Association between race/ethnicity and the risk of amputation of lower extremities among medicare beneficiaries with diabetic foot ulcers and diabetic foot infections

INTRODUCTION

This study aimed to examine the association of race and ethnicity on the risk of lower extremity amputations among Medicare beneficiaries with diabetic foot ulcers (DFUs) and diabetic foot infections (DFIs).

RESEARCH DESIGN AND METHODS

A retrospective study included 2011-2015 data of a 5% sample of fee-for-service Medicare beneficiaries with a newly diagnosed DFU and/or DFI. The primary outcome was the time to the first major amputation episode after a DFU and/or DFI were identified using the diagnosis and procedure codes. We used multivariable Cox proportional hazards models to estimate the risk of time to the first major amputation across races, adjusting for sociodemographic and health status factors. Adjusted hazard ratios (aHRs) with a 95% CI were reported.

RESULTS

Among 92 929 Medicare beneficiaries newly diagnosed with DFUs and/or DFIs, 77% were whites, 14.3% African Americans (AAs), 3.3% Hispanics, 0.7% Native Americans (NAs), and 4.0% were other races. The incidence rates of major amputation were 0.02 person-years for NAs, 0.02 person-years for AAs, 0.01 person-years for Hispanics, 0.01 person-years for other races, and 0.01 person-years for whites (p<0.05). Multivariable analysis showed that AAs (aHR=1.9, 95% CI 1.7 to 2.2, p<0.0001) and NAs (aHR=1.8, 95% CI 1.3 to 2.6, p=0.001) were associated with an increased risk of major amputation compared with whites. Beneficiaries with DFUs and/or DFIs diagnosed by a podiatrist or primary care physician (aHR=0.7, 95% CI 0.6 to 0.8, p<0.0001, specialists as reference) or at an outpatient visit (aHR=0.3, 95% CI 0.3 to 0.3, p<0.0001, inpatient stay as reference) were associated with a decreased risk of major amputation.

CONCLUSIONS

Racial and ethnic disparities in the risk of lower extremity amputations appear to exist among fee-for-service Medicare beneficiaries with diabetic foot problems. AAs and NAs with DFUs and/or DFIs were associated with an increased risk of major amputations compared with white Medicare beneficiaries.

Association of Gender and Race With Allocation of Advanced Heart Failure Therapies

Importance

Racial bias is associated with the allocation of advanced heart failure therapies, heart transplants, and ventricular assist devices. It is unknown whether gender and racial biases are associated with the allocation of advanced therapies among women.

Objective

To determine whether the intersection of patient gender and race is associated with the decision-making of clinicians during the allocation of advanced heart failure therapies.

Design, Setting, and Participants

In this qualitative study, 46 US clinicians attending a conference for an international heart transplant organization in April 2019 were interviewed on the allocation of advanced heart failure therapies. Participants were randomized to examine clinical vignettes that varied 1:1 by patient race (African American to white) and 20:3 by gender (women to men) to purposefully target vignettes of women patients to compare with a prior study of vignettes of men patients. Participants were interviewed about their decision-making process using the think-aloud technique and provided supplemental surveys. Interviews were analyzed using grounded theory methodology, and surveys were analyzed with Wilcoxon tests.

Exposure

Randomization to clinical vignettes.

Main Outcomes and Measures

Thematic differences in allocation of advanced therapies by patient race and gender.

Results

Among 46 participants (24 [52%] women, 20 [43%] racial minority), participants were randomized to the vignette of a white woman (20 participants [43%]), an African American woman (20 participants [43%]), a white man (3 participants [7%]), and an African American man (3 participants [7%]). Allocation differences centered on 5 themes. First, clinicians critiqued the appearance of the women more harshly than the men as part of their overall impressions. Second, the African American man was perceived as experiencing more severe illness than individuals from other racial and gender groups. Third, there was more concern regarding appropriateness of prior care of the African American woman compared with the white woman. Fourth, there were greater concerns about adequacy of social support for the women than for the men. Children were perceived as liabilities for women, particularly the African American woman. Family dynamics and finances were perceived to be greater concerns for the African American woman than for individuals in the other vignettes; spouses were deemed inadequate support for women. Last, participants recommended ventricular assist devices over transplantation for all racial and gender groups. Surveys revealed no statistically significant differences in allocation recommendations for African American and white women patients.

Conclusions and Relevance

This national study of health care professionals randomized to clinical vignettes that varied only by gender and race found evidence of gender and race bias in the decision-making process for offering advanced therapies for heart failure, particularly for African American women patients, who were judged more harshly by appearance and adequacy of social support. There was no associated between patient gender and race and final recommendations for allocation of advanced therapies. However, it is possible that bias may contribute to delayed allocation and ultimately inequity in the allocation of advanced therapies in a clinical setting.

Abstract A085: Challenges and successes in recruiting African Americans with early-stage, non-small cell lung cancer to an NIMHD-funded, NCORP-based patient navigation trial

Background: Enrollment of early-stage lung cancer patients to randomized trials has historically been challenging. The STARS Trial enrolled 36 of 1,030 intended patients from 28 sites, while the ROSEL Trial recruited 22 of 960 intended patients from 10 sites. Unfortunately, evidence shows African Americans with early-stage NSCLC are significantly less likely than their European American counterparts to undergo resection and may also be less likely to participate in lung cancer trials as well.

Purpose: The purpose of this research is to describe interim recruitment results from an NIMHD-funded, NCI NCORP-based patient navigation trial conducted with African Americans with early-stage, probable/proven non-small cell lung cancer (NSCLC).

Design: The protocol-driven, barriers-focused patient navigation intervention is being conducted in the context of a two-arm cluster-randomized trial testing the effectiveness of the intervention in increasing rates of lung-directed curative-intent therapy (surgery and SBRT) in African Americans with Stage I-II NSCLC. The 2 study arms consist of the protocol-driven, intensive navigation intervention vs. usual care. The trial includes 20 study sites in 11 US states. Specific activities to enhance recruitment in the present trial include reaching out to referring physicians (e.g., primary care, pulmonologists, radiologists) to increase referrals of African American patients to the participating NCORP sites, and partnering with the leaders of community engagement activities at the sites to raise community-level awareness of the trial.

