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Okado I, Liu M, Elhajj C, Wilkens L, Holcombe RF. Patient reports of cancer care coordination in rural Hawaii. J Rural Health 2024. [PMID: 38225683 DOI: 10.1111/jrh.12821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 12/16/2023] [Accepted: 01/02/2024] [Indexed: 01/17/2024]
Abstract
PURPOSE Rural residents experience disproportionate burdens of cancer, and poorer cancer health outcomes in rural populations are partly attributed to care delivery challenges. Cancer patients in rural areas often experience unique challenges with care coordination. In this study, we explored patient reports of care coordination among rural Hawaii patients with cancer and compared rural and urban patients' perceptions of cancer care coordination. METHODS 80 patients receiving active treatment for cancer from rural Hawaii participated in a care coordination study in 2020-2021. Participants completed the Care Coordination Instrument, a validated oncology patient questionnaire. FINDINGS Mean age of rural cancer patients was 63.0 (SD = 12.1), and 57.7% were female. The most common cancer types were breast and GI. Overall, rural and urban patients' perceptions of care coordination were comparable (p > 0.05). There were statistically significant differences between rural and urban patients' perceptions in communication and navigation aspects of care coordination (p = 0.02 and 0.04, respectively). Specific differences included a second opinion consultation, clinical trial considerations, and after-hours care. 43% of rural patients reported traveling by air for part or all of their cancer treatment. CONCLUSIONS Findings suggest that while overall perceptions of care coordination were similar between rural and urban patients, differential perceptions of specific care coordination areas between rural and urban patients may reflect limited access to care for rural patients. Improving access to cancer care may be a potential strategy to enhance care coordination for rural patients and ultimately address rural-urban cancer health disparities.
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Affiliation(s)
- Izumi Okado
- Population Sciences in the Pacific Program, University of Hawaii Cancer Center, Honolulu, Hawaii, USA
| | - Michelle Liu
- Population Sciences in the Pacific Program, University of Hawaii Cancer Center, Honolulu, Hawaii, USA
| | - Carry Elhajj
- Population Sciences in the Pacific Program, University of Hawaii Cancer Center, Honolulu, Hawaii, USA
| | - Lynne Wilkens
- Population Sciences in the Pacific Program, University of Hawaii Cancer Center, Honolulu, Hawaii, USA
| | - Randall F Holcombe
- Population Sciences in the Pacific Program, University of Hawaii Cancer Center, Honolulu, Hawaii, USA
- University of Vermont Cancer Center, Department of Medicine, Division of Hematology/Oncology, University of Vermont, Burlington, Vermont, USA
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Lipsyc-Sharf M, Ballman KV, Campbell JD, Muss HB, Perez EA, Shulman LN, Carey LA, Partridge AH, Warner ET. Age, Body Mass Index, Tumor Subtype, and Racial and Ethnic Disparities in Breast Cancer Survival. JAMA Netw Open 2023; 6:e2339584. [PMID: 37878313 PMCID: PMC10600583 DOI: 10.1001/jamanetworkopen.2023.39584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 09/11/2023] [Indexed: 10/26/2023] Open
Abstract
Importance Black women in the United States have higher breast cancer (BC) mortality rates than White women. The combined role of multiple factors, including body mass index (BMI), age, and tumor subtype, remains unclear. Objective To assess the association of race and ethnicity with survival among clinical trial participants with early-stage BC (eBC) according to tumor subtype, age, and BMI. Design, Setting, and Participants This cohort study analyzed survival data, as of November 12, 2021, from participants enrolled between 1997 and 2010 in 4 randomized adjuvant chemotherapy trials: Cancer and Leukemia Group B (CALGB) 9741, 49907, and 40101 as well as North Central Cancer Treatment Group (NCCTG) N9831, legacy groups of the Alliance of Clinical Trials in Oncology. Median follow-up was 9.8 years. Exposures Non-Hispanic Black and Hispanic participants were compared with non-Hispanic White participants within subgroups of subtype (hormone receptor positive [HR+]/ERBB2 [formerly HER2] negative [ERBB2-], ERBB2+, and HR-/ERBB2-), age (<50, 50 to <65, and ≥65 years), and BMI (<18.5, 18.5 to <25.0, 25.0 to <30.0, and ≥30.0). Main