Impact of patient and navigator race and language concordance on care after cancer screening abnormalities

Depression and Anxiety Among English- and Spanish-Speaking Patients With Breast Cancer Receiving Radiation Therapy

PURPOSE

An estimated 30% and 40% of patients with breast cancer experience depression and anxiety, respectively. However, distress experienced by patients with breast cancer receiving radiation therapy may vary among patients and vary at different time points. This study sought to describe the changes in levels of depression and anxiety experienced by English- and Spanish-speaking patients throughout a course of radiation therapy for breast cancer, along with the effect of different variables to better understand potential gaps.

METHODS AND MATERIALS

Eligibility criteria included English- and Spanish-speaking females, aged 18 or older, undergoing radiation therapy treatment for breast cancer at 2 institutions. Pre- and posttreatment surveys were completed before and after delivery of radiation therapy. Sociodemographic characteristics collected included race, ethnicity, marital status, education level, longest residency location, religion, housing, and food insecurity. The survey ended with the standardized PHQ-4 questionnaire to assess anxiety and depression. Results were analyzed using the analysis of covariance procedure.

RESULTS

A total of 160 participants completed pre- and posttreatment surveys, with an initial response rate of 100% (169 patients), though 9 were lost to follow-up. Most of the participants were nonwhite (50%), primarily married (42.5%), and had a high school or associate's level education (46.9%). The total baseline distress mean (BDM) was 2.96 and the final distress mean was 2.78. English-speaking patients comprised 82.5% (n = 132) of the sample and had a BDM of 2.91 with an adjusted change mean decrease of 0.45. Spanish-speaking patients comprised 17.5% (n = 28) of the sample, with a baseline distress mean of 3.21 and an adjusted change mean increase of 1.03 (P = .002). Housing (P = .017) and food insecurity (P = .0002) also showed increasing distress with increased insecurity at baseline.

CONCLUSIONS

Patients who speak Spanish, identify as Hispanic, or are experiencing food and housing insecurity are at an increased risk for depression and anxiety, and could benefit from more support during their course of radiation therapy to minimize distress.

Interventions to increase follow-up of abnormal cervical cancer screening results: A systematic literature review and meta-analysis

INTRODUCTION

Ensuring timely follow-up of abnormal screening results is essential for eliminating cervical cancer.

OBJECTIVE

The purpose of the study was to review single and multicomponent interventions designed to improve follow-up of women with abnormal cervical cancer screening results. We report on effectiveness across studies, and describe what aspects of these interventions might be more impactful.

METHODS

Publications were searched between January 2000 and December 2022. The search included observational, quasi-experimental (pre-post studies) and randomized controlled studies describing at least one intervention to increase follow-up of women with abnormal cervical cancer screening results. Outcomes of studies included completion of any follow-up (i.e., attending a follow-up appointment), timely diagnosis (i.e., colposcopy results within 90 days of screening) and time to diagnostic resolution (i.e., days between screening and final diagnosis). We assessed risk of bias for observational and quasi-experimental studies using the Newcastle-Ottawa Scale (NOS) tool and the Cochrane collaboration tool for randomized studies. We conducted a meta-analysis using studies where data were provided to estimate a summary average effect of the interventions on follow-up of patients and to identify characteristics of studies associated with an increased effectiveness of interventions. We extracted the comparison and intervention proportions of women with follow-up before and after the intervention (control and intervention) and plotted the odds ratios (ORs) of completing follow-up along with the 95% confidence intervals (CIs) using forest plots for the interventions vs. controls when data were available.

FINDINGS

From 7,457 identified studies, 28 met the inclusion criteria. Eleven (39%) of the included studies had used a randomized design. Most studies (63%) assessed completion of any follow-up visit as the primary outcome, whereas others measured time to definite diagnosis (15%) or diagnostic resolution (22%). Navigation was used as a type of intervention in 63% of the included studies. Most interventions utilized behavioral approaches to improve outcomes. The overall estimate of the OR for completion of follow-up for all interventions was 1.81 (1.36-2.42). The highest impact was for programs using more than one approach (multicomponent interventions) to improve outcomes with OR = 3.01 (2.03-4.46), compared with studies with single intervention approaches with OR = 1.56 (1.14-2.14). No statistical risks were noted from publication bias or small-study effects in the studies reviewed.

CONCLUSION

Our findings revealed large heterogeneity in how follow-up of abnormal cervical cancer screening results was defined. Our results suggest that multicomponent interventions were more effective than single component interventions and should be used to improve follow-up after abnormal cervical cancer screening results. Navigation appears to be an important tool for improving follow-up. We also provide recommendations for future studies and implications for policy in terms of better defining outcomes for these interventions.

Patient Satisfaction With Breast Cancer Care Delivery at the National Cancer Institute of Sri Lanka: Does Language Play a Role?

PURPOSE

This study sought to examine whether there was an association between language barriers and patient satisfaction with breast cancer care in Sri Lanka.

METHODS

A telephone-based survey was conducted in the three official languages (Sinhala, Tamil, or English) among adult women (older than 18 years) who had been treated for breast cancer within 6-12 months of diagnosis at the National Cancer Institute of Sri Lanka. The European Organisation for Research and Treatment of Cancer Satisfaction with Cancer Care core questionnaire was adapted to assess three main domains (physicians, allied health care professionals, and the organization). All scores were linearly transformed to a 0-100 scale, and subscores for domains were summarized using means and standard deviations. These were also calculated for the Sinhalese and Tamil groups and compared.

RESULTS

The study included 72 participants (32 ethnically Tamil and 40 Sinhalese, with 100% concordance with preferred language). The most commonly reported best aspect of care (n = 25) involved affective behaviors of the physicians and nurses. Ease of access to the hospital performed poorest overall, with a mean satisfaction score of 54 (30.5). Clinic-related concerns were highlighted as the worst aspect of the care (n = 10), including long waiting times during clinic visits. Sixty-three percent of Tamil patients reported receiving none of their care in Tamil and 18% reported experiencing language barriers during their care. Tamil patients were less satisfied overall and reported lower satisfaction with care coordination (P = .005) and higher financial burden (P = 0.014).

