Key considerations in designing a patient navigation program for colorectal cancer screening

Comparative effectiveness of two interventions to increase colorectal cancer screening among females living in the rural Midwest

PURPOSE

To assess the comparative effectiveness of a tailored, interactive digital video disc (DVD) intervention versus DVD plus patient navigation (PN) intervention versus usual care (UC) on the uptake of colorectal cancer (CRC) screening among females living in Midwest rural areas.

METHODS

As part of a larger study, 663 females (ages 50-74) living in rural Indiana and Ohio and not up-to-date (UTD) with CRC screening at baseline were randomized to one of three study groups. Demographics , health status/history, and beliefs and attitudes about CRC screening were measured at baseline. CRC screening was assessed at baseline and 12 months from medical records and self-report. Multivariable logistic regression was used to determine whether females in each group were UTD for screening and which test they completed.

RESULTS

Adjusted for covariates, females in the DVD plus PN group were 3.5× more likely to complete CRC screening than those in the UC group (odds ratio [OR] 3.62; 95% confidence interval [CI]: 2.09, 6.47) and baseline intention to receive CRC screening (OR 3.45, CI: 2.21,5.42) at baseline. Adjusting for covariates, there was no difference by study arm whether females who became UTD for CRC screening chose to complete a colonoscopy or fecal occult blood test/fecal immunochemical test.

CONCLUSIONS

Many females living in the rural Midwest are not UTD for CRC screening. A tailored intervention that included an educational DVD and PN improved knowledge, addressed screening barriers, provided information about screening test options, and provided support was more effective than UC and DVD-only to increase adherence to recommended CRC screening.

Reach and effectiveness of a centralized navigation program for patients with positive fecal immunochemical tests requiring follow-up colonoscopy

Completion rates for follow-up colonoscopies after an abnormal fecal immunochemical test (FIT) are suboptimal in federally qualified health center (FQHC) settings. We implemented a screening intervention that included mailed FIT outreach to North Carolina FQHC patients from June 2020 to September 2021 and centralized patient navigation to support patients with abnormal FITs in completing follow-up colonoscopy. We evaluated the reach and effectiveness of navigation using electronic medical record data and navigator call logs detailing interactions with patients. Reach assessments included the proportion of patients successfully contacted by phone and who agreed to participate in navigation, intensity of navigation provided (including types of barriers to colonoscopy identified and total navigation time), and differences in these measures by socio-demographic characteristics. Effectiveness outcomes included colonoscopy completion, timeliness of follow-up colonoscopy (i.e., within 9 months), and bowel prep adequacy. Among 514 patients who completed a mailed FIT, 38 patients had an abnormal result and were eligible for navigation. Of these, 26 (68%) accepted navigation, 7 (18%) declined, and 5 (13%) could not be contacted. Among navigated patients, 81% had informational needs, 38% had emotional barriers, 35% had financial barriers, 12% had transportation barriers, and 42% had multiple barriers to colonoscopy. Median navigation time was 48.5 min (range: 24-277 min). Colonoscopy completion differed across groups - 92% of those accepting navigation completed colonoscopy within 9 months, versus 43% for those declining navigation. We found that centralized navigation was widely accepted in FQHC patients with abnormal FIT, and was an effective strategy, resulting in high colonoscopy completion rates.

Components and effectiveness of patient navigation programmes to increase participation to breast, cervical and colorectal cancer screening: A systematic review

BACKGROUND

Inequalities in cancer incidence and mortality can be partly explained by unequal access to high-quality health services, including cancer screening. Several interventions have been described to increase access to cancer screening, among them patient navigation (PN), a barrier-focused intervention. This systematic review aimed to identify the reported components of PN and to assess the effectiveness of PN to promote breast, cervical and colorectal cancer screening.

METHODS

We searched Embase, PubMed and Web of Science Core Collection databases. The components of PN programmes were identified, including the types of barriers addressed by navigators. The percentage change in screening participation was calculated.

RESULTS

The 44 studies included were mainly on colorectal cancer and were conducted in the USA. All described their goals and community characteristics, and the majority reported the setting (97.7%), monitoring and evaluation (97.7%), navigator background and qualifications (81.4%) and training (79.1%). Supervision was only referred to in 16 studies (36.4%). Programmes addressed mainly barriers at the educational (63.6%) and health system level (61.4%), while only 25.0% reported providing social and emotional support. PN increased cancer screening participation when compared with usual care (0.4% to 250.6% higher) and educational interventions (3.3% to 3558.0% higher).