Results/Conclusions: To date, 200 African American patients have been recruited and the trial is now on target to meet its expected accrual goal of 222 patients. The majority of potential participants were ineligible due to receipt of surgical resection or radiation therapy prior to enrollment (24%), not having been told that they had probable/proven NSCLC prior to study contact (22%), or a previous history of lung cancer (10%). The median age of the 200 participants is 65 years (range 40-86 years). Most are unmarried (70%) and have a high school diploma or less (71%). The number of enrolled-to-date African American participants in this ongoing trial exceeds the total number of participants recruited to the STARS Trial or to the ROSEL Trial.

Citation Format: Marvella E. Ford, Debbie C. Bryant, Kathleen B. Cartmell, Katherine Sterba, Dana R. Burshell, Elizabeth G. Hill, Joanne Kim, Allan De Toma, Kendrea D. Knight, Ta'Myiah Reed, Kathryn Weaver, Elizabeth Calhoun, Nestor F. Esnaola. Challenges and successes in recruiting African Americans with early-stage, non-small cell lung cancer to an NIMHD-funded, NCORP-based patient navigation trial [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr A085.

Abstract 22: Affordable Care Act Medicaid Expansion Then and Now: Racial/Ethnic Differences in Receipt of Guideline-Directed Medical Therapy During Heart Failure Hospitalizations

Introduction: Uninsurance is a known contributor to racial/ethnic minority health inequities. Insurance is needed for prescription medications and follow-up visits with specialists. Among racial/ethnic minority patients hospitalized with heart failure (HF), it is not well studied whether the Affordable Care Act (ACA) Medicaid Expansion was associated with increased receipt of guideline-directed medical treatment (GDMT) on discharge from HF hospitalization.

Methods: Using Get With The Guidelines-HF registry, logistic regression models were used to assess the odds of receiving GDMT [angiotensin converting enzyme inhibitor(ACE)/ angiotensin receptor blocker (ARB)/ angiotensin receptor-neprilysin inhibitor(ARNI); beta blocker; aldosterone antagonist; hydralazine/nitrate; HF education; HF follow-up appointment] in early adopter versus non-adopter states in the periods before (2012-2013) and after ACA Medicaid Expansion (2014-2019) within each race/ethnicity. Models were adjusted for patient-level covariates and generalized estimating equations addressed within-hospital clustering. The interaction (p-int) between adopter state status and timing of ACA Medicaid Expansion (2014) was evaluated.

Results: Among 271,606 patients (57.5% early adopter, 42.5% non-adopter states), 65.5% were White, 22.8% were African-American, 8.9% were Hispanic, and 2.9% were Asian. In fully adjusted analyses, ACA Medicaid Expansion was associated with significant likelihood of receipt of ACE/ARB/ARNI at discharge in Hispanics [before ACA: OR 0.40 (95% CI: 0.13, 1.23); after ACA: OR 2.46 (95% CI 1.10, 5.51); p-int <0.01]. Asians were more likely to receive a HF follow-up appointment [before ACA: OR 0.64 (0.20, 2.06); after ACA: OR 1.44 (0.50, 4.15); p-int 0.03]. No significant differences were found in receipt of GDMT at the time of ACA Medicaid Expansion for other racial/ethnic groups. Independent of timing of ACA, Hispanics were more likely to receive all GDMT if they resided in an early adopter state compared to non-adopter state (p<0.01). Individual evidence-based treatments varied by state group independent of ACA timing for other racial/ethnic groups. With the exception of ACE/ARB/ARNI, beta blockers, and HF follow-up, <60% of patients in both state groups received other forms of GDMT despite eligibility.

Conclusions: Among patients hospitalized with HF at centers voluntarily participating in a national quality improvement program, the ACA Medicaid Expansion was associated with increased receipt of ACE/ARB/ARNI in Hispanics, and increased receipt of follow-up appointments in Asians. Independent of the ACA, Hispanics residing in early adopter states were more likely to receive GDMT than Hispanics in non-adopter states. Futher expansion of ACA may reduce racial/ethnic disparities in HF; however, additional steps must be taken to overcome barriers to prescribing GDMT to all.

Abstract 384: Affordable Care Act Medicaid Expansion Then and Now: Racial/Ethnic Differences in Receipt of Guideline-Directed Medical Therapy During Heart Failure Hospitalizations

Introduction: Uninsurance is a known contributor to racial/ethnic minority health inequities. Insurance is needed for prescription medications and follow-up visits with specialists. Among racial/ethnic minority patients hospitalized with heart failure (HF), it is not well studied whether the Affordable Care Act (ACA) Medicaid Expansion was associated with increased receipt of guideline-directed medical treatment (GDMT) on discharge from HF hospitalization.

Methods: Using Get With The Guidelines-HF registry, logistic regression models were used to assess the odds of receiving GDMT [angiotensin converting enzyme inhibitor(ACE)/ angiotensin receptor blocker (ARB)/ angiotensin receptor-neprilysin inhibitor(ARNI); beta blocker; aldosterone antagonist; hydralazine/nitrate; HF education; HF follow-up appointment] in early adopter versus non-adopter states in the periods before (2012-2013) and after ACA Medicaid Expansion (2014-2019) within each race/ethnicity. Models were adjusted for patient-level covariates and generalized estimating equations addressed within-hospital clustering. The interaction (p-int) between adopter state status and timing of ACA Medicaid Expansion (2014) was evaluated.