CONCLUSION

Ethnically Tamil patients were significantly less satisfied than their Sinhalese counterparts and experienced more language barriers, suggesting there is a need to improve access to language-concordant care in Sri Lanka.

Understanding Perceived Barriers to Colposcopy Follow-Up Among Underserved Women at an Urban Teaching Hospital: A Qualitative Study

OBJECTIVE

Loss to follow-up after abnormal cervical cancer screening disproportionately impacts underserved populations. Our objective was to identify perceived barriers to follow-up after abnormal Pap smear among underserved women.

METHODS

Women with abnormal Pap smear presenting for colposcopy at an urban teaching hospital were asked to participate in qualitative interviews. A topic guide was developed to assess knowledge about cervical cancer screening and perceived barriers to follow-up. A demographic survey was completed and interviews were recorded and transcribed. Responses were coded and placed into a framework: intrapersonal, interpersonal, and community barriers. Major themes and subthemes were identified. Demographic data were reported descriptively.

RESULTS

Of 24 women enrolled, 18 (75%) completed full interviews. Median age was 38 years (range = 21-64). Participants were racially diverse: 10 (56%) Hispanic, 7 (39%) non-Hispanic White, 1 (5.5%) non-Hispanic Black, and 1 (5.5%) Asian, and all had public insurance. Seven (39%) presented for their 1st colposcopy visit and 11 (61%) had previous visits. Seventeen (94%) had a positive human papillomavirus test and 7 (39%) had atypical squamous cells of undetermined significance. The most common themes identified were related to knowledge gaps, including lack of understanding of Pap smears/human papillomavirus and cervical cancer risk factors. Most participants were satisfied with provider communication but dissatisfied with communication with the office, like scheduling appointments.

CONCLUSIONS

Despite positive patient perception of physician communication, knowledge was most commonly identified as a barrier to colposcopy follow-up. Implementing a web-based intervention addressing knowledge gaps may improve abnormal cervical cancer screening follow-up among this population.

The Virtual Summer Research Program: supporting future physician-scientists from underrepresented backgrounds

Introduction

Physician-scientist training programs expect applicants to have had extensive research experience prior to applying. Even at the best of times, this leaves individuals from underserved and underrepresented backgrounds at a competitive disadvantage, especially those remote from major academic centers. The COVID-19 pandemic exacerbated that disadvantage by closing research laboratories and suspending summer research opportunities.

Methods

The Virtual Summer Research Program (VSRP) was designed to combat this shortfall by helping participating students become better informed and better prepared for applying to MD/DO-PhD programs. 156 participants were recruited from historically black colleges and universities and from national organizations for underrepresented trainees. Participants were paired with medical school faculty members and current MD/DO-PhD students from 35 participating institutions. The program lasted for at least 4 weeks and included a short research project, interactive sessions, journal clubs, social events, and attendance at a regional American Physician Scientists Association conference.

Results

In follow-up surveys, participants reported improvements in their science-related skills and in their confidence in becoming a physician-scientist, applying to training programs, and navigating mentorship relationships. A follow-up study completed one year later indicated that participants felt they had benefited from an enhanced skill set, long-term relationships with their mentors, and connections to the physician-scientist community at large.

Discussion

The results suggest that VSRP met its primary goals, which were to provide a diverse group of trainees with mentors, provide skills and resources for MD/DO-PhD application and matriculation and to support the development of longitudinal relationships between VSRP mentees and APSA. VSRP provides an approach that can be applied at an even larger scale when the constraints caused by a global pandemic have lifted.

Disparities in Comprehension of the Obstetric Consent According to Language Preference Among Hispanic/Latinx Pregnant Patients

Background: We assessed understanding of the obstetric consent form between patients with English and Spanish language preference.

Methods: This observational study included pregnant patients who identified as Hispanic/Latinx with English or Spanish language preference (defined as what language the patient prefers to receive healthcare information) and prenatal care providers at a large academic medical center from 2018 to 2021. Patient demographics, language preference, literacy, numeracy, acculturation, comprehension of the obstetric consent, and provider explanations were collected.

Results: We report descriptive statistics and thematic analysis with an inductive approach from 30 patients with English preference, 10 with Spanish preference, and 23 providers. The English group demonstrated 72% median correct responses about the consent form; the Spanish group demonstrated 61% median correct responses. Regardless of language, the participants demonstrated limited understanding of certain topics, such as risks of cesarean birth.

Discussion: Overall comprehension of key information in an obstetric consent form was low, with differences in language groups, which highlights opportunities for improvements in communication across language barriers. Innovations in the communication of critical pregnancy information for patients with limited English proficiency need to be developed and tested.

In pursuit of equity in cancer care: moving beyond the Affordable Care Act

Although Medicaid Expansion under the Patient Protection and Affordable Care Act (ACA) has been associated with many improvements for patients with cancer, Snyder et al. provide evidence demonstrating the persistence of racial disparities in cancer. This Editorial describes why insurance coverage alone does not ensure access to health care, highlights various manifestations of structural racism that constitute barriers to access beyond the direct costs of care, and calls for not just equality, but equity, in cancer care.

A qualitative inquiry of communication based barriers to the diagnosis of pediatric cancer: Perceptions of primarily Spanish-speaking caregivers

BACKGROUND

Primarily Spanish-speaking cancer patients and caregivers often experience non-congruence with healthcare providers about beliefs, values, and knowledge of cancer. Our goal was to describe how communication related to the diagnosis of cancer was influenced by culture and language among primarily Spanish-speaking caregivers of pediatric cancer patients.

METHODS

Caregivers participated in three focus groups about their experiences with their child's diagnosis, communication issues, and understanding of their child's diagnosis and treatment plan. Focus groups were audio recorded, transcribed, and qualitatively analyzed using interpretive description.

