001/jama.2023.18755] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 08/31/2023] [Indexed: 10/11/2023]
Abstract
Importance Realizing the benefits of cancer screening requires testing of eligible individuals and processes to ensure follow-up of abnormal results. Objective To test interventions to improve timely follow-up of overdue abnormal breast, cervical, colorectal, and lung cancer screening results. Design, Setting, and Participants Pragmatic, cluster randomized clinical trial conducted at 44 primary care practices within 3 health networks in the US enrolling patients with at least 1 abnormal cancer screening test result not yet followed up between August 24, 2020, and December 13, 2021. Intervention Automated algorithms developed using data from electronic health records (EHRs) recommended follow-up actions and times for abnormal screening results. Primary care practices were randomized in a 1:1:1:1 ratio to (1) usual care, (2) EHR reminders, (3) EHR reminders and outreach (a patient letter was sent at week 2 and a phone call at week 4), or (4) EHR reminders, outreach, and navigation (a patient letter was sent at week 2 and a navigator outreach phone call at week 4). Patients, physicians, and practices were unblinded to treatment assignment. Main Outcomes and Measures The primary outcome was completion of recommended follow-up within 120 days of study enrollment. The secondary outcomes included completion of recommended follow-up within 240 days of enrollment and completion of recommended follow-up within 120 days and 240 days for specific cancer types and levels of risk. Results Among 11 980 patients (median age, 60 years [IQR, 52-69 years]; 64.8% were women; 83.3% were White; and 15.4% were insured through Medicaid) with an abnormal cancer screening test result for colorectal cancer (8245 patients [69%]), cervical cancer (2596 patients [22%]), breast cancer (1005 patients [8%]), or lung cancer (134 patients [1%]) and abnormal test results categorized as low risk (6082 patients [51%]), medium risk (3712 patients [31%]), or high risk (2186 patients [18%]), the adjusted proportion who completed recommended follow-up within 120 days was 31.4% in the EHR reminders, outreach, and navigation group (n = 3455), 31.0% in the EHR reminders and outreach group (n = 2569), 22.7% in the EHR reminders group (n = 3254), and 22.9% in the usual care group (n = 2702) (adjusted absolute difference for comparison of EHR reminders, outreach, and navigation group vs usual care, 8.5% [95% CI, 4.8%-12.0%], P < .001). The secondary outcomes showed similar results for completion of recommended follow-up within 240 days and by subgroups for cancer type and level of risk for the abnormal screening result. Conclusions and Relevance A multilevel primary care intervention that included EHR reminders and patient outreach with or without patient navigation improved timely follow-up of overdue abnormal cancer screening test results for breast, cervical, colorectal, and lung cancer. Trial Registration ClinicalTrials.gov Identifier: NCT03979495.
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Affiliation(s)
- Steven J. Atlas
- Division of General Internal Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Anna N. A. Tosteson
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire
- Dartmouth Cancer Center, Dartmouth Health and Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire
- Department of Community and Family Medicine, Dartmouth Health, Lebanon, New Hampshire
- Department of Medicine, Dartmouth Health, Lebanon, New Hampshire
| | - Adam Wright
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - E. John Orav
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Timothy E. Burdick
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire
- Department of Community and Family Medicine, Dartmouth Health, Lebanon, New Hampshire
- SYNERGY Research Informatics, Dartmouth Health, Lebanon, New Hampshire
- Department of Biomedical Data Science, Dartmouth Health, Lebanon, New Hampshire
| | - Wenyan Zhao
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire
| | - Shoshana J. Hort
- Department of Medicine, Dartmouth Health, Lebanon, New Hampshire
- SYNERGY Research Informatics, Dartmouth Health, Lebanon, New Hampshire
| | - Amy J. Wint
- Division of General Internal Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Rebecca E. Smith
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire
- Department of Community and Family Medicine, Dartmouth Health, Lebanon, New Hampshire
| | - Frank Y. Chang
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - David G. Aman
- Research Computing, Dartmouth College, Lebanon, New Hampshire
| | | | - Courtney J. Diamond
- Department of Biomedical Informatics, Irving Medical Center, Columbia University, New York, New York
| | - Li Zhou
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Jennifer S. Haas
- Division of General Internal Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
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Spencer JC, Kim JJ, Tiro JA, Feldman SJ, Kobrin SC, Skinner CS, Wang L, McCarthy AM, Atlas SJ, Pruitt SL, Silver MI, Haas JS. Racial and Ethnic Disparities in Cervical Cancer Screening From Three U.S. Healthcare Settings. Am J Prev Med 2023; 65:667-677. [PMID: 37146839 PMCID: PMC11135625 DOI: 10.1016/j.amepre.2023.04.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 04/28/2023] [Accepted: 04/28/2023] [Indexed: 05/07/2023]
Abstract
INTRODUCTION This study sought to characterize racial and ethnic disparities in cervical cancer screening and follow-up of abnormal findings across 3 U.S. healthcare settings. METHODS Data were from 2016 to 2019 and were analyzed in 2022, reflecting sites within the Multi-level Optimization of the Cervical Cancer Screening Process in Diverse Settings & Populations Research Center, part of the Population-based Research to Optimize the Screening Process consortium, including a safety-net system in the southwestern U.S., a northwestern mixed-model system, and a northeastern integrated healthcare system. Screening uptake was evaluated among average-risk patients (i.e., no previous abnormalities) by race and ethnicity as captured in the electronic health record, using chi-square tests. Among patients with abnormal findings requiring follow-up, the proportion receiving colposcopy or biopsy within 6 months was reported. Multivariable regression was conducted to assess how clinical, socioeconomic, and structural characteristics mediate observed differences. RESULTS Among 188,415 eligible patients, 62.8% received cervical cancer screening during the 3-year study period. Screening use was lower among non-Hispanic Black patients (53.2%) and higher among Hispanic (65.4%,) and Asian/Pacific Islander (66.5%) than among non-Hispanic White patients (63.5%, all p<0.001). Most differences were explained by the distribution of patients across sites and differences in insurance. Hispanic patients remained more likely to screen after controlling for a variety of clinical and sociodemographic factors (risk ratio=1.14, CI=1.12, 1.16). Among those receiving any screening test, Black and Hispanic patients were more likely to receive Pap-only testing (versus receiving co-testing). Follow-up from abnormal results was low for all groups (72.5%) but highest among Hispanic participants (78.8%, p<0.001). CONCLUSIONS In a large cohort receiving care across 3 diverse healthcare settings, cervical cancer screening and follow-up were below 80% coverage targets. Lower screening for Black patients was attenuated by controlling for insurance and site of care, underscoring the role of systemic inequity. In addition, it is crucial to improve follow-up after abnormalities are identified, which was low for all populations.
