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Cusumano VT, Myint A, Corona E, Yang L, Bocek J, Lopez AG, Huang MZ, Raja N, Dermenchyan A, Roh L, Han M, Croymans D, May FP. Patient Navigation After Positive Fecal Immunochemical Test Results Increases Diagnostic Colonoscopy and Highlights Multilevel Barriers to Follow-Up. Dig Dis Sci 2021; 66:3760-3768. [PMID: 33609211 DOI: 10.1007/s10620-021-06866-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 01/20/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND The fecal immunochemical test (FIT) is a common colorectal cancer screening modality in the USA but often is not followed by diagnostic colonoscopy. AIMS We investigated the efficacy of patient navigation to increase diagnostic colonoscopy after positive FIT results and determined persistent barriers to follow-up despite navigation in a large, academic healthcare system. METHODS The study cohort included all health system outpatients with an assigned primary care provider, a positive FIT result between 12/01/2016 and 06/01/2019, and no documentation of colonoscopy after positive FIT. Two non-clinical patient navigators engaged patients and providers to encourage follow-up, offer solutions to barriers, and assist with colonoscopy scheduling. The primary intervention endpoint was completion of colonoscopy within 6 months of navigation. We documented reasons for persistent barriers to colonoscopy despite navigation and determined predictors of successful follow-up after navigation. RESULTS There were 119 patients who received intervention. Of these, 37 (31.1%) patients completed colonoscopy at 6 months. In 41/119 (34.5%) cases, the PCP did not recommend colonoscopy, most commonly due to a normal colonoscopy prior to the positive FIT (19, 46.3%). There were 41/119 patients (34.5%) that declined colonoscopy despite the patient navigator and the PCP order. Male sex and younger age were significant predictors of follow-up (aOR = 2.91, 95%CI, 1.18-7.13; aOR = 0.92, 95%CI, 0.87-0.99). CONCLUSIONS After implementation of patient navigation, diagnostic colonoscopy was completed for 31.1% of patients with a positive FIT result. However, navigation also highlighted persistent multilevel barriers to follow-up. Future work will develop targeted solutions for these barriers to further increase FIT follow-up rates in our health system.
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Affiliation(s)
- Vivy T Cusumano
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 650 Charles Young Drive South, Room A2-125 CHS, Los Angeles, CA, 90095-6900, USA.,Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Anthony Myint
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 650 Charles Young Drive South, Room A2-125 CHS, Los Angeles, CA, 90095-6900, USA.,Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Edgar Corona
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 650 Charles Young Drive South, Room A2-125 CHS, Los Angeles, CA, 90095-6900, USA.,Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Liu Yang
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 650 Charles Young Drive South, Room A2-125 CHS, Los Angeles, CA, 90095-6900, USA.,Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Jennifer Bocek
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 650 Charles Young Drive South, Room A2-125 CHS, Los Angeles, CA, 90095-6900, USA.,Faculty Practice Group and Office of Population Health and Accountable Care, University of California Los Angeles, Los Angeles, CA, USA
| | - Antonio G Lopez
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 650 Charles Young Drive South, Room A2-125 CHS, Los Angeles, CA, 90095-6900, USA
| | - Marcela Zhou Huang
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 650 Charles Young Drive South, Room A2-125 CHS, Los Angeles, CA, 90095-6900, USA
| | - Naveen Raja
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 650 Charles Young Drive South, Room A2-125 CHS, Los Angeles, CA, 90095-6900, USA.,Faculty Practice Group and Office of Population Health and Accountable Care, University of California Los Angeles, Los Angeles, CA, USA
| | - Anna Dermenchyan
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 650 Charles Young Drive South, Room A2-125 CHS, Los Angeles, CA, 90095-6900, USA.,Quality Program, Department of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Lily Roh
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 650 Charles Young Drive South, Room A2-125 CHS, Los Angeles, CA, 90095-6900, USA.,Faculty Practice Group and Office of Population Health and Accountable Care, University of California Los Angeles, Los Angeles, CA, USA
| | - Maria Han
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 650 Charles Young Drive South, Room A2-125 CHS, Los Angeles, CA, 90095-6900, USA.,Quality Program, Department of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Daniel Croymans
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 650 Charles Young Drive South, Room A2-125 CHS, Los Angeles, CA, 90095-6900, USA.,Quality Program, Department of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Folasade P May
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 650 Charles Young Drive South, Room A2-125 CHS, Los Angeles, CA, 90095-6900, USA. .,Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA. .,Cancer Prevention Control Research, UCLA Kaiser Permanente Center for Health Equity, Jonsson Comprehensive Cancer Center, University of California, Los Angeles, CA, USA. .,Department of Medicine, Division of Gastroenterology, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
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2
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Guerra CE, Verderame E, Nicholson A, Wan L, Brooks AD. A Plan-Do-Study-Act Approach to the Development, Implementation and Evaluation of a Patient Navigation Program to Reduce Breast Cancer Screening Disparities in Un- and Under-Insured, Racially and Ethnically Diverse Urban Women. Front Public Health 2021; 9:595786. [PMID: 33681122 PMCID: PMC7933216 DOI: 10.3389/fpubh.2021.595786] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 01/26/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: For the over 28 million Americans without health insurance, there is a great need to develop programs that help meet the health needs of the uninsured population. Materials and Methods: We applied the Plan-Do-Study-Act (PDSA) quality improvement framework to the development, implementation, and evaluation of a breast cancer screening navigation program for un- and under-insured women. Results: Six critical steps emerged: (1) obtain program funding; (2) navigator training; (3) establish a referral base network of community partners that serve the un- and under-insured women; (4) implement a process to address the barriers to accessing mammography; (5) develop a language- and culturally-tailored messaging and media campaign; and (6) develop measures and process evaluation to optimize and expand the program's reach. Discussion: A Plan-Do-Study-Act approach allowed identification of the key elements for successful development, implementation and optimization of a breast cancer screening navigation program aimed at reaching and screening un- and underinsured women.
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Affiliation(s)
- Carmen E Guerra
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.,Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, United States.,Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA, United States
| | - Emily Verderame
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, United States
| | - Andrea Nicholson
- MD Anderson Cancer Center at Cooper, Cooper University Hospital, Camden, NJ, United States
| | - LiYea Wan
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, United States
| | - Ari D Brooks
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, United States.,Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
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3
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Implementing a multilevel intervention to accelerate colorectal cancer screening and follow-up in federally qualified health centers using a stepped wedge design: a study protocol. Implement Sci 2020; 15:96. [PMID: 33121536 PMCID: PMC7599111 DOI: 10.1186/s13012-020-01045-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 09/10/2020] [Indexed: 12/31/2022] Open
Abstract
Background Screening for colorectal cancer (CRC) not only detects disease early when treatment is more effective but also prevents cancer by finding and removing precancerous polyps. Because many of our nation’s most disadvantaged and vulnerable individuals obtain health care at federally qualified health centers, these centers play a significant role in increasing CRC screening among the most vulnerable populations. Furthermore, the full benefits of cancer screenings must include timely and appropriate follow-up of abnormal results. Thus, the purpose of this study is to implement a multilevel intervention to increase rates of CRC screening, follow-up, and referral-to-care in federally qualified health centers, as well as simultaneously to observe and to gather information on the implementation process to improve the adoption, implementation, and sustainment of the intervention. The multilevel intervention will target three different levels of influences: organization, provider, and individual. It will have multiple components, including provider and staff education, provider reminder, provider assessment and feedback, patient reminder, and patient navigation. Methods This study is a multilevel, three-phase, stepped wedge cluster randomized trial with four clusters of clinics from four different FQHC systems. In the first phase, there will be a 3-month waiting period during which no intervention components will be implemented. After the 3-month waiting period, we will randomize two clusters to cross from the control to the intervention and the remaining two clusters to follow 3 months later. All clusters will stay at the same phase for 9 months, followed by a 3-month transition period, and then cross over to the next phase. Discussion There is a pressing need to reduce disparities in CRC outcomes, especially among racial/ethnic minority populations and among populations who live in poverty. Single-level interventions are often insufficient to lead to sustainable changes. Multilevel interventions, which target two or more levels of changes, are needed to address multilevel contextual influences simultaneously. Multilevel interventions with multiple components will affect not only the desired outcomes but also each other. How to take advantage of multilevel interventions and how to implement such interventions and evaluate their effectiveness are the ultimate goals of this study. Trial registration This protocol is registered at clinicaltrials.gov (NCT04514341) on 14 August 2020.
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4
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Pace LE, Percac-Lima S, Nguyen KH, Crofton CN, Normandin KA, Singer SJ, Rosenthal MB, Chien AT. Comparing Diagnostic Evaluations for Rectal Bleeding and Breast Lumps in Primary Care: a Retrospective Cohort Study. J Gen Intern Med 2019; 34:1146-1153. [PMID: 31011969 PMCID: PMC6614558 DOI: 10.1007/s11606-019-05003-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 11/06/2018] [Accepted: 03/19/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Inadequate diagnostic evaluations of breast lumps and rectal bleeding in primary care are an important source of medical errors. Delays appear particularly common in evaluation of rectal bleeding. Comparing pursuit and completion of diagnostic testing for these two conditions within the same practice settings could help highlight barriers and inform interventions. OBJECTIVES To examine processes undertaken for diagnostic evaluations of breast lumps and rectal bleeding within the same practices and to compare them with regard to (a) the likelihood that diagnostic tests are ordered according to guidelines and (b) the timeliness of order placement and completion. DESIGN A retrospective cohort study using explicit chart abstraction methods. PARTICIPANTS Three hundred women aged 30-80 presenting with breast lumps and 300 men and women aged 40-80 years presenting with rectal bleeding to 15 academically affiliated primary care practices, 2012-2016. MAIN MEASURES Rates and timing of test ordering and completion and patterns of visits and communications. KEY RESULTS At initial presentation, physicians ordered recommended imaging or procedures at higher rates for patients with breast lumps compared to those with rectal bleeding (97% vs. 86% of patients recommended to receive imaging or endoscopy; p < 0.01). Most (90%) patients with breast lumps completed recommended diagnostic testing within 1 month, versus 31% of patients with rectal bleeding (p < 0.01). By 1 year, 7% of patients with breast lumps had not completed indicated imaging, versus 27% of those with rectal bleeding. Patients with breast lumps had fewer subsequent primary care visits related or unrelated to their symptom and had fewer related communications with specialists. LIMITATIONS The study relied on documented care, and findings may be most generalizable to academically affiliated institutions. CONCLUSIONS Diagnostic processes for rectal bleeding were less frequently guideline-concordant and timely than those for breast lumps. The largest discrepancies occurred in initial ordering of indicated tests and the timeliness of test completion.
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Affiliation(s)
- Lydia E Pace
- Harvard Medical School, Boston, MA, USA.
- Division of Women's Health, Brigham and Women's Hospital, OBC 3-34, 75 Francis Street, Boston, MA, 02115-9950, USA.
| | - Sanja Percac-Lima
- Harvard Medical School, Boston, MA, USA
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Kevin H Nguyen
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Charis N Crofton
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Katharine A Normandin
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Sara J Singer
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Stanford University School of Medicine and Graduate School of Business, Stanford, CA, USA
| | - Meredith B Rosenthal
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Alyna T Chien
- Harvard Medical School, Boston, MA, USA
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
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Lopez D, Pratt-Chapman ML, Rohan EA, Sheldon LK, Basen-Engquist K, Kline R, Shulman LN, Flores EJ. Establishing effective patient navigation programs in oncology. Support Care Cancer 2019; 27:1985-1996. [PMID: 30887125 PMCID: PMC8811719 DOI: 10.1007/s00520-019-04739-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 03/07/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE Recent advances in cancer treatment have resulted in greatly improved survival, and yet many patients in the USA have not benefited due to poor access to healthcare and difficulty accessing timely care across the cancer care continuum. Recognizing these issues and the need to facilitate discussions on how to improve navigation services for patients with cancer, the National Cancer Policy Forum of the National Academies of Sciences, Engineering, and Medicine (NASEM) held a workshop entitled, "Establishing Effective Patient Navigation Programs in Oncology. The purpose of this manuscript is to disseminate the conclusions of this workshop while providing a clinically relevant review of patient navigation in oncology. DESIGN Narrative literature review and summary of workshop discussions RESULTS: Patient navigation has been shown to be effective at improving outcomes throughout the spectrum of cancer care. Work remains to develop consensus on scope of practice and evaluation criteria and to align payment incentives and policy. CONCLUSION Patient navigation plays an essential role in overcoming patient- and system-level barriers to improve access to cancer care and outcomes for those most in need.
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Affiliation(s)
| | | | | | | | | | - Ron Kline
- Centers for Medicare & Medicaid Innovation, Baltimore, MD, USA
| | - Lawrence N Shulman
- University of Pennsylvania Abramson Cancer Center, Philadelphia, PA, USA
| | - Efren J Flores
- Massachusetts General Hospital, 55 Fruit St, Boston, MA, USA.
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Bernardo BM, Zhang X, Beverly Hery CM, Meadows RJ, Paskett ED. The efficacy and cost-effectiveness of patient navigation programs across the cancer continuum: A systematic review. Cancer 2019; 125:2747-2761. [PMID: 31034604 DOI: 10.1002/cncr.32147] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 03/04/2019] [Accepted: 03/27/2019] [Indexed: 12/11/2022]
Abstract
Published studies regarding patient navigation (PN) and cancer were reviewed to assess quality, determine gaps, and identify avenues for future research. The PubMed and EMBASE databases were searched for studies investigating the efficacy and cost-effectiveness of PN across the cancer continuum. Each included article was scored independently by 2 separate reviewers with the Quality Assessment Tool for Quantitative Studies. The current review identified 113 published articles that assessed PN and cancer care, between August 1, 2010, and February 1, 2018, 14 of which reported on the cost-effectiveness of PN programs. Most publications focused on the effectiveness of PN in screening (50%) and diagnosis (27%) along the continuum of cancer care. Many described the effectiveness of PN for breast cancer (52%) or colorectal cancer outcomes (51%). Most studies reported favorable outcomes for PN programs, including increased uptake of and adherence to cancer screenings, timely diagnostic resolution and follow-up, higher completion rates for cancer therapy, and higher rates of attending medical appointments. Cost-effectiveness studies showed that PN programs yielded financial benefits. Quality assessment showed that 75 of the 113 included articles (65%) had 2 or more weak components. In conclusion, this review indicates numerous gaps within the PN and cancer literature where improvement is needed. For example, more research is needed at other points along the continuum of cancer care outside of screening and diagnosis. In addition, future research into the effectiveness of PN for understudied cancers outside of breast and colorectal cancer is necessary along with an assessment of cost-effectiveness and more rigorous reporting of study designs and results in published articles.
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Affiliation(s)
- Brittany M Bernardo
- Division of Population Sciences, Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio
| | - Xiaochen Zhang
- Division of Population Sciences, Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio
| | - Chloe M Beverly Hery
- Division of Population Sciences, Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio
| | - Rachel J Meadows
- Division of Population Sciences, Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio.,Division of Epidemiology, College of Public Health, Ohio State University, Columbus, Ohio
| | - Electra D Paskett
- Division of Population Sciences, Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio.,Division of Epidemiology, College of Public Health, Ohio State University, Columbus, Ohio.,Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio.,Division of Cancer Prevention and Control, Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, Ohio
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7
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Dougherty MK, Brenner AT, Crockett SD, Gupta S, Wheeler SB, Coker-Schwimmer M, Cubillos L, Malo T, Reuland DS. Evaluation of Interventions Intended to Increase Colorectal Cancer Screening Rates in the United States: A Systematic Review and Meta-analysis. JAMA Intern Med 2018; 178:1645-1658. [PMID: 30326005 PMCID: PMC6583619 DOI: 10.1001/jamainternmed.2018.4637] [Citation(s) in RCA: 206] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Colorectal cancer screening (CRC) is recommended by all major US medical organizations but remains underused. OBJECTIVE To identify interventions associated with increasing CRC screening rates and their effect sizes. DATA SOURCES PubMed, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, and ClinicalTrials.gov were searched from January 1, 1996, to August 31, 2017. Key search terms included colorectal cancer and screening. STUDY SELECTION Randomized clinical trials of US-based interventions in clinical settings designed to improve CRC screening test completion in average-risk adults. DATA EXTRACTION AND SYNTHESIS At least 2 investigators independently extracted data and appraised each study's risk of bias. Where sufficient data were available, random-effects meta-analysis was used to obtain either a pooled risk ratio (RR) or risk difference (RD) for screening completion for each type of intervention. MAIN OUTCOMES AND MEASURES The main outcome was completion of CRC screening. Examination included interventions to increase completion of (1) initial CRC screening by any recommended modality, (2) colonoscopy after an abnormal initial screening test result, and (3) continued rounds of annual fecal blood tests (FBTs). RESULTS The main review included 73 randomized clinical trials comprising 366 766 patients at low or medium risk of bias. Interventions that were associated with increased CRC screening completion rates compared with usual care included FBT outreach (RR, 2.26; 95% CI, 1.81-2.81; RD, 22%; 95% CI, 17%-27%), patient navigation (RR, 2.01; 95% CI, 1.64-2.46; RD, 18%; 95% CI, 13%-23%), patient education (RR, 1.20; 95% CI, 1.06-1.36; RD, 4%; 95% CI, 1%-6%), patient reminders (RR, 1.20; 95% CI, 1.02-1.41; RD, 3%; 95% CI, 0%-5%), clinician interventions of academic detailing (RD, 10%; 95% CI, 3%-17%), and clinician reminders (RD, 13%; 95% CI, 8%-19%). Combinations of interventions (clinician interventions or navigation added to FBT outreach) were associated with greater increases than single components (RR, 1.18; 95% CI, 1.09-1.29; RD, 7%; 95% CI, 3%-11%). Repeated mailed FBTs with navigation were associated with increased annual FBT completion (RR, 2.09; 95% CI, 1.91-2.29; RD, 39%; 95% CI, 29%-49%). Patient navigation was not associated with colonoscopy completion after an initial abnormal screening test result (RR, 1.21; 95% CI, 0.92-1.60; RD, 14%; 95% CI, 0%-29%). CONCLUSIONS AND RELEVANCE Fecal blood test outreach and patient navigation, particularly in the context of multicomponent interventions, were associated with increased CRC screening rates in US trials. Fecal blood test outreach should be incorporated into population-based screening programs. More research is needed on interventions to increase adherence to continued FBTs, follow-up of abnormal initial screening test results, and cost-effectiveness and other implementation barriers for more intensive interventions, such as navigation.