Results: Among 271,606 patients (57.5% early adopter, 42.5% non-adopter states), 65.5% were White, 22.8% were African-American, 8.9% were Hispanic, and 2.9% were Asian. In fully adjusted analyses, ACA Medicaid Expansion was associated with significant likelihood of receipt of ACE/ARB/ARNI at discharge in Hispanics [before ACA: OR 0.40 (95% CI: 0.13, 1.23); after ACA: OR 2.46 (95% CI 1.10, 5.51); p-int <0.01]. Asians were more likely to receive a HF follow-up appointment [before ACA: OR 0.64 (0.20, 2.06); after ACA: OR 1.44 (0.50, 4.15); p-int 0.03]. No significant differences were found in receipt of GDMT at the time of ACA Medicaid Expansion for other racial/ethnic groups. Independent of timing of ACA, Hispanics were more likely to receive all GDMT if they resided in an early adopter state compared to non-adopter state (p<0.01). Individual evidence-based treatments varied by state group independent of ACA timing for other racial/ethnic groups. With the exception of ACE/ARB/ARNI, beta blockers, and HF follow-up, <60% of patients in both state groups received other forms of GDMT despite eligibility.

Conclusions: Among patients hospitalized with HF at centers voluntarily participating in a national quality improvement program, the ACA Medicaid Expansion was associated with increased receipt of ACE/ARB/ARNI in Hispanics, and increased receipt of follow-up appointments in Asians. Independent of the ACA, Hispanics residing in early adopter states were more likely to receive GDMT than Hispanics in non-adopter states. Futher expansion of ACA may reduce racial/ethnic disparities in HF; however, additional steps must be taken to overcome barriers to prescribing GDMT to all.

Is the Affordable Care Act Medicaid Expansion Linked to Change in Rate of Ventricular Assist Device Implantation for Blacks and Whites?

BACKGROUND

The Affordable Care Act (ACA) has been associated with increased heart transplant listings among blacks, who are disproportionately uninsured. It is unclear whether the ACA is also associated with increased ventricular assist device implantation in blacks.

METHODS

Using Healthcare Cost and Utilization Project Data State Inpatient Databases from 19 states and Washington DC, we analyzed 1157 patients from early-adopter states (ACA Medicaid expansion by January 2014) and 785 patients from nonadopter states (no implementation from 2013 to 2014). Piecewise Poisson regression with a discontinuity was used to estimate change in census-adjusted rates of ventricular assist device implants by race and ACA adopter status 1 year before and after January 2014.

RESULTS

Following the ACA Medicaid expansion, the proportional change in rate increased significantly among blacks from early adopter (1.40 [95% CI, 1.12-1.75], pre 0.57/100 000 to post-ACA 0.80/100 000) but not nonadopter states (1.25 [95% CI, 0.98-1.58], pre 0.40/100 000 to post-ACA 0.50/100 000). However, the early and nonadopter changes in implantation rates were not statistically different from each other (P=0.50). There were no immediate changes in whites in either state group following the ACA Medicaid expansion (early adopter, 1.12 [95% CI, 0.98-1.29], pre 0.27/100 000 to post-ACA 0.30/100 000; nonadopter, 0.98 [95% CI, 0.82-1.16], pre 0.27/100 000 to post-ACA 0.26/100 000).

CONCLUSIONS

Among eligible states participating in Healthcare Cost and Utilization Project Data State Inpatient Databases, the ACA was not associated with immediate changes in ventricular assist device implantation rates by race. Although a significant increase in implantation rate was observed among blacks from early-adopter states, the change was not statistically different from the change seen in nonadopter states.

Approach to High Volume Enrollment in Clinical Research: Experiences from an All of Us Research Program Site

Clinical trials and cohort studies are required to meet target recruitment of study participants within stipulated timelines, especially when the priority is to include populations traditionally unrepresented in biomedical research. By the third quarter of 2019, the University of Arizona‐Banner Health Provider Organization (UA‐Banner HPO) has enrolled > 30,000 core participants into the All of Us Research Program (AoURP), the research cohort of the Precision Medicine Initiative. The majority of enrolled participants meet the criteria for individuals under‐represented in biomedical research. The enrollment goals were calculated based on a target of 20,000 as set by the National Institutes of Health and our health provider organization achieved enrollment numbers between 17% and 86% above the targeted daily enrollment. We evaluated enrollment methods and challenges to enrollments encountered by the UA‐Banner Health Provider Organization into the AoURP. Challenges to enrollment centered around the need for high‐touch engagement methods, time investment necessary for stakeholder inclusion, and the use of purely digital enrollment methods especially in populations under‐represented in biomedical research. These challenges occurred at the level of the individual, provider, institutions, and community, and cumulatively impacted participant enrollment. Successful strategies for engagement and enrollment leveraged provider partners as advocates for the program. For high‐volume enrollment in clinical research, it is important to engage leaders in the healthcare setting, patient providers, and tailor engagement and enrollment to potential participant needs. We emphasize the need for precision engagement and enrollment methods tailored to individual needs.

Abstract P6-11-13: Identification of barriers to breast cancer screening that affect compliance

