Abstract P3-08-16: Strengthening bridges: A navigation plan for survivors of breast and gynecological cancers in the Georgia Cancer Center for excellence at Grady Health

Background: By mandate, comprehensive cancer treatment facilities will have to provide continuum care services for the cancer survivors, such as, survivorship treatment care plans, patient navigation, and psychosocial distress screening by 2015. A dual survivorship patient navigation model was created at The Avon Foundation Comprehensive Breast Center at Grady Health System to include both lay patient navigator (PN) and a survivorship nurse practitioner (SNP). The Strengthening Bridges Survivorship Patient Navigation Program used this combination to provide cancer survivor education, medical follow-up, nutrition and social support services after completion of therapy. We believe formalizing support linkages through patient navigation has the potential to provide the patient with the full spectrum of holistic healthcare. Methods: A survivorship patient navigation program was implemented to assess patients’ support and barriers to continue healthcare; quality of life; understandability of late effects associated with treatment and use of a survivorship care plan. Enrollment into Strengthening Bridges included monthly educational support groups, scheduled appointments with SNPs to address post treatment side effects, pain management, lymph edema, and loss of range of motion, and depression; meetings with PNs for overall support. The survivors completed three assessments to generate a personalized survivorship care plan and to evaluate changes in late effects, emotional well being and socio-economic issues. Results: Twenty-one patients were enrolled in the Strengthening Bridges Program. Most of the patients were African American women (83.3%) that were approved for Medicaid or Medicare (64.7%). More than half of the enrollees (52.4%) reported the need to talk to others who have similar experiences with cancer and treatment. As a result 71.4% reported that they appreciated being part of a group of cancer survivors. Initially, patients’ survivor knowledge regarding late effects was low. However, at the midpoint, knowledge had increased for most participants, especially those who were very engaged in the program. Participants reported experiencing many late effects. While some acute effects such as surgical pain subsided over time, others such as; forgetfulness and fatigue were more static and concerns about appearance gained dominance. We learned that some participants utilized their survivorship care plans well, while others did not use it at all. Conclusions: Using the combined navigation model as a resource to support and guide patients’ post treatment has strong potential to increase the use of their generated individualized survivorship care plan, identify late effects of treatment, improve the use of their Primary Care Physician, and finally improve their quality of life. Patient navigation is one strategy to improve care for the underserved, uninsured, and underinsured cancer survivor. Providing supportive services to cancer survivors through patient and nurse practitioner navigation is an effective way to potentially reduce barriers that post treatment patients may face. This dual program also continually engages the patient in preventative maintenance of their healthcare.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-08-16.

A Model for Strengthening Collaborative Research Capacity: Illustrations From the Atlanta Clinical Translational Science Institute

INTRODUCTION

Community-engaged research is effective in addressing health disparities but may present challenges for both academic institutions and community partners. Therefore, the need to build capacity for conducting collaborative research exists. The purpose of this study is to present a model for building research capacity in academic-community partnerships.

METHOD

The Building Collaborative Research Capacity Model was developed as part of the Community Engagement Research Program (CERP) of the Atlanta Clinical and Translational Science Institute (ACTSI). Six domains of collaborative research capacity were identified and used to develop a model. Inputs, activities, outputs, and outcomes of building collaborative research capacity are described.

RESULTS

To test this model, a competitive request for applications was widely distributed and four community-based organizations were funded to participate in a 2-year program with the aim of conducting a pilot study and submitting a research proposal for funding to National Institutes of Health or another major funding agency. During the first year, the community-based organization partners were trained on conducting collaborative research and matched with an academic partner from an ACTSI institution. Three of the academic-community partnerships submitted pilot study results and two submitted a grant proposal to a national agency.

DISCUSSION

The Building Collaborative Research Capacity Model is an innovative approach to strengthening academic-community partnerships. This model will help build needed research capacity, serve as a framework for academicians and community partners, and lead to sustainable partnerships that improve community health.