RESULTS

Three themes emerged: 1) Negative experiences and barriers during the cancer diagnosis and treatment, 2) Miscommunication and system complexity, and 3) Language barriers throughout the diagnostic process. Due to barriers and negative experiences, some caregivers reported that their child's diagnosis was delayed, that providers sometimes used dehumanizing language, and that they were confused about diagnostic testing and treatment.

CONCLUSION

Cultural and linguistic disparities in pediatric oncology must be systematically addressed at the provider, clinic, and system level.

PRACTICE IMPLICATIONS

High-quality cancer care delivered by oncologists and cancer care teams should include cultural humility when discussing the cancer diagnosis and prognosis.

US Cancer Screening Recommendations: Developments and the Impact of COVID-19

The USPSTF and ACS recommend screening for breast, cervical, colorectal, and lung cancers. Rates of cancer screening, diagnosis, and treatment decreased significantly in the US and other developed nations during the height of the COVID-19 pandemic and lockdown (April 2020) and have since recovered, although not to baseline levels in many cases. For breast cancer, the USPSTF recommends biennial screening with mammography for women aged 50−74, while the ACS recommends annual screening for women aged 45−54, who may transition to biennial after 55. Minority and rural populations have lower rates of screening and lower utilization of DBT, which offers superior sensitivity and specificity. Among 20 US health networks in April 2020, mammography rates were down 89.2% and new breast cancer diagnoses down by 50.5%. For cervical cancer, the USPSTF recommends cervical cytology every three years for women 21−65, or cytology+hrHPV co-testing every five years for women aged 30−65. Cervical cancer screening rates declined by 87% in April 2020 and recovered to a 40% decline by June 2020, with American Indians and Asians most severely affected. For colorectal cancer (CRC), the USPSTF and ACS recommend screening for ages 45−75, recently lowered from a starting age of 50. Most commonly-used modalities include annual FIT testing, FIT+DNA testing every three years, and colonoscopy every ten years, with shorter repeat if polyps are found. In the US, CRC screenings were down by 79−84.5% in April 2020 across several retrospective studies. Patient encounters for CRC were down by 39.9%, and a UK-based model predicted that 5-year-survival would decrease by 6.4%. The USPSTF recommends screening low dose CT scans (LDCTs) for ages 50−80 with a >20 pack-year smoking history who have smoked within the past 15 years. In April 2020, screening LDCTs fell by 72−78% at one US institution and lung cancer diagnoses were down 39.1%.

An examination of the implementation of a patient navigation program to improve breast and cervical cancer screening rates of Chinese immigrant women: a qualitative study

BACKGROUND

Chinese Americans have lower breast and cervical cancer screening rates than the national average and experience multiple barriers to cancer care. Patient navigators have improved screening and follow-up rates for medically underserved populations, yet investigations of cancer navigation programs and their implementation among Chinese Americans are limited. To address this gap, we used the Consolidated Framework for Implementation Research (CFIR) to examine facilitators and barriers to implementing the Chicago-based Chinatown Patient Navigation Program (CPNP) for breast and cervical cancer screening, follow-up, and treatment.

METHODS

Stakeholders from clinical care, supportive care services, and community organizations were invited to participate in qualitative interviews to illuminate implementation processes and stakeholder perspectives of facilitators and barriers to implementing the CPNP. Interviews were audio-recorded, transcribed, and deductively coded according to CFIR domains, including (1) intervention characteristics; (2) outer setting; (3) inner setting; and (4) the implementation process.

RESULTS

We interviewed a convenience sample of 16 stakeholders representing a range of roles in cancer care, including nurses, clinical team members, administrators, physicians, a community-based organization leader, and a CPNP navigator. Findings detail several facilitators to implementing the CPNP, including patient navigators that prepared Chinese-speaking patients for their clinic visits, interpretation services, highly accessible patient navigators, and high-quality flexible services. Barriers to program implementation included limited regular feedback provided to stakeholders regarding their program involvement. Also, early in the program's implementation there was limited awareness of the CPNP navigators' roles and responsibilities, insufficient office space for the navigators, and few Chinese language patient resource materials.

CONCLUSIONS

These findings provide valuable information on implementation of future patient navigation programs serving Chinese American and other limited-English speaking immigrant populations.

Lessons Learned from Two Large Community-Based Glaucoma Screening Studies

Community-based screening programs have had limited success in preventing vision loss from glaucoma due to overall low prevalence of glaucoma, screening limitations, and barriers to follow-up appointments. This editorial highlights lessons learned from two large prospective trials: the Philadelphia Telemedicine Glaucoma Detection and Follow-up Study (PTGDFS) and the Screening To Prevent Glaucoma Study (SToPGS). While some lessons are specific to ophthalmology, many lessons are applicable to screening for asymptomatic diseases in underserved, vulnerable communities.

Racial and Ethnic Disparities in Health Information Technology Use and Associated Trends among Individuals Living with Chronic Diseases

Health information technology (HIT) can enhance optimal health care access and utilization among individuals living with chronic diseases. This study aimed to provide population-level information on racial/ethnic disparities in HIT use and associated trends among those living with chronic diseases. The study sample consisted of adult respondents (≥18 years) of the 2011-2018 National Health Interview Survey living with at least 1 chronic condition. Binomial regression was used to analyze the association between race/ethnicity, year, and 4 measures of HIT use for patient-provider interaction. Regression parameter estimates were used to predict the trends in probability of the outcome variables across race/ethnicity. About 73% of the study sample were non-Hispanic Whites, 15% were non-Hispanic Blacks, and 13% were Hispanics. Compared to non-Hispanic Whites, there were decreased adjusted odds of any HIT use among non-Hispanic Blacks (OR = 0.72; 95% CI = 0.67, 0.76) and Hispanics (OR = 0.78; 95% CI = 0.72, 0.84). The likelihood of any HIT use increased with increasing year (OR: 1.16; 95% CI = 1.15, 1.18). Trends in racial/ethnic disparities were wider for email communication with provider and online prescription refill compared to online scheduling of appointment. The COVID-19 pandemic has led to accelerated adoption or expansion of HIT for patient care. Limited HIT use among non-Hispanic Blacks and Hispanics could worsen the disproportionate chronic disease burden, suboptimal clinical outcomes, and preventable health care costs experienced by this subpopulation. In conclusion, there is a need for intentional and strategic population-level interventions to increase HIT adoption and use among non-Hispanic Blacks and Hispanics living with chronic diseases.