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Affiliation(s)
- Jennifer C Spencer
- Department of Population Health, Dell Medical School, The University of Texas at Austin, Austin, Texas; Department of Internal Medicine, Dell Medical School, The University of Texas at Austin, Austin, Texas.
| | - Jane J Kim
- Department of Health Policy and Management, Harvard TH Chan School of Public Health, Boston, Massachussetts
| | - Jasmin A Tiro
- Department Public Health Sciences, The University of Chicago, Chicago, Illinois; University of Chicago Medicine Comprehensive Cancer Center, The University of Chicago, Chicago, Ilinois
| | - Sarah J Feldman
- Division of Gynecologic Oncology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachussetts
| | - Sarah C Kobrin
- Healthcare Delivery Research Program, Division of Cancer Control & Population Sciences, National Cancer Institute, Bethesda, Maryland
| | - Celette Sugg Skinner
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, Texas; Harold C Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Lei Wang
- Department of Population & Data Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Anne Marie McCarthy
- Department of Biostatistics, Epidemiology & Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Steve J Atlas
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachussetts
| | - Sandi L Pruitt
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, Texas; Harold C Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Michelle I Silver
- Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Jennifer S Haas
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachussetts
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9
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Feldman S, Lykken JM, Haas JS, Werner CL, Kobrin SC, Tiro JA, Chubak J, Kamineni A. Factors associated with timely colposcopy following an abnormal cervical cancer test result. Prev Med 2022; 164:107307. [PMID: 36270434 PMCID: PMC9808794 DOI: 10.1016/j.ypmed.2022.107307] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 10/06/2022] [Accepted: 10/09/2022] [Indexed: 01/05/2023]
Abstract
Successful cervical cancer prevention requires screening and appropriate management of abnormal test results. Management includes diagnostic evaluation and treatment, if indicated, based on cervical cancer risk after most abnormal test results. There is little guidance on the optimal timing of diagnostic evaluation, and few data exist on factors associated with timely management. We quantified time-to-colposcopy within 12 months of an abnormal cervical cancer screening or surveillance test result from 2010 to 2018 across three diverse healthcare systems and described factors associated with timely colposcopy. Among 21-65 year-old patients with an abnormal test result for which colposcopy was indicated (n = 28,706), we calculated the proportion who received a colposcopy within 12 months of the abnormal test and used Kaplan-Meier methods to estimate the probability of colposcopy within 12 months. Across all systems, 75.3% of patients received a colposcopy within 12 months, with site-specific estimates ranging from 70.0 to 83.0%. We fit mixed-effects multivariable logistic regression models to identify factors associated with receipt of colposcopy within 12 months. The healthcare system and cytology result severity were the most important factors associated with of timely colposcopy. We observed that sites with more centralized processes had higher proportions of colposcopy completion, and patients with high-grade results were more consistently evaluated earlier than patients with low-grade results. Patient age also affected receipt of timely colposcopy, though this association differed by healthcare system and result severity. These data suggest opportunities for system-level interventions to improve management of abnormal cervical cancer test results.
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Affiliation(s)
- Sarah Feldman
- Division of Gynecologic Oncology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States of America.
| | - Jacquelyn M Lykken
- Department of Population & Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Jennifer S Haas
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Claudia L Werner
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, United States of America; Parkland Health, Dallas, TX, United States of America
| | - Sarah C Kobrin
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, United States of America
| | - Jasmin A Tiro
- Department of Population & Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, United States of America; Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Jessica Chubak
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America
| | - Aruna Kamineni
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America
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Isaacson S, Adewumi K, Smith JS, Novak C, Oketch S, Huchko MJ. A Qualitative Exploration of Barriers to Treatment Among HPV-Positive Women in a Cervical Cancer Screening Study in Western Kenya. Oncologist 2022; 28:e9-e18. [PMID: 36239434 PMCID: PMC9847557 DOI: 10.1093/oncolo/oyac208] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 09/09/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Cervical cancer screening through self-collected high-risk human papillomavirus (HPV) testing has increased screening uptake, particularly in low-resource settings. Improvement ultimately depends, however, on women with positive results accessing follow-up treatment. Identifying the barriers to timely treatment is needed to tailor service delivery for maximum impact. MATERIALS AND METHODS This qualitative study was conducted within a self-collected HPV screening trial in Migori County, Kenya. HPV-positive women were referred for no-cost cryotherapy treatment at the county hospital. Women not attending within 60 days of receiving HPV-positive results were randomly selected for in-depth interviews (IDIs). IDIs were coded and analyzed to develop an analytical framework and identify treatment barriers. RESULTS Eighty-one women were interviewed. IDIs showed a poor understanding of HPV and cervical cancer, impacting comprehension of screening results and treatment instructions. All 81 had not undergone treatment but reported intending to in the future. Eight reported seeking treatment unsuccessfully or not qualifying, primarily due to pregnancy. Transportation costs and long distances to the hospital were the most reported barriers to treatment. Other obstacles included work, household obligations, and fear of treatment. Impacts of social influences were mixed; some women reported their husbands prevented seeking treatment, others reported their husbands provided financial or emotional support. Few women experienced peer support. CONCLUSIONS Women faced many barriers to treatment following HPV screening in rural Kenya. Transportation barriers highlight a need for local treatment capacity or screen-and-treat approaches. Ensuring women understand their results and how to seek treatment is essential to improving cervical cancer screening in low-resource settings.
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Affiliation(s)
- Sinéad Isaacson
- Epidemiology Department, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Konyin Adewumi
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Jennifer S Smith
- Epidemiology Department, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Carissa Novak
- Harvard Global Health Institute, Harvard University, Cambridge, MA, USA
| | | | - Megan J Huchko
- Corresponding author: Megan J. Huchko, MD, MPH, Duke Global Health Institute, Duke University, Durham, NC, USA.