CONCLUSION

Patient navigation programmes are effective at increasing participation to breast, cervical and colorectal cancer screening. A standardized reporting of the components of PN programmes would allow their replication and a better measure of their impact. Understanding the local context and needs is essential to design a successful PN programme.

Assessing the effectiveness of a community health advisor plus screen to save educational intervention on stool-based testing adherence in an African American safety net clinic population: study protocol for a randomized pragmatic trial

Background

Colorectal cancer (CRC) is the second most deadly cancer affecting US adults and is also one of the most treatable cancers when detected at an earlier clinical stage of disease through screening. CRC health disparities experienced by African Americans are due in part to the later stage of diagnosis, suggesting the importance of improving African Americans’ CRC screening participation. The national Screen to Save (S2S) initiative employs a community health educator to deliver CRC screening education which can be tailored for specific populations, and such approaches have increased CRC screening rates in disadvantaged and racial/ethnic minority populations.

Methods/design

In this trial emphasizing stool-based CRC screening, focus groups informed the development of an adapted S2S video and brochure tailored for African Americans and identified preferred motivational text messages for a multicomponent community health advisor (CHA) intervention. A CHA hired from the community was trained to deliver a 6-week CRC educational intervention consisting of an initial face-to-face meeting followed by 5 weeks of calls and texts. Interested eligible persons are enrolled primarily through recruitment by two partnering community health centers (CHCs) and secondarily through various outreach channels and, after consenting and completing a baseline survey, are randomly assigned to one of two study arms. The CHCs are blinded to study arm assignment. Intervention arm participants receive the brochure and CHA intervention while participants assigned to the control group receive only the brochure. All participants receive a stool-based CRC screening test from their health center, and the primary outcome is the completion of the screening test at 12 months. Secondary objectives are to estimate the effect of the intervention on mediating factors, explore the effect of moderating factors, and perform a cost-effectiveness analysis of the CHA intervention.

Discussion

The TUNE-UP study will enhance understanding about CRC screening in African Americans obtaining primary health care through CHCs and is one of the very few studies to examine a CHA intervention in this context. A better understanding of the mechanisms by which the intervention affects patient beliefs and behaviors will help focus future research while the exploratory cost-effectiveness analysis will inform CHCs’ decision-making about implementing a CHA program to increase screening and reduce cancer health disparities.

Trial registration

ClinicalTrials.govNCT04304001. Registered on March 11, 2020.

Cost-Effectiveness of Community-to-Clinic Tailored Navigation for Colorectal Cancer Screening in an Underserved Population: Economic Evaluation Alongside a Group-Randomized Trial

PURPOSE

Although screening for colorectal cancer (CRC) lowers mortality and morbidity and is generally cost-effective, little is known about the cost-effectiveness of screening promotion.

DESIGN

Cost-effectiveness analysis alongside a group-randomized trial. Setting: Multicultural, underinsured communities in the Phoenix, Arizona, area.

SUBJECTS

English- or Spanish-speaking adults who were out of compliance for CRC screening guidelines.

INTERVENTION

All participants received community-based group education (GE), and the intervention group also received tailored community-to-clinic navigation (GE+TN).

MEASURES

Number of participants screened and costs of tailored navigation, clinic visits, and CRC screening tests.

ANALYSIS

Incremental cost per additional person screened from the perspective of the healthcare system with bootstrapped confidence intervals.

RESULTS

Community sites were recruited and randomized to GE (n = 120) and GE + TN (n = 119). Across these sites 1154 individuals were screened, 504 were eligible, and 345 attended the group education class (n = 134 GE; n = 211 GE + TN). Screening rates (26.5% GE + TN; 10.4% GE; 16.1% increase 95% CI: 7%, 23%) and costs per participant ($271 GE + TN; $167 GE; a net cost increase of $104 95% CI: $1, $189) were significantly higher in the intervention group. Incremental cost-effectiveness was $646 (95% CI: -$68, $953) per additional person screened.

CONCLUSION

Depending on the value placed on an additional person screened, the addition of community-to-clinic tailored navigation to a community-based CRC screening promotion program may be highly cost-effective.

Use of environmental scans in health services delivery research: a scoping review

OBJECTIVE

To examine the extent and nature of evidence on the use of the environmental scan (ES) in the health services delivery literature.

DESIGN

Scoping review.

