BACKGROUND: Colorectal cancer (CRC) is a leading cause of cancer death in the United States. Early detection through recommended screening has been shown to have favorable treatment outcomes, yet screening rates among the medically underserved and uninsured are low, particularly for rural and minority populations. This study evaluated the effectiveness of a patient navigation program that addresses individual and systemic barriers to CRC screening for patients at rural, federally qualified community health centers.
METHODS: This quasi-experimental evaluation compared low-income patients at average risk for CRC (n = 809) from 4 intervention clinics and 9 comparison clinics. We abstracted medical chart data on patient demographics, CRC history and risk factors, and CRC screening referrals and examinations. Outcomes of interest were colonoscopy referral and examination during the study period and being compliant with recommended screening guidelines at the end of the study period. We conducted multilevel logistic analyses to evaluate the program's effectiveness.
RESULTS: Patients at intervention clinics were significantly more likely than patients at comparison clinics to undergo colonoscopy screening (35% versus 7%, odds ratio = 7.9, P < .01) and be guideline-compliant on at least one CRC screening test (43% versus 11%, odds ratio = 5.9, P < .001).
CONCLUSIONS: Patient navigation, delivered through the Community Cancer Screening Program, can be an effective approach to ensure that lifesaving, preventive health screenings are provided to low-income adults in a rural setting.
BACKGROUND: Patient navigator (PN) programs can improve breast cancer screening in low income, ethnic/racial minorities. Refugee women have low breast cancer screening rates, but it has not been shown that PN is similarly effective.
OBJECTIVE: Evaluate whether a PN program for refugee women decreases disparities in breast cancer screening.
DESIGN: Retrospective program evaluation of an implemented intervention.
PARTICIPANTS: Women who self-identified as speaking Somali, Arabic, or Serbo-Croatian (Bosnian) and were eligible for breast cancer screening at an urban community health center (HC). Comparison groups were English-speaking and Spanish-speaking women eligible for breast cancer screening in the same HC.
INTERVENTION: Patient navigators educated women about breast cancer screening, explored barriers to screening, and tailored interventions individually to help complete screening.
MAIN MEASURES: Adjusted 2-year mammography rates from logistic regression models for each calendar year accounting for clustering by primary care physician. Rates in refugee women were compared to English-speaking and Spanish-speaking women in the year before implementation of the PN program and over its first 3 years.
RESULTS: There were 188 refugee (36 Somali, 48 Arabic, 104 Serbo-Croatian speaking), 2,072 English-speaking, and 2,014 Spanish-speaking women eligible for breast cancer screening over the 4-year study period. In the year prior to implementation of the program, adjusted mammography rates were lower among refugee women (64.1 %, 95 % CI: 49-77 %) compared to English-speaking (76.5 %, 95 % CI: 69 %-83 %) and Spanish-speaking (85.2 %, 95 % CI: 79 %-90 %) women. By the end of 2011, screening rates increased in refugee women (81.2 %, 95 % CI: 72 %-88 %), and were similar to the rates in English-speaking (80.0 %, 95 % CI: 73 %-86 %) and Spanish-speaking (87.6 %, 95 % CI: 82 %-91 %) women. PN increased screening rates in both younger and older refugee women.
CONCLUSION: Linguistically and culturally tailored PN decreased disparities over time in breast cancer screening among female refugees from Somalia, the Middle East and Bosnia.
The patient navigator model has not been widely implemented in American Indian/Alaska Native (AI/AN) communities, but may be effective in improving cancer outcomes for this population. Subjects were enrolled from eight clinics at Tribes throughout the Northwest (n = 1,187). Four clinics received navigation. Time between abnormal finding and definitive diagnosis was recorded. We examined whether odds of obtaining definitive diagnosis by 60, 90, and 365 days differed between the two groups. The odds of definitive diagnosis within 365 days for navigated subjects was 3.6 times (95 % CI, 1.47, 8.88; p = 0.01) the odds for control subjects. The outcome at 60 and 90 days did not significantly differ between the two groups. Our findings indicate that patient navigation did not significantly impact chance of diagnosis by 60 or 90 days from abnormal finding. However, it did improve the chance of avoiding extreme delays in obtaining a definitive diagnosis.