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Affiliation(s)
- Michael K Dougherty
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina at Chapel Hill
| | - Alison T Brenner
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill
| | - Seth D Crockett
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina at Chapel Hill
| | - Shivani Gupta
- Division of Gastroenterology and Hepatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Stephanie B Wheeler
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill.,Department of Health Policy and Management, University of North Carolina at Chapel Hill
| | - Manny Coker-Schwimmer
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Laura Cubillos
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill
| | - Teri Malo
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill
| | - Daniel S Reuland
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill.,Division of General Medicine and Clinical Epidemiology, Department of Medicine, University of North Carolina at Chapel Hill
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Bush ML, Kaufman MR, Shackleford T. Adherence in the Cancer Care Setting: a Systematic Review of Patient Navigation to Traverse Barriers. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2018; 33:1222-1229. [PMID: 28567667 PMCID: PMC5711635 DOI: 10.1007/s13187-017-1235-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Patient navigation is an evidence-based intervention involving trained healthcare workers who assist patients in assessing and mitigating personal and environmental factors to promote healthy behaviors. The purpose of this research is to systematically assess the efficacy of patient navigation and similar programs to improve diagnosis and treatment of diseases affecting medically underserved populations. A systematic review was performed by searching PubMed, MEDLINE, PsychINFO, and CINAHL to identify potential studies. Eligible studies were those containing original peer-reviewed research reports in English on patient navigation, community health workers, vulnerable and underserved populations, and healthcare disparity. Specific outcomes regarding patient navigator including the effect of the intervention on definitive diagnosis and effect on initiation of treatment were extracted from each study. The search produced 1428 articles, and 16 were included for review. All studies involved patient navigation in the field of oncology in underserved populations. Timing of initial contact with a patient navigator after diagnostic or screening testing is correlated to the effectiveness of the navigator intervention. The majority of the studies reported significantly shorter time intervals to diagnosis and to treatment with patient navigation. Patient navigation expedites oncologic diagnosis and treatment of patients in underserved populations. This intervention is more efficacious when utilized shortly after screening or diagnostic testing.
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Affiliation(s)
- Matthew L Bush
- Department of Otolaryngology-Head and Neck Surgery, University of Kentucky Medical Center, 800 Rose St, Rm C-236, Lexington, KY, 40536, USA.
| | - Michael R Kaufman
- Department of Otolaryngology-Head and Neck Surgery, University of Kentucky Medical Center, 800 Rose St, Rm C-236, Lexington, KY, 40536, USA
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9
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Sprecher E, Conroy K, Chan J, Lakin PR, Cox J. Utilization of Patient Navigators in an Urban Academic Pediatric Primary Care Practice. Clin Pediatr (Phila) 2018; 57:1154-1160. [PMID: 29451008 DOI: 10.1177/0009922818759318] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Navigating health care systems can be a challenge for families. A retrospective descriptive cohort analysis was conducted assessing referrals to patient navigators (PNs) in one urban academic pediatric primary care practice. PNs tracked referral processes and a subset of PN referrals was assessed for markers of successful referrals. The most common reasons for referral were assistance overcoming barriers to care (46%), developmental concerns (38%), and adherence/care coordination concerns (14%). Significant predictors of referral were younger age, medical complexity, public insurance, male sex, and higher rates of no-show to visits in primary or subspecialist care. The majority of referrals were resolved. The referrals for process-oriented needs were significantly more successful than those for other concerns. PNs were more effective for discrete process tasks than for those that required behavior change by patients or families. Future directions include analysis of cost effectiveness of the PN program and analysis of parent and primary care provider experience.
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Affiliation(s)
- Eli Sprecher
- 1 Boston Children's Hospital, Boston, MA, USA.,2 Harvard Medical School, Boston, MA, USA
| | - Kathleen Conroy
- 1 Boston Children's Hospital, Boston, MA, USA.,2 Harvard Medical School, Boston, MA, USA
| | - Jenny Chan
- 1 Boston Children's Hospital, Boston, MA, USA
| | | | - Joanne Cox
- 1 Boston Children's Hospital, Boston, MA, USA.,2 Harvard Medical School, Boston, MA, USA
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10
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Lee SC, Higashi RT, Sanders JM, Zhu H, Inrig SJ, Mejias C, Argenbright KE, Tiro JA. Effects of program scale-up on time to resolution for patients with abnormal screening mammography results. Cancer Causes Control 2018; 29:995-1005. [PMID: 30140972 DOI: 10.1007/s10552-018-1074-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 08/17/2018] [Indexed: 01/07/2023]
Abstract
PURPOSE Effects of geographic program expansion to rural areas on screening program outcomes are understudied. We sought to determine whether time-to-resolution (TTR) varied significantly by service delivery time period, location, and participant characteristics across 19 North Texas counties. METHODS We calculated proportions undergoing diagnostic follow-up and resolved ≤ 60 days. We calculated median TTR for each time period and abnormal result BI-RADS 0, 4, 5. Cox proportional hazards regressions estimated time period and patient characteristic effects on TTR. Wilcoxon rank sum tests evaluated whether TTR differed between women who did or did not transfer between counties for services. RESULTS TTR ranged from 14 to 17 days for BI-RADs 0, 4, and 5; 12.4% transferred to a different county, resulting in longer median TTR (26 vs. 16 days; p < .001). Of those completing follow-up, 92% were resolved ≤ 60 days (median 15 days). For BI-RAD 3, TTR was 208 days (including required 180 day waiting period). Follow-up was significantly lower for women with BI-RAD 3 (59% vs. 96%; p < .0001). CONCLUSION Expansion maintained timely service delivery, increasing access to screening among rural, uninsured women. Policies adding a separate quality metric for BI-RAD 3 could encourage follow-up monitoring to address lower completion and longer TTR among women with this result.
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Affiliation(s)
- Simon Craddock Lee
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9066, USA.
- Harold C. Simmons Comprehensive Cancer Center, 2201 Inwood Drive, Dallas, TX, 75390, USA.
| | - Robin T Higashi
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9066, USA
| | - Joanne M Sanders
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9066, USA
| | - Hong Zhu
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9066, USA
- Harold C. Simmons Comprehensive Cancer Center, 2201 Inwood Drive, Dallas, TX, 75390, USA
| | - Stephen J Inrig
- Mount St. Mary's University, 10 Chester Place, Los Angeles, CA, 90007, USA
| | - Caroline Mejias
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9066, USA
| | - Keith E Argenbright
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9066, USA
- Harold C. Simmons Comprehensive Cancer Center, 2201 Inwood Drive, Dallas, TX, 75390, USA
- Moncrief Cancer Institute, 400 W. Magnolia Ave, Fort Worth, TX, 76104, USA
| | - Jasmin A Tiro
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9066, USA
- Harold C. Simmons Comprehensive Cancer Center, 2201 Inwood Drive, Dallas, TX, 75390, USA
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11
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Sunny A, Rustveld L. The Role of Patient Navigation on Colorectal Cancer Screening Completion and Education: a Review of the Literature. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2018; 33:251-259. [PMID: 27878766 DOI: 10.1007/s13187-016-1140-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Although the general assumption is that patient navigation helps patients adhere to CRC screening recommendations, concrete evidence for its effectiveness is still currently under investigation. The present literature review was conducted to explore effectiveness of patient navigation and education on colorectal cancer (CRC) screening completion in medically underserved populations. Data collection included PubMed, Google Scholar, and Cochrane reviews searches. Study inclusion criteria included randomized controlled trials and prospective investigations that included an intervention and control group. Case series, brief communications, commentaries, case reports, and uncontrolled studies were excluded. Twenty-seven of the 36 studies screened for relevance were selected for inclusion. Most studies explored the utility of lay and clinic-based patient navigation. Others implemented interventions that included tailored messaging, and culturally and linguistically appropriate outreach and education efforts to meet CRC screening needs of medically underserved individuals. More recent studies have begun to conduct cost-effectiveness analyses of patient navigation programs that impacted CRC screening and completion. Peer-reviewed publications consistently indicate a positive impact of patient navigation programs on CRC screening completion, as well have provided preliminary evidence for their cost-effectiveness.
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Affiliation(s)
- Ajeesh Sunny
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Luis Rustveld
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA.
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12
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Broder-Fingert S, Walls M, Augustyn M, Beidas R, Mandell D, Wiltsey-Stirman S, Silverstein M, Feinberg E. A hybrid type I randomized effectiveness-implementation trial of patient navigation to improve access to services for children with autism spectrum disorder. BMC Psychiatry 2018; 18:79. [PMID: 29587698 PMCID: PMC5870193 DOI: 10.1186/s12888-018-1661-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 03/12/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Significant racial, ethnic, and socioeconomic disparities exist in access to evidence-based treatment services for children with autism spectrum disorder (ASD). Patient Navigation (PN) is a theory-based care management strategy designed to reduce disparities in access to care. The purpose of this study is to test the effectiveness of PN a strategy to reduce disparities in access to evidence-based services for vulnerable children with ASD, as well as to explore factors that impact implementation. METHODS This study uses a hybrid type I randomized effectiveness/implementation design to test effectiveness and collect data on implementation concurrently. It is a two-arm comparative effectiveness trial with a target of 125 participants per arm. Participants are families of children age 15-27 months who receive a positive screen for ASD at a primary care visit at urban clinics in Massachusetts (n = 6 clinics), Connecticut (n = 1), and Pennsylvania (n = 2). The trial measures diagnostic interval (number of days from positive screen to diagnostic determination) and time to receipt of evidence-based ASD services/recommended services (number of days from date of diagnosis to receipt of services) in those with PN compared to and activated control -Conventional Care Management - which is similar to care management received in a high quality medical home. At the same time, a mixed-method implementation evaluation is being carried out. DISCUSSION This study will examine the effectiveness of PN to reduce the time to and receipt of evidence-based services for vulnerable children with ASD, as well as factors that influence implementation. Findings will tell us both if PN is an effective approach for improving access to evidence-based care for children with ASD, and inform future strategies for dissemination. TRIAL REGISTRATION NCT02359084 Registered February 1, 2015.
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Affiliation(s)
- Sarabeth Broder-Fingert
- Department of Pediatrics, Boston University School of Medicine, Boston, MA, 02114, USA. .,Division of General Pediatrics, Boston University School of Medicine, 850 Harrison Ave, Room 310A, Boston, MA, 02118, USA.
| | - Morgan Walls
- 0000 0004 0367 5222grid.475010.7Department of Pediatrics, Boston University School of Medicine, Boston, MA 02114 USA
| | - Marilyn Augustyn
- 0000 0004 0367 5222grid.475010.7Division of Developmental and Behavioral Pediatrics, Boston University School of Medicine, Boston, MA 02114 USA
| | - Rinad Beidas
- 0000 0004 1936 8972grid.25879.31Center for Mental Health Policy and Services Research, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104 USA
| | - David Mandell
- 0000 0004 1936 8972grid.25879.31Center for Mental Health Policy and Services Research, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104 USA
| | | | - Michael Silverstein
- 0000 0004 0367 5222grid.475010.7Department of Pediatrics, Boston University School of Medicine, Boston, MA 02114 USA
| | - Emily Feinberg
- 0000 0004 0367 5222grid.475010.7Department of Pediatrics, Boston University School of Medicine, Boston, MA 02114 USA ,0000 0004 1936 7558grid.189504.1Department of Community Health Sciences, Boston University School of Public Health, Boston, MA 02114 USA
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13
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Affiliation(s)
- Ruofei Du
- Biostatistics Shared Resource, University of New Mexico Comprehensive Cancer Center, Albuquerque, New Mexico, USA
- University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Ji-Hyun Lee
- Biostatistics Shared Resource, University of New Mexico Comprehensive Cancer Center, Albuquerque, New Mexico, USA
- University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
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14
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Effects of patient navigation on satisfaction with cancer care: a systematic review and meta-analysis. Support Care Cancer 2018; 26:1369-1382. [PMID: 29497815 DOI: 10.1007/s00520-018-4108-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 02/11/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE Patient navigation (PN) is a model of healthcare coordination designed to reduce barriers to achieving optimal health outcomes. Systematic reviews evaluating whether PN is associated with higher patient satisfaction with cancer care are lacking. METHODS We conducted a systematic review to synthesize evidence of comparative studies evaluating the effectiveness of PN programs to improve satisfaction with cancer-related care. We included studies reported in English that: (1) evaluated a PN intervention designed to increase satisfaction with cancer care; and (2) involved a randomized controlled trial (RCT) or non-RCT approach. Standardized forms were used to abstract data from studies. These data were evaluated for methodological quality, summarized qualitatively, and synthesized under a random effects model. RESULTS The initial search yielded 831 citations. Nine met inclusion criteria. Five had adequate data (1 RCT and 4 non-RCTs) to include in the meta-analysis. Methodological quality of included studies ranged from weak to strong, with half rated as weak. Findings of the RCTs showed a statistically significant increase in satisfaction with cancer care involving PN (standardized mean difference (SMD) = 2.30; 95% confidence interval 1.79, 2.80, p < 0.001). Pooled results from non-RCTs showed no significant association between PN and satisfaction with cancer-related care (standardized mean difference = 0.39; 95% confidence interval - 0.02, 0.80, p = 0.06). CONCLUSIONS Although PN has been widely implemented to improve cancer care, high-quality studies are needed to characterize the relationship between PN and satisfaction with cancer-related care.
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McBrien KA, Ivers N, Barnieh L, Bailey JJ, Lorenzetti DL, Nicholas D, Tonelli M, Hemmelgarn B, Lewanczuk R, Edwards A, Braun T, Manns B. Patient navigators for people with chronic disease: A systematic review. PLoS One 2018; 13:e0191980. [PMID: 29462179 PMCID: PMC5819768 DOI: 10.1371/journal.pone.0191980] [Citation(s) in RCA: 155] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 01/14/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND People with chronic diseases experience barriers to managing their diseases and accessing available health services. Patient navigator programs are increasingly being used to help people with chronic diseases navigate and access health services. OBJECTIVE The objective of this review was to summarize the evidence for patient navigator programs in people with a broad range of chronic diseases, compared to usual care. METHODS We searched MEDLINE, EMBASE, CENTRAL, CINAHL, PsycINFO, and Social Work Abstracts from inception to August 23, 2017. We also searched the reference lists of included articles. We included original reports of randomized controlled trials of patient navigator programs compared to usual care for adult and pediatric patients with any one of a defined set of chronic diseases. RESULTS From a total of 14,672 abstracts, 67 unique studies fit our inclusion criteria. Of these, 44 were in cancer, 8 in diabetes, 7 in HIV/AIDS, 4 in cardiovascular disease, 2 in chronic kidney disease, 1 in dementia and 1 in patients with more than one condition. Program characteristics varied considerably. Primary outcomes were most commonly process measures, and 45 of 67 studies reported a statistically significant improvement in the primary outcome. CONCLUSION Our findings indicate that patient navigator programs improve processes of care, although few studies assessed patient experience, clinical outcomes or costs. The inability to definitively outline successful components remains a key uncertainty in the use of patient navigator programs across chronic diseases. Given the increasing popularity of patient navigators, future studies should use a consistent definition for patient navigation and determine which elements of this intervention are most likely to lead to improved outcomes. TRIAL REGISTRATION PROSPERO #CRD42013005857.
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Affiliation(s)
- Kerry A. McBrien
- Departments of Family Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Noah Ivers
- Department of Family and Community Medicine, Women’s College Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Lianne Barnieh
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jacob J. Bailey
- W21C Research and Innovation Centre, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Diane L. Lorenzetti
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - David Nicholas
- Faculty of Social Work, University of Calgary, Calgary, Alberta, Canada
| | - Marcello Tonelli
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Brenda Hemmelgarn
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Richard Lewanczuk
- Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, Alberta, Canada
| | - Alun Edwards
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ted Braun
- Department of Family Medicine, Alberta Health Services, Calgary, Alberta, Canada
| | - Braden Manns
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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Selby K, Baumgartner C, Levin TR, Doubeni CA, Zauber AG, Schottinger J, Jensen CD, Lee JK, Corley DA. Interventions to Improve Follow-up of Positive Results on Fecal Blood Tests: A Systematic Review. Ann Intern Med 2017; 167:565-575. [PMID: 29049756 PMCID: PMC6178946 DOI: 10.7326/m17-1361] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Fecal immunochemical testing is the most commonly used method for colorectal cancer screening worldwide. However, its effectiveness is frequently undermined by failure to obtain follow-up colonoscopy after positive test results. PURPOSE To evaluate interventions to improve rates of follow-up colonoscopy for adults after a positive result on a fecal test (guaiac or immunochemical). DATA SOURCES English-language studies from the Cochrane Central Register of Controlled Trials, PubMed, and Embase from database inception through June 2017. STUDY SELECTION Randomized and nonrandomized studies reporting an intervention for colonoscopy follow-up of asymptomatic adults with positive fecal test results. DATA EXTRACTION Two reviewers independently extracted data and ranked study quality; 2 rated overall strength of evidence for each category of study type. DATA SYNTHESIS Twenty-three studies were eligible for analysis, including 7 randomized and 16 nonrandomized studies. Three were at low risk of bias. Eleven studies described patient-level interventions (changes to invitation, provision of results or follow-up appointments, and patient navigators), 5 provider-level interventions (reminders or performance data), and 7 system-level interventions (automated referral, precolonoscopy telephone calls, patient registries, and quality improvement efforts). Moderate evidence supported patient navigators and provider reminders or performance data. Evidence for system-level interventions was low. Seventeen studies reported the proportion of test-positive patients who completed colonoscopy compared with a control population, with absolute differences of -7.4 percentage points (95% CI, -19 to 4.3 percentage points) to 25 percentage points (CI, 14 to 35 percentage points). LIMITATION More than half of studies were at high or very high risk of bias; heterogeneous study designs and characteristics precluded meta-analysis. CONCLUSION Patient navigators and giving providers reminders or performance data may help improve colonoscopy rates of asymptomatic adults with positive fecal blood test results. Current evidence about useful system-level interventions is scant and insufficient. PRIMARY FUNDING SOURCE National Cancer Institute. (PROSPERO: CRD42016048286).