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11
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Alimena S, Davis M, Pelletier A, Terry K, King M, Feldman S. Regional Variation in Access to Oncologic Care and Racial Disparities Among Cervical Cancer Patients. Am J Clin Oncol 2022; 45:415-421. [PMID: 36111738 DOI: 10.1097/coc.0000000000000944] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES The goal of this study was to determine whether access to gynecologic oncologists is correlated with disparate outcomes among cervical cancer patients, especially among Black women. MATERIALS AND METHODS An ecological study was performed using the National Cancer Database among stage I-IVA cervical cancer patients from 2004 to 2014. Data from the National Cancer Institute, the Society of Gynecologic Oncology, and the United States Census were compiled to describe access to care by region. Factors associated with receipt of optimal treatment (defined as surgery and/or radiation for stage IA-IB1 and IIA1; radiation and chemotherapy for stage IB2, IIA2, IIB-IVA or node positive disease) were identified using multivariate logistic regressions stratified by region, controlling for confounding factors including the number of gynecologic oncologists per states in each subregion. Cox multivariate survival analyses stratified by region were also performed. RESULTS Of 42,213 women, 17.0% were Black. On multivariate analysis controlling for confounders, all Southern women were less likely to receive optimal treatment (adjusted odds ratio [aOR]: 0.80, 95% confidence interval [95% CI]: 0.75-0.85, P <0.001) compared with Northeastern women. Black women in the South (aOR: 0.76, 95% CI: 0.70-0.83, P <0.001) and Midwest (aOR: 0.78, 95% CI: 0.68-0.90, P <0.001) were less likely to receive optimal treatment compared with non-Black women in those regions. Black women in the South (adjusted hazard ratio [aHR]: 1.11, 95% CI: 1.04-1.18, P <0.001) and West (aHR: 1.34, 95% CI: 1.11-1.62, P =0.002) had worse mortality compared with non-Black women in those regions, despite controlling for access to gynecologic oncologists. The South, Midwest, and West had proportionally fewer cancer centers and gynecologic oncologists compared with the Northeast. CONCLUSIONS Southern women are at risk of inadequate treatment for cervical cancer, and Black Southern women are at even higher risk of inadequate treatment and worse overall survival despite controlling for access to gynecologic oncologists. Social determinants of health and other barriers besides access to oncologists likely contribute to observed regional and racial disparities among cervical cancer patients.
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Affiliation(s)
- Stephanie Alimena
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology
| | - Michelle Davis
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology
- Division of Gynecologic Oncology, Dana Farber Cancer Institute
| | - Andrea Pelletier
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology
- Department of Epidemiology, Harvard School of Public Health, Boston, MA
| | - Kathryn Terry
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology
- Department of Epidemiology, Harvard School of Public Health, Boston, MA
| | - Martin King
- Department of Radiation Oncology, Brigham and Women's Hospital, Harvard Medical School
| | - Sarah Feldman
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology
- Division of Gynecologic Oncology, Dana Farber Cancer Institute
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12
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Martinez NG, Yee LM, Miller ES. Is Postpartum Patient Navigation Uniquely Beneficial for Women with Antenatal Depressive Symptoms? Am J Perinatol 2022; 39:1189-1195. [PMID: 33321528 DOI: 10.1055/s-0040-1721696] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Women with depression benefit substantively from the comprehensive postpartum visit yet are less likely to attend such visits. Postpartum patient navigation has been associated with improved postpartum visit attendance. Thus, the objective of this study was to determine whether patient navigation was associated with differential postpartum visit attendance for low-income, largely racial/ethnic minority women with antenatal depressive symptoms. STUDY DESIGN This is a secondary analysis of a prospective postpartum patient navigation program for adult, low-income, largely racial/ethnic minority women receiving prenatal care at a single university clinic (n = 474). Patient navigators assumed supportive and logistical responsibilities for patients between delivery and postpartum visit completion ("navigation cohort"); women in the navigation cohort were compared with women who would have been eligible for patient navigation but received care the year before program implementation ("pre-navigation cohort"). Women were considered to have antenatal depressive symptoms if they had a Patient Health Questionnaire-9 score above 9 prior to delivery. The primary outcome was attendance at the comprehensive postpartum visit by 12 weeks. Factors associated with this outcome were assessed in a prenavigation cohort of women and were subsequently evaluated in the total cohort (prenavigation and navigation groups) using multivariable models. An interaction term between antenatal depressive symptoms and navigation status was generated to evaluate for effect modification. RESULTS In the prenavigation cohort, antenatal depressive symptoms were more frequent among women who did not attend the postpartum visit (25.0 vs. 10.2%, p = 0.002) and remained a risk factor for postpartum visit nonattendance on multivariable analysis (adjusted odds ratio [aOR]: 0.39, 95% confidence interval [CI]: 0.18-0.83). In the navigation cohort (n = 218), the presence of antenatal depressive symptoms was not associated with attendance (p = 0.117). In multivariable analyses of the total cohort, the interaction term between antenatal depressive symptoms and navigation was statistically significant (aOR: 11.06, 95% CI: 1.21-101.08). CONCLUSION Postpartum patient navigation appears particularly beneficial among women with antenatal depressive symptoms for increasing postpartum appointment attendance. KEY POINTS · Patient navigation has been associated with improved postpartum visit attendance.. · Among low-income women, antenatal depressive symptoms are a risk factor for postpartum visit nonattendance.. · Postpartum patient navigation appears particularly beneficial among women with antenatal depressive symptoms..
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Affiliation(s)
- Noelle G Martinez
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lynn M Yee
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Emily S Miller
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Battaglia TA, Fleisher L, Dwyer AJ, Wiatrek DE, Wells KJ, Wightman P, Strusowski T, Calhoun E. Barriers and opportunities to measuring oncology patient navigation impact: Results from the National Navigation Roundtable survey. Cancer 2022; 128 Suppl 13:2568-2577. [PMID: 35699612 DOI: 10.1002/cncr.33805] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 05/28/2021] [Accepted: 06/04/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Patient navigation improves cancer care delivery for those most at risk for poor outcomes. Lack of sustainable funding threatens the full integration of navigation services into health care delivery systems. Standardized navigation metrics that document impact and identify best practices are necessary to support sustainability. METHODS The National Navigation Roundtable administered a web-based, cross-sectional survey to oncology patient navigation programs to identify barriers and facilitators to the use of navigation metrics. The 38-item survey asked about data-collection practices and specific navigation metrics used by the program. Exploratory and descriptive statistics were used to identify factors associated with data collection and reporting. RESULTS Seven hundred fifty respondents from across the country represented navigation programs across the continuum of care. Although 538 respondents (72%) reported participating in routine data collection, only one-half of them used data for reporting purposes. For the 374 programs that used electronic health records, only 40% had discrete, reportable navigation fields, and 25% had an identifier for navigated patients. Program funding was identified as the only characteristic associated with data collection, whereas the type of data collected was associated with work setting, participation in alternative payment models, and where on the continuum navigation services are provided. Respondents participating in an oncology accreditation program were more likely to collect specific outcome metrics across the continuum and to use those data for reporting purposes. The most common barriers to data collection were time (55%) and lack of support for complex data systems and/or platforms (50%). CONCLUSIONS Inconsistent data collection and reporting of oncology navigation programs remain a threat to sustainability. Aligning data collection with oncology accreditation, funding, and reimbursement is a viable path forward.