Outcomes and Measures Recurrence-free survival (RFS) and overall survival (OS). Results Of 9479 participants, 436 (4.4%) were Hispanic, 871 (8.8%) non-Hispanic Black, and 7889 (79.5%) non-Hispanic White. The median (range) age was 52 (19.0-89.7) years. Among participants with HR+/ERBB2- tumors, non-Hispanic Black individuals had worse RFS (hazard ratio [HR], 1.49; 95% CI, 1.04-2.12; 5-year RFS, 88.5% vs 93.2%) than non-Hispanic White individuals, although the global test for association of race and ethnicity with RFS was not significant within any tumor subtype. There were no OS differences by race and ethnicity in any subtype. Race and ethnicity were associated with OS in young participants (age <50 years; global P = .008); young non-Hispanic Black participants (HR, 1.34; 95% CI, 1.04-1.71; 5-year OS, 86.6% vs 92.0%) and Hispanic participants (HR, 1.62; 95% CI, 1.16-2.29; 5-year OS, 86.2% vs 92.0%) had worse OS than young non-Hispanic White participants. Race and ethnicity were associated with RFS in participants with BMIs of 25 to less than 30, with non-Hispanic Black participants having worse RFS (HR, 1.81; 95% CI, 1.23-2.68; 5-year RFS, 83.2% vs 87.3%) than non-Hispanic White participants. Conclusions and Relevance In this cohort study, racial and ethnic survival disparities were identified in patients with eBC receiving standardized initial care, and potentially at-risk subgroups, for whom focused interventions may improve outcomes, were found.
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Affiliation(s)
- Marla Lipsyc-Sharf
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- David Geffen School of Medicine at UCLA/Jonsson Comprehensive Cancer Center, Los Angeles, California
| | - Karla V. Ballman
- Alliance Statistics and Data Management Center, Mayo Clinic, Rochester, Minnesota
| | - Jordan D. Campbell
- Alliance Statistics and Data Management Center, Mayo Clinic, Rochester, Minnesota
| | - Hyman B. Muss
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill
| | | | | | - Lisa A. Carey
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill
| | - Ann H. Partridge
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Erica T. Warner
- Clinical Translational Epidemiology Unit, Mongan Institute, Massachusetts General Hospital, Boston
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Ossowski S, Lyon L, Linehan E, Gordon NP, Egorova O, Mark B, Beringer K, Abbe T, Shirazi A, Weldon C, Trosman J, Ravelo A, Liu R. Advance Directives for Patients With Breast Cancer: Applying the Right Info/Right Care/Right Patient/Right Time Oncology Model. Perm J 2023; 27:30-36. [PMID: 37255340 PMCID: PMC10502389 DOI: 10.7812/tpp/22.177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Background Advance directives (AD) are an important component of life care planning for patients undergoing treatment for cancer; however, there are few effective interventions to increase AD rates. In this quality improvement project, the authors integrated AD counseling into a novel right info/right care/right patient/right time (4R) sequence of care oncology delivery intervention for breast cancer patients in an integrated health care delivery system. Methods The authors studied two groups of patients with newly diagnosed breast cancer who attended a multidisciplinary clinic and underwent definitive surgery at a single facility. The usual care (UC) cohort (N = 139) received care from October 1, 2019 to September 30, 2020. The 4R cohort (N = 141) received care from October 1, 2020 to September 30, 2121 that included discussing AD completion with a health educator prior to surgery. The authors used bivariate analyses to assess whether the AD intervention increased AD completion rates and to identify factors influencing AD completion. Results The UC and 4R cohorts were similar in age, gender, race/ethnicity, interpreter need, Elixhauser comorbidity index, National Comprehensive Cancer Network distress score ≥ 5, surgery type, stage, histology, grade, and Estrogen receptor/Progesterone receptor/ human epidermal growth factor receptor 2 (ER/PR/HER2) status. AD completion rates prior to surgery were significantly higher for the 4R vs UC cohort (73.8%, 95% confidence interval [CI] [66.5%-81.0%] vs 15.1%, 95% CI [9.2%-21.1%], p < .01) and did not significantly differ by age, race, need for interpreter, or distress scores. Conclusion Incorporation of a health educator discussion into a 4R care sequence plan significantly increased rates of time-sensitive AD completion.