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Affiliation(s)
- Kevin Selby
- From Kaiser Permanente Division of Research, Oakland, California; University of Lausanne, Lausanne, Switzerland; University of California at San Francisco, San Francisco, California; Bern University Hospital, Bern, Switzerland; Kaiser Permanente Medical Center, Walnut Creek, California; University of Pennsylvania, Philadelphia, Pennsylvania; Memorial Sloan Kettering Cancer Center, New York, New York; and Kaiser Permanente, Pasadena, California
| | - Christine Baumgartner
- From Kaiser Permanente Division of Research, Oakland, California; University of Lausanne, Lausanne, Switzerland; University of California at San Francisco, San Francisco, California; Bern University Hospital, Bern, Switzerland; Kaiser Permanente Medical Center, Walnut Creek, California; University of Pennsylvania, Philadelphia, Pennsylvania; Memorial Sloan Kettering Cancer Center, New York, New York; and Kaiser Permanente, Pasadena, California
| | - Theodore R Levin
- From Kaiser Permanente Division of Research, Oakland, California; University of Lausanne, Lausanne, Switzerland; University of California at San Francisco, San Francisco, California; Bern University Hospital, Bern, Switzerland; Kaiser Permanente Medical Center, Walnut Creek, California; University of Pennsylvania, Philadelphia, Pennsylvania; Memorial Sloan Kettering Cancer Center, New York, New York; and Kaiser Permanente, Pasadena, California
| | - Chyke A Doubeni
- From Kaiser Permanente Division of Research, Oakland, California; University of Lausanne, Lausanne, Switzerland; University of California at San Francisco, San Francisco, California; Bern University Hospital, Bern, Switzerland; Kaiser Permanente Medical Center, Walnut Creek, California; University of Pennsylvania, Philadelphia, Pennsylvania; Memorial Sloan Kettering Cancer Center, New York, New York; and Kaiser Permanente, Pasadena, California
| | - Ann G Zauber
- From Kaiser Permanente Division of Research, Oakland, California; University of Lausanne, Lausanne, Switzerland; University of California at San Francisco, San Francisco, California; Bern University Hospital, Bern, Switzerland; Kaiser Permanente Medical Center, Walnut Creek, California; University of Pennsylvania, Philadelphia, Pennsylvania; Memorial Sloan Kettering Cancer Center, New York, New York; and Kaiser Permanente, Pasadena, California
| | - Joanne Schottinger
- From Kaiser Permanente Division of Research, Oakland, California; University of Lausanne, Lausanne, Switzerland; University of California at San Francisco, San Francisco, California; Bern University Hospital, Bern, Switzerland; Kaiser Permanente Medical Center, Walnut Creek, California; University of Pennsylvania, Philadelphia, Pennsylvania; Memorial Sloan Kettering Cancer Center, New York, New York; and Kaiser Permanente, Pasadena, California
| | - Christopher D Jensen
- From Kaiser Permanente Division of Research, Oakland, California; University of Lausanne, Lausanne, Switzerland; University of California at San Francisco, San Francisco, California; Bern University Hospital, Bern, Switzerland; Kaiser Permanente Medical Center, Walnut Creek, California; University of Pennsylvania, Philadelphia, Pennsylvania; Memorial Sloan Kettering Cancer Center, New York, New York; and Kaiser Permanente, Pasadena, California
| | - Jeffrey K Lee
- From Kaiser Permanente Division of Research, Oakland, California; University of Lausanne, Lausanne, Switzerland; University of California at San Francisco, San Francisco, California; Bern University Hospital, Bern, Switzerland; Kaiser Permanente Medical Center, Walnut Creek, California; University of Pennsylvania, Philadelphia, Pennsylvania; Memorial Sloan Kettering Cancer Center, New York, New York; and Kaiser Permanente, Pasadena, California
| | - Douglas A Corley
- From Kaiser Permanente Division of Research, Oakland, California; University of Lausanne, Lausanne, Switzerland; University of California at San Francisco, San Francisco, California; Bern University Hospital, Bern, Switzerland; Kaiser Permanente Medical Center, Walnut Creek, California; University of Pennsylvania, Philadelphia, Pennsylvania; Memorial Sloan Kettering Cancer Center, New York, New York; and Kaiser Permanente, Pasadena, California
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Bush ML, Taylor ZR, Noblitt B, Shackleford T, Gal TJ, Shinn JB, Creel LM, Lester C, Westgate PM, Jacobs JA, Studts CR. Promotion of early pediatric hearing detection through patient navigation: A randomized controlled clinical trial. Laryngoscope 2017; 127 Suppl 7:S1-S13. [PMID: 28940335 DOI: 10.1002/lary.26822] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 06/26/2017] [Accepted: 06/30/2017] [Indexed: 12/31/2022]
Abstract
OBJECTIVES/HYPOTHESIS To assess the efficacy of a patient navigator intervention to decrease nonadherence to obtain audiological testing following failed screening, compared to those receiving the standard of care. METHODS Using a randomized controlled design, guardian-infant dyads, in which the infants had abnormal newborn hearing screening, were recruited within the first week after birth. All participants were referred for definitive audiological diagnostic testing. Dyads were randomized into a patient navigator study arm or standard of care arm. The primary outcome was the percentage of patients with follow-up nonadherence to obtain diagnostic testing. Secondary outcomes were parental knowledge of infant hearing testing recommendations and barriers in obtaining follow-up testing. RESULTS Sixty-one dyads were enrolled in the study (patient navigator arm = 27, standard of care arm = 34). The percentage of participants nonadherent to diagnostic follow-up during the first 6 months after birth was significantly lower in the patient navigator arm compared with the standard of care arm (7.4% vs. 38.2%) (P = .005). The timing of initial follow-up was significantly lower in the navigator arm compared with the standard of care arm (67.9 days after birth vs. 105.9 days, P = .010). Patient navigation increased baseline knowledge regarding infant hearing loss diagnosis recommendations compared with the standard of care (P = .004). CONCLUSIONS Patient navigation decreases nonadherence rates following abnormal infant hearing screening and improves knowledge of follow-up recommendations. This intervention has the potential to improve the timeliness of delivery of infant hearing healthcare; future research is needed to assess the cost and feasibility of larger scale implementation. LEVEL OF EVIDENCE 1b. Laryngoscope, 127:S1-S13, 2017.
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Affiliation(s)
- Matthew L Bush
- Department of Otolaryngology-Head and Neck Surgery, University of Kentucky, Lexington, Kentucky
| | - Zachary R Taylor
- Department of Otolaryngology-Head and Neck Surgery, University of Kentucky, Lexington, Kentucky
| | - Bryce Noblitt
- Department of Otolaryngology-Head and Neck Surgery, University of Kentucky, Lexington, Kentucky
| | | | - Thomas J Gal
- Department of Otolaryngology-Head and Neck Surgery, University of Kentucky, Lexington, Kentucky
| | - Jennifer B Shinn
- Department of Otolaryngology-Head and Neck Surgery, University of Kentucky, Lexington, Kentucky
| | - Liza M Creel
- Department of Health Management and Systems Sciences, University of Louisville School of Public Health and Information Sciences, Louisville, Kentucky
| | - Cathy Lester
- Cabinet for Health and Family Services, Commission for Children with Special Health Care Needs, Louisville, Kentucky
| | - Philip M Westgate
- Department of Biostatistics, University of Kentucky College of Public Health, Lexington, Kentucky
| | - Julie A Jacobs
- Department of Health, Behavior and Society, University of Kentucky College of Public Health, Lexington, Kentucky, U.S.A
| | - Christina R Studts
- Department of Health, Behavior and Society, University of Kentucky College of Public Health, Lexington, Kentucky, U.S.A
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18
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Rice K, Gressard L, DeGroff A, Gersten J, Robie J, Leadbetter S, Glover-Kudon R, Butterly L. Increasing colonoscopy screening in disparate populations: Results from an evaluation of patient navigation in the New Hampshire Colorectal Cancer Screening Program. Cancer 2017; 123:3356-3366. [PMID: 28464213 DOI: 10.1002/cncr.30761] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 04/05/2017] [Accepted: 04/12/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND To investigate uniformly successful results from a statewide program of patient navigation (PN) for colonoscopy, this comparison study evaluated the effectiveness of the PN intervention by comparing outcomes for navigated versus non-navigated patients in one of the community health clinics included in the statewide program. Outcomes measured included screening completion, adequacy of bowel preparation, missed appointments and cancellations, communication of test results, and consistency of follow-up recommendations with clinical guidelines. METHODS The authors compared a subset of 131 patients who were navigated to a screening or surveillance colonoscopy with a similar subset of 75 non-navigated patients at one endoscopy clinic. The prevalence and prevalence odds ratios were computed to measure the association between PN and each study outcome measure. RESULTS Patients in the PN intervention group were 11.2 times more likely to complete colonoscopy than control patients (96.2% vs 69.3%; P<.001), and were 5.9 times more likely to have adequate bowel preparation (P =.010). In addition, intervention patients had no missed appointments compared with 15.6% of control patients, and were 24.8 times more likely to not have a cancellation <24 hours before their appointment (P<.001). All navigated patients and their primary care providers received test results, and all follow-up recommendations were consistent with clinical guidelines compared with 82.4% of patients in the control group (P<.001). CONCLUSIONS PN appears to be effective for improving colonoscopy screening completion and quality in the disparate populations most in need of intervention. To the best of our knowledge, the results of the current study demonstrate some of the strongest evidence for the effectiveness of PN to date, and highlight its value for public health. Cancer 2017;123:3356-66. © 2017 American Cancer Society.
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Affiliation(s)
- Ketra Rice
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lindsay Gressard
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Amy DeGroff
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Joanne Gersten
- New Hampshire Colorectal Cancer Screening Program, Mary Hitchcock Memorial Hospital, Lebanon, New Hampshire
| | - Janene Robie
- New Hampshire Colorectal Cancer Screening Program, Mary Hitchcock Memorial Hospital, Lebanon, New Hampshire
| | - Steven Leadbetter
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Rebecca Glover-Kudon
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lynn Butterly
- New Hampshire Colorectal Cancer Screening Program, Mary Hitchcock Memorial Hospital, Lebanon, New Hampshire.,Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
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Ali-Faisal SF, Colella TJF, Medina-Jaudes N, Benz Scott L. The effectiveness of patient navigation to improve healthcare utilization outcomes: A meta-analysis of randomized controlled trials. PATIENT EDUCATION AND COUNSELING 2017; 100:436-448. [PMID: 27771161 DOI: 10.1016/j.pec.2016.10.014] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 09/09/2016] [Accepted: 10/14/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To determine the effects of patient navigation (PN) on healthcare utilization outcomes using meta-analysis and the quality of evidence. METHODS Medical and social science databases were searched for randomized controlled trials published in English between 1989 and May 2015. The review process was guided by PRISMA. Included studies were assessed for quality using the Downs and Black tool. Data were extracted to assess the effect of navigation on: health screening rates, diagnostic resolution, cancer care follow-up treatment adherence, and attendance of care events. Random-effects models were used to compute risk ratios and I2 statistics determined the impact of heterogeneity. RESULTS Of 3985 articles screened, 25 articles met inclusion criteria. Compared to usual care, patients who received PN were significantly more likely to access health screening (OR 2.48, 95% CI, 1.93-3.18, P<0.00001) and attend a recommended care event (OR 2.55, 95% CI, 1.27-5.10, P<0.01). PN was favoured to increase adherence to cancer care follow-up treatment and obtain diagnoses. Most studies involved trained lay navigators (n=12) compared to health professionals (n=9). CONCLUSION PN is effective to increase screening rates and complete care events. PRACTICE IMPLICATIONS PN is an effective intervention for use in healthcare.
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Affiliation(s)
- Sobia F Ali-Faisal
- Program in Public Health, Stony Brook Medicine, Stony Brook University, Stony Brook, USA.
| | - Tracey J F Colella
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada; University Health Network/Toronto Rehabilitation Cardiovascular Prevention & Rehabilitation Program, Toronto, Canada.
| | - Naomi Medina-Jaudes
- Program in Public Health, Stony Brook Medicine, Stony Brook University, Stony Brook, USA.
| | - Lisa Benz Scott
- Program in Public Health, Stony Brook Medicine, Stony Brook University, Stony Brook, USA; The School of Health Technology & Management, Stony Brook University, Stony Brook, USA.
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McDonald J, McKinlay E, Keeling S, Levack W. The ‘wayfinding’ experience of family carers who learn to manage technical health procedures at home: a grounded theory study. Scand J Caring Sci 2017; 31:850-858. [DOI: 10.1111/scs.12406] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 10/06/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Janet McDonald
- Department of Primary Health Care and General Practice; University of Otago; Wellington New Zealand
| | - Eileen McKinlay
- Department of Primary Health Care and General Practice; University of Otago; Wellington New Zealand
| | - Sally Keeling
- Department of Medicine; University of Otago; Christchurch New Zealand
| | - William Levack
- Rehabilitation Teaching and Research Unit; Department of Medicine; University of Otago; Wellington New Zealand
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Shi Y, Lee JH. Sample size calculations for group randomized trials with unequal group sizes through Monte Carlo simulations. Stat Methods Med Res 2016; 27:2569-2580. [PMID: 30103663 DOI: 10.1177/0962280216682775] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Group randomized trial design is common in cancer prevention and health promotion research with intervention development. Several methods have been developed to handle the design and analytical issues for group randomized trial including the intraclass correlation coefficient. The widely used methods for the sample size calculation for the group randomized trial assume equal sizes across groups. In practice this assumption often fails and group randomized trial studies suffer from considerably lower statistical power than as planned. A few studies have developed sample size calculation methods for unequal group sizes, but most of them are limited to continuous outcomes. In this study, we develop a method for sample size calculation for group randomized trial studies with unequal group sizes based on Monte Carlo simulation in the mixed effect model framework. This approach incorporates the variation of group sizes and can be applied to group randomized trials with different types of outcomes. Further, it is easy to implement and can be applied to most commonly used group randomized trial designs such as pre-and-post cross-sectional and cohort study designs. We demonstrate the application of the proposed approach to two-arm group randomized trial studies with continuous and binary outcomes through simulations and analysis of a real group randomized trial dataset.
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Affiliation(s)
- Yang Shi
- 1 Biostatistics Shared Resource, University of New Mexico Comprehensive Cancer Center, NM, USA
| | - Ji-Hyun Lee
- 1 Biostatistics Shared Resource, University of New Mexico Comprehensive Cancer Center, NM, USA.,2 Department of Internal Medicine, School of Medicine, University of New Mexico, Albuquerque, NM, USA
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22
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Patient Navigation in a Colorectal Cancer Screening Program. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2016; 21:433-40. [PMID: 25140407 DOI: 10.1097/phh.0000000000000132] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
CONTEXT Colorectal cancer (CRC) is the second leading cause of cancer death among cancers affecting both men and women in the United States. The Centers for Disease Control and Prevention's Colorectal Cancer Control Program (CRCCP) supports both direct clinical screening services (screening provision) and activities to promote screening at the population level (screening promotion). OBJECTIVE The purpose of this study was to characterize patient navigation (PN) programs for screening provision and promotion for the first 1 to 2 years of program funding. PARTICIPANTS We conducted a cross-sectional survey of the 29 CRCCP grantees (25 states and 4 tribal organizations) and 14 in-depth interviews to assess program implementation. MAIN OUTCOME MEASURES The survey and interview guide collected information on CRC screening provision and promotion activities and PN, including the structure of the PN program, characteristics of the navigators, funding mechanism, and navigators' activities. RESULTS Twenty-four of 28 CRCCP grantees of the survey used PN for screening provision whereas 18 grantees used navigation for screening promotion. Navigators were often trained in nursing or public health. Navigation activities were similar for both screening provision and promotion, and common tasks included assessing and responding to patient barriers to screening, providing patient education, and scheduling appointments. For screening provision, activities centered on making reminder calls, educating patients on bowel preparation for colonoscopies, and tracking patients for completion of the tests. Navigation may influence screening quality by improving patients' bowel preparation for colonoscopies. CONCLUSIONS Our study provides insights into PN across a federally funded CRC program. Results suggest that PN activities may be instrumental in recruiting people into cancer screening and ensuring completed screening and follow-up.