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Affiliation(s)
- Tracy A Battaglia
- Women's Health Unit, Section of General Internal Medicine, Evans Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts
| | - Linda Fleisher
- Cancer Prevention and Control, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Andrea J Dwyer
- Department of Community and Behavioral Health, The Colorado School of Public Health, University of Colorado, Aurora, Colorado
| | | | - Kristen J Wells
- Department of Psychology, San Diego State University, San Diego, California
| | - Patrick Wightman
- Center for Population Health Sciences, Arizona Health Sciences, University of Arizona, Tucson, Arizona
| | | | - Elizabeth Calhoun
- Department of Population Health, University of Kansas School of Medicine, Kansas City, Kansas
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Development of a patient-oriented navigation model for patients with lung cancer and stroke in Germany. BMC Health Serv Res 2022; 22:785. [PMID: 35710375 PMCID: PMC9202203 DOI: 10.1186/s12913-022-08063-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 05/09/2022] [Indexed: 11/10/2022] Open
Abstract
Background The concept of patient navigation was first established in the USA to support vulnerable patient groups in receiving timely and comprehensive access to cancer care. It has recently gained increasing interest in Germany to support patients with chronic diseases in a fragmented healthcare system. The aim of this paper is to present the development of such a model adapted to the German context based on the results of mixed-methods studies investigating the need for and barriers to patient-oriented care. Methods In a process adapted from Delphi rounds, we conducted regular structured workshops with investigators of the project to discuss results of their studies and identify content and structure of the model based on the data. Workshop discussions were structured along seven core components of a navigation model including target patient groups, navigator tasks, occupational background and education of navigators, and patient-navigator interaction mode. Results Using an approach based on empirical data of current care practices with special focus on patients’ perspectives, we developed a patient-oriented navigation model for patients who have experienced stroke and lung cancer in the German healthcare context. Patients without personal social support were viewed as struggling most with the healthcare system, as well as multimorbid and elderly patients. Navigators should serve as a longer-term contact person with a flexible contact mode and timing based on the individual situation and preferences of patients. Navigator tasks include the provision of administrative and organizational support as well as referral and guidance to available resources and beneficial health programs with special forms of knowledge. Implementation of the navigator should be flexibly located to ensure a reliable outreach to vulnerable patients for first contact in settings like specialized in-patient and out-patient settings, while navigation itself focuses on care coordination in the out-patient setting. Conclusion Flexibility of navigator tasks needed to be a core characteristic of a navigation model to be perceived as supportive from patients’ perspectives. In a subsequent feasibility study, an intervention based on the model will be evaluated according to its acceptance, demand, and practicality.
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15
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Brooks SE, Davis EC, Farley JH. Disparities in pap smear screening follow up: A catalyst for collective action vs. collective despair. Gynecol Oncol 2021; 160:361-363. [PMID: 33500117 DOI: 10.1016/j.ygyno.2021.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Sandra E Brooks
- Thomas Jefferson University Hospitals, Inc, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, 111 S. 11(th) Street, Suite 2210, Philadelphia, PA 19102, USA.
| | - Eloise Chapman Davis
- Department of Obstetrics and Gynecology, Weill Cornell Medicine, 525 E 68th St J130, New York, NY 10065, USA
| | - John H Farley
- Department of Obstetrics and Gynecology, Dignity Health Medical Group, Division Head for Gynecologic Oncology, UA Cancer Center at Dignity Health St. Joseph's, Gynecologic Oncology, UA College of Medicine, Creighton University School of Medicine at St. Joseph's Hospital and Medical, 500 West Thomas Road Suite 660, Phoenix, AZ 85255, USA
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Kuroki L, Massad LS, Martin A, Liu J, Brown D, Leon A, Groesch K, Wilson T, Zeino Y, Diaz-Sylvester P, Delfino K, Hyon K, Kreuter M. Addressing Unmet Basic Needs to Improve Colposcopy Adherence Among Women With Abnormal Cervical Cancer Screening. J Low Genit Tract Dis 2021; 25:106-112. [PMID: 33631781 PMCID: PMC7987876 DOI: 10.1097/lgt.0000000000000593] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aims of the study were to identify unmet basic needs (BNs) among women referred to colposcopy, to assess patient acceptability/satisfaction with assistance from a navigator to address unmet BNs, and to estimate adherence to colposcopy. METHODS Women were recruited between September 2017 and January 2019 from 2 academic colposcopy centers, one serving a rural and one an urban area. Basic needs were assessed by phone before colposcopy appointments and considered unmet if unlikely to resolve in 1 month. Colposcopy adherence prestudy and poststudy implementation was abstracted over 4-6 months from administrative records. After a lead-in phase of 25 patients at each site, a BN navigator was offered to new participants with 1 or more unmet BNs. Primary outcome was adherence to initial appointment. RESULTS Among 100 women, 59% had 1 or more unmet BNs, with similar prevalence between urban and rural sites. Adherence to initial colposcopy was 83% overall, 72% at the rural clinic, and 94% at the urban clinic (p = .006). These adherence rates were improved from 4 months before study launch (30/59 [51%] rural clinic and 68/137 [50%] urban clinic). Although acceptability of BN navigation was greater than 96% and women felt that it helped them get to their colposcopy visit, having a navigator was not associated with adherence. Women reporting no unmet BNs had the lowest adherence compared with women with 1 or more unmet BNs, regardless of navigator assistance (p = .03). CONCLUSIONS Disadvantaged women who need colposcopy have unmet BNs and value navigator assistance for initial appointments. However, when appointment scheduling includes telephone reminders and inquiring about BNs, a navigator may not add value.