METHODS

This scoping review followed the five-stage scoping review methodology outlined by Khalil et al. A Peer Review of Electronic Search Strategies was completed. Seven electronic databases and the grey literature were searched. Pairs of researchers independently performed two levels of screening and data extraction. Data were analysed using qualitative content and thematic analysis.

RESULTS

Ninety-six studies were included in the scoping review. Researchers conducted ESs for many purposes, the most common being to examine the current state of programmes, services or policies. Recommendations were informed by ESs in 20% of studies. Most common data collection methods were literature review (71%), key informant or semistructured interviews (46%) and surveys (35%). Over half (53%) of the studies used a combination of passive (looking at information eg, literature, policies, guidelines) and active (looking for information eg, surveys, interviews) approaches to data collection. Person sources of data (eg, healthcare stakeholders, community representatives) and non-person sources of data (eg, documents, electronic databases, the web) were drawn on to a similar extent. The thematic analysis of the definitions/descriptions yielded several themes including instrument of discovery, knowledge synthesis, forward-looking and decision making. Research gaps identified included absence of a standard definition, inconsistencies in terminology and lack of guiding frameworks in the health services delivery context.

CONCLUSION

ESs were conducted to gather evidence and to help inform decision making on a range of policy and health services delivery issues across the continuum of care. Consistency in terminology, a consensus definition and more guidance on ES design may help provide structure for researchers and other stakeholders, and ultimately advance ES as a methodological approach. A working definition of ES in a health services delivery context is presented.

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

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.

Peer Support Interventions in Physical Medicine and Rehabilitation: A Framework to Advance the Field

Peer support is a central tenet of the Disability Rights Movement and is based on the recognition that experiential knowledge and shared experiences provide opportunities for informational, emotional, and appraisal support among people with physical disabilities. "Peer support interventions" is an umbrella term used to describe a range of ancillary services provided by people with disabilities to people with disabilities, including peer mentoring, peer health education, and peer health navigation. A growing body of research documents the development, implementation, and outcomes of peer support interventions for people with physical disabilities in physical medicine and rehabilitation. The organization, structure, and objectives of peer support interventions vary tremendously, making it difficult to synthesize findings across studies and establish best practices to support their systematic implementation across the continuum of care. This article is a call to action for greater conceptual clarity in how peer support interventions are developed, implemented, and evaluated. We propose a 9-part evidence-informed framework delineating both theory-driven and contextual considerations to help strengthen the evidence base of peer support interventions for people with disabilities in physical medicine and rehabilitation.

The Effects of the Nurse Navigation Program in Promoting Colorectal Cancer Screening Behaviors: a Randomized Controlled Trial

Although screening programs are known and recommended for the early detection of colorectal cancer (CRC), the screening rates for the fecal occult blood test (FOBT) and colonoscopy are very low among adult individuals. Navigation programs, also known as individualized counseling, have recently begun to be used for increasing screening rates. The purpose of this study was to compare the efficacy of the Nurse Navigation Program versus usual care on CRC screening participation and movement in stage of adoption for CRC screening and to examine perceived benefits of and barriers to CRC screening. This study was designed in line with a pre- and posttest two-group methodology. A total of 110 participants (55 nurse-navigated and 55 non-navigated patients) were studied. Data were collected using the following three tools: a sociodemographic information form, the Harvard Colorectal Cancer Risk Assessment Tool, and Instruments to Measure Colorectal Cancer Screening Benefits and Barriers. Following the Nurse Navigation Program, the FOBT (82 and 84%, respectively) and colonoscopy completion rates (15 and 22%, respectively) were significantly higher in the nurse-navigated group than in the non-navigated group at 3 and 6 months follow-up. Following the program, the benefit perceptions of the nurse-navigated group about CRC screening were improved, and their barrier perceptions were reduced. The results showed that the Nurse Navigation Program had significant effects on CRC screening behavior and health-related beliefs concerning CRC screening. Further assessment of the Nurse Navigation Program in different groups should be performed to observe its effects.

Evaluating an Online Training Course to Develop and Sustain Cancer Navigation and Survivorship Programs

OBJECTIVES

To evaluate the impact of the Executive Training on Navigation and Survivorship (Executive Training) online training course, designed by the George Washington University Cancer Center, on nurses and other healthcare professionals.

SAMPLE & SETTING

A volunteer sample of 499 healthcare professionals, including nurses and patient navigators, were recruited through multiple Internet-based channels.