Residential racial composition, spatial access to care, and breast cancer mortality among women in Georgia

We explored the association between neighborhood residential racial composition and breast cancer mortality among Black and White breast cancer patients in Georgia and whether spatial access to cancer care mediates this association. Participants included 15,256 women living in 15 metropolitan statistical areas in Georgia who were diagnosed with breast cancer between 1999 and 2003. Residential racial composition was operationalized as the percent of Black residents in the census tract. We used gravity-based modeling methods to ascertain spatial access to oncology care. Multilevel Cox proportional hazards models and mediation analyses were used to test associations. Black women were 1.5 times more likely to die from breast cancer than White women. Residential racial composition had a small but significant association with breast cancer mortality (hazard ratios [HRs] = 1.04-1.08 per 10% increase in the percent of Black tract residents). Individual race did not moderate this relationship, and spatial access to care did not mediate it. Residential racial composition may be part of the socioenvironmental milieu that produces increased breast cancer mortality among Black women. However, there is a lack of evidence that spatial access to oncology care mediates these processes.

Development and psychometric evaluation of the public health surveillance well-being scale

PURPOSE

To develop and psychometrically evaluate the brief Public Health Surveillance Well-Being Scale (PHS-WB) that captures mental, physical, and social components of well-being.

METHODS

Using data from 5,399 HealthStyles survey respondents, we conducted bi-factor, item response theory, and differential item functioning analyses to examine the psychometric properties of a pool of 34 well-being items. Based on the statistical results and content considerations, we developed a brief 10-item well-being scale and assessed its construct validity through comparisons of demographic subgroups and correlations with measures of related constructs.

RESULTS

Based on the bi-factor analyses, the items grouped into both an overall factor and individual domain-specific factors. The PHS-WB scale demonstrated good internal consistency (alpha = 0.87) and correlated highly with scores for the entire item pool (r = 0.94). The well-being scale scores differed as expected across demographic groups and correlated with global and domain-specific measures of similar constructs, supporting its construct validity.

CONCLUSION

The 10-item PHS-WB scale demonstrates good psychometric properties, and its high correlation with the item pool suggests minimal loss of information with the use of fewer items. The brief PHS-WB allows for well-being assessment on national surveys or in other situations where a longer form may not be feasible.

Evaluation of the Avon Foundation community education and outreach initiative Community Patient Navigation Program

INTRODUCTION

Black women in the United States experience disproportionate breast cancer mortality. Culturally appropriate community education on the importance of breast health coupled with the availability of free or low-cost mammography screening services may help improve the use of mammography screening services among Black women. The Avon Foundation Community Patient Navigation Program seeks to fill this need. The current study presents a process and outcome evaluation of this program.

METHOD

Trained and uniformed community patient navigators (PNs) host breast health education events where they recruit community members to complete a mammography interest form. Participants are referred to a nurse practitioner who determines eligibility for a free or low-cost mammogram. The community PN delivers telephone follow-up to encourage participants to make and keep their mammogram appointments.

RESULTS

Over a 15-month period, 22 community PNs hosted 207 breast health events, which included 9,601 attendees. Three hundred and four participants completed a mammography interest form, and 21% of these individuals received mammograms at the collaborating health facility. Participants who reported breast symptoms were twice as likely to get a mammogram as those who did not report symptoms.

DISCUSSION

Community patient navigation may be a useful resource for encouraging mammography screening among underserved women.

A qualitative evaluation of the Avon Foundation Community Education and Outreach Initiative Patient Navigation Program

This study presents a qualitative evaluation of the Avon Foundation Community Education and Outreach Initiative (CEOI) Patient Navigation Program. Qualitative in-depth interviews were conducted with breast cancer patients (N = 18) of the CEOI Patient Navigation Program. Primary strengths of the program include the nature of the relationship between the patient and navigator, the availability of navigators to attend appointments, and the fact that navigators were breast cancer survivors. The process of enrolling patients into the program was a weakness. Participants described positive experiences with this program. They also identified areas of improvement that are relevant to other patient navigation programs in the US.