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Affiliation(s)
- Lindsay Kuroki
- Division of Gynecologic Oncology, Washington University School of Medicine, Alvin J. Siteman Cancer Center, St Louis, MO
| | - L Stewart Massad
- Division of Gynecologic Oncology, Washington University School of Medicine, Alvin J. Siteman Cancer Center, St Louis, MO
| | - Anne Martin
- Department of Obstetrics and Gynecology, Southern Illinois University School of Medicine (SIUM), Springfield, IL
| | - Jingxia Liu
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, MO
| | - Dominique Brown
- Health Communication Research Laboratory, The Brown School, Washington University in St Louis, St Louis, MO
| | - Andrea Leon
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St Louis, MO
| | | | | | - Yahia Zeino
- Department of Obstetrics and Gynecology, Southern Illinois University School of Medicine (SIUM), Springfield, IL
| | | | | | - Katherine Hyon
- Department of Obstetrics and Gynecology, Southern Illinois University School of Medicine (SIUM), Springfield, IL
| | - Matthew Kreuter
- Health Communication Research Laboratory, The Brown School, Washington University in St Louis, St Louis, MO
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Kronenfeld JP, Graves KD, Penedo FJ, Yanez B. Overcoming Disparities in Cancer: A Need for Meaningful Reform for Hispanic and Latino Cancer Survivors. Oncologist 2021; 26:443-452. [PMID: 33594785 DOI: 10.1002/onco.13729] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 12/29/2020] [Indexed: 12/12/2022] Open
Abstract
Hispanic and Latino (HL) cancer survivors are at a critical disadvantage compared with non-Hispanic White (NHW) patients regarding sociodemographic adversities and access to equitable treatment options. By 2030, there will be about four million HL cancer survivors in the U.S., representing nearly 20% of survivors in this country. Hispanics and Latinos are subjected to significant challenges in accessing and receiving equitable care relative to NHWs. Hispanics and Latinos also experience lower rates of health insurance and financial resources, limiting health care options. These disparities often originate from disparate social determinants of health, including lower funding for education and school programs, greater neighborhood stressors and violence, lower access to healthy and affordable food, and greater barriers to community health and exercise opportunities. Even among HL cancer survivors with proper access to health care, they experience disparate treatment options, including low inclusion in clinical trials and/or access to experimental therapies. A solution to these barriers necessitates complex and systemic changes that involve, for example, investing in public health programs, increasing the diversity and cultural awareness of the medical workforce, and promoting research opportunities such as clinical trials that are inclusive of HLs. Only through meaningful reform will equitable cancer care be available for all in the U.S. regardless of racial and/or ethnic background. This article reviews some of the critical social determinants of health and biases relevant to HL cancer survivors and provides recommendations for achieving cancer health equity. IMPLICATIONS FOR PRACTICE: Hispanics and Latinos experience a significant and often disproportionate cancer-related burden compared with non-Hispanic and Latino White individuals and other racial and ethnic groups. Meaningful reform to achieve health equity in oncology should focus on approaches to gaining trust among diverse patients, cultural and community sensitivity and engagement in oncology care and research, diversifying the workforce, and improving inclusion in clinical trial participation. Taken together, these recommendations can lead to exemplary and equitable care for all patients.
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Affiliation(s)
- Joshua P Kronenfeld
- University of Miami Miller School of Medicine & Sylvester Comprehensive Cancer Center, Miami, Florida, USA
| | - Kristi D Graves
- Georgetown University Lombardi Comprehensive Cancer Center, Washington, District of Columbia, USA
| | - Frank J Penedo
- University of Miami Miller School of Medicine & Sylvester Comprehensive Cancer Center, Miami, Florida, USA
| | - Betina Yanez
- Northwestern University Feinberg School of Medicine and Lurie Comprehensive Cancer Center, Chicago, Illinois, USA
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Kronenfeld JP, Graves KD, Penedo FJ, Yanez B. Overcoming Disparities in Cancer: A Need for Meaningful Reform for Hispanic and Latino Cancer Survivors. Oncologist 2021. [PMID: 33594785 DOI: 10.1002/onco.13729.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Hispanic and Latino (HL) cancer survivors are at a critical disadvantage compared with non-Hispanic White (NHW) patients regarding sociodemographic adversities and access to equitable treatment options. By 2030, there will be about four million HL cancer survivors in the U.S., representing nearly 20% of survivors in this country. Hispanics and Latinos are subjected to significant challenges in accessing and receiving equitable care relative to NHWs. Hispanics and Latinos also experience lower rates of health insurance and financial resources, limiting health care options. These disparities often originate from disparate social determinants of health, including lower funding for education and school programs, greater neighborhood stressors and violence, lower access to healthy and affordable food, and greater barriers to community health and exercise opportunities. Even among HL cancer survivors with proper access to health care, they experience disparate treatment options, including low inclusion in clinical trials and/or access to experimental therapies. A solution to these barriers necessitates complex and systemic changes that involve, for example, investing in public health programs, increasing the diversity and cultural awareness of the medical workforce, and promoting research opportunities such as clinical trials that are inclusive of HLs. Only through meaningful reform will equitable cancer care be available for all in the U.S. regardless of racial and/or ethnic background. This article reviews some of the critical social determinants of health and biases relevant to HL cancer survivors and provides recommendations for achieving cancer health equity. IMPLICATIONS FOR PRACTICE: Hispanics and Latinos experience a significant and often disproportionate cancer-related burden compared with non-Hispanic and Latino White individuals and other racial and ethnic groups. Meaningful reform to achieve health equity in oncology should focus on approaches to gaining trust among diverse patients, cultural and community sensitivity and engagement in oncology care and research, diversifying the workforce, and improving inclusion in clinical trial participation. Taken together, these recommendations can lead to exemplary and equitable care for all patients.
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Affiliation(s)
- Joshua P Kronenfeld
- University of Miami Miller School of Medicine & Sylvester Comprehensive Cancer Center, Miami, Florida, USA
| | - Kristi D Graves
- Georgetown University Lombardi Comprehensive Cancer Center, Washington, District of Columbia, USA
| | - Frank J Penedo
- University of Miami Miller School of Medicine & Sylvester Comprehensive Cancer Center, Miami, Florida, USA
| | - Betina Yanez
- Northwestern University Feinberg School of Medicine and Lurie Comprehensive Cancer Center, Chicago, Illinois, USA
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Hu F, Strohbach A, Martinez NG, Simon MA, Yee LM. Patient and Provider Perceptions of a Patient Navigation Program to Improve Postpartum Care Among Publicly Insured Women. Am J Perinatol 2021; 38:248-257. [PMID: 31491803 PMCID: PMC9472559 DOI: 10.1055/s-0039-1696671] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE This study was aimed to assess patient and provider perceptions of a postpartum patient navigation program. STUDY DESIGN This was a mixed-method assessment of a postpartum patient navigation program. Navigating New Motherhood (NNM) participants completed a follow-up survey including the Patient Satisfaction with Interpersonal Relationship with Navigator (PSN-I) scale and an open-ended question. PSN-I scores were analyzed descriptively. Eighteen provider stakeholders underwent in-depth interviews to gauge program satisfaction, perceived outcomes, and ideas for improvement. Qualitative data were analyzed by the constant comparative method. RESULTS In this population of low-income, minority women, participants (n = 166) were highly satisfied with NNM. The median PSN-I score was 45 out of 45 (interquartile range [IQR]: 43-45), where a higher score corresponds to higher satisfaction. Patient feedback was also highly positive, though a small number desired more navigator support. Provider stakeholders offered consistently positive program feedback, expressing satisfaction with NNM execution and outcomes. Provider stakeholders noted that navigators avoided inhibiting clinic workflow and eased clinic administrative burden. They perceived NNM improved multiple clinical and satisfaction outcomes. All provider stakeholders believed that NNM should be sustained long-term; suggestions for improvement were offered. CONCLUSION A postpartum patient navigation program can perceivably improve patient satisfaction, clinical care, and clinic workflow without burden to clinic providers.