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23
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Shokar NK, Byrd T, Salaiz R, Flores S, Chaparro M, Calderon-Mora J, Reininger B, Dwivedi A. Against colorectal cancer in our neighborhoods (ACCION): A comprehensive community-wide colorectal cancer screening intervention for the uninsured in a predominantly Hispanic community. Prev Med 2016; 91:273-280. [PMID: 27575314 DOI: 10.1016/j.ypmed.2016.08.039] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 06/17/2016] [Accepted: 08/25/2016] [Indexed: 12/14/2022]
Abstract
Colorectal cancer (CRC) is the second leading cause of cancer deaths in the USA. Screening is widely recommended but underutilized, particularly among the low income, the uninsured, recent immigrants and Hispanics. The study objective was to determine the effectiveness of a comprehensive community-wide, bilingual, CRC screening intervention among uninsured predominantly Hispanic individuals. This prospective study was embedded in a CRC screening program and utilized a quasi-experimental design. Recruitment occurred from Community and clinic sites. Inclusion criteria were aged 50-75years, uninsured, due for CRC screening, Texas address and exclusions were a history of CRC, or recent rectal bleeding. Eligible subjects were randomized to either promotora (P), video (V), or combined promotora and video (PV) education, and also received no-cost screening with fecal immunochemical testing or colonoscopy and navigation. The non-randomly allocated controls recruited from a similar county, received no intervention. The main outcome was 6month self-reported CRC screening. Per protocol and worst case scenario analyses, and logistic regression with covariate adjustment were performed. 784 subjects (467 in intervention group, 317 controls) were recruited; mean age was 56.8years; 78.4% were female, 98.7% were Hispanic and 90.0% were born in Mexico. In the worst case scenario analysis (n=784) screening uptake was 80.5% in the intervention group and 17.0% in the control group [relative risk 4.73, 95% CI: 3.69-6.05, P<0.001]. No educational group differences were observed. Covariate adjustment did not significantly alter the effect. A multicomponent community-wide, bilingual, CRC screening intervention significantly increased CRC screening in an uninsured predominantly Hispanic population.
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Affiliation(s)
- Navkiran K Shokar
- Department of Family and Community Medicine and Biomedical Sciences, Texas Tech University Health Sciences Center-El Paso, 9849 Kenworthy Street, El Paso, TX 79924, United States.
| | - Theresa Byrd
- Department of Public Health, Texas Tech University Health Sciences Center, 3601 4th Street STOP 9430, Lubbock, TX 79430-9430, United States.
| | - Rebekah Salaiz
- Department of Family and Community Medicine and Biomedical Sciences, Texas Tech University Health Sciences Center-El Paso, 9849 Kenworthy Street, El Paso, TX 79924, United States.
| | - Silvia Flores
- Department of Family and Community Medicine and Biomedical Sciences, Texas Tech University Health Sciences Center-El Paso, 9849 Kenworthy Street, El Paso, TX 79924, United States.
| | - Maria Chaparro
- Department of Family and Community Medicine and Biomedical Sciences, Texas Tech University Health Sciences Center-El Paso, 9849 Kenworthy Street, El Paso, TX 79924, United States.
| | - Jessica Calderon-Mora
- Texas Tech University Health Sciences Center, Paul L. Foster School of Medicine, Office of Diversity Affairs, 5001 El Paso Drive, El Paso, TX 79905, United States
| | - Belinda Reininger
- Department of Health Promotion and Behavioral Sciences, University of Texas School of Public Health, Regional Brownsville Campus, 80 Fort Brown, Brownsville, TX 78520, United States.
| | - Alok Dwivedi
- Department of Biomedical Sciences, Texas Tech University Health Sciences Center, 5001 El Paso Drive, El Paso, TX 79905, United States
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24
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Whitley EM, Raich PC, Dudley DJ, Freund KM, Paskett ED, Patierno SR, Simon M, Warren-Mears V, Snyder FR. Relation of comorbidities and patient navigation with the time to diagnostic resolution after abnormal cancer screening. Cancer 2016; 123:312-318. [PMID: 27648520 DOI: 10.1002/cncr.30316] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 07/20/2016] [Accepted: 08/08/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Whether patient navigation improves outcomes for patients with comorbidities is unknown. The aims of this study were to determine the effect of comorbidities on the time to diagnostic resolution after an abnormal cancer screening test and to examine whether patient navigation improves the timeliness and likelihood of diagnostic resolution for patients with comorbidities in comparison with no navigation. METHODS A secondary analysis of comorbidity data collected by Patient Navigation Research Program sites using the Charlson Comorbidity Index (CCI) was conducted. The participants were 6,349 patients with abnormal breast, cervical, colon, or prostate cancer screening tests between 2007 and 2011. The intervention was patient navigation or usual care. The CCI data were highly skewed across projects and cancer sites, and the CCI scores were categorized as 0 (CCI score of 0 or no comorbidities identified; 76% of cases); 1 (CCI score of 1; 16% of cases), or 2 (CCI score ≥ 2; 8% of cases). Separate adjusted hazard ratios for each site and cancer type were obtained, and then they were pooled with a meta-analysis random effects methodology. RESULTS Patients with a CCI score ≥ 2 had delayed diagnostic resolution after an abnormal cancer screening test in comparison with those with no comorbidities. Patient navigation reduced delays in diagnostic resolution, with the greatest benefits seen for those with a CCI score ≥ 2. CONCLUSIONS Persons with a CCI score ≥ 2 experienced significant delays in timely diagnostic care in comparison with patients without comorbidities. Patient navigation was effective in reducing delays in diagnostic resolution among those with CCI scores > 1. Cancer 2017;123:312-318. © 2016 American Cancer Society.
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Affiliation(s)
- Elizabeth M Whitley
- Prevention Services Division, Colorado Department of Public Health and Environment, Denver, Colorado
| | - Peter C Raich
- Denver Health, Denver, Colorado.,University of Colorado Denver, Aurora, Colorado
| | - Donald J Dudley
- Cancer Therapy and Research Center, University of Texas Health Science Center, San Antonio, Texas.,University of Virginia, Charlottesville, Virginia
| | - Karen M Freund
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts
| | - Electra D Paskett
- Division of Cancer Prevention and Control, Department of Internal Medicine, Ohio State University, Columbus, Ohio.,Division of Epidemiology, Ohio State University, Columbus, Ohio.,Comprehensive Cancer Center, Ohio State University, Columbus, Ohio
| | - Steven R Patierno
- George Washington Cancer Institute, Washington, DC.,Duke Cancer Institute, Durham, North Carolina
| | - Melissa Simon
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois
| | - Victoria Warren-Mears
- Northwest Portland Area Indian Health Board, Northwest Tribal Epidemiology Center, Portland, Oregon
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25
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Oppong BA, Dash C, Coleman T, Torres T, Adams-Campbell LL. Time to Diagnostic Evaluation After Mammographic Screening in an Urban Setting. J Womens Health (Larchmt) 2016; 25:1225-1230. [PMID: 27182625 DOI: 10.1089/jwh.2015.5661] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The Capital Breast Care Center (CBCC), a screening facility established to serve minority women, developed a culturally sensitive patient care paradigm that would address concerns of adherence to follow-up of abnormal results after initial mammogram. Women with abnormal mammograms are assigned a Black or Latina navigator who facilitates the additional workup needed by scheduling follow-up, arranging transportation, providing counsel/emotional support, and even accompanying them to diagnostic imaging or biopsy appointment. We present data on follow-up rates after breast cancer screening. METHODS All patients seen at CBCC are entered into a prospectively collected database. We calculated intervals (in days) between the screening and diagnostic visits. Descriptive statistics and median time to follow-up are reported. Differences between Black and Hispanic women on time interval were tested by t-test. RESULTS From January 2010 to December 2012, 4605 digital screening mammograms were performed. Fifty-two percent of the women self-identified as Black, 41% as Hispanic, 4% White, 2% Asian, and 1% as "other." Of the screening studies, 451 (9.8%) required additional workup, out of which 362 (80%) of the women returned for the recommended diagnostic imaging. The median interval between screening and diagnostic imaging was 39 days (range: 6-400). Of the 162 women recommended to have a core needle biopsy, 81.5% underwent biopsy within a median of 21 days (range: 0-221 days). CONCLUSION At the CBCC, time to patient follow-up after initial mammographic screening is within the CDC-recommended performance standard of less than 60 days. For a population that historically has low rates of clinical follow-up, we attribute this reduction in delays to breast cancer diagnostic resolution to a culturally sensitive patient navigation program. Additional studies are needed to assess how the existing navigation program can be individualized/tailored to target the remaining 20% of women who did not adhere to the recommended workup.
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Affiliation(s)
- Bridget A Oppong
- 1 Breast Division, Department of Surgery, MedStar Georgetown University Hospital , Washington, District of Columbia.,2 Georgetown University Lombardi Comprehensive Cancer Center , Washington, District of Columbia
| | - Chiranjeev Dash
- 2 Georgetown University Lombardi Comprehensive Cancer Center , Washington, District of Columbia
| | - Tesha Coleman
- 3 Capital Breast Care Center, Georgetown Lombardi Comprehensive Cancer Center , Washington, District of Columbia
| | - Tanya Torres
- 3 Capital Breast Care Center, Georgetown Lombardi Comprehensive Cancer Center , Washington, District of Columbia
| | - Lucile L Adams-Campbell
- 2 Georgetown University Lombardi Comprehensive Cancer Center , Washington, District of Columbia
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26
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de la Riva EE, Hajjar N, Tom LS, Phillips S, Dong X, Simon MA. Providers' Views on a Community-Wide Patient Navigation Program: Implications for Dissemination and Future Implementation. Health Promot Pract 2016; 17:382-90. [PMID: 27009130 PMCID: PMC5600160 DOI: 10.1177/1524839916628865] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The DuPage Patient Navigation Collaborative (DPNC) adapted and scaled the Patient Navigation Research Program's intervention model to navigate uninsured suburban DuPage County women with an abnormal breast or cervical cancer screening result. Recent findings reveal the effectiveness of the DPNC in addressing patient risk factors for delayed follow-up, but gaps remain as patient measures may not adequately capture navigator impact. Using semistructured interviews with 19 DPNC providers (representing the county health department, clinics, advocacy organizations, and academic partners), this study explores the critical roles of the DPNC in strengthening community partnerships and enhancing clinical services. Findings from these provider interviews revealed that a wide range of resources existed within DuPage but were often underused. Providers indicated that the DPNC was instrumental in fostering community partnerships and that navigators enhanced the referral processes, communications, and service delivery among clinical teams. Providers also recommended expanding navigation to mental health, women's health, and for a variety of chronic conditions. Considering that many in the United States have recently gained access to the health care system, clinical teams might benefit by incorporating navigators who serve a dual working purpose embedded in the community and clinics to enhance the service delivery for vulnerable populations.
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Affiliation(s)
| | | | - Laura S Tom
- Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
| | - Sara Phillips
- Northwestern University-Feinberg School of Medicine, Chicago, IL, USA
| | - XinQi Dong
- Rush University Medical Center, Chicago, IL, USA
| | - Melissa A Simon
- Northwestern University-Feinberg School of Medicine, Chicago, IL, USA Robert H. Lurie Comprehensive Cancer Center, Chicago, IL, USA
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27
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Wells KJ, Winters PC, Jean-Pierre P, Warren-Mears V, Post D, Van Duyn MAS, Fiscella K, Darnell J, Freund KM. Effect of patient navigation on satisfaction with cancer-related care. Support Care Cancer 2016; 24:1729-53. [PMID: 26438146 PMCID: PMC4767607 DOI: 10.1007/s00520-015-2946-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 09/14/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Despite growing popularity of patient navigation (PN) as a means to improve cancer care quality and reduce cancer-related disparities, there are few well-designed controlled trials assessing the impact of PN on patient outcomes like satisfaction with care. The present controlled study examined effect of PN on satisfaction with cancer-related care. METHODS Patients who presented with a symptom or abnormal screening test (n = 1788) or definitive diagnosis (n = 445) of breast, cervical, colorectal, or prostate cancer from eight Patient Navigator Research Program sites were included in one of two groups: intervention (PN) or comparison (usual care or usual care plus cancer educational materials). Trained patient navigators met with intervention group participants to help them assess and identify resources to address barriers to cancer diagnostic or treatment care. Using a validated instrument, we assessed participants' satisfaction with their cancer diagnostic or treatment care up to 3 months after diagnostic resolution of a cancer-related abnormality or within 3 months of initiation of cancer treatment. RESULTS Overall, patients reported high satisfaction with diagnostic care and cancer treatment. There were no statistically significant differences between PN and control groups in satisfaction with cancer-related care (p > 0.05). Hispanic and African American participants were less likely to report high satisfaction with cancer care when compared to White patients. Middle-aged participants with higher education, higher household income, private insurance, owning their own home, working full-time, and those whose primary language is English had higher satisfaction with cancer-related diagnostic care. CONCLUSIONS PN had no statistically significant effect on patients' satisfaction with cancer-related care. Further research is needed to define the patient populations who might benefit from PN, content of PN that is most useful, and services that might enhance PN. TRIAL REGISTRATIONS clinicaltrials.gov identifiers: NCT00613275 , NCT00496678 , NCT00375024 , NCT01569672.
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Affiliation(s)
- Kristen J Wells
- Department of Psychology, San Diego State University and University of California, San Diego Moores Cancer Center, 6363 Alvarado Court, Suite 103, San Diego, CA, 92120-1863, USA.
| | - Paul C Winters
- Family Medicine Research Programs, University of Rochester Medical Center, 1381 South Avenue, Rochester, NY, 14620, USA
| | - Pascal Jean-Pierre
- Department of Psychology, University of Notre Dame, 109 Haggar Hall, Notre Dame, IN, 46556, USA
| | - Victoria Warren-Mears
- Northwest Portland Area Indian Health Board, 2121 SW Broadway Suite 300, Portland, OR, 97201, USA
| | - Douglas Post
- Ohio State University, 1590 North High Street, Suite 525, Columbus, OH, 43201, USA
| | - Mary Ann S Van Duyn
- National Institutes of Health, National Cancer Institute, 9609 Medical Center Drive, Room 6W118, Bethesda, MD, 20892, USA
| | - Kevin Fiscella
- Family Medicine Research Programs, University of Rochester Medical Center, 1381 South Avenue, Rochester, NY, 14620, USA
| | - Julie Darnell
- Division of Health Policy & Administration, School of Public Health, University of Illinois at Chicago, 1603 W. Taylor Street, Room 758, Chicago, IL, 60612, USA
| | - Karen M Freund
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Tufts University School of Medicine, 800 Washington Street #63, Boston, MA, 02111, USA
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28
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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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29
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Ustjanauskas AE, Bredice M, Nuhaily S, Kath L, Wells KJ. Training in Patient Navigation: A Review of the Research Literature. Health Promot Pract 2015; 17:373-81. [PMID: 26656600 DOI: 10.1177/1524839915616362] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Despite the proliferation of patient navigation programs designed to increase timely receipt of health care, little is known about the content and delivery of patient navigation training, or best practices in this arena. The current study begins to address these gaps in understanding, as it is the first study to comprehensively review descriptions of patient navigation training in the peer-reviewed research literature. Seventy-five patient navigation efficacy studies published since 1995, identified through PubMed and by the authors, were included in this narrative review. Fifty-nine of the included studies (79%) mentioned patient navigation training, and 55 of these studies additionally provided a description of training. Most studies did not thoroughly document patient navigation training practices. Additionally, several topics integral to the role of patient navigators, as well as components of training central to successful adult learning, were not commonly described in the research literature. Descriptions of training also varied widely across studies in terms of duration, location, format, learning strategies employed, occupation of trainer, and content. These findings demonstrate the need for established standards of navigator training as well as for future research on the optimal delivery and content of patient navigation training.
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Affiliation(s)
- Amy E Ustjanauskas
- University of California, San Diego Moores Cancer Center, San Diego, CA, USA San Diego State University/University of California, San Diego Joint Doctoral Program in Clinical Psychology, San Diego, CA, USA
| | | | | | - Lisa Kath
- San Diego State University, San Diego, CA, USA
| | - Kristen J Wells
- University of California, San Diego Moores Cancer Center, San Diego, CA, USA San Diego State University/University of California, San Diego Joint Doctoral Program in Clinical Psychology, San Diego, CA, USA San Diego State University, San Diego, CA, USA
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30
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Dissemination of patient navigation programs across the United States. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2015; 20:E15-24. [PMID: 24858322 DOI: 10.1097/phh.0b013e3182a505ec] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To use diffusion and dissemination frameworks to describe how indicators of economic and health care disparity affect the location and type of patient navigation programs. METHODS A cross-sectional national Web-based survey conducted during 2009-2010 with support from 65 separate national and regional stakeholder organizations. PARTICIPANTS A total of 1116 self-identified patient navigators across the United States. MAIN OUTCOME MEASURE The location and characteristics of patient navigation programs according to economic and health care disparity indicators. RESULTS Patient navigation programs appear to be geographically dispersed across the United States. Program differences were observed in navigator type, population served, and setting by poverty level. Programs in high-poverty versus low-poverty areas were more likely to use lay navigators (P < .001) and to be located in community health centers and agencies with religious affiliations (50.6 vs 36.4%, and 21.5% vs 16.7%. respectively; P ≤ 0.01). CONCLUSION(S) Results suggest that navigation programs have spread beyond initial target inception areas and also serve as a potentially important resource in communities with higher levels of poverty and/or relatively low access to care. In addition, while nurse navigators have emerged as a significant component of the patient navigation workforce, lay health navigators serve a vital role in underserved communities. Other factors from dissemination frameworks may influence the spread of navigation and provide useful insights to support the dissemination of programs to areas of high need.