METHODS & VARIABLES

Participants completed questionnaires before and after each module and at the end of the training. Descriptive statistics were calculated, and paired t tests were used to assess pre- and post-test learning confidence gains for each module. Qualitative feedback from participants was also summarized.

RESULTS

From pre- to post-test, each group demonstrated statistically significant improvements in confidence (p < 0.05) for all seven training modules. Confidence gains were statistically significant for 19 of 20 learning objectives (p < 0.05). Overall rating scores and qualitative feedback were positive.

IMPLICATIONS FOR NURSING

The Executive Training course prepares healthcare professionals from diverse backgrounds to establish navigation and survivorship programs. In addition, the training content addresses gaps in nursing education on planning and budgeting that can improve success.

Our Peers-Empowerment and Navigational Support (OP-ENS): Development of a Peer Health Navigator Intervention to Support Medicaid Beneficiaries With Physical Disabilities

People with disabilities (PWD) are a health disparities population who experience well-documented physical, structural, attitudinal, and financial barriers to health care. The disability rights community is deeply engaged in advocacy to promote health care justice for all PWD. As the community continues to work toward systems change, there is a critical need for community-directed interventions that ensure individuals with disabilities are able to access the health care services they need and are entitled to. Peer health navigator (PHN) programs have been shown to help people from diverse underserved communities break down barriers to health care. The PHN model has not been systematically adapted to meet the needs of PWD. In this article, we describe the collaborative process of developing Our Peers—Empowerment and Navigational Supports (OP-ENS), an evidence-informed PHN intervention for Medicaid beneficiaries with physical disabilities in Chicago, IL, USA. Our Peers—Empowerment and Navigational Supports is a 12-month community-based PHN intervention that pairs Medicaid beneficiaries with physical disabilities (peers) with disability PHNs who use a structured recursive process of barrier identification and asset mapping, goal setting, and action planning to help peers meet their health care needs. Our Peers—Empowerment and Navigational Supports was developed by a collaborative team that included disability rights leaders, representatives from a Medicaid managed care organization, and academic disability health care justice researchers. We highlight both the conceptual and empirical evidence that informed OP-ENS as well as the lessons learned that can assist future developers.

Use of Health Information Technology among Patient Navigators in Community Health Interventions

Overview

As chronic disease and comorbidities increase, so does the complexity of patient care.This complexity requires interdisciplinary care teams and multifactor interventions to ensure that patients get the most efficient care. Patient navigators-defined as individuals who help patients move through the complex care continuum-can improve access to care and patient engagement, which can translate into better outcomes. Health information technology (health IT) can support timely communication and information sharing for patient navigators and the providers with whom they interact to better coordinate care. We explored the health IT that patient navigators used, how they used it, and their health IT needs in community-based interventions.

Methods

We analyzed three years of qualitative program evaluation data captured though progress reports, site visits, and telephone interviews as part of a larger evaluation of community-based demonstration projects. We used inductive analysis to identify preliminary themes to develop a codebook. Using QSR International's NVivo qualitative analysis software (version 11.0), we then used the preliminary themes in a second round of independent coding. We identified themes relevant to navigators and to barriers and facilitators for health IT. Coders achieved a final kappa of 0.8, suggesting excellent interrater reliability.

Results

Navigators used various types of health IT (e.g., health information exchanges, electronic health records, short message service) to capture and share information with the rest of the care team. Navigators used technology to document patient information, track services, and schedule appointments for patients; however, some respondents reported challenges with systems that were not integrated. Navigators must learn to use health IT systems of varying complexity to complete their job duties.

Discussion

Health IT can improve workflow by facilitating task organization and communication with the care team. Ultimately, integrating the health IT systems used by navigators with those used by other care team members was most beneficial. Because of the various types of health IT used, patient navigators should receive training to ensure that they have the technical skills to use these systems efficiently and reduce duplication of effort.

Conclusion

Managing the care of patients with chronic disease requires comprehensive care teams, which can include patient navigators. Integrating navigators' documentation into other health IT systems can keep providers updated on information while patients are outside of the providers' care. With the growth of health IT use in recent years, technical skills are becoming increasingly important. These findings can help leaders who are planning complex health interventions involving navigators to ensure that technology is used efficiently to support coordination and allow navigators to reach more patients.

Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society

In the United States, colorectal cancer (CRC) is the fourth most common cancer diagnosed among adults and the second leading cause of death from cancer. For this guideline update, the American Cancer Society (ACS) used an existing systematic evidence review of the CRC screening literature and microsimulation modeling analyses, including a new evaluation of the age to begin screening by race and sex and additional modeling that incorporates changes in US CRC incidence. Screening with any one of multiple options is associated with a significant reduction in CRC incidence through the detection and removal of adenomatous polyps and other precancerous lesions and with a reduction in mortality through incidence reduction and early detection of CRC. Results from modeling analyses identified efficient and model-recommendable strategies that started screening at age 45 years. The ACS Guideline Development Group applied the Grades of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria in developing and rating the recommendations. The ACS recommends that adults aged 45 years and older with an average risk of CRC undergo regular screening with either a high-sensitivity stool-based test or a structural (visual) examination, depending on patient preference and test availability. As a part of the screening process, all positive results on noncolonoscopy screening tests should be followed up with timely colonoscopy. The recommendation to begin screening at age 45 years is a qualified recommendation. The recommendation for regular screening in adults aged 50 years and older is a strong recommendation. The ACS recommends (qualified recommendations) that: 1) average-risk adults in good health with a life expectancy of more than 10 years continue CRC screening through the age of 75 years; 2) clinicians individualize CRC screening decisions for individuals aged 76 through 85 years based on patient preferences, life expectancy, health status, and prior screening history; and 3) clinicians discourage individuals older than 85 years from continuing CRC screening. The options for CRC screening are: fecal immunochemical test annually; high-sensitivity, guaiac-based fecal occult blood test annually; multitarget stool DNA test every 3 years; colonoscopy every 10 years; computed tomography colonography every 5 years; and flexible sigmoidoscopy every 5 years. CA Cancer J Clin 2018;68:250-281. © 2018 American Cancer Society.

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A theory-driven tailored intervention developed in partnership with the community used evidence-based practices to (a) increase knowledge about colon cancer and screening and (b) assist patients in completing screenings. During the 16 months of delivery screening, patient navigators integrated into gastroenterology clinics met all goals, which included (a) enrolling an ethnically diverse group of participants ( N = 415) through inreach (clinic-referred patients who did not schedule appointments) and community outreach, (b) facilitating screening completions for 217 of the 358 (61%) patients identified as needing screening, and (c) obtaining satisfaction ratings from 89% of participants. A random sample ( N = 214) of nonnavigated patients matched on gender and age revealed no differences between navigated and nonnavigated patients on polyps detected. Navigated males (but not females) were significantly less likely than nonnavigated males to have either poor or only fair bowel preparation quality (odds ratio = .418, p = .020, 95% confidence interval [.197, .885]). Low-quality bowel preparation can lead to incomplete readings of the colon or cancelling a colonoscopy. This intervention demonstrates that evidence-based patient navigator programs are effective in increasing screening among a hard-to-reach population and improving bowel preparation quality for males.

What are patient navigators doing, for whom, and where? A national survey evaluating the types of services provided by patient navigators

OBJECTIVE

A nationwide cross-sectional study was conducted to assess patient navigator, patient population, and work setting characteristics associated with performance of various patient navigation (PN) tasks.

METHODS

Using respondent-driven sampling, 819 navigators completed a survey assessing frequency of providing 83 PN services, along with information about themselves, populations they serve, and setting in which they worked. Analyses of variance and Pearson correlations were conducted to determine differences and associations in frequency of PN services provided by various patient, navigator, and work setting characteristics.

RESULTS

Nurse navigators and navigators with lower education provide basic navigation; social workers typically made arrangements and referrals; and individuals with higher education, social workers, and nurses provide treatment support and clinical trials/peer support. Treatment support and clinical trials/peer support are provided to individuals with private insurance. Basic navigation, arrangements and referrals, and care coordination are provided to individuals with Medicaid or no insurance.

CONCLUSION

Providing basic navigation is a core competency for patient navigators. There may be two different specialties of PN, one which seeks to reduce health disparities and a second which focuses on treatment and emotional support.

PRACTICE IMPLICATIONS

The selection and training of patient navigators should reflect the specialization required for a position.

Patient Navigation for Colonoscopy Completion: Results of an RCT

INTRODUCTION

Colorectal cancer is a leading cause of cancer-related death in the U.S. Although screening reduces colorectal cancer incidence and mortality, screening rates among U.S. adults remain less than optimal, especially among disadvantaged populations. This study examined the efficacy of patient navigation to increase colonoscopy screening.