Background: In 2015, the latest year for which the Center for Disease Control (CDC) has incidence data, 242,476 new cases of Female Breast Cancer were reported, and 41,523 women died of Female Breast Cancer in the United States. For every 100,000 women, 125 new Female Breast Cancer cases were reported and 20 died of cancer. In Arizona, breast was the leading site of new cancers in 2015, with 110.9 new breast cancer diagnoses per 100,000 women, and is second for cancer deaths, reporting 19 deaths per 100,000 women. This study specifically addresses low screening rates among women in Pima County in Southern Arizona through a telephone navigation program with the goal of increasing follow-up mammograms and recommended breast imaging. Our short-term goal is to increase both initial screening and diagnostic resolution rates among women in Southern Arizona. Our long-term plan is to develop a sustainable model to increase breast cancer screening among women that is expected to inform programs state-wide and nationally. Specific aims are: 1) to increase adherence or repeat screening rate by 20% for women lost to follow-up; 2) Establish the framework for a community-academic partnership that can be replicated in other Hispanic-based areas. Methods: Potential study participants were identified using Electronic Health Records and categorized by Breast Imaging-Reporting and Data System (BI-RADS) 0 to 5. Inclusion criteria include non-compliant women of any race/ethnicity between the ages of 40 and 75 who have been referred to, or seen at a breast imaging clinic in Tucson, Arizona (Pima County) from January 1, 2014 to September 30, 2017. Of those non-compliant, 47% had a BI-RADS 0,3,4, or 5. With IRB approval from University of Arizona, we adapted a questionnaire validated for use in colon cancer to measure screening knowledge, motivations and barriers to adherence, and self-efficacy. Two navigators reached out to participants to recruit and re-engage them in the care process. Results: The sample is n=9661 of noncompliant patients from a clinic in Southern Arizona, 26% were Hispanic and 65% non-Hispanic, with 10% with 9% requiring an interpreter. From this sample, 123 study participants have been recruited (300 target accrual) with a 21% recruitment rate, 46% unable to reach rate, and a 47% decline rate. Notably, of those who declined, 66% reported being compliant at another clinic. The participants were 46% non-Hispanic and 52% Hispanic, with 25% requiring an English/Spanish interpreter. Nearly half had less than or a high school degree and similarly, nearly half had a monthly family income of $2000 or less. On the questionnaire section of knowledge, there were no statistically significant results indicating extensive knowledge, except for how often one should have a mammogram, in which 93% answered correctly. On the Barriers to Getting a Mammogram section, when the data was disaggregated by ethnicity, there was statistically significant (P⇒.05) responses. One barrier identified was financial reasons (P=.05), but interestingly no (0) Hispanics reported financial reasons to be a barrier. Conclusion: The high number of declined due to compliant elsewhere points to the need to develop a business case to sustain lay navigators across the breast cancer continuum, from screening to diagnostic resolution, treatment, survivorship, and/or palliative care. Further, breast cancer and breast screening education materials will be developed in the next phase of this study and interventions to address financial reasons. For more information on this study, please contact Drs. Jorge Gomez (Jorgejgomez@email.arizona.edu), Allison Huff MacPherson (allison7@email.arizona.edu).

Citation Format: Allison Huff MacPherson, Jorge Gomez, Elizabeth Calhoun, Marisa Borders, Kimberly Fitzpatrick, Yessenia Prado, Dora Bezies-Lopez, Chiu-Hsieh Hsu. Identification of barriers to breast cancer screening that affect compliance [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P6-11-13.

Does Race Influence Decision Making for Advanced Heart Failure Therapies?

Background

Race influences medical decision making, but its impact on advanced heart failure therapy allocation is unknown. We sought to determine whether patient race influences allocation of advanced heart failure therapies.

Methods and Results

Members of a national heart failure organization were randomized to clinical vignettes that varied by patient race (black or white man) and were blinded to study objectives. Participants (N=422) completed Likert scale surveys rating factors for advanced therapy allocation and think‐aloud interviews (n=44). Survey results were analyzed by least absolute shrinkage and selection operator and multivariable regression to identify factors influencing advanced therapy allocation, including interactions with vignette race and participant demographics. Interviews were analyzed using grounded theory. Surveys revealed no differences in overall racial ratings for advanced therapies. Least absolute shrinkage and selection operator regression selected no interactions between vignette race and clinical factors as important in allocation. However, interactions between participants aged ≥40 years and black vignette negatively influenced heart transplant allocation modestly (−0.58; 95% CI, −1.15 to −0.0002), with adherence and social history the most influential factors. Interviews revealed sequential decision making: forming overall impression, identifying urgency, evaluating prior care appropriateness, anticipating challenges, and evaluating trust while making recommendations. Race influenced each step: avoiding discussing race, believing photographs may contribute to racial bias, believing the black man was sicker compared with the white man, developing greater concern for trust and adherence with the black man, and ultimately offering the white man transplantation and the black man ventricular assist device implantation.

Conclusions

Black race modestly influenced decision making for heart transplant, particularly during conversations. Because advanced therapy selection meetings are conversations rather than surveys, allocation may be vulnerable to racial bias.

Design of the patient navigator to Reduce Readmissions (PArTNER) study: A pragmatic clinical effectiveness trial

Previous work indicates the potential for community health workers and peer coaches serving as patient navigators to improve processes of care and health outcomes during care transitions, but have not been sufficiently tested to determine if such programs improve measures of patient experience in minority serving institutions. The objectives of the Patient Navigator to Reduce Readmissions (PArTNER) study was to: 1) conduct a pragmatic clinical effectiveness trial comparing a multi-faceted, stakeholder-supported Navigator intervention (in-person CHW visits in the hospital and after hospital discharge, plus telephone-based peer coaching) versus usual care on the experience of hospital-to-home care transitions in patients hospitalized with heart failure, pneumonia, chronic obstructive pulmonary disease, myocardial infarction, or sickle cell disease; 2) examine the effectiveness of the Navigator intervention in patient subgroups; and 3) understand the barriers and facilitators of successfully implementing the Navigator intervention across patient populations. The co-primary outcomes are the 30-day changes in: 1) Patient Reported Outcomes Measurement Information System (PROMIS) emotional distress-anxiety, and 2) PROMIS informational support. Secondary outcomes at 30 and 60 days include other PROMIS health measures and hospital readmissions. Innovative features of the PArTNER study include early and continuous engagement of patients, their caregivers, clinicians, health system administrators, and other stakeholders to inform the design and implementation of the Navigator intervention. In this report, we describe the design of the PArTNER study.

Temporal Trends in Contemporary Use of Ventricular Assist Devices by Race and Ethnicity

BACKGROUND

The proportion of racial/ethnic minorities receiving ventricular assist devices (VADs) has previously been less than expected. It is unclear if trends have changed since the broadening of access to insurance in 2014 and the rapid adoption of VAD technology.