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31
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Ramachandran A, Snyder FR, Katz ML, Darnell JS, Dudley DJ, Patierno SR, Sanders MR, Valverde PA, Simon MA, Warren-Mears V, Battaglia TA. Barriers to health care contribute to delays in follow-up among women with abnormal cancer screening: Data from the Patient Navigation Research Program. Cancer 2015; 121:4016-24. [PMID: 26385420 DOI: 10.1002/cncr.29607] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Revised: 06/18/2015] [Accepted: 06/22/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND There is limited understanding of the association between barriers to care and clinical outcomes within patient navigation programs. METHODS Secondary analyses of data from the intervention arms of the Patient Navigation Research Program were performed, which included navigated participants with abnormal breast and cervical cancer screening tests from 2007 to 2010. Independent variables were: 1) the number of unique barriers to care (0, 1, 2, or ≥3) documented during patient navigation encounters; and 2) the presence of socio-legal barriers originating from social policy (yes/no). The median time to diagnostic resolution of index screening abnormalities was estimated using Kaplan-Meier cumulative incidence curves. Multivariable Cox proportional hazards regression examined the impact of barriers on time to resolution, controlling for sociodemographics and stratifying by study center. RESULTS Among 2600 breast screening participants, approximately 75% had barriers to care documented (25% had 1 barrier, 16% had 2 barriers, and 34% had ≥3 barriers). Among 1387 cervical screening participants, greater than one-half had barriers documented (31% had 1 barrier, 11% had 2 barriers, and 13% had ≥3 barriers). Among breast screening participants, the presence of barriers was associated with less timely resolution for any number of barriers compared with no barriers. Among cervical screening participants, only the presence of ≥2 barriers was found to be associated with less timely resolution. Both types of barriers, socio-legal and other barriers, were found to be associated with delay among breast and cervical screening participants. CONCLUSIONS Navigated women with barriers resolved cancer screening abnormalities at a slower rate compared with navigated women with no barriers. Further innovations in navigation care are necessary to maximize the impact of patient navigation programs nationwide.
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Affiliation(s)
- Ambili Ramachandran
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | | | - Mira L Katz
- College of Public Health, The Ohio State University, Columbus, Ohio
| | - Julie S Darnell
- School of Public Health, University of Illinois at Chicago, Chicago, Illinois
| | - Donald J Dudley
- Department of Obstetrics and Gynecology, University of Virginia, Charlottesville, Virginia
| | - Steven R Patierno
- Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina
| | - Mechelle R Sanders
- Department of Family Medicine, University of Rochester, Rochester, New York
| | - Patricia A Valverde
- Colorado School of Public Health, University of Colorado at Denver, Denver, Colorado
| | - Melissa A Simon
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Victoria Warren-Mears
- Northwest Portland Area Indian Health Board, Northwest Tribal Epidemiology Center, Portland, Oregon
| | - Tracy A Battaglia
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
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Shokar NK, Byrd T, Lairson DR, Salaiz R, Kim J, Calderon-Mora J, Nguyen N, Ortiz M. Against Colorectal Cancer in Our Neighborhoods, a Community-Based Colorectal Cancer Screening Program Targeting Low-Income Hispanics. Health Promot Pract 2015; 16:656-66. [DOI: 10.1177/1524839915587265] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background. Colorectal cancer is the second leading cause of cancer-related death in the United States. Despite universal screening recommendations, screening rates in the United States remain suboptimal, especially among the poor, the uninsured, recent immigrants, and Hispanics. This article describes the development of a large community-based colorectal cancer screening program designed to address these disparities. Method. The Against Colorectal Cancer in our Neighborhoods program is a bilingual, evidence-based, theory-guided, multicomponent community screening intervention, targeting the uninsured and developed using a systematic planning process. It combines community health worker–led outreach, bilingual and culturally tailored community education, and no-cost screening with provision of the fecal immunochemical test or colonoscopy and navigation services. A detailed process and outcome evaluation is planned. Program development cost calculated prospectively (in 2011 dollars) using a societal perspective and micro-costing methods was $243,278, of which $180,344 was direct cost. Discussion. The detailed description of the development processes and costs of this health promotion program targeting low-income Hispanics will inform health program decision makers about the resource requirements for planning and developing new programs to reduce disease burden in communities.
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Affiliation(s)
| | - Theresa Byrd
- Texas Tech University Health Sciences Center, El Paso, TX, USA
| | | | - Rebekah Salaiz
- Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Junghyun Kim
- University of Texas Health Science Center at Houston, TX, USA
| | | | | | - Melchor Ortiz
- Texas Tech University Health Sciences Center, El Paso, TX, USA
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33
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Simon MA, Tom LS, Nonzee NJ, Murphy KR, Endress R, Dong X, Feinglass J. Evaluating a bilingual patient navigation program for uninsured women with abnormal screening tests for breast and cervical cancer: implications for future navigator research. Am J Public Health 2015; 105:e87-94. [PMID: 25713942 DOI: 10.2105/ajph.2014.302341] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES The DuPage Patient Navigation Collaborative evaluated the Patient Navigation Research Program (PNRP) model for uninsured women receiving free breast or cervical cancer screening through the Illinois Breast and Cervical Cancer Program in DuPage County, Illinois. METHODS We used medical records review and patient surveys of 477 women to compare median follow-up times with external Illinois Breast and Cervical Cancer Program and Chicago PNRP benchmarks of performance. We examined the extent to which we mitigated community-defined timeliness risk factors for delayed follow-up, with a focus on Spanish-speaking participants. RESULTS Median follow-up time (29.0 days for breast and 56.5 days for cervical screening abnormalities) compared favorably to external benchmarks. Spanish-speaking patients had lower health literacy, lower patient activation, and more health care system distrust than did English-speaking patients, but despite the prevalence of timeliness risk factors, we observed no differences in likelihood of delayed (> 60 days) follow-up by language. CONCLUSIONS Our successful replication and scaling of the PNRP navigation model to DuPage County illustrates a promising approach for future navigator research.
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Affiliation(s)
- Melissa A Simon
- Melissa A. Simon is with the Departments of Obstetrics and Gynecology and Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, and the Robert H. Lurie Comprehensive Cancer Center, Chicago. Laura S. Tom and Narissa J. Nonzee are with the Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University. Kara R. Murphy and Richard Endress are with Access DuPage, Wheaton, IL. XinQi Dong is with the Institute for Healthy Aging, Rush University Medical Center, Chicago. Joe Feinglass is with the Departments of General Internal Medicine and Geriatrics and Preventive Medicine, Feinberg School of Medicine, Northwestern University
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Percac-Lima S, Cronin PR, Ryan DP, Chabner BA, Daly EA, Kimball AB. Patient navigation based on predictive modeling decreases no-show rates in cancer care. Cancer 2015; 121:1662-70. [PMID: 25585595 DOI: 10.1002/cncr.29236] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 11/21/2014] [Indexed: 12/26/2022]
Abstract
BACKGROUND Patient adherence to appointments is key to improving outcomes in health care. "No-show" appointments contribute to suboptimal resource use. Patient navigation and telephone reminders have been shown to improve cancer care and adherence, particularly in disadvantaged populations, but may not be cost-effective if not targeted at the appropriate patients. METHODS In 5 clinics within a large academic cancer center, patients who were considered to be likely (the top 20th percentile) to miss a scheduled appointment without contacting the clinic ahead of time ("no-shows") were identified using a predictive model and then randomized to an intervention versus a usual-care group. The intervention group received telephone calls from a bilingual patient navigator 7 days before and 1 day before the appointment. RESULTS Over a 5-month period, of the 40,075 appointments scheduled, 4425 patient appointments were deemed to be at high risk of a "no-show" event. After the patient navigation intervention, the no-show rate in the intervention group was 10.2% (167 of 1631), compared with 17.5% in the control group (280 of 1603) (P<.001). Reaching a patient or family member was associated with a significantly lower no-show rate (5.9% and 3.0%, respectively; P<.001 and .006, respectively) compared with leaving a message (14.7%: P = .117) or no contact (no-show rate, 21.6%: P = .857). CONCLUSIONS Telephone navigation targeted at those patients predicted to be at high risk of visit nonadherence was found to effectively and substantially improve patient adherence to cancer clinic appointments. Further studies are needed to determine the long-term impact on patient outcomes, but short-term gains in the optimization of resources can be recognized immediately.
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Affiliation(s)
- Sanja Percac-Lima
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts; Center for Community Health Improvement, Massachusetts General Hospital, Boston, Massachusetts
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Costas-Muniz R, Leng J, Diamond L, Aragones A, Ramirez J, Gany F. Psychosocial correlates of appointment keeping in immigrant cancer patients. J Psychosoc Oncol 2015; 33:107-23. [PMID: 25574581 DOI: 10.1080/07347332.2014.992084] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
This study aims to determine the psychosocial correlates of self-reported adherence to cancer treatment appointments and treatment delays and interruptions. The sample included 622 immigrant cancer patients from New York City. Patients completed a survey that included sociodemographic and health-related questions, questions assessing missed appointments and delays/or interruptions, and quality of life and depression scales. After controlling for sociodemographic characteristics, having a positive depression screen and poor physical and emotional well-being were significant predictors of missed appointments and delays and/or interruptions of treatment. Non-adherence to treatment appointments in immigrant cancer patients is a complex outcome related to important modifiable or treatable factors.
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Affiliation(s)
- Rosario Costas-Muniz
- a Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, Immigrant Health & Cancer Disparities Service , New York , NY , USA
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Percac-Lima S, Ashburner JM, McCarthy AM, Piawah S, Atlas SJ. Patient navigation to improve follow-up of abnormal mammograms among disadvantaged women. J Womens Health (Larchmt) 2014; 24:138-43. [PMID: 25522246 DOI: 10.1089/jwh.2014.4954] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Patient navigation (PN) can improve breast cancer care among disadvantaged women. We evaluated the impact of a PN program on follow-up after an abnormal mammogram. METHODS Between 2007 and 2010, disadvantaged women with an abnormal mammogram (Breast Imaging-Reporting and Data System [BI-RADS] codes 0, 3, 4, 5) cared for in a community health center (CHC) with PN were compared to those receiving care in 11 network practices without PN. Multivariable logistic regression and Cox proportional hazards modeling were used to compare the percentages receiving appropriate follow-up and time to follow-up between the groups. RESULTS Abnormal mammography findings were reported for 132 women in the CHC with PN and 168 from practices without PN. The percentage of women with appropriate follow-up care was higher in the practice with PN than in non-PN practices (90.4% vs. 75.3%, adjusted p=0.006). RESULTS varied by BI-RADS score for women in PN and non-PN practices (BI-RADS 0, 93.7% vs. 90.2%, p=0.24; BI-RADS 3, 85.7% vs. 49.2%, p=0.003; BI-RADS 4/5, 95.1% vs. 82.8%, p=0.26). Time to follow-up was similar for BI-RADS 0 and occurred sooner for women in the PN practice than in non-PN practices for BI-RADS 3 and 4/5 (BI-RADS 3, adjusted hazard ratio [aHR], 95% confidence interval [CI]: 2.41 [1.36-4.27], BI-RADS 4/5, aHR [95% CI]: 1.41 [0.88-2.24]). CONCLUSIONS Disadvantaged women from a CHC with PN were more likely to receive appropriate follow-up after an abnormal mammogram than were those from practices without PN. Expanding PN to include all disadvantaged women within primary care networks could improve equity in cancer care.
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Affiliation(s)
- Sanja Percac-Lima
- 1 Chelsea HealthCare Center, Massachusetts General Hospital , Chelsea, Massachusetts
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Patterns of task and network actions performed by navigators to facilitate cancer care. Health Care Manage Rev 2014; 39:90-101. [PMID: 23478753 DOI: 10.1097/hmr.0b013e31828da41e] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patient navigation is a widely implemented intervention to facilitate access to care and reduce disparities in cancer care, but the activities of navigators are not well characterized. PURPOSE The aim of this study is to describe what patient navigators actually do and explore patterns of activity that clarify the roles they perform in facilitating cancer care. METHODOLOGY/APPROACH We conducted field observations of nine patient navigation programs operating in diverse health settings of the national patient navigation research program, including 34 patient navigators, each observed an average of four times. Trained observers used a structured observation protocol to code as they recorded navigator actions and write qualitative field notes capturing all activities in 15-minute intervals during observations ranging from 2 to 7 hours; yielding a total of 133 observations. Rates of coded activity were analyzed using numerical cluster analysis of identified patterns, informed by qualitative analysis of field notes. FINDINGS Six distinct patterns of navigator activity were identified, which differed most relative to how much time navigators spent directly interacting with patients and how much time they spent dealing with medical records and documentation tasks. Navigator actions reveal a complex set of roles in which navigators both provide the direct help to patients denoted by their title and also carry out a variety of actions that function to keep the health system operating smoothly. PRACTICE IMPLICATIONS Working to navigate patients through complex health services entails working to repair the persistent challenges of health services that can render them inhospitable to patients. The organizations that deploy navigators might learn from navigators' efforts and explore alternative approaches, structures, or systems of care in addressing both the barriers patients face and the complex solutions navigators create in helping patients.
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Results of nurse navigator follow-up after positive colorectal cancer screening test: a randomized trial. J Am Board Fam Med 2014; 27:789-95. [PMID: 25381076 PMCID: PMC4278960 DOI: 10.3122/jabfm.2014.06.140125] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Follow-up after a positive colorectal cancer screening test is necessary for screening to be effective. We hypothesized that nurse navigation would increase the completion of colonoscopy after a positive screening test. METHODS This study was conducted between 2008 and 2012 at 21 primary care medical centers in western Washington State. Participants in the Systems of Support to Increase Colorectal Cancer Screening study who had a positive fecal occult blood test (FOBT) or flexible sigmoidoscopy needing follow-up were randomized to usual care (UC) or a nurse navigator (navigation). UC included an electronic health record-based positive FOBT registry and physician reminder system. Navigation included UC plus care coordination and patient self-management support from a registered nurse who tracked and assisted patients until they completed or refused colonoscopy. The primary outcome was completion of colonoscopy within 6 months. After 6 months, both groups received navigation. RESULTS We randomized 147 participants with a positive FOBT or sigmoidoscopy. Completion of colonoscopy was higher in the intervention group at 6 months, but differences were not statistically significant (91.0% in navigation group vs 80.8% in UC group; adjusted difference, 10.1%; P = .10). Reasons for no or late colonoscopies included refusal, failure to schedule or missed appointments, concerns about risks or costs, and competing health concerns. CONCLUSIONS Navigation did not lead to a statistically significant incremental benefit at 6 months. IMPACT Follow-up rates after a positive colorectal cancer (CRC) screening test are high in a health care system where UC included a registry and physician reminders. Because of high follow-up rates in a health care system where UC included a registry and physician reminders, and small sample size, we cannot rule out incremental benefits of nurse navigation.
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Gunn CM, Clark JA, Battaglia TA, Freund KM, Parker VA. An assessment of patient navigator activities in breast cancer patient navigation programs using a nine-principle framework. Health Serv Res 2014; 49:1555-77. [PMID: 24820445 PMCID: PMC4213049 DOI: 10.1111/1475-6773.12184] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To determine how closely a published model of navigation reflects the practice of navigation in breast cancer patient navigation programs. DATA SOURCE Observational field notes describing patient navigator activities collected from 10 purposefully sampled, foundation-funded breast cancer navigation programs in 2008-2009. STUDY DESIGN An exploratory study evaluated a model framework for patient navigation published by Harold Freeman by using an a priori coding scheme based on model domains. DATA COLLECTION Field notes were compiled and coded. Inductive codes were added during analysis to characterize activities not included in the original model. PRINCIPAL FINDINGS Programs were consistent with individual-level principles representing tasks focused on individual patients. There was variation with respect to program-level principles that related to program organization and structure. Program characteristics such as the use of volunteer or clinical navigators were identified as contributors to patterns of model concordance. CONCLUSIONS This research provides a framework for defining the navigator role as focused on eliminating barriers through the provision of individual-level interventions. The diversity observed at the program level in these programs was a reflection of implementation according to target population. Further guidance may be required to assist patient navigation programs to define and tailor goals and measurement to community needs.
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Affiliation(s)
- Christine M Gunn
- Department of Health Policy and Management, Boston University School of Public HealthBoston, MA
- Women’s Health Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of MedicineBoston, MA
| | - Jack A Clark
- Department of Health Policy and Management, Boston University School of Public HealthBoston, MA
- Center for Healthcare Organization and Implementation Research (CHOIR), VA HSR&DBoston, MA
| | - Tracy A Battaglia
- Women’s Health Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of MedicineBoston, MA
| | - Karen M Freund
- Tufts University School of Medicine, Institute for Clinical Research and Health Policy Studies, Tufts Medical CenterBoston, MA
| | - Victoria A Parker
- Department of Health Policy and Management, Boston University School of Public HealthBoston, MA
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Ko NY, Darnell JS, Calhoun E, Freund KM, Wells KJ, Shapiro CL, Dudley DJ, Patierno SR, Fiscella K, Raich P, Battaglia TA. Can patient navigation improve receipt of recommended breast cancer care? Evidence from the National Patient Navigation Research Program. J Clin Oncol 2014. [PMID: 25071111 DOI: 10.1200/jco.2013.53.6037.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Poor and underserved women face barriers in receiving timely and appropriate breast cancer care. Patient navigators help individuals overcome these barriers, but little is known about whether patient navigation improves quality of care. The purpose of this study is to examine whether navigated women with breast cancer are more likely to receive recommended standard breast cancer care. PATIENTS AND METHODS Women with breast cancer who participated in the national Patient Navigation Research Program were examined to determine whether the care they received included the following: initiation of antiestrogen therapy in patients with hormone receptor-positive breast cancer; initiation of postlumpectomy radiation therapy; and initiation of chemotherapy in women younger than age 70 years with triple-negative tumors more than 1 cm. This is a secondary analysis of a multicenter quasi-experimental study funded by the National Cancer Institute to evaluate patient navigation. Multiple logistic regression was performed to compare differences in receipt of care between navigated and non-navigated participants. RESULTS Among participants eligible for antiestrogen therapy, navigated participants (n = 380) had a statistically significant higher likelihood of receiving antiestrogen therapy compared with non-navigated controls (n = 381; odds ratio [OR], 1.73; P = .004) in a multivariable analysis. Among the participants eligible for radiation therapy after lumpectomy, navigated participants (n = 255) were no more likely to receive radiation (OR, 1.42; P = .22) than control participants (n = 297). CONCLUSION We demonstrate that navigated participants were more likely than non-navigated participants to receive antiestrogen therapy. Future studies are required to determine the full impact patient navigation may have on ensuring that vulnerable populations receive quality care.