Helping Men Find Their Way: Improving Prostate Cancer Clinic Attendance via Patient Navigation

Navigation programs aim to help patients overcome barriers to cancer diagnosis and treatment. Missed clinic appointments have undesirable effects on the patient, health system, and society, and treatment delays have been shown to result in inferior surgical cure rates for men with prostate cancer (CaP). We sought to measure the impact of patient navigation on CaP clinic adherence. Patient navigators contacted patients prior to their first encounter for known or suspected CaP between 7/1/2016 and 6/30/2017. Encounters from 7/1/2014 to 6/30/2015 were used as a historical control. Patient-variables were analyzed including age, health insurance status, home address, zip code, race, ethnicity, and referring primary care clinic. Encounter-level variables included diagnosis (categorized as known or suspected CaP), date of appointment, type of appointment [new vs. return], and provider. The associations between several factors including navigation contact and these variables with missed appointment were analyzed using generalized linear mixed effects multivariate logistic regression. A total of 2854 scheduled clinic encounters from 986 unique patients were analyzed. Patient navigation resulted in a lower missed appointment rate (8.8% vs. 13.9%, OR = 0.64, IQR 0.44-0.93, p = 0.02 on multivariable analysis). Lack of health insurance (OR = 13.18 [5.13-33.83]), suspected but not confirmed CaP diagnosis (OR = 7.44 [4.85-11.42]), and Black (1.97 [1.06-3.65]) or Hispanic (OR = 3.61 [1.42-9.16]) race, were associated with missed appointment. Implementation of patient navigation reduced missed appointment rates for CaP related ambulatory encounters. Identifying risk factors for missed appointment may aid in targeting navigation services to those most likely to benefit from this intervention.

Overcoming Disparities in Cancer: A Need for Meaningful Reform for Hispanic and Latino Cancer Survivors

Hispanic and Latino (HL) cancer survivors are at a critical disadvantage compared with non-Hispanic White (NHW) patients regarding sociodemographic adversities and access to equitable treatment options. By 2030, there will be about four million HL cancer survivors in the U.S., representing nearly 20% of survivors in this country. Hispanics and Latinos are subjected to significant challenges in accessing and receiving equitable care relative to NHWs. Hispanics and Latinos also experience lower rates of health insurance and financial resources, limiting health care options. These disparities often originate from disparate social determinants of health, including lower funding for education and school programs, greater neighborhood stressors and violence, lower access to healthy and affordable food, and greater barriers to community health and exercise opportunities. Even among HL cancer survivors with proper access to health care, they experience disparate treatment options, including low inclusion in clinical trials and/or access to experimental therapies. A solution to these barriers necessitates complex and systemic changes that involve, for example, investing in public health programs, increasing the diversity and cultural awareness of the medical workforce, and promoting research opportunities such as clinical trials that are inclusive of HLs. Only through meaningful reform will equitable cancer care be available for all in the U.S. regardless of racial and/or ethnic background. This article reviews some of the critical social determinants of health and biases relevant to HL cancer survivors and provides recommendations for achieving cancer health equity. IMPLICATIONS FOR PRACTICE: Hispanics and Latinos experience a significant and often disproportionate cancer-related burden compared with non-Hispanic and Latino White individuals and other racial and ethnic groups. Meaningful reform to achieve health equity in oncology should focus on approaches to gaining trust among diverse patients, cultural and community sensitivity and engagement in oncology care and research, diversifying the workforce, and improving inclusion in clinical trial participation. Taken together, these recommendations can lead to exemplary and equitable care for all patients.

Mammography Screening Among Latinas: Does Gender and Ethnic Patient-Physician Concordance Matter?

Breast cancer is the most commonly diagnosed cancer among Latinas. Dominican women in particular have a higher lifetime risk of breast cancer than do other Latinas in the U.S. This study examines how gender, ethnic, and language concordance between providers and patients are associated with recent mammography screening for Latina immigrant women from the Dominican Republic. We conducted structured interviews, in Spanish, with 419 Dominican women aged 40 years or older living in New York City. Using bivariate analysis and logistic regressions, we tested whether patient-provider gender, ethnic, and language concordance was associated with recent mammography when controlling for demographic covariates, breast cancer screening knowledge, and self-rated health. Gender concordance predicted recent mammography after controlling for covariates (β = 0.13). Neither ethnic nor language concordance significantly predicted recent mammography. Our findings suggest that promotion of patient-provider gender concordance may help reduce health disparities among Latinos/as and other minority groups across the United States.

Overcoming Disparities in Cancer: A Need for Meaningful Reform for Hispanic and Latino Cancer Survivors

Hispanic and Latino (HL) cancer survivors are at a critical disadvantage compared with non-Hispanic White (NHW) patients regarding sociodemographic adversities and access to equitable treatment options. By 2030, there will be about four million HL cancer survivors in the U.S., representing nearly 20% of survivors in this country. Hispanics and Latinos are subjected to significant challenges in accessing and receiving equitable care relative to NHWs. Hispanics and Latinos also experience lower rates of health insurance and financial resources, limiting health care options. These disparities often originate from disparate social determinants of health, including lower funding for education and school programs, greater neighborhood stressors and violence, lower access to healthy and affordable food, and greater barriers to community health and exercise opportunities. Even among HL cancer survivors with proper access to health care, they experience disparate treatment options, including low inclusion in clinical trials and/or access to experimental therapies. A solution to these barriers necessitates complex and systemic changes that involve, for example, investing in public health programs, increasing the diversity and cultural awareness of the medical workforce, and promoting research opportunities such as clinical trials that are inclusive of HLs. Only through meaningful reform will equitable cancer care be available for all in the U.S. regardless of racial and/or ethnic background. This article reviews some of the critical social determinants of health and biases relevant to HL cancer survivors and provides recommendations for achieving cancer health equity. IMPLICATIONS FOR PRACTICE: Hispanics and Latinos experience a significant and often disproportionate cancer-related burden compared with non-Hispanic and Latino White individuals and other racial and ethnic groups. Meaningful reform to achieve health equity in oncology should focus on approaches to gaining trust among diverse patients, cultural and community sensitivity and engagement in oncology care and research, diversifying the workforce, and improving inclusion in clinical trial participation. Taken together, these recommendations can lead to exemplary and equitable care for all patients.