METHODS AND RESULTS

Using the Interagency Registry of Mechanically Assisted Circulatory Support, we analyzed time trends by race/ethnicity for 10 795 patients (white, 67.4%; African-American, 24.8%; Hispanic, 6.3%; Asian, 1.5%) who had a VAD implanted between 2012 and 2015. Linear models were fit to the annual census-adjusted rate of VAD implantation for each racial/ethnic group, stratified by sex and age group. From 2012 to 2015, African-Americans had an increase in the census-adjusted annual rate of VAD implantation per 100 000 (0.26 [95% confidence interval, 0.17-0.34]) while other ethnic groups exhibited no significant changes (white: 0.06 [-0.03 to 0.14]; Hispanic: 0.04 [-0.05 to 0.12]; Asian: 0.04 [-0.04 to 0.13]). Stratified by sex, rates increased in both African-American men and women (P<0.05), but the change in rate was highest among African-American men (men 0.37 [0.28-0.46]; women 0.16 [0.07-0.25]; interaction with sex P=0.004). Stratified by age group, rates increased in African-Americans aged 40 to 69 years and Asians aged 50 to 59 years (P<0.05). The observed differential change in VAD implantation rate by age group was significant among African-Americans (interaction with age, P<0.01) and Asians (interaction with age, P=0.02).

CONCLUSIONS

From 2012 to 2015, VAD implantation rates increased among African-Americans but not other racial/ethnic groups. The greatest increase in rate was observed among middle-aged African-American men, suggesting a decline in racial disparities. Further investigation is warranted to reduce disparities among women and older racial/ethnic minorities.

Abstract P5-13-19: Addressing non-adherence for breast cancer screening across ethnicity in southern Arizona

Background In Arizona, female breast cancer has the highest incidence rate and the second highest death rate compared to all other cancers. This ongoing single arm intervention study investigates non-adherence with recommended annual mammography or follow-up breast imaging. Data collected for this study is both retrospective, using the university Electronic Health Record (EHR) system (January 1, 2014 to September 30, 2017), and prospective, implementing a questionnaire during the intervention phase. Potential study participants were identified using EHR and categorized by BI-RADS (Breast Imaging-Reporting and Data System) 0 to 5. With IRB approval from University of Arizona, we designed a questionnaire to measure barriers to adherence and we navigate participants to schedule and attend follow-up appointments. This study's overall specific aims are to increase first time mammography screening by 25% among women in Southern Arizona; increase adherence or repeat screening rate by 20% among women lost to follow-up; establish the framework for a community- academic partnership in ethnically diverse areas. Women, age 40 and older who are not compliant with recommended annual mammograms or recommended follow-up screenings after a suspicious finding are eligible to participate in this study. Men and children, as well as women for whom breast imaging is not recommended are excluded from participating in this study. Results Patient's age was summarized by mean ± standard deviation for continuous variables and frequency and the associated percentage for categorical variables. BI-RADS scores were classified into Negative, Benign, Possible Malignancy and Proven Malignancy and compared between ethnic and racial groups using Fisher's exact test. Of 8823 non-compliant woman over nearly 4 years of data, 0.2% are BI-RADS 4 and 5, 2.2% are BI-RADS 3, 96% are BI-RADS 1 and 2, and 0.3% are BI-RADS 0. The mean age is 61.59 years, with 25% reporting as Hispanic, 66% reporting as non-Hispanic women (NHW), and 10% preferring to receive care in Spanish. Initial data shows only .24% with proven malignancies. Further, the data reveals that Hispanics have a slightly higher rate of possible malignancy (.36%) than NHW (.18%); however, NHW show a slightly higher rate of proven malignancy (.27% compared to .18%, respectively). Discussion These data provide valuable information for the direction of this study; in particular, understanding the disparity between Hispanic and NHW malignancies and developing culturally competent interventions and education materials to increase compliance with breast cancer screening recommendations. Further, these data indicate our focus should be on screening compliance for BI-RADS 1 and 2. These data also point to a possible high non-compliance issue. Comparing non-compliance data from other regional clinics will continue to shape this study's direction. The target sample size for this study is 300 participants. We accept a 95% confidence level and a 5% margin of error. Out of 420 recruitment letters mailed, the navigators have reached 152 potential participants by phone and have a 26% study recruitment rate (n=40).

Citation Format: Huff AJ, Gomez J, Calhoun E, Hsu C-H, Chalasani P, Fitzpatrick K, Borders M, Lang L, Prado Y. Addressing non-adherence for breast cancer screening across ethnicity in southern Arizona [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-13-19.

Abstract A23: Interim Recruitment Outcomes in an NCORP-Based Patient Navigation Trial for African Americans with Early Stage Lung Cancer

Background: Enrollment of early-stage lung cancer patients to randomized trials has historically been challenging. The STARS Trial enrolled 36 of 1,030 intended patients from 28 sites, while the ROSEL Trial recruited 22 of 960 intended patients from 10 sites. Unfortunately, evidence shows African Americans with early-stage non-small cell lung cancer (NSCLC) are significantly less likely than their European American counterparts to undergo resection and may also be less likely to participate in lung cancer trials as well.

Purpose: The purpose of this research is to describe interim recruitment results from an NIMHD-funded, NCI NCORP-based patient navigation trial conducted with African Americans with early-stage, probable/proven NSCLC.

Design: The protocol-driven, barriers-focused patient navigation intervention is being conducted in the context of a two-arm cluster-randomized trial testing the effectiveness of the intervention in increasing rates of lung-directed curative-intent therapy (surgery and SBRT) in African Americans with Stage I-II NSCLC. The two study arms consist of the protocol-driven, intensive navigation intervention vs. usual care. The trial includes 24 study sites in 13 U.S. states. Specific activities to enhance recruitment in the present trial include reaching out to referring physicians (e.g., primary care, pulmonologists, radiologists) to increase referrals of African American patients to the participating NCORP sites, and partnering with the leaders of community-engagement activities at the sites to raise community-level awareness of the trial.