STUDY DESIGN

RCT.

SETTING/PARTICIPANTS

A total of 843 low-income adults, primarily Hispanic and non-Hispanic blacks, aged 50-75 years referred for colonoscopy at Boston Medical Center were randomized into the intervention (n=429) or control (n=427) groups. Participants were enrolled between September 2012 and December 2014, with analysis following through 2015.

INTERVENTION

Two bilingual lay navigators provided individualized education and support to reduce patient barriers and facilitate colonoscopy completion. The intervention was delivered largely by telephone.

MAIN OUTCOME MEASURE

Colonoscopy completion within 6 months of study enrollment.

RESULTS

Colonoscopy completion was significantly higher for navigated patients (61.1%) than control group patients receiving usual care (53.2%, p=0.021). Based on regression analysis, the odds of completing a colonoscopy for navigated patients was one and a half times greater than for controls (95% CI=1.12, 2.03, p=0.007). There were no differences between navigated and control groups in regard to adequacy of bowel preparation (95.3% vs 97.3%, respectively).

CONCLUSIONS

Navigation significantly improved colonoscopy screening completion among a racially diverse, low-income population. Results contribute to mounting evidence demonstrating the efficacy of patient navigation in increasing colorectal cancer screening. Screening can be further enhanced when navigation is combined with other evidence-based practices implemented in healthcare systems and the community.

Use of Community Health Workers and Patient Navigators to Improve Cancer Outcomes Among Patients Served by Federally Qualified Health Centers: A Systematic Literature Review

Introduction: In the United States, disparities in cancer screening, morbidity, and mortality are well documented, and often are related to race/ethnicity and socioeconomic indicators including income, education, and healthcare access. Public health approaches that address social determinants of health have the greatest potential public health benefit, and can positively impact health disparities. As public health interventions, community health workers (CHWs), and patient navigators (PNs) work to address disparities and improve cancer outcomes through education, connecting patients to and navigating them through the healthcare system, supporting patient adherence to screening and diagnostic services, and providing social support and linkages to financial and community resources. Clinical settings, such as federally qualified health centers (FQHCs) are mandated to provide care to medically underserved communities, and thus are also valuable in the effort to address health disparities. We conducted a systematic literature review to identify studies of cancer-related CHW/PN interventions in FQHCs, and to describe the components and characteristics of those interventions in order to guide future intervention development and evaluation.

Method: We searched five databases for peer-reviewed CHW/PN intervention studies conducted in partnership with FQHCs with a focus on cancer, carried out in the United States, and published in English between January 1990 and December 2013.

Results: We identified 24 articles, all reporting positive outcomes of CHW/PNs interventions in FQHCs. CHW/PN interventions most commonly promoted breast, cervical, or colorectal cancer screening and/or referral for diagnostic resolution. Studies were supported largely through federal funding. Partnerships with academic institutions and community-based organizations provided support and helped develop capacity among FQHC clinic leadership and community members.

Discussion: Both the FQHC system and CHW/PNs were borne from the need to address persistent, complex health disparities among medically underserved communities. Our findings support the effectiveness of CHW/PN programs to improve completion and timeliness of breast, cervical, and colorectal cancer screening in FQHCs, and highlight intervention components useful to design and sustainability.

Characteristics of Effective Colorectal Cancer Screening Navigation Programs in Federally Qualified Health Centers: A Systematic Review

In the U.S., colorectal cancer (CRC) incidence and mortality have declined due to screening and improvements in early detection; however, racial/ethnic disparities in screening and mortality persist. Patient navigation has been shown to be effective in increasing CRC screening prevalence. This systematic review answered three questions about navigation in federally qualified community health centers (FQHCs): 1) Which navigation activities increased CRC screening prevalence? 2) What were the challenges to implementing these programs in FQHCs? 3) Which clinic protocols supported screening completion? Findings suggest that navigation services must be tailored to the specific screening test provided. Federally qualified community health centers report difficulty maintaining a current electronic medical records system and sustaining funding; they should establish excellent patient tracking systems (for follow-up and annual rescreening) and establish multiple protocols to facilitate screening completion. With the movement toward patient-centered care models, patient navigation will be integral to FQHCs and their clients.