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Affiliation(s)
- Naomi Y Ko
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO.
| | - Julie S Darnell
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO
| | - Elizabeth Calhoun
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO
| | - Karen M Freund
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO
| | - Kristin J Wells
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO
| | - Charles L Shapiro
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO
| | - Donald J Dudley
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO
| | - Steven R Patierno
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO
| | - Kevin Fiscella
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO
| | - Peter Raich
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO
| | - Tracy A Battaglia
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO
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Meade CD, Wells KJ, Arevalo M, Calcano ER, Rivera M, Sarmiento Y, Freeman HP, Roetzheim RG. Lay navigator model for impacting cancer health disparities. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2014; 29:449-57. [PMID: 24683043 PMCID: PMC4133280 DOI: 10.1007/s13187-014-0640-z] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
This paper recounts experiences, challenges, and lessons learned when implementing a lay patient navigator program to improve cancer care among medically underserved patients who presented in a primary care clinic with a breast or colorectal cancer abnormality. The program employed five lay navigators to navigate 588 patients. Central programmatic elements were the following: (1) use of bilingual lay navigators with familiarity of communities they served; (2) provision of training, education, and supportive activities; (3) multidisciplinary clinical oversight that factored in caseload intensity; and (4) well-developed partnerships with community clinics and social service entities. Deconstruction of healthcare system information was fundamental to navigation processes. We conclude that a lay model of navigation is well suited to assist patients through complex healthcare systems; however, a stepped care model that includes both lay and professional navigation may be optimal to help patients across the entire continuum.
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Affiliation(s)
- Cathy D Meade
- Division of Population Science, Moffitt Cancer Center, 12902 Magnolia Drive, Fow-Edu, Tampa, FL, 33612, USA,
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Ko NY, Darnell JS, Calhoun E, Freund KM, Wells KJ, Shapiro CL, Dudley DJ, Patierno SR, Fiscella K, Raich P, Battaglia TA. Can patient navigation improve receipt of recommended breast cancer care? Evidence from the National Patient Navigation Research Program. J Clin Oncol 2014; 32:2758-64. [PMID: 25071111 DOI: 10.1200/jco.2013.53.6037] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Poor and underserved women face barriers in receiving timely and appropriate breast cancer care. Patient navigators help individuals overcome these barriers, but little is known about whether patient navigation improves quality of care. The purpose of this study is to examine whether navigated women with breast cancer are more likely to receive recommended standard breast cancer care. PATIENTS AND METHODS Women with breast cancer who participated in the national Patient Navigation Research Program were examined to determine whether the care they received included the following: initiation of antiestrogen therapy in patients with hormone receptor-positive breast cancer; initiation of postlumpectomy radiation therapy; and initiation of chemotherapy in women younger than age 70 years with triple-negative tumors more than 1 cm. This is a secondary analysis of a multicenter quasi-experimental study funded by the National Cancer Institute to evaluate patient navigation. Multiple logistic regression was performed to compare differences in receipt of care between navigated and non-navigated participants. RESULTS Among participants eligible for antiestrogen therapy, navigated participants (n = 380) had a statistically significant higher likelihood of receiving antiestrogen therapy compared with non-navigated controls (n = 381; odds ratio [OR], 1.73; P = .004) in a multivariable analysis. Among the participants eligible for radiation therapy after lumpectomy, navigated participants (n = 255) were no more likely to receive radiation (OR, 1.42; P = .22) than control participants (n = 297). CONCLUSION We demonstrate that navigated participants were more likely than non-navigated participants to receive antiestrogen therapy. Future studies are required to determine the full impact patient navigation may have on ensuring that vulnerable populations receive quality care.
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Affiliation(s)
- Naomi Y Ko
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO.
| | - Julie S Darnell
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO
| | - Elizabeth Calhoun
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO
| | - Karen M Freund
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO
| | - Kristin J Wells
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO
| | - Charles L Shapiro
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO
| | - Donald J Dudley
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO
| | - Steven R Patierno
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO
| | - Kevin Fiscella
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO
| | - Peter Raich
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO
| | - Tracy A Battaglia
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO
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Freund KM, Battaglia TA, Calhoun E, Darnell JS, Dudley DJ, Fiscella K, Hare ML, LaVerda N, Lee JH, Levine P, Murray DM, Patierno SR, Raich PC, Roetzheim RG, Simon M, Snyder FR, Warren-Mears V, Whitley EM, Winters P, Young GS, Paskett ED. Impact of patient navigation on timely cancer care: the Patient Navigation Research Program. J Natl Cancer Inst 2014; 106:dju115. [PMID: 24938303 DOI: 10.1093/jnci/dju115] [Citation(s) in RCA: 194] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Patient navigation is a promising intervention to address cancer disparities but requires a multisite controlled trial to assess its effectiveness. METHODS The Patient Navigation Research Program compared patient navigation with usual care on time to diagnosis or treatment for participants with breast, cervical, colorectal, or prostate screening abnormalities and/or cancers between 2007 and 2010. Patient navigators developed individualized strategies to address barriers to care, with the focus on preventing delays in care. To assess timeliness of diagnostic resolution, we conducted a meta-analysis of center- and cancer-specific adjusted hazard ratios (aHRs) comparing patient navigation vs usual care. To assess initiation of cancer therapy, we calculated a single aHR, pooling data across all centers and cancer types. We conducted a metaregression to evaluate variability across centers. All statistical tests were two-sided. RESULTS The 10521 participants with abnormal screening tests and 2105 with a cancer or precancer diagnosis were predominantly from racial/ethnic minority groups (73%) and publically insured (40%) or uninsured (31%). There was no benefit during the first 90 days of care, but a benefit of navigation was seen from 91 to 365 days for both diagnostic resolution (aHR = 1.51; 95% confidence interval [CI] = 1.23 to 1.84; P < .001)) and treatment initiation (aHR = 1.43; 95% CI = 1.10 to 1.86; P < .007). Metaregression revealed that navigation had its greatest benefits within centers with the greatest delays in follow-up under usual care. CONCLUSIONS Patient navigation demonstrated a moderate benefit in improving timely cancer care. These results support adoption of patient navigation in settings that serve populations at risk of being lost to follow-up.
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Affiliation(s)
- Karen M Freund
- Affiliations of authors: Division of Cancer Prevention and Control, Department of Internal Medicine, College of Medicine, Comprehensive Cancer Center (EDP), and Center for Biostatistics (GSY), The Ohio State University, Columbus, OH; Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA (KMF); Women's Health Unit, Section of General Internal Medicine, Evans Department of Medicine, Boston Medical Center and Women's Health Interdisciplinary Research Center, Boston University School of Medicine, Boston, MA (TAB); Division of Health Policy and Administration, School of Public Health, University of Illinois at Chicago, Chicago, IL (EC, JSD); Department of Obstetrics and Gynecology, University of Texas Health Science Center, San Antonio, TX (DLD); Department of Family Medicine and Public Health Sciences and Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY (KF); Center to Reduce Cancer Health Disparities, National Cancer Institute (MLH), and Biostatistics and Bioinformatics Branch, Division of Epidemiology, Statistics, and Prevention Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health (DMM), Rockville, MD (MLH); George Washington University School of Public Health and Health Services, Washington, DC (NL, PL); H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J-HL, RGR); George Washington Cancer Institute, Washington, DC (PL. SRP); Duke Cancer Institute, Durham, NC (SRP); Denver Health, Denver, CO (PCR, EMW); University of Colorado Denver, Aurora, CO (PCR); Department of Family Medicine, University of South Florida, Tampa, FL (RGR); Department of Obstetrics and Gynecology and Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (MS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (MS); Clinical Research Ser
| | - Tracy A Battaglia
- Affiliations of authors: Division of Cancer Prevention and Control, Department of Internal Medicine, College of Medicine, Comprehensive Cancer Center (EDP), and Center for Biostatistics (GSY), The Ohio State University, Columbus, OH; Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA (KMF); Women's Health Unit, Section of General Internal Medicine, Evans Department of Medicine, Boston Medical Center and Women's Health Interdisciplinary Research Center, Boston University School of Medicine, Boston, MA (TAB); Division of Health Policy and Administration, School of Public Health, University of Illinois at Chicago, Chicago, IL (EC, JSD); Department of Obstetrics and Gynecology, University of Texas Health Science Center, San Antonio, TX (DLD); Department of Family Medicine and Public Health Sciences and Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY (KF); Center to Reduce Cancer Health Disparities, National Cancer Institute (MLH), and Biostatistics and Bioinformatics Branch, Division of Epidemiology, Statistics, and Prevention Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health (DMM), Rockville, MD (MLH); George Washington University School of Public Health and Health Services, Washington, DC (NL, PL); H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J-HL, RGR); George Washington Cancer Institute, Washington, DC (PL. SRP); Duke Cancer Institute, Durham, NC (SRP); Denver Health, Denver, CO (PCR, EMW); University of Colorado Denver, Aurora, CO (PCR); Department of Family Medicine, University of South Florida, Tampa, FL (RGR); Department of Obstetrics and Gynecology and Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (MS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (MS); Clinical Research Ser
| | - Elizabeth Calhoun
- Affiliations of authors: Division of Cancer Prevention and Control, Department of Internal Medicine, College of Medicine, Comprehensive Cancer Center (EDP), and Center for Biostatistics (GSY), The Ohio State University, Columbus, OH; Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA (KMF); Women's Health Unit, Section of General Internal Medicine, Evans Department of Medicine, Boston Medical Center and Women's Health Interdisciplinary Research Center, Boston University School of Medicine, Boston, MA (TAB); Division of Health Policy and Administration, School of Public Health, University of Illinois at Chicago, Chicago, IL (EC, JSD); Department of Obstetrics and Gynecology, University of Texas Health Science Center, San Antonio, TX (DLD); Department of Family Medicine and Public Health Sciences and Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY (KF); Center to Reduce Cancer Health Disparities, National Cancer Institute (MLH), and Biostatistics and Bioinformatics Branch, Division of Epidemiology, Statistics, and Prevention Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health (DMM), Rockville, MD (MLH); George Washington University School of Public Health and Health Services, Washington, DC (NL, PL); H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J-HL, RGR); George Washington Cancer Institute, Washington, DC (PL. SRP); Duke Cancer Institute, Durham, NC (SRP); Denver Health, Denver, CO (PCR, EMW); University of Colorado Denver, Aurora, CO (PCR); Department of Family Medicine, University of South Florida, Tampa, FL (RGR); Department of Obstetrics and Gynecology and Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (MS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (MS); Clinical Research Ser
| | - Julie S Darnell
- Affiliations of authors: Division of Cancer Prevention and Control, Department of Internal Medicine, College of Medicine, Comprehensive Cancer Center (EDP), and Center for Biostatistics (GSY), The Ohio State University, Columbus, OH; Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA (KMF); Women's Health Unit, Section of General Internal Medicine, Evans Department of Medicine, Boston Medical Center and Women's Health Interdisciplinary Research Center, Boston University School of Medicine, Boston, MA (TAB); Division of Health Policy and Administration, School of Public Health, University of Illinois at Chicago, Chicago, IL (EC, JSD); Department of Obstetrics and Gynecology, University of Texas Health Science Center, San Antonio, TX (DLD); Department of Family Medicine and Public Health Sciences and Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY (KF); Center to Reduce Cancer Health Disparities, National Cancer Institute (MLH), and Biostatistics and Bioinformatics Branch, Division of Epidemiology, Statistics, and Prevention Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health (DMM), Rockville, MD (MLH); George Washington University School of Public Health and Health Services, Washington, DC (NL, PL); H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J-HL, RGR); George Washington Cancer Institute, Washington, DC (PL. SRP); Duke Cancer Institute, Durham, NC (SRP); Denver Health, Denver, CO (PCR, EMW); University of Colorado Denver, Aurora, CO (PCR); Department of Family Medicine, University of South Florida, Tampa, FL (RGR); Department of Obstetrics and Gynecology and Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (MS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (MS); Clinical Research Ser
| | - Donald J Dudley
- Affiliations of authors: Division of Cancer Prevention and Control, Department of Internal Medicine, College of Medicine, Comprehensive Cancer Center (EDP), and Center for Biostatistics (GSY), The Ohio State University, Columbus, OH; Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA (KMF); Women's Health Unit, Section of General Internal Medicine, Evans Department of Medicine, Boston Medical Center and Women's Health Interdisciplinary Research Center, Boston University School of Medicine, Boston, MA (TAB); Division of Health Policy and Administration, School of Public Health, University of Illinois at Chicago, Chicago, IL (EC, JSD); Department of Obstetrics and Gynecology, University of Texas Health Science Center, San Antonio, TX (DLD); Department of Family Medicine and Public Health Sciences and Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY (KF); Center to Reduce Cancer Health Disparities, National Cancer Institute (MLH), and Biostatistics and Bioinformatics Branch, Division of Epidemiology, Statistics, and Prevention Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health (DMM), Rockville, MD (MLH); George Washington University School of Public Health and Health Services, Washington, DC (NL, PL); H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J-HL, RGR); George Washington Cancer Institute, Washington, DC (PL. SRP); Duke Cancer Institute, Durham, NC (SRP); Denver Health, Denver, CO (PCR, EMW); University of Colorado Denver, Aurora, CO (PCR); Department of Family Medicine, University of South Florida, Tampa, FL (RGR); Department of Obstetrics and Gynecology and Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (MS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (MS); Clinical Research Ser
| | - Kevin Fiscella
- Affiliations of authors: Division of Cancer Prevention and Control, Department of Internal Medicine, College of Medicine, Comprehensive Cancer Center (EDP), and Center for Biostatistics (GSY), The Ohio State University, Columbus, OH; Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA (KMF); Women's Health Unit, Section of General Internal Medicine, Evans Department of Medicine, Boston Medical Center and Women's Health Interdisciplinary Research Center, Boston University School of Medicine, Boston, MA (TAB); Division of Health Policy and Administration, School of Public Health, University of Illinois at Chicago, Chicago, IL (EC, JSD); Department of Obstetrics and Gynecology, University of Texas Health Science Center, San Antonio, TX (DLD); Department of Family Medicine and Public Health Sciences and Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY (KF); Center to Reduce Cancer Health Disparities, National Cancer Institute (MLH), and Biostatistics and Bioinformatics Branch, Division of Epidemiology, Statistics, and Prevention Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health (DMM), Rockville, MD (MLH); George Washington University School of Public Health and Health Services, Washington, DC (NL, PL); H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J-HL, RGR); George Washington Cancer Institute, Washington, DC (PL. SRP); Duke Cancer Institute, Durham, NC (SRP); Denver Health, Denver, CO (PCR, EMW); University of Colorado Denver, Aurora, CO (PCR); Department of Family Medicine, University of South Florida, Tampa, FL (RGR); Department of Obstetrics and Gynecology and Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (MS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (MS); Clinical Research Ser
| | - Martha L Hare
- Affiliations of authors: Division of Cancer Prevention and Control, Department of Internal Medicine, College of Medicine, Comprehensive Cancer Center (EDP), and Center for Biostatistics (GSY), The Ohio State University, Columbus, OH; Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA (KMF); Women's Health Unit, Section of General Internal Medicine, Evans Department of Medicine, Boston Medical Center and Women's Health Interdisciplinary Research Center, Boston University School of Medicine, Boston, MA (TAB); Division of Health Policy and Administration, School of Public Health, University of Illinois at Chicago, Chicago, IL (EC, JSD); Department of Obstetrics and Gynecology, University of Texas Health Science Center, San Antonio, TX (DLD); Department of Family Medicine and Public Health Sciences and Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY (KF); Center to Reduce Cancer Health Disparities, National Cancer Institute (MLH), and Biostatistics and Bioinformatics Branch, Division of Epidemiology, Statistics, and Prevention Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health (DMM), Rockville, MD (MLH); George Washington University School of Public Health and Health Services, Washington, DC (NL, PL); H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J-HL, RGR); George Washington Cancer Institute, Washington, DC (PL. SRP); Duke Cancer Institute, Durham, NC (SRP); Denver Health, Denver, CO (PCR, EMW); University of Colorado Denver, Aurora, CO (PCR); Department of Family Medicine, University of South Florida, Tampa, FL (RGR); Department of Obstetrics and Gynecology and Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (MS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (MS); Clinical Research Ser
| | - Nancy LaVerda
- Affiliations of authors: Division of Cancer Prevention and Control, Department of Internal Medicine, College of Medicine, Comprehensive Cancer Center (EDP), and Center for Biostatistics (GSY), The Ohio State University, Columbus, OH; Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA (KMF); Women's Health Unit, Section of General Internal Medicine, Evans Department of Medicine, Boston Medical Center and Women's Health Interdisciplinary Research Center, Boston University School of Medicine, Boston, MA (TAB); Division of Health Policy and Administration, School of Public Health, University of Illinois at Chicago, Chicago, IL (EC, JSD); Department of Obstetrics and Gynecology, University of Texas Health Science Center, San Antonio, TX (DLD); Department of Family Medicine and Public Health Sciences and Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY (KF); Center to Reduce Cancer Health Disparities, National Cancer Institute (MLH), and Biostatistics and Bioinformatics Branch, Division of Epidemiology, Statistics, and Prevention Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health (DMM), Rockville, MD (MLH); George Washington University School of Public Health and Health Services, Washington, DC (NL, PL); H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J-HL, RGR); George Washington Cancer Institute, Washington, DC (PL. SRP); Duke Cancer Institute, Durham, NC (SRP); Denver Health, Denver, CO (PCR, EMW); University of Colorado Denver, Aurora, CO (PCR); Department of Family Medicine, University of South Florida, Tampa, FL (RGR); Department of Obstetrics and Gynecology and Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (MS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (MS); Clinical Research Ser
| | - Ji-Hyun Lee
- Affiliations of authors: Division of Cancer Prevention and Control, Department of Internal Medicine, College of Medicine, Comprehensive Cancer Center (EDP), and Center for Biostatistics (GSY), The Ohio State University, Columbus, OH; Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA (KMF); Women's Health Unit, Section of General Internal Medicine, Evans Department of Medicine, Boston Medical Center and Women's Health Interdisciplinary Research Center, Boston University School of Medicine, Boston, MA (TAB); Division of Health Policy and Administration, School of Public Health, University of Illinois at Chicago, Chicago, IL (EC, JSD); Department of Obstetrics and Gynecology, University of Texas Health Science Center, San Antonio, TX (DLD); Department of Family Medicine and Public Health Sciences and Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY (KF); Center to Reduce Cancer Health Disparities, National Cancer Institute (MLH), and Biostatistics and Bioinformatics Branch, Division of Epidemiology, Statistics, and Prevention Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health (DMM), Rockville, MD (MLH); George Washington University School of Public Health and Health Services, Washington, DC (NL, PL); H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J-HL, RGR); George Washington Cancer Institute, Washington, DC (PL. SRP); Duke Cancer Institute, Durham, NC (SRP); Denver Health, Denver, CO (PCR, EMW); University of Colorado Denver, Aurora, CO (PCR); Department of Family Medicine, University of South Florida, Tampa, FL (RGR); Department of Obstetrics and Gynecology and Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (MS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (MS); Clinical Research Ser