Revista»Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology
BACKGROUND: There is a need for controlled studies to assess the impact of patient navigation in vulnerable cancer populations.
METHODS: Boston Patient Navigation Research Program conducted a quasi-experimental patient navigation intervention across six federally qualified inner-city community health centers, three assigned to a breast cancer navigation intervention and three assigned to a cervical cancer navigation intervention; each group then served as the control for the other. Eligible women had an abnormal breast or cervical cancer screening test conducted at one of the participating health centers during a baseline (2004-2005) or intervention period (2007-2008). Kaplan-Meier survival curves and proportional hazards regression examined the effect of patient navigation on time to definitive diagnosis, adjusting for covariates, clustering by clinic and differences between the baseline and intervention period.
RESULTS: We enrolled 997 subjects in the baseline period and 3,041 subjects during the intervention period, of whom 1,497 were in the navigated arm, and 1,544 in the control arm. There was a significant decrease in time to diagnosis for subjects in the navigated group compared with controls among those with a cervical screening abnormality [aHR 1.46; 95% confidence interval (CI), 1.1-1.9]; and among those with a breast cancer screening abnormality that resolved after 60 days (aHR 1.40; 95% CI, 1.1-1.9), with no differences before 60 days.
CONCLUSIONS: This study documents a benefit of patient navigation on time to diagnosis among a racially/ethnically diverse inner city population.
IMPACT: Patient navigation may address cancer health disparities by reducing time to diagnosis following an abnormal cancer-screening event.
Refugee women have low breast cancer screening rates. This study highlights the culturally competent implementation and reports the outcomes of a breast cancer screening patient navigation program for refuge/immigrant women from Bosnia. Refugees/immigrant women from Bosnia age 40-79 were contacted by a Serbo-Croatian speaking patient navigator who addressed patient-reported barriers to breast cancer screening and, using individually tailored interventions, helped women obtain screening. The proportion of women up-to-date for mammography was compared at baseline and after 1-year using McNemar's Chi-Square test. 91 Serbo-Croatian speaking women were eligible for mammography screening. At baseline, 44.0% of women had a mammogram within the previous year, with the proportion increasing to 67.0% after 1-year (P = 0.001). A culturally-tailored, language-concordant navigator program designed to overcome specific barriers to breast cancer screening can significantly improve mammography rates in refugees/immigrants.
Revista»Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology
BACKGROUND: We evaluated the efficacy of a Chicago-based cancer patient navigation program developed to increase the proportion of patients reaching diagnostic resolution and reduce the time from abnormal screening test to definitive diagnostic resolution.
METHODS: Women with an abnormal breast (n = 352) or cervical (n = 545) cancer screening test were recruited for the quasi-experimental study. Navigation subjects originated from five federally qualified health center sites and one safety net hospital. Records-based concurrent control subjects were selected from 20 sites. Control sites had similar characteristics to the navigated sites in terms of patient volume, racial/ethnic composition, and payor mix. Mixed-effects logistic regression and Cox proportional hazard regression analyses were conducted to compare navigation and control patients reaching diagnostic resolution by 60 days and time to resolution, adjusting for demographic covariates and site.
RESULTS: Compared with controls, the breast navigation group had shorter time to diagnostic resolution (aHR = 1.65, CI = 1.20-2.28) and the cervical navigation group had shorter time to diagnostic resolution for those who resolved after 30 days (aHR = 2.31, CI = 1.75-3.06), with no difference before 30 days (aHR = 1.42, CI = 0.83-2.43). Variables significantly associated with longer time to resolution for breast cancer screening abnormalities were being older, never partnered, abnormal mammogram and BI-RADS 3, and being younger and Black for cervical abnormalities.
CONCLUSIONS: Patient navigation reduces time from abnormal cancer finding to definitive diagnosis in underserved women.
IMPACT: Results support efforts to use patient navigation as a strategy to reduce cancer disparities among socioeconomically disadvantaged women.
BACKGROUND: Patient navigators may increase colorectal cancer (CRC) screening rates among adults in underserved communities, but prior randomized trials have been small or conducted at single sites and have not included substantial numbers of Haitian Creole-speaking or Portuguese-speaking patients.