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Affiliation(s)
- Stephanie Ossowski
- Department of Hematology & Oncology, The Permanente Medical Group, San Francisco, CA, USA
| | - Liisa Lyon
- Kaiser Permanente Division of Research, Oakland, CA, USA
| | - Elizabeth Linehan
- Department of Surgery, The Permanente Medical Group, San Francisco, CA, USA
| | - Nancy P Gordon
- Kaiser Permanente Division of Research, Oakland, CA, USA
| | - Olga Egorova
- Department of Hematology & Oncology, The Permanente Medical Group, San Francisco, CA, USA
| | - Becky Mark
- Department of Hematology & Oncology, The Permanente Medical Group, San Francisco, CA, USA
| | - Kimberly Beringer
- Department of Hematology & Oncology, The Permanente Medical Group, San Francisco, CA, USA
| | - Thea Abbe
- Department of Hematology & Oncology, The Permanente Medical Group, San Francisco, CA, USA
| | - Aida Shirazi
- Kaiser Permanente, Department of Graduate Medical Education, San Francisco, CA, USA
| | | | - Julia Trosman
- Center for Business Models in Healthcare, Chicago, IL, USA
| | - Arliene Ravelo
- Department of Hematology & Oncology, The Permanente Medical Group, Walnut Creek, CA, USA
| | - Raymond Liu
- Department of Hematology & Oncology, The Permanente Medical Group, San Francisco, CA, USA
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Dunne W, Adebayo N, Danner S, Post S, O'Brian C, Tom L, Osei C, Blum C, Rivera J, Molina E, Trosman J, Weldon C, Ekong A, Adetoro E, Rapkin B, Simon MA. A Learning Health System Approach to Cancer Survivorship Care Among LGBTQ+ Communities. JCO Oncol Pract 2023; 19:e103-e114. [PMID: 36475752 PMCID: PMC10166358 DOI: 10.1200/op.22.00386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 10/19/2022] [Accepted: 10/26/2022] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) individuals who receive primary care services at community health centers are often referred to external specialty care centers after cancer diagnosis, upon which primary care services are disrupted and may be discontinued because of gaps in communication between primary and oncologic care providers. This qualitative study evaluated barriers and facilitators to effective care coordination for LGBTQ+ patients with cancer and the utility of a novel cancer care coordination tool to mitigate identified barriers. MATERIALS AND METHODS Semistructured interviews with LGBTQ+ cancer survivors, caregivers to LGBTQ+ persons, clinical team members who provide care to LGBTQ+ patients, and members of community-based organizations that work with LGBTQ+ patients were conducted. Interview analysis was a multistage process, wherein a constant comparison approach was used. Transcripts were reviewed and coded using Atlas.ti Cloud. RESULTS A total of 26 individuals were interviewed: 10 patients, four caregivers, 10 clinical care team members, and two community organization representatives. Interview analysis yielded insight regarding (1) LGBTQ+ patient experiences engaging with primary and oncologic care at the clinic level and (2) perceptions of patient-provider and provider-provider communication and coordination. CONCLUSION Interview findings indicate a need for further development of interventions aimed at improving care coordination, patient experience, and outcomes in the cancer care continuum for LGBTQ+ patients. Learning health systems, like the one studied, show great potential for contributing to the development of such interventions.