Toward the Elimination of Colorectal Cancer Disparities Among African Americans

BACKGROUND

In the USA, race and socioeconomic status are well-known factors associated with colorectal cancer incidence and mortality rates. These are higher among blacks than whites and other racial/ethnic groups.

METHODS

In this article, we review opportunities to address disparities in colorectal cancer incidence, mortality, and survivorship among African Americans.

RESULTS

First, we summarize the primary prevention of colorectal cancer and recent advances in the early detection of the disease and disparities in screening. Then, we consider black-white disparities in colorectal cancer treatment and survival including factors that may contribute to such disparities and the important roles played by cultural competency, patient trust in one's physician, and health literacy in addressing colorectal cancer disparities, including the need for studies involving the use of colorectal cancer patient navigators who are culturally competent.

CONCLUSION

To reduce these disparities, intervention efforts should focus on providing high-quality screening and treatment for colorectal cancer and on educating African Americans about the value of diet, weight control, screening, and treatment. Organized approaches for delivering colorectal cancer screening should be accompanied by programs and policies that provide access to diagnostic follow-up and treatment for underserved populations.

Patient-Reported Attributions for Missed Colonoscopy Appointments in Two Large Healthcare Systems

BACKGROUND

Missed colonoscopy appointments (no-shows) can lead to wasted resources and delays in colorectal cancer diagnosis, an area of special concern in public health systems that often provide care for vulnerable patients. Our objective was to identify reasons for missed colonoscopy appointments in patients seeking care at two large public health systems in Houston, TX.

METHODS

We conducted a telephone survey of patients who missed their colonoscopy appointments at two tertiary care health systems. Using a structured survey instrument, we collected information on patient-specific and health services barriers. Patient-specific barriers included perceived procedural-related factors (e.g., difficulty in preparation), cognitive-emotional factors (e.g., fear or concern about modesty), and changes in health status (e.g., improvement or worsening of health). Health services barriers included logistical factors (e.g., travel-related difficulties) and appointment scheduling problems (inconvenient date or time). We examined differences in attributions for missed appointments between the two study sites.

RESULTS

Of 160 unique patients (102 Site A and 58 Site B) who missed their appointment during the study period, 153 (95.6 %) attributed their no-show to at least one of the listed barriers. Most respondents (125; 78.1 %) cited travel-related issues or scheduling problems as reasons for their missed appointment. Not having a ride or a travel companion was the most commonly reported travel-related issue. We also found significant differences for barriers between the two sites.

CONCLUSIONS

Most missed colonoscopy appointments resulted from potentially preventable travel- and scheduling-related issues. Because barriers to keeping colonoscopy appointments are different across health systems, each health system might need to develop unique interventions to reduce missed colonoscopy appointments.

Use of Evidence-Based Interventions to Address Disparities in Colorectal Cancer Screening

Colorectal cancer (CRC) is the second leading cause of cancer death among cancers that affect both men and women. Despite strong evidence of their effectiveness, CRC screening tests are underused. Racial/ethnic minority groups, persons without insurance, those with lower educational attainment, and those with lower household income levels have lower rates of CRC screening. Since 2009, CDC's Colorectal Cancer Control Program (CRCCP) has supported state health departments and tribal organizations in implementing evidence-based interventions (EBIs) to increase use of CRC screening tests among their populations. This report highlights the successful implementation of EBIs to address disparities by two CRCCP grantees: the Alaska Native Tribal Health Consortium (ANTHC) and Washington State's Breast, Cervical, and Colon Health Program (BCCHP). ANTHC partnered with regional tribal health organizations in the Alaska Tribal Health System to implement provider and client reminders and use patient navigators to increase CRC screening rates among Alaska Native populations. BCCHP identified patient care coordinators in each clinic who coordinated staff training on CRC screening and integrated client and provider reminder systems. In both the Alaska and Washington programs, instituting provider reminder systems, client reminder systems, or both was facilitated by use of electronic health record systems. Using multicomponent interventions in a single clinical site or facility can support more organized screening programs and potentially result in greater increases in screening rates than relying on a single strategy. Organized screening systems have an explicit policy for screening, a defined target population, a team responsible for implementation of the screening program, and a quality assurance structure. Although CRC screening rates in the United States have increased steadily over the past decade, this increase has not been seen equally across all populations. Increasing the use of EBIs, such as those described in this report, in health care clinics and systems that serve populations with lower CRC screening rates could substantially increase CRC screening rates.

Training in Patient Navigation: A Review of the Research Literature

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.