Results/Conclusions: To date, 90 African American patients have been recruited and the trial is now on target to meet its expected accrual goal of 200 patients. The majority of potential participants were ineligible due to receipt of surgical resection or radiation therapy prior to enrollment (27%), not having been told that they had probable/proven NSCLC prior to study contact (32%), or a previous history of lung cancer (10%). Only 13 potential participants have refused trial participation. The median age of the 90 participants is 66 years (range 51-86 years). Most are unmarried (64%) and have a high school diploma or less (73%). Only 10 of the participants (24%) have no comorbidities. The number of enrolled-to-date African American participants in this ongoing trial exceeds the total number of participants recruited to the STARS Trial or to the ROSEL Trial.

Citation Format: Marvella E. Ford, Debbie C. Bryant. Kathleen B. Cartmell, Katherine Sterba, Dana R. Burshell, Elizabeth G. Hill, Allan De Toma, Kendrea D. Knight, Kathryn Weaver Elizabeth Calhoun, Nestor F. Esnaola. Interim Recruitment Outcomes in an NCORP-Based Patient Navigation Trial for African Americans with Early Stage Lung Cancer [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr A23.

The early dissemination of patient navigation interventions: results of a respondent-driven sample survey

Patient navigators (PNs) coordinate medical services and connect patients with resources to improve outcomes, satisfaction, and reduce costs. Little national information is available to inform workforce development. We analyzed 819 responses from an online PN survey conducted in 2009-2010. Study variables were mapped to the five Consolidated Framework for Implementation Research (CFIR) constructs to explore program variations by type of PN. Five logistic regression models compared each PN type to all others while adjusting for covariates. Thirty-five percent of respondents were nurse navigators, 28% lay navigators, 20% social work (SW)/counselor navigators, 7% allied health navigators, and 10% were "other" types of PNs. Most were non-Hispanic White (71%), female (94%), and at least college educated (70%). The primary differences were observed among: the core intervention tasks; position structure; work setting; health conditions navigated; navigator race/ethnicity; personal cancer experiences; navigation training; and patient populations served. Lay PNs had fewer odds of identifying as Hispanic, work in rural settings and assist underserved populations compared to others. Nurse navigators showed greater odds of clinical responsibilities, work in hospital or government settings and fewer odds of navigating minority populations compared to others. SW/counselor navigators also had additional duties, provided greater assistance to Medicare patient populations, and less odds of navigating underserved populations than others. In summary, our survey indicates that the type of PN utilized is an indicator of other substantial differences in program implementation. CFIR provides a robust method to compare differences and should incorporate care coordination outcomes in future PN research.

Engaging Patients and Caregivers to Design Transitional Care Management Services at a Minority Serving Institution

Limited socioeconomic resources contribute to high readmission rates at minority serving institutions (MSIs). A better understanding of patient-level factors and need for patient navigators could inform approaches to enhance care transitions tailored to these vulnerable patient populations. We sought to understand the perspectives of patients and their caregivers about hospital to home transitions from an MSI, as well as their attitudes about patient navigators to facilitate care transitions. We conducted qualitative research using focus groups (FGs)-five disease-specific patient FGs and two caregiver FGs, including 23 patients and 10 caregivers. Findings support the need for additional services to address: (1) gaps in the hospital discharge; (2) socioeconomic resources; (3) access to post-discharge care; (4) patient's health care seeking behaviors; (5) patient anxiety; (6) self-management education; and (7) social supports for patients and caregivers. While caregivers uniformly expressed interest in patient navigators, support for navigators among patients was more variable.

Abstract A72: Interim Recruitment Outcomes in an NCORP-Based Patient Navigation Trial for African Americans with Early Stage Lung Cancer

BACKGROUND: Enrollment of early stage lung cancer patients to randomized trials has historically been challenging. The STARS Trial enrolled 36 of 1,030 intended patients from 28 sites, while the ROSEL Trial recruited 22 of 960 intended patients from 10 sites. Unfortunately, evidence shows African Americans with early stage, NSCLC are significantly less likely than their European American counterparts to undergo resection and may also be less likely to participate in lung cancer trials as well.

PURPOSE: The purpose of this research is to describe interim recruitment results from an NIMHD-funded, NCI NCORP-based patient navigation trial conducted with African Americans with early stage, probable/proven non-small cell lung cancer (NSCLC).

DESIGN: The protocol-driven, barriers-focused patient navigation intervention is being conducted in the context of a two-arm cluster-randomized trial testing the effectiveness of the intervention in increasing rates of lung-directed curative-intent therapy (surgery and SBRT) in African Americans with Stage I-II NSCLC. The 2 study arms consist of the protocol-driven, intensive navigation intervention vs. usual care. The trial includes 24 study sites in 13 US states. Specific activities to enhance recruitment in the present trial include reaching out to referring physicians (e.g., primary care, pulmonologists, radiologists) to increase referrals of African American patients to the participating NCORP sites, and partnering with the leaders of community engagement activities at the sites to raise community-level awareness of the trial.

RESULTS/CONCLUSIONS: To date, 64 African American patients have been recruited and the trial is now on target to meet its expected accrual goal of 200 patients. The majority of potential participants were ineligible due to receipt of surgical resection or radiation therapy prior to enrollment (32%), not having been told that they had probable/proven NSCLC prior to study contact (13%) or a previous history of lung cancer (13%). Only 9 potential participants have refused trial participation. The median age of the 64 participants is 64 years (range 37-86 years). Most are unmarried (64%) and have a high school diploma or less (72%). Only 13 of the participants (20%) have no comorbidities. The number of enrolled-to-date African American participants in this ongoing trial exceeds the total number of participants recruited to the STARS Trial or to the ROSEL Trial.

Citation Format: Marvella E. Ford, Debbie C. Bryant, Kathleen B. Cartmell, Katherine Sterba, Dana R. Burshell, Elizabeth G. Hill, Allan De Toma, Kendrea D. Knight, Kathryn Weaver, Elizabeth Calhoun, Nestor F. Esnaola. Interim Recruitment Outcomes in an NCORP-Based Patient Navigation Trial for African Americans with Early Stage Lung Cancer. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr A72.