METHODS: We identified 465 primary care patients from 4 community health centers and 2 public hospital-based clinics who were not up-to-date with CRC screening and spoke English, Haitian Creole, Portuguese, or Spanish as their primary language. We enrolled participants from September 1, 2008, through March 31, 2009, and followed them up for 1 year after enrollment. We randomly allocated patients to receive a patient navigation-based intervention or usual care. Intervention patients received an introductory letter from their primary care provider with educational material, followed by telephone calls from a language-concordant navigator. The navigators offered patients the option of being screened by fecal occult blood testing or colonoscopy. The primary outcome was completion of any CRC screening within 1 year. Secondary outcomes included the proportions of patients screened by colonoscopy who had adenomas or cancer detected.
RESULTS: During a 1-year period, intervention patients were more likely to undergo CRC screening than control patients (33.6% vs 20.0%; P < .001), to be screened by colonoscopy (26.4% vs 13.0%; P < .001), and to have adenomas detected (8.1% vs 3.9%; P = .06). In prespecified subgroup analyses, the navigator intervention was particularly beneficial for patients whose primary language was other than English (39.8% vs 18.6%; P < .001) and black patients (39.7% vs 16.7%; P = .004).
CONCLUSIONS: Patient navigation increased completion of CRC screening among ethnically diverse patients. Targeting patient navigation to black and non-English-speaking patients may be a useful approach to reducing disparities in CRC screening.
TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01141114.
BACKGROUND: The Boston REACH Coalition developed a case management intervention for Black women in primary care settings to identify and reduce medical and social obstacles to cervical cancer screening and following up abnormal results.
METHODS: The 5-year intervention was evaluated among 732 Black women aged 18 to 75 who were at high risk for inadequate Pap smear screening and follow-up. Case managers provided social services referrals to address patient-identified social concerns (e.g., transportation, housing), as well as navigation to prompt screening and follow-up of abnormal tests. The three study aims were to (1) identify the social factors associated with Pap smear screening at baseline before intervention, (2) evaluate the correlation between exposure to case management intervention and achieving recommended Pap screening intervals, and (3) evaluate the correlation between exposure to case management intervention and having timely follow-up of abnormal Pap smear tests.
RESULTS: We found that a lack of a regular clinical provider, concerns communicating with providers, poor self-rated health, and having less than a high school education were important correlates of recent Pap smear screening before the case management intervention. During the case management intervention, we found a significant increase in achieving recommended Pap smear screening intervals among women with a recent Pap smear at study entry (increasing from 52% in the first year to 80% after 4 or more years; p < .01), but not among women who entered the study without a recent Pap smear (increasing from 31% in the first year to 44% after 4 or more years; p = .39). During case management intervention, having social support for childcare was associated with regular screening among women without a recent Pap smear (odds ratio [OR], 3.52; 95% confidence interval [CI], 1.28-9.69). Insurance status was the key factor in timely clinically indicated follow-up of abnormal results (uninsured OR, 0.27; 95% CI, 0.08-0.86), rather than case management intervention.
CONCLUSIONS: Exposure to case management was associated with regular Pap smear screening among women who recently engaged in screening. Future research should focus on systems changes to address social determinants of health, including strategies to facilitate screening for Black women without social support for childcare. To improve follow-up of abnormal results, financial access to care should be addressed.
OBJETIVO: Para probar una intervención para aumentar la adherencia a las pruebas de seguimiento de diagnóstico entre las mujeres estadounidenses de origen asiático.
MÉTODOS: mujeres americanas coreanas que fueron remitidos para un examen de diagnóstico de seguimiento (mamografías diagnósticas, principalmente) y que habían perdido su cita de seguimiento fueron elegibles para participar en el estudio. Las mujeres de dos clínicas (n = 176) fueron asignados al azar a un grupo de control de atención habitual o un brazo pares intervención navegador. Una encuesta telefónica de 20 minutos se administró a las mujeres en ambos brazos del estudio seis meses después de que se identificaron para evaluar las características demográficas y socioeconómicas y el resultado primario, la realización de auto-reporte del examen de seguimiento recomendado.