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Affiliation(s)
- Fengling Hu
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Angelina Strohbach
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Noelle G. Martinez
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Melissa A. Simon
- Departments of Obstetrics and Gynecology, Preventive Medicine, and Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lynn M. Yee
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Corbett CM, Somers TJ, Nuñez CM, Majestic CM, Shelby RA, Worthy VC, Barrett NJ, Patierno SR. Evolution of a longitudinal, multidisciplinary, and scalable patient navigation matrix model. Cancer Med 2020; 9:3202-3210. [PMID: 32129946 PMCID: PMC7196067 DOI: 10.1002/cam4.2950] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 12/06/2019] [Accepted: 02/02/2020] [Indexed: 12/12/2022] Open
Abstract
This Longitudinal patient navigation Matrix Model was developed to overcome barriers across the cancer care continuum by offering prepatients, patients, and their families with support services. The extraordinary heterogeneity of patient needs during cancer screening, risk assessment, treatment, and survivorship as well as the vast heterogeneity of oncology care settings make it nearly impossible to follow a static navigation model. Our model of patient cancer navigation is unique as it enhances the traditional model by being highly adaptable based on both patient and family needs and scalable based on institutional needs and resources (eg, clinical volumes, financial resources, and community‐based resources). This relatively new operational model for system‐wide and systematic navigation incorporates a carefully cultivated supportive care program that evolved over the last decade from a bottom up approach that identified patient and family needs and developed appropriate resources. A core component of this model includes shifting away from department‐centric operations. This model does not require a patient to opt in or independently be able to report their needs or ask for services—it is an opt out model. The multidisciplinary “cross‐training” model can also facilitate reimbursement and sustainability by clarifying the differentiating actions that define navigation services: identification of barriers to quality care and specific actions taken to overcome those barriers, across the full continue of cancer care from community engagement to survivorship or end‐of‐life care.
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Affiliation(s)
- Cheyenne M Corbett
- Duke Cancer Institute, Duke University School of Medicine, Durham, NC, USA
| | - Tamara J Somers
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Christine M Nuñez
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA.,Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Catherine M Majestic
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Rebecca A Shelby
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Valarie C Worthy
- Duke Cancer Institute, Duke University School of Medicine, Durham, NC, USA
| | - Nadine J Barrett
- Duke Cancer Institute, Duke University School of Medicine, Durham, NC, USA.,Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, NC, USA
| | - Steven R Patierno
- Duke Cancer Institute, Duke University School of Medicine, Durham, NC, USA.,Department of Medicine, Duke University School of Medicine, Durham, NC, USA
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Bernardo BM, Zhang X, Beverly Hery CM, Meadows RJ, Paskett ED. The efficacy and cost-effectiveness of patient navigation programs across the cancer continuum: A systematic review. Cancer 2019; 125:2747-2761. [PMID: 31034604 DOI: 10.1002/cncr.32147] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 03/04/2019] [Accepted: 03/27/2019] [Indexed: 12/11/2022]
Abstract
Published studies regarding patient navigation (PN) and cancer were reviewed to assess quality, determine gaps, and identify avenues for future research. The PubMed and EMBASE databases were searched for studies investigating the efficacy and cost-effectiveness of PN across the cancer continuum. Each included article was scored independently by 2 separate reviewers with the Quality Assessment Tool for Quantitative Studies. The current review identified 113 published articles that assessed PN and cancer care, between August 1, 2010, and February 1, 2018, 14 of which reported on the cost-effectiveness of PN programs. Most publications focused on the effectiveness of PN in screening (50%) and diagnosis (27%) along the continuum of cancer care. Many described the effectiveness of PN for breast cancer (52%) or colorectal cancer outcomes (51%). Most studies reported favorable outcomes for PN programs, including increased uptake of and adherence to cancer screenings, timely diagnostic resolution and follow-up, higher completion rates for cancer therapy, and higher rates of attending medical appointments. Cost-effectiveness studies showed that PN programs yielded financial benefits. Quality assessment showed that 75 of the 113 included articles (65%) had 2 or more weak components. In conclusion, this review indicates numerous gaps within the PN and cancer literature where improvement is needed. For example, more research is needed at other points along the continuum of cancer care outside of screening and diagnosis. In addition, future research into the effectiveness of PN for understudied cancers outside of breast and colorectal cancer is necessary along with an assessment of cost-effectiveness and more rigorous reporting of study designs and results in published articles.
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Affiliation(s)
- Brittany M Bernardo
- Division of Population Sciences, Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio
| | - Xiaochen Zhang
- Division of Population Sciences, Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio
| | - Chloe M Beverly Hery
- Division of Population Sciences, Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio
| | - Rachel J Meadows
- Division of Population Sciences, Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio.,Division of Epidemiology, College of Public Health, Ohio State University, Columbus, Ohio
| | - Electra D Paskett
- Division of Population Sciences, Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio.,Division of Epidemiology, College of Public Health, Ohio State University, Columbus, Ohio.,Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio.,Division of Cancer Prevention and Control, Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, Ohio
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Warnecke RB, Campbell RT, Vijayasiri G, Barrett RE, Rauscher GH. Multilevel Examination of Health Disparity: The Role of Policy Implementation in Neighborhood Context, in Patient Resources, and in Healthcare Facilities on Later Stage of Breast Cancer Diagnosis. Cancer Epidemiol Biomarkers Prev 2018; 28:59-66. [PMID: 30352817 DOI: 10.1158/1055-9965.epi-17-0945] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 03/26/2018] [Accepted: 10/16/2018] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND There is a substantial racial/ethnic disparity in female breast cancer mortality in Chicago between non-Hispanic black (NHblack) and Hispanic patients compared with their non-Hispanic white (NHwhite) counterparts. This observation prompted a multilevel examination of factors that might account for the disparity, with the goal of identifying potential policy interventions that might meaningfully address it METHODS: In the Breast Cancer Care in Chicago study, 411 NHblack, 397 NHwhite, and 181 Hispanic patients diagnosed between the ages of 30 and 79 were interviewed, and medical records were abstracted for information on screening and diagnostic follow-up. We conducted a multilevel analysis to assess the role of neighborhood context, patient resources, facility characteristics, and mode of detection in determining the disparity in later stage at diagnosis. RESULTS After adjustment for neighborhood context, mode of detection, and facility accreditation/resources, there was no significant disparity in later stage breast cancer diagnosis between NHblack or Hispanic patients compared with NHwhite patients. CONCLUSIONS The results suggest that racial/ethnic differences in mode of detection and facility accreditation/resources account for most of the disparity in stage at diagnosis. Understanding the causes of differential screen detection and access to highly accredited facilities could inform interventions to meaningfully address this disparity. IMPACT Multilevel approaches to studying health disparities are becoming the research standard for understanding and addressing health disparities. Optimal design of multilevel interventions addressing disparities in later stage diagnosis would benefit from enhanced understanding of pathways to detection and diagnosis available to patients in medically underserved communities.