The Role of Care Navigators Working with People with Dementia and Their Caregivers

BACKGROUND

Care navigation is an approach to personalized care management and care coordination that can help overcome barriers to care. Care navigation has not been extensively studied in dementia, where health care workforce innovations are needed as a result of increasing disease prevalence and resulting costs to the health care system.

OBJECTIVE

To identify facilitators and barriers to care navigation in dementia and to assess dementia caregiver satisfaction with care navigation.

METHODS

Methods include qualitative research (interviews, focus groups, observations) with "Care Team Navigators" (CTNs) who were part of a dementia care navigation program, the Care Ecosystem, and a quantitative survey with caregivers about their experiences with CTNs. Transcripts were analyzed to identify themes within the data.

RESULTS

CTNs identified the following facilitators to care navigation in dementia: working closely with caregivers; providing emotional support; tailoring education and resources; and coordinating with a clinical team around issues ranging from clinical questions to financial and legal decision-making. The barriers CTNS identified included burn-out, the progressive nature of the disease; coordinating with primary care providers; and identifying resources for dyads who are low-income, do not speak English, or live in rural areas. Caregivers across both sites highly rated CTNs, though satisfaction was higher among those in Nebraska and Iowa.

CONCLUSIONS

Innovative approaches to care delivery in dementia are crucial. Care navigation offers a feasible model to train unlicensed people to deliver care as a way to deliver larger-scale support for the growing population of adults living with dementia and their caregivers.

Health Literacy, Language, and Cancer-Related Needs in the First 6 Months After a Breast Cancer Diagnosis

PURPOSE

Low health literacy (HL) and language negatively affect cancer screening and prevention behaviors; less is known about how they affect the patient's experience during cancer treatment. This study explores associations among HL, spoken language, and dimensions of cancer-related needs within 6 months of receiving a breast cancer diagnosis.

METHODS

Women speaking English, Spanish, or Haitian Creole, enrolled in a patient navigation study at diagnosis, completed a survey in their primary spoken language at baseline and 6 months to characterize their cancer-related needs. HL was measured using the Brief Health Literacy Screening Tool. Outcomes included the Cancer Needs Distress Inventory (CaNDI; n = 38 items) and the Communication and Attitudinal Self-Efficacy scale (CASE-Cancer) for cancer (n = 12 items). Linear regressions measured the impact of HL and language on total CaNDI and CASE-Cancer scale for cancer scores and subscales, adjusted for demographics.

RESULTS

At baseline, 262 women participated and 228 (87%) followed up at 6 months. Of these, 38% had adequate HL, 33% had marginal HL, and 29% had inadequate HL. Women with inadequate or marginal HL had higher median baseline CaNDI scores (P = .02) and lower self-efficacy scores (P = .008), relative to those with adequate HL. Haitian-Creole speakers had significantly lower CANDI scores at baseline (P = .03). Adjusting for demographics, differences in CaNDI scores at baseline remained significant for those with lower HL and Haitian-Creole speakers. At 6 months, differences in self-efficacy persisted for Haitian-Creole speakers.

CONCLUSION

Findings suggest that interventions oriented to mitigating HL and language barriers might reduce distress at the time of diagnosis and improve self-efficacy over the course of treatment.

Is Perceived Stigma in Clinical Settings Associated With Poor Health Status Among New York City's Residents of Color?

OBJECTIVES

Our objectives were to assess rates of perceived stigma in health care (clinical) settings reported by racially diverse New York City residents and to examine if this perceived stigma is associated with poorer physical and mental health outcomes.

METHODS

We analyzed data from the 2016 New York City Community Health Survey. We applied bivariable and multivariable methods to assess rates of perceived stigma, and perceived stigma's statistical relationship with health care access, physical health status, and mental health status controlling for sociodemographics and health insurance status.

RESULTS

Perceived stigma was associated with poorer health care access [odds ratio (OR)=7.07, confidence interval (CI)=5.32-9.41), depression (OR=3.80, CI=2.66-5.43), diabetes (OR=1.86, CI=1.36-2.54), and poor overall general health (OR=0.43, CI=0.33-0.57). Hispanic respondents reported the highest rate of perceived stigma among racial and ethnic minority groups (mean=0.07, CI=0.05-0.08).

CONCLUSIONS

We found that perceived stigma in health care settings was a potential barrier to good health. Prior studies have illustrated that negative health outcomes are common for patients who avoid or delay care; thus, the unfortunate conclusion is that even in a diverse, heterogeneous community, stigma persists and may negatively affect well-being. Therefore, eliminating stigma in clinical settings should be a top priority for health care providers and public health professionals seeking to improve health equity.

Patient navigator reported patient barriers and delivered activities in two large federally-funded cancer screening programs

Few data are available on patient navigators (PNs) across diverse roles and organizational settings that could inform optimization of patient navigation models for cancer prevention. The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) and the Colorectal Cancer and Control Program (CRCCP) are two federally-funded screening programs that support clinical- and community-based PNs who serve low-income and un- or underinsured populations across the United States. An online survey assessing PN characteristics, delivered activities, and patient barriers to screening was completed by 437 of 1002 identified PNs (44%). Responding PNs were racially and ethnically diverse, had varied professional backgrounds and practice-settings, worked with diverse populations, and were located within rural and urban/suburban locations across the U.S. More PNs reported working to promote screening for breast/cervical cancers (BCC, 94%) compared to colorectal cancer (CRC, 39%). BCC and CRC PNs reported similar frequencies of individual- (e.g., knowledge, motivation, fear) and community-level patient barriers (e.g., beliefs about healthcare and screening). Despite reporting significant patient structural barriers (e.g., transportation, work and clinic hours), most BCC and CRC PNs delivered individual-level navigation activities (e.g., education, appointment reminders). PN training to identify and champion timely and patient-centered adjustments to organizational policies, practices, and norms of the NBCCEDP, CRCCP, and partner organizations may be beneficial. More research is needed to determine whether multilevel interventions that support this approach could reduce structural barriers and increase screening and diagnostic follow-up among the marginalized communities served by these two important cancer-screening programs.