Patient navigation to increase colorectal cancer screening among Latino Medicare enrollees: a randomized controlled trial

PURPOSE

Latino Medicare enrollees report suboptimal rates of colorectal cancer screening (CRCS) despite Medicare policies designed to improve CRCS access for older persons. Patient navigation (PN) may address many underlying barriers to CRCS, yet little is known about the effectiveness of PN to increase CRCS adherence among Latino Medicare enrollees.

METHODS

Using a randomized controlled trial study design, we evaluated tailored PN delivered outside of primary care settings as an intervention to increase CRCS adherence in this population. Intervention participants (n = 135) received tailored PN services which included education, counseling, and logistical support administered in their language of choice. Comparison participants (n = 168) received mailed cancer education materials. We compared CRCS rates between interventions and used multivariable logistic regression to assess the odds of CRCS adherence for PN versus comparison groups after adjusting for covariates of interest.

RESULTS

More navigated than non-navigated participants became CRCS adherent during the study period (43.7 vs. 32.1%, p = 0.04). The odds of CRCS adherence were significantly higher for PN relative to comparison participants before and after adjusting for covariates (unadjusted OR 1.64, p = 0.04; adjusted OR 1.82, p = 0.02). Higher CRCS adherence rates were observed primarily in the uptake of endoscopic screening methods.

CONCLUSION

This study demonstrates that PN delivered outside of the primary care environment is modestly effective in increasing CRCS adherence among Latino Medicare enrollees. This intervention strategy should be further evaluated as a complement to primary care-based PN and other care coordination strategies to increase adherence with CRCS and other evidence-based screenings among older Latinos.

A Process Evaluation of the Alaska Native Colorectal Cancer Family Outreach Program

This article presents the results of a process evaluation of the Alaska Native (AN) Colorectal Cancer (CRC) Family Outreach Program, which encourages CRC screening among AN first-degree relatives (i.e., parents, siblings, adult children; hereafter referred to as relatives) of CRC patients. Among AN people incidence and death rates from CRC are the highest of any ethnic/racial group in the United States. Relatives of CRC patients are at increased risk; however, CRC can be prevented and detected early through screening. The evaluation included key informant interviews (August to November 2012) with AN and non-AN stakeholders and program document review. Five key process evaluation components were identified: program formation, evolution, outreach responses, strengths, and barriers and challenges. Key themes included an incremental approach that led to a fully formed program and the need for dedicated, culturally competent patient navigation. Challenges included differing relatives' responses to screening outreach, health system data access and coordination, and the program impact of reliance on grant funding. This program evaluation indicated a need for more research into motivating patient screening behaviors, electronic medical records systems quality improvement projects, improved data-sharing protocols, and program sustainability planning to continue the dedicated efforts to promote screening in this increased risk population.

Promotion and provision of colorectal cancer screening: a comparison of colorectal cancer control program grantees and nongrantees, 2011-2012

INTRODUCTION

Since 2009, the Centers for Disease Control and Prevention (CDC) has awarded nearly $95 million to 29 states and tribes through the Colorectal Cancer Control Program (CRCCP) to fund 2 program components: 1) providing colorectal cancer (CRC) screening to uninsured and underinsured low-income adults and 2) promoting population-wide CRC screening through evidence-based interventions identified in the Guide to Community Preventive Services (Community Guide). CRCCP is a new model for disseminating and promoting use of evidence-based interventions. If the program proves successful, CDC may adopt the model for future cancer control programs. The objective of our study was to compare the colorectal cancer screening practices of recipients of CRCCP funding (grantees) with those of nonrecipients (nongrantees).

METHODS

We conducted parallel Web-based surveys in 2012 with CRCCP grantees (N = 29) and nongrantees (N = 24) to assess promotion and provision of CRC screening, including the use of evidence-based interventions.

RESULTS

CRCCP grantees were significantly more likely than nongrantees to use Community Guide-recommended evidence-based interventions (mean, 3.14 interventions vs 1.25 interventions, P < .001) and to use patient navigation services (eg, transportion or language translation services) (72% vs 17%, P < .001) for promoting CRC screening. Both groups were equally likely to use other strategies. CRCCP grantees were significantly more likely to provide CRC screening than were nongrantees (100% versus 50%, P < .001).

CONCLUSION

Results suggest that CRCCP funding and support increases use of evidence-based interventions to promote CRC screening, indicating the program's potential to increase population-wide CRC screening rates.