A simulation model for assessing aberration detection methods used in public health surveillance for systems with limited baselines

Public health officials continue to develop and implement new types of ongoing surveillance systems in an attempt to detect aberrations in surveillance data as early as possible. In public health surveillance, aberrations are traditionally defined as an observed value being greater than an expected historical value for that same time period. To account for seasonality, traditional aberration detection methods use three or more years of baseline data across the same time period to calculate the expected historical value. Due to the recent implementation of short-term bioterrorism surveillance systems, many of the new surveillance systems have limited historical data from which to calculate an expected baseline value. Three limited baseline aberration detection methods, C1-MILD, C2-MEDIUM, and C3-ULTRA, were developed based on a one-sided positive CUSUM (cumulative sum) calculation, a commonly used quality control method used in the manufacturing industry. To evaluate the strengths and weakness of these methods, data were simulated to represent syndromic data collected through the recently developed hospital-based enhanced syndromic surveillance systems. The three methods were applied to the simulated data and estimates of sensitivity, specificity, and false-positive rates for the three methods were obtained. For the six syndromes, sensitivity for the C1-MILD, C2-MEDIUM, and C3-ULTRA models averaged 48.2, 51.3, and 53.7 per cent, respectively. Similarly, the specificities averaged 97.7, 97.8, and 96.1 per cent, respectively. The average false-positive rates for the three models were 31.8, 29.2, and 41.5 per cent, respectively. The results highlight the value and importance of developing and testing new aberration detection methods for public health surveillance data with limited baseline information.

Observations on mortality during the 1918 influenza pandemic

The original purpose of our study was to examine the unusual W-shaped mortality curve associated with the 1918 influenza pandemic and possibly explain the peak in mortality among individuals aged 20-40 years. We plotted age-specific excess mortality instead of total mortality for the 1918 pandemic using a 5-year baseline. For comparison, we also graphed excess mortality curves for the 1957 and 1968 pandemics using 5-year baselines. The 1957 and 1968 curves exhibited the usual U-shaped curve, with high excess mortality among infants and the elderly population relative to young adults. The 1918 curve, however, presented unexpected results. A peak in excess mortality among infants and young adults was seen, but the expected W shape did not result. We instead found negative excess mortality among elderly individuals, suggesting that this group was exposed, at an earlier date, to an influenza strain similar to the so-called Spanish influenza (H1N1) strain.

Effectiveness and cost-benefit of influenza vaccination of healthy working adults: A randomized controlled trial

CONTEXT

Although the cost-effectiveness and cost-benefit of influenza vaccination are well established for persons aged 65 years or older, the benefits for healthy adults younger than 65 years are less clear.

OBJECTIVE

To evaluate the effectiveness and cost-benefit of influenza vaccine in preventing influenza-like illness (ILI) and reducing societal costs of ILI among healthy working adults.

DESIGN

Double-blind, randomized, placebo-controlled trial conducted during 2 influenza seasons.

SETTING AND PARTICIPANTS

Healthy adults aged 18 to 64 years and employed full-time by a US manufacturing company (for 1997-1998 season, n = 1184; for 1998-1999 season, n = 1191).

INTERVENTIONS

For each season, participants were randomly assigned to receive either trivalent inactivated influenza vaccine (n = 595 in 1997-1998 and n = 587 in 1998-1999) or sterile saline injection (placebo; n = 589 in 1997-1998 and n = 604 in 1998-1999). Participants in 1997-1998 were rerandomized if they participated in 1998-1999.

MAIN OUTCOME MEASURES

Influenza-like illnesses and associated physician visits and work absenteeism reported in biweekly questionnaires by all participants, and serologically confirmed influenza illness among 23% of participants in each year (n = 275 in 1997-1998; n = 278 in 1998-1999); societal cost of ILI per vaccinated vs unvaccinated person.

RESULTS

For 1997-1998 and 1998-1999, respectively, 95% (1130/1184) and 99% (1178/1191) of participants had complete follow-up, and 23% in each year had serologic testing. In 1997-1998, when the vaccine virus differed from the predominant circulating viruses, vaccine efficacy against serologically confirmed influenza illness was 50% (P =.33). In this season, vaccination did not reduce ILI, physician visits, or lost workdays; the net societal cost was $65.59 per person compared with no vaccination. In 1998-1999, the vaccine and predominant circulating viruses were well matched. Vaccine efficacy was 86% (P =.001), and vaccination reduced ILI, physician visits, and lost workdays by 34%, 42%, and 32%, respectively. However, vaccination resulted in a net societal cost of $11.17 per person compared with no vaccination.