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Affiliation(s)
- Richard B Warnecke
- Institute for Health Research and Policy, University of Illinois at Chicago, Chicago, Illinois. .,UI Health Cancer Center, University of Illinois at Chicago, Chicago, Illinois.,Institute for Health Research and Policy, Winnetka, Illinois
| | - Richard T Campbell
- Institute for Health Research and Policy, University of Illinois at Chicago, Chicago, Illinois.,UI Health Cancer Center, University of Illinois at Chicago, Chicago, Illinois
| | - Ganga Vijayasiri
- Institute for Health Research and Policy, University of Illinois at Chicago, Chicago, Illinois
| | - Richard E Barrett
- Department of Sociology, University of Illinois at Chicago, Chicago, Illinois
| | - Garth H Rauscher
- UI Health Cancer Center, University of Illinois at Chicago, Chicago, Illinois.,Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, Illinois
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Hansen RN, Pham AT, Böing EA, Lovelace B, Wan GJ, Thomas DA, Fontes ML. Hospitalization costs and resource allocation in cholecystectomy with use of intravenous versus oral acetaminophen. Curr Med Res Opin 2018; 34:1549-1555. [PMID: 29192528 DOI: 10.1080/03007995.2017.1412301] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To evaluate intravenous (IV) acetaminophen (APAP) vs oral APAP use as adjunctive analgesics in cholecystectomy patients by comparing associated hospital length of stay (LOS), hospital costs, opioid use, and rates of nausea/vomiting, respiratory depression, and bowel obstruction. METHODS We conducted a retrospective analysis of the Premier Database (January 2012 to September 2015) including cholecystectomy patients who received either IV APAP or oral APAP. Differences in LOS, hospitalization costs, mean daily morphine equivalent dose (MED), and potential opioid-related adverse events were estimated. Multivariable logistic regression was performed for the binary outcomes and instrumental variable regressions, using the quarterly rate of IV APAP use for all hospitalizations by hospital as the instrument in two-stage least squares regressions for continuous outcomes. Models were adjusted for patient demographics, clinical risk factors, and hospital characteristics. RESULTS Among 61,017 cholecystectomy patients, 31,133 (51%) received IV APAP. Subjects averaged 51 and 57 years of age, respectively, in the IV and oral APAP cohorts. In the adjusted models, IV APAP was associated with 0.42 days shorter LOS (95% CI = -0.58 to -0.27; p < .0001), $1,045 lower hospitalization costs (95% CI = -$1,521 to -$569; p < .0001), 2 mg lower average daily MED (95% CI = -3 mg to -0.9 mg; p = .0005), and lower rates of respiratory depression (odds ratio [OR] = 0.89, 95% CI = 0.82-0.97; p = .006), and nausea and vomiting (OR = 0.86, 95% CI = 0.86-0.86; p < .0001). CONCLUSIONS In patients having cholecystectomy, the addition of IV APAP to perioperative pain management is associated with shorter LOS, lower costs, reduced opioid use, and less frequent nausea/vomiting and respiratory depression compared to oral APAP. These findings should be confirmed in a prospective study comparing IV and oral APAP.
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Affiliation(s)
- Ryan N Hansen
- a University of Washington , School of Pharmacy , Seattle , WA , USA
| | - An T Pham
- b University of California San Francisco , School of Pharmacy , San Francisco , CA , USA
| | - Elaine A Böing
- c Mallinckrodt Pharmaceuticals, Health Economics and Outcomes Research Department , Bedminster , NJ , USA
| | - Belinda Lovelace
- c Mallinckrodt Pharmaceuticals, Health Economics and Outcomes Research Department , Bedminster , NJ , USA
| | - George J Wan
- c Mallinckrodt Pharmaceuticals, Health Economics and Outcomes Research Department , Bedminster , NJ , USA
| | - Donna A Thomas
- d Yale University School of Medicine , New Haven , CT , USA
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Abstract
OBJECTIVE To estimate whether postpartum visit attendance was improved in women exposed to a postpartum patient navigation program compared with those who received care immediately before the program's initiation and to assess whether other postpartum health behaviors improved during the intervention period. METHODS This is a prospective observational study of women enrolled in a patient navigation program compared with women receiving care before the program. Navigating New Motherhood was a postpartum patient navigation program for adult, English-speaking women receiving prenatal care at a Medicaid-based university clinic. In 2015, Navigating New Motherhood introduced a clinic-level change in which a navigator was hired and assumed supportive and logistic responsibilities for enrolled patients between delivery and postpartum visit completion. We compared medical record data from women who enrolled in Navigating New Motherhood with those of women receiving care in the same clinic for 1 year immediately before Navigating New Motherhood. The primary outcome was postpartum visit attendance. Secondary outcomes included World Health Organization (WHO) Tier 1 or 2 contraception uptake and other health services measures. We conducted bivariable and multivariable analyses. RESULTS Of the 225 women approached for Navigating New Motherhood participation after program initiation, 96.9% (n=218) enrolled; these women were compared with 256 women in the historical cohort. Most women in both groups were racial or ethnic minorities and all had Medicaid insurance. There were no important differences in demographic, clinical, or health service characteristics between groups, although women in Navigating New Motherhood were more likely to transfer into the clinic for prenatal care and to deliver neonates admitted to the neonatal intensive care unit. The primary outcome, return for postpartum care, was more common among women in Navigating New Motherhood (88.1% compared with 70.3%, P<.001), a difference that persisted after adjustment for potential confounding factors (adjusted odds ratio [OR] 3.57, 95% confidence interval [CI] 2.11-6.04). Women in Navigating New Motherhood also were more likely to receive a WHO Tier 1 or 2 contraceptive method (adjusted OR 1.56, 95% CI 1.02-2.38), postpartum depression screening (adjusted OR 2.82, 95% CI 1.79-4.43), and influenza (adjusted OR 2.10, 95% CI 1.38-3.19) and human papillomavirus vaccination (adjusted OR 2.33, 95% CI 1.25-4.33). CONCLUSION Implementation of a postpartum navigation program was associated with improved retention in routine postpartum care and frequency of contraception uptake, depression screening, and vaccination.