The impact of patient navigation on the delivery of diagnostic breast cancer care in the National Patient Navigation Research Program: a prospective meta-analysis

Patient navigation is emerging as a standard in breast cancer care delivery, yet multi-site data on the impact of navigation at reducing delays along the continuum of care are lacking. The purpose of this study was to determine the effect of navigation on reaching diagnostic resolution at specific time points after an abnormal breast cancer screening test among a national sample. A prospective meta-analysis estimated the adjusted odds of achieving timely diagnostic resolution at 60, 180, and 365 days. Exploratory analyses were conducted on the pooled sample to identify which groups had the most benefit from navigation. Clinics from six medical centers serving vulnerable populations participated in the Patient Navigation Research Program. Women with an abnormal breast cancer screening test between 2007 and 2009 were included and received the patient navigation intervention or usual care. Patient navigators worked with patients and their care providers to address patient-specific barriers to care to prevent delays in diagnosis. A total of 4675 participants included predominantly racial/ethnic minorities (74 %) with public insurance (40 %) or no insurance (31 %). At 60 days and 180 days, there was no statistically significant effect of navigation on achieving timely diagnostic care, but a benefit of navigation was seen at 365 days (aOR 2.12, CI 1.36-3.29). We found an equal benefit of navigation across all groups, regardless of race/ethnicity, language, insurance status, and type of screening abnormality. Patient navigation resulted in more timely diagnostic resolution at 365 days among a diverse group of minority, low-income women with breast cancer screening abnormalities. Trial registrations clinicaltrials.gov Identifiers: NCT00613275, NCT00496678, NCT00375024, NCT01569672.

Abstract C45: A patient navigation model to increase rates of lung-directed therapy with curative intent (LDTCI) in African Americans with early stage non-small cell lung cancer (NSCLC)

Background: LDTCI (i.e., surgical resection or stereotactic body radiation therapy [SBRT] in patients who are not surgical candidates]) is the standard of care for patients with early stage NSCLC. Unfortunately, African Americans with early stage, NSCLC are significantly less likely than their European American counterparts to undergo resection.

Purpose: This presentation will describe the design of an NIH/NIMHD-funded, NCORP-sponsored, cluster-randomized trial testing the effectiveness of a barriers-focused, protocol-driven patient navigation intervention on increasing rates of LDTCI in African Americans with early stage, probable/proven NSCLC.

Design: The trial is currently being conducted at 13 study sites across the United States. The investigators developed an electronic, web-based version of the NIH/NCI Patient Navigation Barrier Checklist. Patient navigators at each intervention site use the electronic Checklist to identify patient barriers to care and guide their interactions with patients. The navigators then enter the data from these interactions into a secure, web-based electronic data management system.

Results/Conclusions: Most of the African American patients at the study sites are ineligible for study participation due to advanced stage at diagnosis. Of the 2,529 patients who have been pre-screened for study eligibility to date, only 43 (1.7%) were determined to be African American with likely/proven stage I-II NSCLC. Of this number, 34 (79.1%) were consented for the study, and 29 are currently enrolled. During this presentation, the investigators will present de-identified case examples of barriers experienced by patients and the strategies used by the navigators to overcome these barriers. Plans are underway to add study sites to increase the denominator of potentially eligible participants.

Citation Format: Nestor F. Esnaola, Debbie C. Bryant, Kathleen B. Cartmell, Elizabeth Calhoun, Katherine Sterba, Dana R. Burshell, Elizabeth G. Hill, Amy E. Wahlquist, Kendrea D. Knight, Marvella E. Ford. A patient navigation model to increase rates of lung-directed therapy with curative intent (LDTCI) in African Americans with early stage non-small cell lung cancer (NSCLC). [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr C45.

The effects of navigation and types of neighborhoods on timely follow-up of abnormal mammogram among black women

BACKGROUND

Despite the availability of relatively simple and inexpensive screening tools, minority women are more often diagnosed at a late stage of breast cancer, in part due to delays in follow-up of abnormal screening result. One of the key factors for timely follow-up of abnormal mammogram may be neighborhood characteristics. Patient Navigation (PN) programs aim to diminish barriers, but its differential effects by neighborhood have not been fully examined. The current study examines the effect of types of neighborhoods on time to follow-up of abnormal mammogram, and the differential effects of PN by neighborhood characteristics.

METHODS

We examined data from a total of 1,696 randomized patients from a randomized controlled trial, "the Patient Navigation in Medically Underserved Areas" study that explored the effect of navigation on breast health outcomes. We categorized participants' neighborhoods into three categories and compared the effect of navigation between these neighborhood types.

RESULTS

Navigated women in mixed race neighborhoods had a shorter time to follow-up compared with non-navigated women in the neighborhoods. Black women living in mixed neighborhoods had a significant longer time to follow-up of abnormal mammogram, compared with black women living in middle class black neighborhoods.

CONCLUSION

Patient navigation interventions improve timely follow-up of abnormal mammogram. Patient navigation may be particularly beneficial for minority women who reside in racially heterogeneous neighborhoods which may be less likely to have access to affordable health clinics and social services. Health policies concerning breast cancer early detection for minority women need to pay further attention to those who might potentially be excluded from health services due to the characteristics of neighborhoods. Socioeconomic conditions of neighborhood may affect individual health through multiple interlinked mechanisms. Neighborhood characteristics, such as poverty, segregation, access to resources, and social cohesion, cannot be fully understood with simplistic measures of neighborhood disadvantage.

Abstract B72: Timely breast cancer diagnostic resolution: Effects of individual and neighborhood characteristics

Background: Disparities occur throughout the breast cancer continuum. African American women are more likely to be diagnosed with cancer at later stages, which results in poorer outcomes. In fact, despite lower incidence, the mortality rates are higher among black women.

While timely follow-up of abnormal breast cancer diagnostic test results could lead to early diagnosis and better treatment outcomes, a myriad of factors may influence timely diagnostic resolution, even with patient navigation in place. Individual and neighborhood socioeconomic characteristics affect access to care, quality, and timeliness of care, which consequently affect health outcomes.