CONCLUSION

Influenza vaccination of healthy working adults younger than 65 years can reduce the rates of ILI, lost workdays, and physician visits during years when the vaccine and circulating viruses are similar, but vaccination may not provide overall economic benefits in most years. JAMA. 2000;284:1655-1663.

Influenza outbreak detection and control measures in nursing homes in the United States

OBJECTIVE

To evaluate the use of influenza vaccine, rapid influenza testing, and influenza antiviral medication in nursing homes in the US to prevent and control outbreaks.

METHODS

Survey questionnaires were sent to 1017 randomly selected nursing homes in nine states. Information was collected on influenza prevention, detection and control practices, and on outbreaks during three influenza seasons (1995-1998).

RESULTS

The survey response rate was 78%. Influenza vaccine was offered to residents and staff by 99% and 86%, respectively, of nursing homes. Among nursing homes offering the influenza vaccine, the average vaccination rate was 83% for residents and 46% for staff. Sixty-seven percent of the nursing homes reported having access to laboratories with rapid antigen testing capabilities, and 19% reported having a written policy for the use of influenza antiviral medications for outbreak control. Nursing homes from New York, where organized education programs on influenza detection and control have been conducted for many years, were more likely to have reported a suspected or laboratory-confirmed influenza outbreak (51% vs 10%, P = .01), to have access to rapid antigen testing for influenza (92% vs 63%, P = .01), and to use antivirals for prophylaxis and treatment of influenza A for their nursing home residents (94% vs 55%, P = .01) compared with nursing homes from the other eight states.

CONCLUSIONS

Influenza outbreaks among nursing home residents can lead to substantial morbidity and mortality when prevention measures are not rapidly instituted. However, many nursing homes in this survey were neither prepared to detect nor to control influenza A outbreaks. Targeted, sustained educational efforts can improve the detection and control of outbreaks in nursing homes.

Influenza and the rates of hospitalization for respiratory disease among infants and young children

BACKGROUND

Young children may be at increased risk for serious complications from influenzavirus infection. However, in population-based studies it has been difficult to separate the effects of influenzavirus from those of respiratory syncytial virus. Respiratory syncytial virus often circulates with influenzaviruses and is the most frequent cause of hospitalization for lower respiratory tract infections in infants and young children. We studied the rates of hospitalization for acute respiratory-disease among infants and children during periods when the circulation of influenzaviruses predominated over the circulation of respiratory syncytial virus.

METHODS

For each season from October to May during the period from 1992 to 1997, we used local viral surveillance data to define periods in Washington State and northern California when the circulation of influenzaviruses predominated over that of respiratory syncytial virus. We calculated the rates of hospitalization for acute respiratory disease, excess rates attributable to influenzavirus, and incidence-rate ratios for all infants and children younger than 18 years of age who were enrolled in either the Kaiser Permanente Medical Care Program of Northern California or the Group Health Cooperative of Puget Sound.

RESULTS

The rates of hospitalization for acute respiratory disease among children who did not have conditions that put them at high risk for complications of influenza (e.g., asthma, cardiovascular diseases, or premature birth) and who were younger than two years of age were 231 per 100,000 person-months at Northern California Kaiser sites (from 1993 to 1997) and 193 per 100,000 person-months at Group Health Cooperative sites (from 1992 to 1997). These rates were approximately 12 times as high as the rates among children without high-risk conditions who were 5 to 17 years of age (19 per 100,000 person-months at Northern California Kaiser sites and 16 per 100,000 person-months at Group Health Cooperative sites) and approached the rates among children with chronic health conditions who were 5 to 17 years of age (386 per 100,000 person-months and 216 per 100,000 person-months, respectively).

CONCLUSIONS

Infants and young children without chronic or serious medical conditions are at increased risk for hospitalization during influenza seasons. Routine influenza vaccination should be considered in these children.