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Affiliation(s)
- Will Dunne
- Center for Health Equity Transformation, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Nihmotallahi Adebayo
- Center for Health Equity Transformation, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Sankirtana Danner
- Center for Health Equity Transformation, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Sharon Post
- Center for Health Equity Transformation, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Catherine O'Brian
- Center for Health Equity Transformation, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Laura Tom
- Center for Health Equity Transformation, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Cassandra Osei
- Center for Health Equity Transformation, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | | | | | | | - Julia Trosman
- Center for Health Equity Transformation, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Center for Business Models in Healthcare, Glencoe, IL
| | - Christine Weldon
- Center for Health Equity Transformation, Feinberg School of Medicine, Northwestern University, Chicago, IL
- Center for Business Models in Healthcare, Glencoe, IL
| | | | | | - Bruce Rapkin
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY
| | - Melissa A. Simon
- Center for Health Equity Transformation, Feinberg School of Medicine, Northwestern University, Chicago, IL
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Trosman JR, Weldon CB, Rapkin BD, Benson AB, Makower DF, Liang SY, Kulkarni SA, Perez CB, Lo SS, Krueger EA, Throckmorton AD, Gallagher C, Hoskins K, Schaeffer CM, Van Horn J, Schapira L, Ravelo A, Yu E, Gradishar WJ. Evaluation of the Novel 4R Oncology Care Planning Model in Breast Cancer: Impact on Patient Self-Management and Care Delivery in Safety-Net and Non-Safety-Net Centers. JCO Oncol Pract 2021; 17:e1202-e1214. [PMID: 34375560 DOI: 10.1200/op.21.00161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
PURPOSE Optimal cancer care requires patient self-management and coordinated timing and sequence of interdependent care. These are challenging, especially in safety-net settings treating underserved populations. We evaluated the 4R Oncology model (4R) of patient-facing care planning for impact on self-management and delivery of interdependent care at safety-net and non-safety-net institutions. METHODS Ten institutions (five safety-net and five non-safety-net) evaluated the 4R intervention from 2017 to 2020 with patients with stage 0-III breast cancer. Data on self-management and care delivery were collected via surveys and compared between the intervention cohort and the historical cohort (diagnosed before 4R launch). 4R usefulness was assessed within the intervention cohort. RESULTS Survey response rate was 63% (422/670) in intervention and 47% (466/992) in historical cohort. 4R usefulness was reported by 79.9% of patients receiving 4R and was higher for patients in safety-net than in non-safety-net centers (87.6%, 74.2%, P = .001). The intervention cohort measured significantly higher than historical cohort in five of seven self-management metrics, including clarity of care timing and sequence (71.3%, 55%, P < .001) and ability to manage care (78.9%, 72.1%, P = .02). Referrals to interdependent care were significantly higher in the intervention than in the historical cohort along all six metrics, including primary care consult (33.9%, 27.7%, P = .045) and flu vaccination (38.6%, 27.9%, P = .001). Referral completions were significantly higher in four of six metrics. For safety-net patients, improvements in most self-management and care delivery metrics were similar or higher than for non-safety-net patients, even after controlling for all other variables. CONCLUSION 4R Oncology was useful to patients and significantly improved self-management and delivery of interdependent care, but gaps remain. Model enhancements and further evaluations are needed for broad adoption. Patients in safety-net settings benefited from 4R at similar or higher rates than non-safety-net patients, indicating that 4R may reduce care disparities.
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Affiliation(s)
- Julia R Trosman
- Center for Business Models in Healthcare, Glencoe, IL.,Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Christine B Weldon
- Center for Business Models in Healthcare, Glencoe, IL.,Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Bruce D Rapkin
- Montefiore Medical Center, Albert Einstein Cancer Center, Bronx, NY.,Department of Epidemiology and Population Health, Albert Einstein College of Medicine, New York, NY
| | - Al B Benson
- Northwestern Medicine, Chicago, IL.,Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL
| | | | - Su-Ying Liang
- Sutter Health-Palo Alto Medical Foundation Research Institute, Palo Alto, CA
| | - Swati A Kulkarni
- Northwestern Medicine, Chicago, IL.,Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL
| | | | - Shelly S Lo
- Loyola University Medical Center, Maywood, IL
| | | | | | | | - Kent Hoskins
- Division of Medical Oncology, University of Illinois at Chicago College of Medicine, Chicago, IL
| | - Cathleen M Schaeffer
- Division of Medical Oncology, University of Illinois at Chicago College of Medicine, Chicago, IL
| | - Jennifer Van Horn
- Banner MD Anderson Cancer Center, Loveland, CO, Formerly Cheyenne Regional Medical Center, Cheyenne, WY
| | - Lidia Schapira
- Stanford University and Stanford Cancer Institute, Stanford, CA
| | | | - Elaine Yu
- Genentech Inc, South San Francisco, CA
| | - William J Gradishar
- Northwestern Medicine, Chicago, IL.,Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL
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