Patient Navigation: Addressing Social Challenges in Dialysis Patients

Members of racial and ethnic minority groups make up nearly 50% of US patients with end-stage kidney disease and face a disproportionate burden of socioeconomic challenges (ie, low income, job insecurity, low educational attainment, housing instability, and communication challenges) compared with non-Hispanic whites. Patients with end-stage kidney disease who face social challenges often have poor patient-centered and clinical outcomes. These challenges may have a negative impact on quality-of-care performance measures for dialysis facilities caring for primarily minority and low-income patients. One path toward improving outcomes for this group is to develop culturally tailored interventions that provide individualized support, potentially improving patient-centered, clinical, and health system outcomes by addressing social challenges. One such approach is using community-based culturally and linguistically concordant patient navigators, who can serve as a bridge between the patient and the health care system. Evidence points to the effectiveness of patient navigators in the provision of cancer care and, to a lesser extent, caring for people with chronic kidney disease and those who have undergone kidney transplantation. However, little is known about the effectiveness of patient navigators in the care of patients with kidney failure receiving dialysis, who experience a number of remediable social challenges.

Supporting Latina Breast Health with Community-based Navigation

Latina women continue to face disproportionate breast cancer risk and well-documented breast health care barriers in Philadelphia. In response to breast health needs among Latinas in Philadelphia, a health-focused community-based organization, in partnership with a network of social and health service providers, began offering community-based navigation in 2005. Later, through funding from a federal agency, the organization launched the Naveguemos con Salud (NCS) Breast Health Partnership Project from 2010 to 2013. NCS offered breast health awareness and education to a broad audience of Latinas in Philadelphia and community-based navigation services to all interested in accessing a clinical breast exam (CBE) and/or mammogram. A 2017 survey revisited breast health needs among the same core population to inform next steps. Here, we explore how findings and lessons learned from a past program and an assessment of current needs can inform future community-clinical linkage and community-based navigation to improve access to breast cancer screening and a continuum of care for Latinas.

Patient-Provider Language Concordance and Health Outcomes: A Systematic Review, Evidence Map, and Research Agenda

Although patient-provider language concordance has the potential to reduce health disparities for people with limited English proficiency, no previous work has synthesized this literature. Our systematic review sought to describe the characteristics of studies examining relationships between language concordance and health outcomes, summarize the nature of observed associations, and propose an evidence map and research agenda. A comprehensive search of published articles identified 38 quantitative studies for inclusion. Most studies were cross-sectional, conducted in primary care, concentrated in Western states, and focused on Spanish speakers and physician providers. Results were split between supporting a positive association versus no association of language concordance with patient behaviors, provider behaviors, interpersonal processes of care, and clinical outcomes. Several methodological limitations were identified. Based on these results, we developed an evidence map, identified knowledge gaps, and proposed a research agenda. There is a particular need for quasi-experimental longitudinal studies with well-characterized samples.

Beyond the United States Medical Licensing Examination Score: Assessing Competence for Entering Residency

Assessments of physician learners during the transition from undergraduate to graduate medical education generate information that may inform their learning and improvement needs, determine readiness to move along the medical education continuum, and predict success in their residency programs. To achieve a constructive transition for the learner, residency program, and patients, high-quality assessments should provide meaningful information regarding applicant characteristics, academic achievement, and competence that lead to a suitable match between the learner and the residency program's culture and focus.The authors discuss alternative assessment models that may correlate with resident physician clinical performance and patient care outcomes. Currently, passing the United States Medical Licensing Examination Step examinations provides one element of reliable assessment data that could inform judgments about a learner's likelihood for success in residency. Yet, learner capabilities in areas beyond those traditionally valued in future physicians, such as life experiences, community engagement, language skills, and leadership attributes, are not afforded the same level of influence when candidate selections are made.While promising new methods of screening and assessment-such as objective structured clinical examinations, holistic assessments, and competency-based assessments-have attracted increased attention in the medical education community, currently they may be expensive, be less psychometrically sound, lack a national comparison group, or be complicated to administer. Future research and experimentation are needed to establish measures that can best meet the needs of programs, faculty, staff, students, and, more importantly, patients.

Process evaluation of counseling delivered by a patient navigator in an efficacious smoking cessation intervention among low-income primary care patients

Introduction

This exploratory study examined the relationship between receipt of counseling by a patient navigator and socio-demographic characteristics of primary care patients enrolled in a smoking cessation trial.

Methods

We grouped intervention participants (n = 177) into two categories: 1) no or some contact with the navigator or 2) minimum counseling intervention dose or higher delivered.

Results

In logistic regression analyses, controlling for patient race/ethnicity, education, age, gender, household annual income, stress/chaos/hassles composite score, heavy smoking, and substance use, non-Hispanic white participants had lower odds (aOR 0.30; 95% CI 0.13–0.70, p < 0.01) of receiving the minimum intervention dose or higher compared to all other race/ethnicity categories. There was also effect modification such that patients aged 50 or younger who were non-Hispanic white were less likely (aOR 0.09, 95% CI: 0.02-0.54, p < 0.01) to receive the minimum intervention dose compared to older patients from all other race/ethnicity groups.

Conclusions

Future research should explore issues such as acceptability of the intervention to white and younger age participants, and the potential impact of co-occurring substance use disorders on intervention uptake.

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Examined effects of receiving sufficient patient navigation for smoking cessation.

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White participants were less likely to receive sufficient navigation vs. other groups.

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Future work could explore barriers to receipt of patient navigation.