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25
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Hansen RN, Pham AT, Lovelace B, Balaban S, Wan GJ. Comparative Analysis of Inpatient Costs for Obstetrics and Gynecology Surgery Patients Treated With IV Acetaminophen and IV Opioids Versus IV Opioid-only Analgesia for Postoperative Pain. Ann Pharmacother 2017; 51:834-839. [PMID: 28608722 DOI: 10.1177/1060028017715651] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Recovery from obstetrics and gynecology (OB/GYN) surgery, including hysterectomy and cesarean section delivery, aims to restore function while minimizing hospital length of stay (LOS) and medical expenditures. OBJECTIVE Our analyses compare OB/GYN surgery patients who received combination intravenous (IV) acetaminophen and IV opioid analgesia with those who received IV opioid-only analgesia and estimate differences in LOS, hospitalization costs, and opioid consumption. METHODS We performed a retrospective analysis of the Premier Database between January 2009 and June 2015, comparing OB/GYN surgery patients who received postoperative pain management with combination IV acetaminophen and IV opioids with those who received only IV opioids starting on the day of surgery and continuing up to the second postoperative day. We performed instrumental variable 2-stage least-squares regressions controlling for patient and hospital covariates to compare the LOS, hospitalization costs, and daily opioid doses (morphine equivalent dose) of IV acetaminophen recipients with that of opioid-only analgesia patients. RESULTS We identified 225 142 OB/GYN surgery patients who were eligible for our study of whom 89 568 (40%) had been managed with IV acetaminophen and opioids. Participants averaged 36 years of age and were predominantly non-Hispanic Caucasians (60%). Multivariable regression models estimated statistically significant differences in hospitalization cost and opioid use with IV acetaminophen associated with $484.4 lower total hospitalization costs (95% CI = -$760.4 to -$208.4; P = 0.0006) and 8.2 mg lower daily opioid use (95% CI = -10.0 to -6.4), whereas the difference in LOS was not significant, at -0.09 days (95% CI = -0.19 to 0.01; P = 0.07). CONCLUSION Compared with IV opioid-only analgesia, managing post-OB/GYN surgery pain with the addition of IV acetaminophen is associated with decreased hospitalization costs and reduced opioid use.
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Affiliation(s)
| | - An T Pham
- 2 Mallinckrodt Pharmaceuticals, Hampton, NJ, USA
| | | | | | - George J Wan
- 2 Mallinckrodt Pharmaceuticals, Hampton, NJ, USA
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Hansen RN, Pham A, Strassels SA, Balaban S, Wan GJ. Comparative Analysis of Length of Stay and Inpatient Costs for Orthopedic Surgery Patients Treated with IV Acetaminophen and IV Opioids vs. IV Opioids Alone for Post-Operative Pain. Adv Ther 2016; 33:1635-45. [PMID: 27423648 PMCID: PMC5020121 DOI: 10.1007/s12325-016-0368-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Indexed: 11/28/2022]
Abstract
Introduction Recovery from orthopedic surgery is oriented towards restoring functional health outcomes while reducing hospital length of stay (LOS) and medical expenditures. Optimal pain management is a key to reaching these objectives. We sought to compare orthopedic surgery patients who received combination intravenous (IV) acetaminophen and IV opioid analgesia to those who received IV opioids alone and compared the two groups on LOS and hospitalization costs. Methods We performed a retrospective analysis of the Premier Database (Premier, Inc.; between January 2009 and June 2015) comparing orthopedic surgery patients who received post-operative pain management with combination IV acetaminophen and IV opioids to those who received only IV opioids starting on the day of surgery and continuing up to the second post-operative day. The quarterly rate of IV acetaminophen use for all hospitalizations by hospital served as the instrumental variable in two-stage least squares regressions controlling for patient and hospital covariates to compare the LOS and hospitalization costs of IV acetaminophen recipients to opioid monotherapy patients. Results We identified 4,85,895 orthopedic surgery patients with 1,74,805 (36%) who had received IV acetaminophen. Study subjects averaged 64 years of age and were predominantly non-Hispanic Caucasians (78%) and female (58%). The mean unadjusted LOS for IV acetaminophen patients was 3.2 days [standard deviation (SD) 2.6] compared to 3.9 days (SD 3.9) with only IV opioids (P < 0.0001). Average unadjusted hospitalization costs were $19,024.9 (SD $13,113.7) for IV acetaminophen patients and $19,927.6 (SD $19,578.8) for IV opioid patients (P < 0.0001). These differences remained statistically significant in our instrumental variable models, with IV acetaminophen associated with 0.51 days shorter hospitalization [95% confidence interval (CI) −0.58 to −0.44, P < 0.0001] and $634.8 lower hospitalization costs (95% CI −$1032.5 to −$237.1, P = 0.0018). Conclusion Compared to opioids alone, managing post-orthopedic surgery pain with the addition of IV acetaminophen is associated with shorter LOS and decreased hospitalization costs. Funding Mallinckrodt Pharmaceuticals.
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Affiliation(s)
- Ryan N Hansen
- Pharmaceutical Outcomes Research and Policy Program, School of Pharmacy, University of Washington, Seattle, WA, USA.
| | - An Pham
- Mallinckrodt Pharmaceuticals, Hazelwood, MO, USA
| | | | | | - George J Wan
- Mallinckrodt Pharmaceuticals, Hazelwood, MO, USA
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27
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Fouad MN, Acemgil A, Bae S, Forero A, Lisovicz N, Martin MY, Oates GR, Partridge EE, Vickers SM. Patient Navigation As a Model to Increase Participation of African Americans in Cancer Clinical Trials. J Oncol Pract 2016; 12:556-63. [PMID: 27189356 PMCID: PMC4957258 DOI: 10.1200/jop.2015.008946] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Mona N Fouad
- University of Alabama at Birmingham, Birmingham, AL
| | - Aras Acemgil
- University of Alabama at Birmingham, Birmingham, AL
| | - Sejong Bae
- University of Alabama at Birmingham, Birmingham, AL
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Krok-Schoen JL, Oliveri JM, Paskett ED. Cancer Care Delivery and Women's Health: The Role of Patient Navigation. Front Oncol 2016; 6:2. [PMID: 26858934 PMCID: PMC4729879 DOI: 10.3389/fonc.2016.00002] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 01/03/2016] [Indexed: 01/09/2023] Open
Abstract
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.
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Affiliation(s)
| | - Jill M Oliveri
- Comprehensive Cancer Center, The Ohio State University , Columbus, OH , USA
| | - Electra D Paskett
- Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA; Division of Cancer Prevention and Control, Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, OH, USA; Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH, USA
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