In this study, we focus on the effects of neighborhood racial composition and poverty on timeliness of diagnostic test in African American women living in relatively poor neighborhoods in Chicago, IL.

Purpose: The purpose of this study is to examine the effects of individual and neighborhood characteristics on timely resolution of breast cancer diagnostic tests among African American women who received breast cancer screening and diagnostic tests from three community hospitals in disadvantaged neighborhoods in Chicago.

Methods: The analysis utilized a total of 405 African American women who participated in the Patient Navigation in Medically Underserved Areas Project in Chicago. Participating women were recruited from three hospitals. We created an indicator variable for timely diagnostic resolution (completion of follow-up tests within 60 days). We geo-coded participants' home addresses, and calculated distance from home to clinic in miles. We added census tract level data from the American Community Survey 2005-2009, including racial composition and % poverty. In addition, we used Medically Underserved Area (MUA) designation (affluent; MUA designated poor; MUA undesignated poor). Individual characteristics were: age, education, distance to clinic, marital status, and health care distrust. We used Hierarchical Linear Model (HLM) to perform two-level models explaining diagnostic resolution timeliness.

Results: The average age of participants was 60 years old. Over 92% completed high school education and 81% lived in MUA designated and undesignated but poor areas (vs. 19% living in affluent areas that are not eligible for MUA). On average, women traveled 5.5 miles to clinics. The mean % whites and % poverty were respectively 11% and 32%, respectively, which differed from overall % whites (32%) and % poverty in Chicago (21%). Women living in areas with a higher % of white residents were more likely to complete diagnostic tests within 60 days, controlling for all other variables. On the other hand, women living in areas with a higher % of African American residents were less likely to have timely diagnostic resolution, controlling for % poverty and all other individual level characteristics. Neighborhood poverty level was not significantly associated with diagnostic test completion.

Conclusions: Even though all participants were African American women, living in neighborhoods with a higher proportion of whites was associated with timely diagnostic test resolution. Ethnic minority women seem to benefit from living in more racially integrated neighborhood environment, regardless of the level of poverty or MUA designation. While MUA designation and poverty are known to affect access to care, which is expected to influence timeliness of diagnostic test, racial composition of neighborhoods was shown to have a significant independent effect on timeliness of diagnostic test. The mechanisms of racial residential segregation on timeliness of diagnostic tests need to be further evaluated.

Citation Format: Seijeoung Kim, Yamile Molina, Nerida Berriors, Elizabeth Calhoun. Timely breast cancer diagnostic resolution: Effects of individual and neighborhood characteristics. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr B72. doi:10.1158/1538-7755.DISP13-B72

Can patient navigation improve receipt of recommended breast cancer care? Evidence from the National Patient Navigation Research Program

PURPOSE

Poor and underserved women face barriers in receiving timely and appropriate breast cancer care. Patient navigators help individuals overcome these barriers, but little is known about whether patient navigation improves quality of care. The purpose of this study is to examine whether navigated women with breast cancer are more likely to receive recommended standard breast cancer care.

PATIENTS AND METHODS

Women with breast cancer who participated in the national Patient Navigation Research Program were examined to determine whether the care they received included the following: initiation of antiestrogen therapy in patients with hormone receptor-positive breast cancer; initiation of postlumpectomy radiation therapy; and initiation of chemotherapy in women younger than age 70 years with triple-negative tumors more than 1 cm. This is a secondary analysis of a multicenter quasi-experimental study funded by the National Cancer Institute to evaluate patient navigation. Multiple logistic regression was performed to compare differences in receipt of care between navigated and non-navigated participants.

RESULTS

Among participants eligible for antiestrogen therapy, navigated participants (n = 380) had a statistically significant higher likelihood of receiving antiestrogen therapy compared with non-navigated controls (n = 381; odds ratio [OR], 1.73; P = .004) in a multivariable analysis. Among the participants eligible for radiation therapy after lumpectomy, navigated participants (n = 255) were no more likely to receive radiation (OR, 1.42; P = .22) than control participants (n = 297).

CONCLUSION

We demonstrate that navigated participants were more likely than non-navigated participants to receive antiestrogen therapy. Future studies are required to determine the full impact patient navigation may have on ensuring that vulnerable populations receive quality care.

Can patient navigation improve receipt of recommended breast cancer care? Evidence from the National Patient Navigation Research Program

PURPOSE

Poor and underserved women face barriers in receiving timely and appropriate breast cancer care. Patient navigators help individuals overcome these barriers, but little is known about whether patient navigation improves quality of care. The purpose of this study is to examine whether navigated women with breast cancer are more likely to receive recommended standard breast cancer care.

PATIENTS AND METHODS

Women with breast cancer who participated in the national Patient Navigation Research Program were examined to determine whether the care they received included the following: initiation of antiestrogen therapy in patients with hormone receptor-positive breast cancer; initiation of postlumpectomy radiation therapy; and initiation of chemotherapy in women younger than age 70 years with triple-negative tumors more than 1 cm. This is a secondary analysis of a multicenter quasi-experimental study funded by the National Cancer Institute to evaluate patient navigation. Multiple logistic regression was performed to compare differences in receipt of care between navigated and non-navigated participants.

RESULTS

Among participants eligible for antiestrogen therapy, navigated participants (n = 380) had a statistically significant higher likelihood of receiving antiestrogen therapy compared with non-navigated controls (n = 381; odds ratio [OR], 1.73; P = .004) in a multivariable analysis. Among the participants eligible for radiation therapy after lumpectomy, navigated participants (n = 255) were no more likely to receive radiation (OR, 1.42; P = .22) than control participants (n = 297).

CONCLUSION

We demonstrate that navigated participants were more likely than non-navigated participants to receive antiestrogen therapy. Future studies are required to determine the full impact patient navigation may have on ensuring that vulnerable populations receive quality care.