Case-control study of risk factors for avian influenza A (H5N1) disease, Hong Kong, 1997

In May 1997, a 3-year-old boy in Hong Kong died of a respiratory illness related to influenza A (H5N1) virus infection, the first known human case of disease from this virus. An additional 17 cases followed in November and December. A case-control study of 15 of these patients hospitalized for influenza A (H5N1) disease was conducted using controls matched by age, sex, and neighborhood to determine risk factors for disease. Exposure to live poultry (by visiting either a retail poultry stall or a market selling live poultry) in the week before illness began was significantly associated with H5N1 disease (64% of cases vs. 29% of controls, odds ratio, 4.5, P=.045). By contrast, travel, eating or preparing poultry products, recent exposure to persons with respiratory illness, including persons with known influenza A (H5N1) infection, were not associated with H5N1 disease.

Detection of antibody to avian influenza A (H5N1) virus in human serum by using a combination of serologic assays

From May to December 1997, 18 cases of mild to severe respiratory illness caused by avian influenza A (H5N1) viruses were identified in Hong Kong. The emergence of an avian virus in the human population prompted an epidemiological investigation to determine the extent of human-to-human transmission of the virus and risk factors associated with infection. The hemagglutination inhibition (HI) assay, the standard method for serologic detection of influenza virus infection in humans, has been shown to be less sensitive for the detection of antibodies induced by avian influenza viruses. Therefore, we developed a more sensitive microneutralization assay to detect antibodies to avian influenza in humans. Direct comparison of an HI assay and the microneutralization assay demonstrated that the latter was substantially more sensitive in detecting human antibodies to H5N1 virus in infected individuals. An H5-specific indirect enzyme-linked immunosorbent assay (ELISA) was also established to test children's sera. The sensitivity and specificity of the microneutralization assay were compared with those of an H5-specific indirect ELISA. When combined with a confirmatory H5-specific Western blot test, the specificities of both assays were improved. Maximum sensitivity (80%) and specificity (96%) for the detection of anti-H5 antibody in adults aged 18 to 59 years were achieved by using the microneutralization assay combined with Western blotting. Maximum sensitivity (100%) and specificity (100%) in detecting anti-H5 antibody in sera obtained from children less than 15 years of age were achieved by using ELISA combined with Western blotting. This new test algorithm is being used for the seroepidemiologic investigations of the avian H5N1 influenza outbreak.

Chronic multisymptom illness affecting Air Force veterans of the Gulf War

CONTEXT

Gulf War (GW) veterans report nonspecific symptoms significantly more often than their nondeployed peers. However, no specific disorder has been identified, and the etiologic basis and clinical significance of their symptoms remain unclear.

OBJECTIVES

To organize symptoms reported by US Air Force GW veterans into a case definition, to characterize clinical features, and to evaluate risk factors.

DESIGN

Cross-sectional population survey of individual characteristics and symptoms and clinical evaluation (including a structured interview, the Medical Outcomes Study Short Form 36, psychiatric screening, physical examination, clinical laboratory tests, and serologic assays for antibodies against viruses, rickettsia, parasites, and bacteria) conducted in 1995.

PARTICIPANTS AND SETTING

The cross-sectional questionnaire survey included 3723 currently active volunteers, irrespective of health status or GW participation, from 4 air force populations. The cross-sectional clinical evaluation included 158 GW veterans from one unit, irrespective of health status.

MAIN OUTCOME MEASURES

Symptom-based case definition; case prevalence rate for GW veterans and nondeployed personnel; clinical and laboratory findings among veterans who met the case definition.

RESULTS

We defined a case as having 1 or more chronic symptoms from at least 2 of 3 categories (fatigue, mood-cognition, and musculoskeletal). The prevalence of mild-to-moderate and severe cases was 39% and 6%, respectively, among 1155 GW veterans compared with 14% and 0.7% among 2520 nondeployed personnel. Illness was not associated with time or place of deployment or with duties during the war. Fifty-nine clinically evaluated GW veterans (37%) were noncases, 86 (54%) mild-to-moderate cases, and 13 (8%) severe cases. Although no physical examination, laboratory, or serologic findings identified cases, veterans who met the case definition had significantly diminished functioning and well-being.

CONCLUSIONS

Among currently active members of 4 Air Force populations, a chronic multisymptom condition was significantly associated with deployment to the GW. The condition was not associated with specific GW exposures and also affected nondeployed personnel.