| | - Paul Levine
- Affiliations of authors: Division of Cancer Prevention and Control, Department of Internal Medicine, College of Medicine, Comprehensive Cancer Center (EDP), and Center for Biostatistics (GSY), The Ohio State University, Columbus, OH; Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA (KMF); Women's Health Unit, Section of General Internal Medicine, Evans Department of Medicine, Boston Medical Center and Women's Health Interdisciplinary Research Center, Boston University School of Medicine, Boston, MA (TAB); Division of Health Policy and Administration, School of Public Health, University of Illinois at Chicago, Chicago, IL (EC, JSD); Department of Obstetrics and Gynecology, University of Texas Health Science Center, San Antonio, TX (DLD); Department of Family Medicine and Public Health Sciences and Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY (KF); Center to Reduce Cancer Health Disparities, National Cancer Institute (MLH), and Biostatistics and Bioinformatics Branch, Division of Epidemiology, Statistics, and Prevention Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health (DMM), Rockville, MD (MLH); George Washington University School of Public Health and Health Services, Washington, DC (NL, PL); H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J-HL, RGR); George Washington Cancer Institute, Washington, DC (PL. SRP); Duke Cancer Institute, Durham, NC (SRP); Denver Health, Denver, CO (PCR, EMW); University of Colorado Denver, Aurora, CO (PCR); Department of Family Medicine, University of South Florida, Tampa, FL (RGR); Department of Obstetrics and Gynecology and Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (MS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (MS); Clinical Research Ser
| | - David M Murray
- Affiliations of authors: Division of Cancer Prevention and Control, Department of Internal Medicine, College of Medicine, Comprehensive Cancer Center (EDP), and Center for Biostatistics (GSY), The Ohio State University, Columbus, OH; Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA (KMF); Women's Health Unit, Section of General Internal Medicine, Evans Department of Medicine, Boston Medical Center and Women's Health Interdisciplinary Research Center, Boston University School of Medicine, Boston, MA (TAB); Division of Health Policy and Administration, School of Public Health, University of Illinois at Chicago, Chicago, IL (EC, JSD); Department of Obstetrics and Gynecology, University of Texas Health Science Center, San Antonio, TX (DLD); Department of Family Medicine and Public Health Sciences and Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY (KF); Center to Reduce Cancer Health Disparities, National Cancer Institute (MLH), and Biostatistics and Bioinformatics Branch, Division of Epidemiology, Statistics, and Prevention Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health (DMM), Rockville, MD (MLH); George Washington University School of Public Health and Health Services, Washington, DC (NL, PL); H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J-HL, RGR); George Washington Cancer Institute, Washington, DC (PL. SRP); Duke Cancer Institute, Durham, NC (SRP); Denver Health, Denver, CO (PCR, EMW); University of Colorado Denver, Aurora, CO (PCR); Department of Family Medicine, University of South Florida, Tampa, FL (RGR); Department of Obstetrics and Gynecology and Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (MS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (MS); Clinical Research Ser
| | - Steven R Patierno
- Affiliations of authors: Division of Cancer Prevention and Control, Department of Internal Medicine, College of Medicine, Comprehensive Cancer Center (EDP), and Center for Biostatistics (GSY), The Ohio State University, Columbus, OH; Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA (KMF); Women's Health Unit, Section of General Internal Medicine, Evans Department of Medicine, Boston Medical Center and Women's Health Interdisciplinary Research Center, Boston University School of Medicine, Boston, MA (TAB); Division of Health Policy and Administration, School of Public Health, University of Illinois at Chicago, Chicago, IL (EC, JSD); Department of Obstetrics and Gynecology, University of Texas Health Science Center, San Antonio, TX (DLD); Department of Family Medicine and Public Health Sciences and Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY (KF); Center to Reduce Cancer Health Disparities, National Cancer Institute (MLH), and Biostatistics and Bioinformatics Branch, Division of Epidemiology, Statistics, and Prevention Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health (DMM), Rockville, MD (MLH); George Washington University School of Public Health and Health Services, Washington, DC (NL, PL); H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J-HL, RGR); George Washington Cancer Institute, Washington, DC (PL. SRP); Duke Cancer Institute, Durham, NC (SRP); Denver Health, Denver, CO (PCR, EMW); University of Colorado Denver, Aurora, CO (PCR); Department of Family Medicine, University of South Florida, Tampa, FL (RGR); Department of Obstetrics and Gynecology and Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (MS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (MS); Clinical Research Ser
| | - Peter C Raich
- Affiliations of authors: Division of Cancer Prevention and Control, Department of Internal Medicine, College of Medicine, Comprehensive Cancer Center (EDP), and Center for Biostatistics (GSY), The Ohio State University, Columbus, OH; Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA (KMF); Women's Health Unit, Section of General Internal Medicine, Evans Department of Medicine, Boston Medical Center and Women's Health Interdisciplinary Research Center, Boston University School of Medicine, Boston, MA (TAB); Division of Health Policy and Administration, School of Public Health, University of Illinois at Chicago, Chicago, IL (EC, JSD); Department of Obstetrics and Gynecology, University of Texas Health Science Center, San Antonio, TX (DLD); Department of Family Medicine and Public Health Sciences and Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY (KF); Center to Reduce Cancer Health Disparities, National Cancer Institute (MLH), and Biostatistics and Bioinformatics Branch, Division of Epidemiology, Statistics, and Prevention Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health (DMM), Rockville, MD (MLH); George Washington University School of Public Health and Health Services, Washington, DC (NL, PL); H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J-HL, RGR); George Washington Cancer Institute, Washington, DC (PL. SRP); Duke Cancer Institute, Durham, NC (SRP); Denver Health, Denver, CO (PCR, EMW); University of Colorado Denver, Aurora, CO (PCR); Department of Family Medicine, University of South Florida, Tampa, FL (RGR); Department of Obstetrics and Gynecology and Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (MS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (MS); Clinical Research Ser
| | - Richard G Roetzheim
- Affiliations of authors: Division of Cancer Prevention and Control, Department of Internal Medicine, College of Medicine, Comprehensive Cancer Center (EDP), and Center for Biostatistics (GSY), The Ohio State University, Columbus, OH; Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA (KMF); Women's Health Unit, Section of General Internal Medicine, Evans Department of Medicine, Boston Medical Center and Women's Health Interdisciplinary Research Center, Boston University School of Medicine, Boston, MA (TAB); Division of Health Policy and Administration, School of Public Health, University of Illinois at Chicago, Chicago, IL (EC, JSD); Department of Obstetrics and Gynecology, University of Texas Health Science Center, San Antonio, TX (DLD); Department of Family Medicine and Public Health Sciences and Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY (KF); Center to Reduce Cancer Health Disparities, National Cancer Institute (MLH), and Biostatistics and Bioinformatics Branch, Division of Epidemiology, Statistics, and Prevention Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health (DMM), Rockville, MD (MLH); George Washington University School of Public Health and Health Services, Washington, DC (NL, PL); H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J-HL, RGR); George Washington Cancer Institute, Washington, DC (PL. SRP); Duke Cancer Institute, Durham, NC (SRP); Denver Health, Denver, CO (PCR, EMW); University of Colorado Denver, Aurora, CO (PCR); Department of Family Medicine, University of South Florida, Tampa, FL (RGR); Department of Obstetrics and Gynecology and Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (MS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (MS); Clinical Research Ser
| | - Melissa Simon
- Affiliations of authors: Division of Cancer Prevention and Control, Department of Internal Medicine, College of Medicine, Comprehensive Cancer Center (EDP), and Center for Biostatistics (GSY), The Ohio State University, Columbus, OH; Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA (KMF); Women's Health Unit, Section of General Internal Medicine, Evans Department of Medicine, Boston Medical Center and Women's Health Interdisciplinary Research Center, Boston University School of Medicine, Boston, MA (TAB); Division of Health Policy and Administration, School of Public Health, University of Illinois at Chicago, Chicago, IL (EC, JSD); Department of Obstetrics and Gynecology, University of Texas Health Science Center, San Antonio, TX (DLD); Department of Family Medicine and Public Health Sciences and Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY (KF); Center to Reduce Cancer Health Disparities, National Cancer Institute (MLH), and Biostatistics and Bioinformatics Branch, Division of Epidemiology, Statistics, and Prevention Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health (DMM), Rockville, MD (MLH); George Washington University School of Public Health and Health Services, Washington, DC (NL, PL); H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J-HL, RGR); George Washington Cancer Institute, Washington, DC (PL. SRP); Duke Cancer Institute, Durham, NC (SRP); Denver Health, Denver, CO (PCR, EMW); University of Colorado Denver, Aurora, CO (PCR); Department of Family Medicine, University of South Florida, Tampa, FL (RGR); Department of Obstetrics and Gynecology and Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (MS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (MS); Clinical Research Ser
| | - Frederick R Snyder
- Affiliations of authors: Division of Cancer Prevention and Control, Department of Internal Medicine, College of Medicine, Comprehensive Cancer Center (EDP), and Center for Biostatistics (GSY), The Ohio State University, Columbus, OH; Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA (KMF); Women's Health Unit, Section of General Internal Medicine, Evans Department of Medicine, Boston Medical Center and Women's Health Interdisciplinary Research Center, Boston University School of Medicine, Boston, MA (TAB); Division of Health Policy and Administration, School of Public Health, University of Illinois at Chicago, Chicago, IL (EC, JSD); Department of Obstetrics and Gynecology, University of Texas Health Science Center, San Antonio, TX (DLD); Department of Family Medicine and Public Health Sciences and Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY (KF); Center to Reduce Cancer Health Disparities, National Cancer Institute (MLH), and Biostatistics and Bioinformatics Branch, Division of Epidemiology, Statistics, and Prevention Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health (DMM), Rockville, MD (MLH); George Washington University School of Public Health and Health Services, Washington, DC (NL, PL); H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J-HL, RGR); George Washington Cancer Institute, Washington, DC (PL. SRP); Duke Cancer Institute, Durham, NC (SRP); Denver Health, Denver, CO (PCR, EMW); University of Colorado Denver, Aurora, CO (PCR); Department of Family Medicine, University of South Florida, Tampa, FL (RGR); Department of Obstetrics and Gynecology and Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (MS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (MS); Clinical Research Ser
| | - Victoria Warren-Mears
- Affiliations of authors: Division of Cancer Prevention and Control, Department of Internal Medicine, College of Medicine, Comprehensive Cancer Center (EDP), and Center for Biostatistics (GSY), The Ohio State University, Columbus, OH; Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA (KMF); Women's Health Unit, Section of General Internal Medicine, Evans Department of Medicine, Boston Medical Center and Women's Health Interdisciplinary Research Center, Boston University School of Medicine, Boston, MA (TAB); Division of Health Policy and Administration, School of Public Health, University of Illinois at Chicago, Chicago, IL (EC, JSD); Department of Obstetrics and Gynecology, University of Texas Health Science Center, San Antonio, TX (DLD); Department of Family Medicine and Public Health Sciences and Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY (KF); Center to Reduce Cancer Health Disparities, National Cancer Institute (MLH), and Biostatistics and Bioinformatics Branch, Division of Epidemiology, Statistics, and Prevention Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health (DMM), Rockville, MD (MLH); George Washington University School of Public Health and Health Services, Washington, DC (NL, PL); H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J-HL, RGR); George Washington Cancer Institute, Washington, DC (PL. SRP); Duke Cancer Institute, Durham, NC (SRP); Denver Health, Denver, CO (PCR, EMW); University of Colorado Denver, Aurora, CO (PCR); Department of Family Medicine, University of South Florida, Tampa, FL (RGR); Department of Obstetrics and Gynecology and Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (MS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (MS); Clinical Research Ser
| | - Elizabeth M Whitley
- Affiliations of authors: Division of Cancer Prevention and Control, Department of Internal Medicine, College of Medicine, Comprehensive Cancer Center (EDP), and Center for Biostatistics (GSY), The Ohio State University, Columbus, OH; Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA (KMF); Women's Health Unit, Section of General Internal Medicine, Evans Department of Medicine, Boston Medical Center and Women's Health Interdisciplinary Research Center, Boston University School of Medicine, Boston, MA (TAB); Division of Health Policy and Administration, School of Public Health, University of Illinois at Chicago, Chicago, IL (EC, JSD); Department of Obstetrics and Gynecology, University of Texas Health Science Center, San Antonio, TX (DLD); Department of Family Medicine and Public Health Sciences and Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY (KF); Center to Reduce Cancer Health Disparities, National Cancer Institute (MLH), and Biostatistics and Bioinformatics Branch, Division of Epidemiology, Statistics, and Prevention Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health (DMM), Rockville, MD (MLH); George Washington University School of Public Health and Health Services, Washington, DC (NL, PL); H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J-HL, RGR); George Washington Cancer Institute, Washington, DC (PL. SRP); Duke Cancer Institute, Durham, NC (SRP); Denver Health, Denver, CO (PCR, EMW); University of Colorado Denver, Aurora, CO (PCR); Department of Family Medicine, University of South Florida, Tampa, FL (RGR); Department of Obstetrics and Gynecology and Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (MS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (MS); Clinical Research Ser
| | - Paul Winters
- Affiliations of authors: Division of Cancer Prevention and Control, Department of Internal Medicine, College of Medicine, Comprehensive Cancer Center (EDP), and Center for Biostatistics (GSY), The Ohio State University, Columbus, OH; Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA (KMF); Women's Health Unit, Section of General Internal Medicine, Evans Department of Medicine, Boston Medical Center and Women's Health Interdisciplinary Research Center, Boston University School of Medicine, Boston, MA (TAB); Division of Health Policy and Administration, School of Public Health, University of Illinois at Chicago, Chicago, IL (EC, JSD); Department of Obstetrics and Gynecology, University of Texas Health Science Center, San Antonio, TX (DLD); Department of Family Medicine and Public Health Sciences and Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY (KF); Center to Reduce Cancer Health Disparities, National Cancer Institute (MLH), and Biostatistics and Bioinformatics Branch, Division of Epidemiology, Statistics, and Prevention Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health (DMM), Rockville, MD (MLH); George Washington University School of Public Health and Health Services, Washington, DC (NL, PL); H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J-HL, RGR); George Washington Cancer Institute, Washington, DC (PL. SRP); Duke Cancer Institute, Durham, NC (SRP); Denver Health, Denver, CO (PCR, EMW); University of Colorado Denver, Aurora, CO (PCR); Department of Family Medicine, University of South Florida, Tampa, FL (RGR); Department of Obstetrics and Gynecology and Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (MS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (MS); Clinical Research Ser
| | - Gregory S Young
- Affiliations of authors: Division of Cancer Prevention and Control, Department of Internal Medicine, College of Medicine, Comprehensive Cancer Center (EDP), and Center for Biostatistics (GSY), The Ohio State University, Columbus, OH; Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA (KMF); Women's Health Unit, Section of General Internal Medicine, Evans Department of Medicine, Boston Medical Center and Women's Health Interdisciplinary Research Center, Boston University School of Medicine, Boston, MA (TAB); Division of Health Policy and Administration, School of Public Health, University of Illinois at Chicago, Chicago, IL (EC, JSD); Department of Obstetrics and Gynecology, University of Texas Health Science Center, San Antonio, TX (DLD); Department of Family Medicine and Public Health Sciences and Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY (KF); Center to Reduce Cancer Health Disparities, National Cancer Institute (MLH), and Biostatistics and Bioinformatics Branch, Division of Epidemiology, Statistics, and Prevention Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health (DMM), Rockville, MD (MLH); George Washington University School of Public Health and Health Services, Washington, DC (NL, PL); H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J-HL, RGR); George Washington Cancer Institute, Washington, DC (PL. SRP); Duke Cancer Institute, Durham, NC (SRP); Denver Health, Denver, CO (PCR, EMW); University of Colorado Denver, Aurora, CO (PCR); Department of Family Medicine, University of South Florida, Tampa, FL (RGR); Department of Obstetrics and Gynecology and Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (MS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (MS); Clinical Research Ser
| | - Electra D Paskett
- Affiliations of authors: Division of Cancer Prevention and Control, Department of Internal Medicine, College of Medicine, Comprehensive Cancer Center (EDP), and Center for Biostatistics (GSY), The Ohio State University, Columbus, OH; Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA (KMF); Women's Health Unit, Section of General Internal Medicine, Evans Department of Medicine, Boston Medical Center and Women's Health Interdisciplinary Research Center, Boston University School of Medicine, Boston, MA (TAB); Division of Health Policy and Administration, School of Public Health, University of Illinois at Chicago, Chicago, IL (EC, JSD); Department of Obstetrics and Gynecology, University of Texas Health Science Center, San Antonio, TX (DLD); Department of Family Medicine and Public Health Sciences and Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY (KF); Center to Reduce Cancer Health Disparities, National Cancer Institute (MLH), and Biostatistics and Bioinformatics Branch, Division of Epidemiology, Statistics, and Prevention Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health (DMM), Rockville, MD (MLH); George Washington University School of Public Health and Health Services, Washington, DC (NL, PL); H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL (J-HL, RGR); George Washington Cancer Institute, Washington, DC (PL. SRP); Duke Cancer Institute, Durham, NC (SRP); Denver Health, Denver, CO (PCR, EMW); University of Colorado Denver, Aurora, CO (PCR); Department of Family Medicine, University of South Florida, Tampa, FL (RGR); Department of Obstetrics and Gynecology and Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (MS); Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL (MS); Clinical Research Ser
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Wells KJ, Lima DS, Meade CD, Muñoz-Antonia T, Scarinci I, McGuire A, Gwede CK, Pledger WJ, Partridge E, Lipscomb J, Matthews R, Matta J, Flores I, Weiner R, Turner T, Miele L, Wiese TE, Fouad M, Moreno CS, Lacey M, Christie DW, Price-Haywood EG, Quinn GP, Coppola D, Sodeke SO, Green BL, Lichtveld MY. Assessing needs and assets for building a regional network infrastructure to reduce cancer related health disparities. EVALUATION AND PROGRAM PLANNING 2014; 44:14-25. [PMID: 24486917 PMCID: PMC4360072 DOI: 10.1016/j.evalprogplan.2013.12.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Revised: 10/12/2013] [Accepted: 12/19/2013] [Indexed: 05/09/2023]
Abstract
Significant cancer health disparities exist in the United States and Puerto Rico. While numerous initiatives have been implemented to reduce cancer disparities, regional coordination of these efforts between institutions is often limited. To address cancer health disparities nation-wide, a series of regional transdisciplinary networks through the Geographic Management Program (GMaP) and the Minority Biospecimen/Biobanking Geographic Management Program (BMaP) were established in six regions across the country. This paper describes the development of the Region 3 GMaP/BMaP network composed of over 100 investigators from nine institutions in five Southeastern states and Puerto Rico to develop a state-of-the-art network for cancer health disparities research and training. We describe a series of partnership activities that led to the formation of the infrastructure for this network, recount the participatory processes utilized to develop and implement a needs and assets assessment and implementation plan, and describe our approach to data collection. Completion, by all nine institutions, of the needs and assets assessment resulted in several beneficial outcomes for Region 3 GMaP/BMaP. This network entails ongoing commitment from the institutions and institutional leaders, continuous participatory and engagement activities, and effective coordination and communication centered on team science goals.