RESULTADOS: Entre las mujeres que completaron la encuesta en seis meses de seguimiento, finalización de auto-reporte de los procedimientos de seguimiento fue de 97% en el grupo de intervención y 67% en el grupo control (p <0,001). Con base en un análisis por intención de tratar de todas las mujeres que fueron aleatorizados y un supuesto de no realización del examen de seguimiento para las mujeres con los datos de resultado faltantes, la finalización de auto-reporte de seguimiento fue de 61% en el grupo de intervención y 46 % en el grupo de control de atención habitual (p <0,069).
CONCLUSIONES: Nuestros resultados sugieren que una intervención navegador pares para ayudar a las mujeres americanas de Corea para obtener pruebas de diagnóstico de seguimiento después de una prueba de detección de cáncer de mama anormal es eficaz.
Revista»Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology
ANTECEDENTES: bajos ingresos las mujeres afroamericanas se enfrentan a numerosas barreras para la mamografía de cribado. Pusimos a prueba la eficacia de un programa de computadora interactivo combinado y laicos intervención asesor de salud para aumentar la mamografía de cribado.
MÉTODOS: En este estudio doble ciego, aleatorizado, simple, los participantes fueron 181 pacientes del centro de salud de la mujer afro-americanas de edades entre 41 y 75 años, a <o = 250% del nivel de pobreza, sin antecedentes de cáncer de mama, y sin mamografía de detección en el pasado 15 meses. Ellos fueron asignados a (a) un grupo de comparación de dosis baja que consiste en un folleto la mamografía de cribado culturalmente apropiados o (b) instrucción interactiva, adaptada equipo al inicio del estudio y cuatro sesiones mensuales de asesoramiento laicos asesor de la salud. Los datos del cribado Auto-reporte se recogieron al inicio del estudio ya los 6 meses y verificados por expediente médico.
RESULTADOS: En el análisis por intención de tratar de resultado primario (cribado mamográfico récord verificado médica, disponible en todos menos dos de los participantes), el grupo de intervención aumentó la detección de 51% (45 de 89) en comparación con el 18% (16 de 90 ) para el grupo de comparación a los 6 meses. Al controlar la situación en el empleo, la discapacidad, los familiares de primer grado con cáncer de mama, el seguro de salud, y las biopsias de mama anteriores, el grupo de intervención fue tres veces más probabilidades (riesgo ajustado relativo, 2,7; 95% intervalo de confianza, 01.08 a 03.07, P < 0.0001) para hacerse las pruebas que el grupo de comparación de dosis baja. Se encontraron resultados similares para la etapa de la mamografía de auto-reporte de la adopción de cribado.
CONCLUSIONES: La intervención combinada fue eficaz en la mejora de la mamografía de cribado en mujeres de bajos ingresos afroamericanos, con un tamaño no ajustado del efecto (riesgo relativo, 2,84) significativamente mayor (P <0,05) que en los estudios previos de cada intervención por sí sola.
Colorectal cancer (CRC) is a leading cause of cancer death in the United States. Early detection through recommended screening has been shown to have favorable treatment outcomes, yet screening rates among the medically underserved and uninsured are low, particularly for rural and minority populations. This study evaluated the effectiveness of a patient navigation program that addresses individual and systemic barriers to CRC screening for patients at rural, federally qualified community health centers.
METHODS:
This quasi-experimental evaluation compared low-income patients at average risk for CRC (n = 809) from 4 intervention clinics and 9 comparison clinics. We abstracted medical chart data on patient demographics, CRC history and risk factors, and CRC screening referrals and examinations. Outcomes of interest were colonoscopy referral and examination during the study period and being compliant with recommended screening guidelines at the end of the study period. We conducted multilevel logistic analyses to evaluate the program's effectiveness.
RESULTS:
Patients at intervention clinics were significantly more likely than patients at comparison clinics to undergo colonoscopy screening (35% versus 7%, odds ratio = 7.9, P < .01) and be guideline-compliant on at least one CRC screening test (43% versus 11%, odds ratio = 5.9, P < .001).
CONCLUSIONS:
Patient navigation, delivered through the Community Cancer Screening Program, can be an effective approach to ensure that lifesaving, preventive health screenings are provided to low-income adults in a rural setting.