The demographics of disability in the south

A major issue for health reform is the equitable distribution of health services. Equity in the use of services depends in large part on the distribution of need for services, in addition to availability, accessibility, affordability, and acceptability of the services. The present paper focuses on one set of indicators of need, the disability data reported in the 1990 U.S. Census of Population and Housing for 14 southern states. The Census data on work limitation, inability to work, physical mobility, and ability to perform routine personal care show differentials for subpopulations defined by rural versus urban areas within levels of poverty, age, sex, education, and ethnic group. Highest rates of work disability are found for rural, female, elderly, less educated, African-American, and below poverty level populations. The implications of such findings for health care reform suggest that there should be greater access to services by populations of greater identified need. Historically, the opposite has been true, perhaps exacerbating the observed differentials in need.

Selection and related threats to group comparisons: an example comparing factorial structures of higher and lower ability groups of adult twins

Is it possible to construct valid explanations of behavioral phenomena from differences found among naturally existing groups? Many of psychology's cherished findings in such domains as intellectual performance and temperament rest on differences of this kind. A venerable and rich literature on selection and selection effects both reminds us that naturally existing groups might or might not derive from a common parent population and warns that valid decisions between these alternatives are often jeopardized by the very methods on which those decisions rest. We examine these matters within the context of intellectual performance, illustrate key points with an analysis of data, and examine the implications for current research on differences in ability levels.

Paternal and maternal genetic and environmental contributions to cerebrospinal fluid monoamine metabolites in rhesus monkeys (Macaca mulatta)

BACKGROUND

To study genetic and environmental contributions to cerebrospinal fluid (CSF) monoamine concentrations, 55 young rhesus monkeys (Macaca mulatta) were reared apart from their 10 fathers to perform a paternal half-sibling analysis.

METHODS

To study maternal genetic contributions, 23 infants were reared with their mothers, 23 infants were removed from their mothers at birth and fostered to unrelated lactating female monkeys, and 24 infants were removed from their mothers at birth and reared with age-matched peers. When the monkeys reached age 6 months, CSF samples were obtained via cisternal puncture prior to and during a series of social separations.

RESULTS

When the results were statistically pooled according to the biological father, comparisons using analysis of variance indicated that both CSF 5-hydroxyindoleacetic acid (5-HIAA) and homovanillic acid (HVA) concentrations showed significant heritable (h2) effects (h2 > 0.5) for both sons and daughters, whereas 3-methoxy-4-hydroxyphenylglycol (MHPG) showed a nearly significant paternal genetic effect only for sons (h2 > 0.5). In addition, there were substantial maternal genetic influences on the young monkeys' CSF MHPG and 5-HIAA (h2 > 0.5) levels. Structural equation analyses indicated a maternal genetic contribution without a maternal environmental contribution to CSF 5-HIAA concentration; on the other hand, there was both a maternal genetic and environmental contribution to MHPG.

CONCLUSIONS

These findings suggest that a significant portion of the variance in the turnover of the monoamine neurotransmitters is determined by genetic mechanisms.

Blood donation behavior of Hispanics in the lower Rio Grande Valley

This study was designed to determine the blood donation behavior and attitudes of Hispanic residents of the Lower Rio Grande Valley for the purpose of developing promotional and educational approaches to enhance levels of donor participation. Personal interviews of 545 respondents were conducted in English and Spanish using quota sampling and standard intercept techniques at lower- and middle-income supermarkets in five cities during a payday weekend. A number of research hypotheses were established to test for demographic, behavioral, and attitudinal differences that were observed in donors and nondonors using chi-square analysis and multiple discriminant analysis. After analyzing the difference between Hispanics and non-Hispanics for blood donation rates, all non-Hispanics were eliminated from analysis, and the remaining 419 Hispanics were evaluated on the basis of their donor behavior. Donation among Hispanics was most likely to be by better-educated, English-speaking, higher-job-status individuals who had participated in a blood donation drive. Donors tend to have parent(s) who were donors, and they were also more likely to carry an organ donor card. Donors were found to vary in their behaviors as well as their attitudes and beliefs. Perceptions of a lack of safety in donating, the risk of contracting acquired immune deficiency syndrome, and the financial motivation of donors were most pronounced among Hispanics, which indicated a need for improved education on these issues.