Peer characteristics associated with improved glycemic control in a randomized controlled trial of a reciprocal peer support program for diabetes

OBJECTIVE

In a secondary analysis of a randomized controlled trial of diabetes reciprocal peer support, we examined characteristics of peers associated with improvements in their partner's glycemic control.

METHODS

A total of 102 adults with diabetes were randomized to the reciprocal peer support arm (vs. a nurse care management arm). The primary outcome was change in A1c over six months. Intermediate outcomes were insulin initiation and peer engagement. A number of baseline characteristics of peers were hypothesized to influence outcomes for their peer, and concordant characteristics of peer dyads were hypothesized that would influence outcomes for both peer partners.

RESULTS

Improvement in A1c was associated with having a peer older than oneself ( P < .05) or with higher diabetes-related distress ( P < .01). Participants with peers who reported poorer health at baseline had worse glycemic control at follow-up ( P < .01). Hypothesized concordant characteristics were not associated with A1c improvements. Participants whose peers had a more controlled self-regulation style were more likely to initiate insulin ( P < .05).

DISCUSSION

The improved outcomes of peers whose partners were older and reported more diabetes distress at baseline supports the need for further research into the peer characteristics that lead to improved outcomes. This could allow for better matching and more effective partnerships.

Feasibility of Patient Navigation to Improve Breast Cancer Care in Malaysia

PURPOSE

Late stage at presentation and poor adherence to treatment remain major contributors to poor survival in low- and middle-income countries (LMICs). Patient navigation (PN) programs in the United States have led to improvement in diagnostic or treatment timeliness, particularly for women in lower socioeconomic classes or minority groups. To date, studies of PN in Asia have been limited. We aimed to assess the feasibility of PN in a state-run hospital in an LMIC and to report the impact on diagnostic and treatment timeliness for patients in its first year of implementation.

METHODS

We established PN in a dedicated breast clinic of a Malaysian state-run hospital. We compared diagnostic and treatment timeliness between navigated patients (n = 135) and patients diagnosed in the prior year (n = 148), and described factors associated with timeliness.

RESULTS

Women with PN received timely mammography compared with patients in the prior year (96.4% v 74.4%; P < .001), biopsy (92.5% v 76.1%; P = .003), and communication of news (80.0% v 58.5%; P < .001). PN reduced treatment default rates (4.4% v 11.5%; P = .048). Among navigated patients, late stage at presentation was independently associated with having emotional and language barriers ( P = .01). Finally, the main reason reported for delay, default, or refusal of treatment was the preference for alternative therapy.

CONCLUSION

PN is feasible for addressing barriers to cancer care when integrated with a state-run breast clinic of an LMIC. Its implementation resulted in improved diagnostic timeliness and reduced treatment default. Wider adoption of PN could be a key element of cancer control in LMICs.

Barriers to Care in Chinese Immigrants with Hepatocellular Carcinoma: A Focus Group Study in New York City

The incidence of hepatocellular carcinoma (HCC) is rising sharply in the United States and deaths from HCC have increased at the highest rate of all cancers. Though Asians have the highest incidence of HCC of all ethnicities in the US, racial/ethnic minorities, including Asians, have worse survival from HCC. We sought to identify barriers to care in treatment of HCC among affected individuals in the NYC Chinese immigrant community. We held focus groups with Chinese immigrant patients in NYC with HCC. 29 individuals participated in the focus groups. We analyzed focus group data using grounded theory methodology. Barriers to care identified included insurance, money, time, language, residency status, and stigma. The impact of provider bias and culture were also discussed. Knowledge gathering with minority patients with HCC is essential for us to fully comprehend the barriers to healthcare experienced by this community. Future policy and intervention efforts must be founded in this reality.

The Efficacy of Direct Mail, Patient Navigation, and Incentives for Increasing Mammography and Colonoscopy in the Medicaid Population: A Randomized Controlled Trial

Background: Despite lower cancer screening rates and survival rates in the Medicaid population compared with those with private insurance, there is a dearth of population-based, evidence-based interventions targeting Medicaid clients to address this problem.Methods: This study reports results of a population-based randomized controlled trial (RCT) among all individuals enrolled in Minnesota's Medicaid program who were overdue for breast cancer (n = 22,113) and/or colorectal cancer (n = 94,294) screening. Individuals were randomized to intervention or control groups. The intervention group received persuasive and innovative direct mail materials coupled with a $20 incentive for using their Medicaid benefit to get screened. Direct mail materials provided a phone number to a call center staffed by patient navigators who addressed barriers and scheduled appointments via three-way calls. The control group received the intervention 15 months later. Primary outcomes were completion of mammography or colonoscopy within 12 weeks of the intervention. Billing claims served as evidence of screening.Results: Multivariate logistic regression showed significant differences for both breast cancer (P < 0.001) and colorectal cancer (P < 0.01). The odds of receiving a mammogram for the treatment group were significantly higher than the control group [OR = 1.30; 95% confidence interval (95% CI) = 1.16-1.46], and the treatment group was more likely to receive a colonoscopy than the control group (OR = 1.12; 95% CI = 1.04-1.21).Conclusions: This population-based intervention increased breast cancer and colorectal cancer screening in a Medicaid population overdue for screening.Impact: These findings may have broad application for reaching individuals who generally remain outside the health care system despite having public health insurance. Cancer Epidemiol Biomarkers Prev; 27(9); 1047-56. ©2018 AACR.

Patient navigation across the spectrum of women's health care in the United States

Patient navigation is a patient-centered intervention that uses trained personnel to identify patient-level barriers, including financial, cultural, logistical, and educational obstacles to health care and then mitigate these barriers to facilitate complete and timely access to health services. For example, to assist a woman with Medicaid who is seeking postpartum care, a patient navigator could help her schedule an appointment before her insurance benefits change, coordinate transportation and child care, give her informational pamphlets on contraception options, and accompany her to the appointment to ensure her questions are answered. Existing studies examining the efficacy of patient navigation interventions show particularly striking benefits in the realm of cancer care, including gynecological oncology; patient navigation has been demonstrated to increase access to screening, shorten time to diagnostic resolution, and improve cancer outcomes, particularly in health disparity populations, such as women of color, rural populations, and poor women. Because of the successes in cancer care at reducing disparities in health care access and health outcomes, patient navigation has the potential to improve care and reduce disparities in obstetric and benign gynecological care. We review the concept of patient navigation, offer potential roles for patient navigation in obstetrics and gynecology, and discuss areas for further investigation.