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Affiliation(s)
- Kristen J Wells
- University of South Florida, 4202 East Fowler Avenue, Tampa, FL 33620, USA
| | - Diana S Lima
- H. Lee Moffitt Cancer Center & Research Institute, 12902 Magnolia Drive, Tampa, FL 33612, USA.
| | - Cathy D Meade
- H. Lee Moffitt Cancer Center & Research Institute, 12902 Magnolia Drive, Tampa, FL 33612, USA
| | - Teresita Muñoz-Antonia
- H. Lee Moffitt Cancer Center & Research Institute, 12902 Magnolia Drive, Tampa, FL 33612, USA
| | - Isabel Scarinci
- University of Alabama at Birmingham Comprehensive Cancer Center, 1824 6th Avenue South, Birmingham, AL 35210, USA
| | - Allison McGuire
- University of Alabama at Birmingham Comprehensive Cancer Center, 1824 6th Avenue South, Birmingham, AL 35210, USA
| | - Clement K Gwede
- H. Lee Moffitt Cancer Center & Research Institute, 12902 Magnolia Drive, Tampa, FL 33612, USA
| | - W Jack Pledger
- H. Lee Moffitt Cancer Center & Research Institute, 12902 Magnolia Drive, Tampa, FL 33612, USA
| | - Edward Partridge
- University of Alabama at Birmingham Comprehensive Cancer Center, 1824 6th Avenue South, Birmingham, AL 35210, USA
| | - Joseph Lipscomb
- Emory University, 615 Michael Street, Atlanta, GA 30322, USA
| | - Roland Matthews
- Morehouse School of Medicine, 720 Westview Drive Southwest, Atlanta, GA 30310, USA
| | - Jaime Matta
- Ponce School of Medicine, 388 Zona Ind Reparada 2, Ponce, PR 00716-2347, USA
| | - Idhaliz Flores
- Ponce School of Medicine, 388 Zona Ind Reparada 2, Ponce, PR 00716-2347, USA
| | - Roy Weiner
- Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70112, USA
| | - Timothy Turner
- Tuskegee University, 1200 West Montgomery Road, Tuskegee Institute, AL 36088, USA
| | - Lucio Miele
- University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA
| | - Thomas E Wiese
- Xavier University of Louisiana College of Pharmacy, 1 Drexel Drive, New Orleans, LA 70125, USA
| | - Mona Fouad
- University of Alabama at Birmingham Comprehensive Cancer Center, 1824 6th Avenue South, Birmingham, AL 35210, USA
| | - Carlos S Moreno
- Emory University, 615 Michael Street, Atlanta, GA 30322, USA
| | - Michelle Lacey
- Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70112, USA
| | - Debra W Christie
- University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA
| | - Eboni G Price-Haywood
- Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70112, USA
| | - Gwendolyn P Quinn
- H. Lee Moffitt Cancer Center & Research Institute, 12902 Magnolia Drive, Tampa, FL 33612, USA
| | - Domenico Coppola
- H. Lee Moffitt Cancer Center & Research Institute, 12902 Magnolia Drive, Tampa, FL 33612, USA
| | - Stephen O Sodeke
- Tuskegee University, 1200 West Montgomery Road, Tuskegee Institute, AL 36088, USA
| | - B Lee Green
- H. Lee Moffitt Cancer Center & Research Institute, 12902 Magnolia Drive, Tampa, FL 33612, USA
| | - Maureen Y Lichtveld
- Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70112, USA
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Lee JH, Fulp W, Wells KJ, Meade CD, Calcano E, Roetzheim R. Effect of patient navigation on time to diagnostic resolution among patients with colorectal cancer-related abnormalities. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2014; 29:144-50. [PMID: 24113902 PMCID: PMC3945676 DOI: 10.1007/s13187-013-0561-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
The objective of this study is to evaluate whether a patient navigation (PN) program is effective in reducing delay in diagnostic resolution among medically underserved patients with colorectal cancer (CRC)-related abnormalities in Tampa Bay, Florida. This study involved ten primary care clinics randomized either to receive navigation or to serve as controls (five clinics per arm). Each clinic identified all subjects with CRC-related abnormalities in the year prior to the clinic beginning participation in the Moffitt Patient Navigator Research Program. Patients with CRC-related abnormalities were navigated from the time of a colorectal abnormality to diagnostic resolution. Control patients received usual care, and outcome information was obtained from medical record abstraction. Using a frailty Cox proportional hazard model, we examined the length of time between colorectal abnormality and definitive diagnosis. One hundred ninety-three patients were eligible for the study because of a CRC-related abnormality (75 navigated and 118 controls). Analysis of PN effect by two time periods of resolution (0-4 and >4 months) showed a lagged effect of PN. The adjusted time-varying PN effect on diagnostic resolution compared to the controls was marginally significant (adjusted hazard ratio [aHR] = 1.15, 95% confidence interval = 1.02-1.29) after controlling for insurance status. The predicted aHR at 4 months was 1.2, but showed no significant effect until 12 months. For patients having an abnormal symptom of CRC, PN appeared to have a positive effect over time and sped diagnostic resolution after 4 months. However, the small sample size limits drawing a definitive conclusion regarding the positive PN effect.
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Affiliation(s)
- Ji-Hyun Lee
- H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Drive, Tampa, FL, 33612, USA,
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Bensink ME, Ramsey SD, Battaglia T, Fiscella K, Hurd TC, McKoy JM, Patierno SR, Raich PC, Seiber EE, Mears VW, Whitley E, Paskett ED, Mandelblatt JS. Costs and outcomes evaluation of patient navigation after abnormal cancer screening: evidence from the Patient Navigation Research Program. Cancer 2014; 120:570-8. [PMID: 24166217 PMCID: PMC3946403 DOI: 10.1002/cncr.28438] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 08/01/2013] [Accepted: 08/21/2013] [Indexed: 11/11/2022]
Abstract
BACKGROUND Navigators can facilitate timely access to cancer services, but to the authors' knowledge there are little data available regarding their economic impact. METHODS The authors conducted a cost-consequence analysis of navigation versus usual care among 10,521 individuals with abnormal breast, cervical, colorectal, or prostate cancer screening results who enrolled in the Patient Navigation Research Program study from January 1, 2006 to March 31, 2010. Navigation costs included diagnostic evaluation, patient and staff time, materials, and overhead. Consequences or outcomes were time to diagnostic resolution and probability of resolution. Differences in costs and outcomes were evaluated using multilevel, mixed-effects regression modeling adjusting for age, race/ethnicity, language, marital status, insurance status, cancer, and site clustering. RESULTS The majority of individuals were members of a minority (70.7%) and uninsured or publically insured (72.7%). Diagnostic resolution was higher for navigation versus usual care at 180 days (56.2% vs 53.8%; P = .008) and 270 days (70.0% vs 68.2%; P < .001). Although there were no differences in the average number of days to resolution between the 2 groups (110 days vs 109 days; P = .63), the probability of ever having diagnostic resolution was higher for the navigation group versus the usual-care group (84.5% vs 79.6%; P < .001). The added cost of navigation versus usual care was $275 per patient (95% confidence interval, $260-$290; P < .001). There was no significant difference in stage distribution among the 12.4% of patients in the navigation group vs 11% of the usual-care patients diagnosed with cancer. CONCLUSIONS Navigation adds costs and modestly increases the probability of diagnostic resolution among patients with abnormal screening test results. Navigation is only likely to be cost-effective if improved resolution translates into an earlier cancer stage at the time of diagnosis.
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Affiliation(s)
- Mark E. Bensink
- Research and Economic Assessment in Cancer and Healthcare Group, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Scott D. Ramsey
- Research and Economic Assessment in Cancer and Healthcare Group, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Tracy Battaglia
- Women’s Health Unit, Department of Medicine and Women’s Health Interdisciplinary Research Center, Boston University School of Medicine, Boston, Massachusetts
| | - Kevin Fiscella
- Department of Family Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Thelma C. Hurd
- School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - June M. McKoy
- Departments of Medicine and Preventative Medicine, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Steven R. Patierno
- George Washington University Cancer Institute, Washington, District of Columbia
| | | | - Eric E. Seiber
- College of Public Health, Ohio State University, Columbus, Ohio
| | - Victoria Warren Mears
- Northwest Portland Area Indian Health Board, Northwest Tribal Epidemiology Center, Portland, Oregon
| | | | | | - Jeanne S. Mandelblatt
- Cancer Prevention and Control Program, Georgetown Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, District of Columbia
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Koester KA, Morewitz M, Pearson C, Weeks J, Packard R, Estes M, Tulsky J, Kang-Dufour M, Myers JJ. Patient navigation facilitates medical and social services engagement among HIV-infected individuals leaving jail and returning to the community. AIDS Patient Care STDS 2014; 28:82-90. [PMID: 24517539 DOI: 10.1089/apc.2013.0279] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
HIV-infected individuals leaving jails, facilities typically used to confine accused persons awaiting trial or to incarcerate persons for minor offenses, often face barriers to engagement with medical and social-support services. Patient navigation is a model that may ease these barriers by supporting individuals in negotiating fragmented and highly bureaucratic systems for services and care. While there is evidence linking navigation to a reduction in health disparities, little is known about the mechanisms by which the model works. We present findings of an ethnographic study of interactions between navigators and their clients: HIV-infected men and women recently released from jails in San Francisco, California. We conducted 29 field observations of navigators as they accompanied their clients to appointments, and 40 in-depth interviews with clients and navigators. Navigators worked on strengthening clients' abilities to engage with social-services and care systems. Building this strength required navigators to gain clients' trust by leveraging their own similar life experiences or expressing social concordance. After establishing meaningful connections, navigators spent time with clients in their day-to-day environments serving as mentors while escorting clients to and through their appointments. Intensive time spent together, in combination with a shared background of incarceration, HIV, and drug use, was a critical mechanism of this model. This study illustrates that socially concordant navigators are well positioned to facilitate successful transition to care and social-services engagement among a vulnerable population.
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Affiliation(s)
- Kimberly A. Koester
- Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco, California
| | - Mark Morewitz
- Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco, California
| | - Charles Pearson
- Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco, California
| | - John Weeks
- Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco, California
| | - Rebecca Packard
- Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco, California
| | - Milton Estes
- San Francisco Department of Public Health, San Francisco, California
| | - Jacqueline Tulsky
- Department of Medicine, Positive Health Program, University of California, San Francisco, California
| | - Mi_Suk Kang-Dufour
- Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco, California
| | - Janet J. Myers
- Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco, California
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Meyer AM, Wheeler SB, Weinberger M, Chen RC, Carpenter WR. An Overview of Methods for Comparative Effectiveness Research. Semin Radiat Oncol 2014; 24:5-13. [DOI: 10.1016/j.semradonc.2013.09.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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49
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Katz ML, Young GS, Reiter PL, Battaglia TA, Wells KJ, Sanders M, Simon M, Dudley DJ, Patierno SR, Paskett ED. Barriers reported among patients with breast and cervical abnormalities in the patient navigation research program: impact on timely care. Womens Health Issues 2014; 24:e155-62. [PMID: 24439942 PMCID: PMC3896921 DOI: 10.1016/j.whi.2013.10.010] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Revised: 10/25/2013] [Accepted: 10/28/2013] [Indexed: 12/28/2022]
Abstract
BACKGROUND Patient navigation (PN) is a system-level strategy to decrease cancer mortality rates by reducing barriers to cancer care. Barriers to resolution among participants in the PN intervention arm with a breast or cervical abnormality in the Patient Navigation Research Program and navigators' actions to address those barriers were examined. METHODS Data from seven institutions (2005-2010) included 1,995 breast and 1,194 cervical patients. A stratified Cox proportional hazards regression model was used to examine the effects of barriers on time to resolution of an abnormal screening test or clinical finding. FINDINGS The range of unique barriers was 0 to 12 and 0 to 7 among participants with breast and cervical abnormalities, respectively. About two thirds of breast and one half of cervical participants had at least one barrier resulting in longer time to diagnostic resolution among breast (adjusted hazard ratio [HR], 0.744; p < .001) and cervical (adjusted HR, 0.792; p < .001) participants. Patient- and system-level barriers were most common. Frequent navigator actions were making arrangements, scheduling appointments, referrals, and education. CONCLUSIONS Having a barrier resulted in a delay in diagnostic resolution of an abnormal screening test or clinical finding. Health care systems can use these findings to improve existing PN programs or when developing new programs.
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Affiliation(s)
| | | | | | | | | | | | | | - Donald J Dudley
- University of Texas Health Science Center at San Antonio, San Antonio, Texas
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50
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DeGroff A, Coa K, Morrissey KG, Rohan E, Slotman B. Key considerations in designing a patient navigation program for colorectal cancer screening. Health Promot Pract 2013; 15:483-95. [PMID: 24357862 DOI: 10.1177/1524839913513587] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Colorectal cancer is the second leading cause of cancer mortality among those cancers affecting both men and women. Screening is known to reduce mortality by detecting cancer early and through colonoscopy, removing precancerous polyps. Only 58.6% of adults are currently up-to-date with colorectal cancer screening by any method. Patient navigation shows promise in increasing adherence to colorectal cancer screening and reducing health disparities; however, it is a complex intervention that is operationalized differently across institutions. This article describes 10 key considerations in designing a patient navigation intervention for colorectal cancer screening based on a literature review and environmental scan. Factors include (1) identifying a theoretical framework and setting program goals, (2) specifying community characteristics, (3) establishing the point(s) of intervention within the cancer continuum, (4) determining the setting in which navigation services are provided, (5) identifying the range of services offered and patient navigator responsibilities, (6) determining the background and qualifications of navigators, (7) selecting the method of communications between patients and navigators, (8) designing the navigator training, (9) defining oversight and supervision for the navigators, and (10) evaluating patient navigation. Public health practitioners can benefit from the practical perspective offered here for designing patient navigation programs.
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Affiliation(s)
- Amy DeGroff
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Kisha Coa
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Elizabeth Rohan
- Centers for Disease Control and Prevention, Atlanta, GA, USA
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