Satisfaction With Health Care Among Patients Navigated for Preventive Cancer Screening

Background:

Patient navigation (PN) programs can improve cancer screening in underserved populations. PN may advance quality and equity of care by supporting individuals at increased risk of not receiving recommended care.

Objective:

To evaluate patient satisfaction with medical care and PN for cancer screening.

Methods:

We conducted a telephone survey of patients enrolled in a randomized control trial evaluating the impact of PN for cancer screening to assess their satisfaction with overall medical care and the PN program. We measured patient satisfaction with medical care using the Patient Satisfaction Questionnaire-18 and evaluated patient satisfaction with PN in the navigated group using the Patient Satisfaction with Interpersonal Relationships with Navigator questionnaire.

Key Results:

Satisfaction surveys were completed by 114 navigated and 108 non-navigated patients (33% response rate). Patients who received PN had higher satisfaction scores with overall medical care (71.0 vs 66.8; P < .001).

Conclusions:

Our findings show that patients at high risk of nonadherence with comprehensive cancer screening were satisfied with PN and suggest that PN could positively influence patient satisfaction with overall medical care.

Effect of Patient Navigation and Financial Incentives on Smoking Cessation Among Primary Care Patients at an Urban Safety-Net Hospital: A Randomized Clinical Trial

IMPORTANCE

While the proportion of adults who smoke cigarettes has declined substantially in the past decade, socioeconomic disparities in cigarette smoking remain. Few interventions have targeted low socioeconomic status (SES) and minority smokers in primary care settings.

OBJECTIVE

To evaluate a multicomponent intervention to promote smoking cessation among low-SES and minority smokers.

DESIGN, SETTING, AND PARTICIPANTS

For this prospective, unblinded, randomized clinical trial conducted between May 1, 2015, and September 4, 2017, adults 18 years and older who spoke English, smoked 10 or more cigarettes per day in the past week, were contemplating or preparing to quit smoking, and had a primary care clinician were recruited from general internal medicine and family medicine practices at 1 large safety-net hospital in Boston, Massachusetts.

INTERVENTIONS

Patients were randomized to a control group that received an enhancement of usual care (n = 175 participants) or to an intervention group that received up to 4 hours of patient navigation delivered over 6 months in addition to usual care, as well as financial incentives for biochemically confirmed smoking cessation at 6 and 12 months following enrollment (n = 177 participants).

MAIN OUTCOMES AND MEASURES

The primary outcome determined a priori was biochemically confirmed smoking cessation at 12 months.

RESULTS

Among 352 patients who were randomized (mean [SD] age, 50.0 [11.0] years; 191 women [54.3%]; 197 participants who identified as non-Hispanic black [56.0%]; 40 participants who identified as Hispanic of any race [11.4%]), all were included in the intention-to-treat analysis. At 12 months following enrollment, 21 participants [11.9%] in the navigation and incentives group, compared with 4 participants [2.3%] in the control group, had quit smoking (odds ratio, 5.8; 95% CI, 1.9-17.1; number needed to treat, 10.4; P < .001). In prespecified subgroup analyses, the intervention was particularly beneficial for older participants (19 [19.8%] vs 1 [1.0%]; P < .001), women (17 [16.8%] vs 2 [2.2%]; P < .001), participants with household yearly income of $20 000 or less (15 [15.5%] vs 3 [3.1%]; P = .003), and nonwhite participants (21 [15.2%] vs 4 [3.0%]; P < .001).

CONCLUSIONS AND RELEVANCE

In this study of adult daily smokers at 1 large urban safety-net hospital, patient navigation and financial incentives for smoking cessation significantly increased the rates of smoking cessation.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02351609.

Patient navigation to improve diabetes outpatient care at a safety-net hospital: a retrospective cohort study

BACKGROUND

Recent emphasis on value based care and population management, such as Accountable Care Organizations in the United States, promote patient navigation to improve the quality of care and reduce costs. Evidence supporting the efficacy of patient navigation for chronic disease care is limited. The objective of this study was to evaluate the effect of a patient navigation program on medical and administrative outcomes among patients with diabetes in an urban, safety-net hospital clinic setting.

METHODS

A retrospective cohort study with pre- and post-intervention periods was conducted. Eligible patients were those with A1C ≥ 8.5% and at least one appointment no-show in the previous 12 months. The intervention and reference groups were balanced on observed characteristics and baseline outcome levels using propensity score matching. The effect of patient navigation was isolated using the difference-in-differences approach. Primary outcomes were A1C, low-density lipoprotein cholesterol, triglycerides, random urine microalbumin, the number of scheduled appointments, clinic visits, emergency visits, and inpatient stays, and the percentage of arrivals, cancellations, and no-shows to scheduled appointments.

RESULTS

Of 797 eligible patients, 328 entered the navigation program. Matching reduced the sample size to 392 individuals (196 in each group). Patient navigation resulted in improved A1C (-1.1 percentage points; p < .001), more scheduled appointments (+ 5.3 per year; p < .001), more clinic visits (+6.4 per year; p < .001), more arrivals to scheduled appointments (+7.4 percentage points; p = .009) and fewer no-shows (-9.8 percentage points; p < .001).

CONCLUSIONS

Navigation was associated with improved glycemic control and better clinic engagement among patients with diabetes. Further research is important to identify what features of navigation in diabetes care are critical to achieving success and to understand navigators' role in other settings.

Implementation of evidence-based patient navigation programs

BACKGROUND

Patient navigation refers to a direct patient care role that links patients with clinical providers and their support system and provides individualized support during cancer care, ensuring that patients have access to the knowledge and resources necessary to complete recommended treatment. While most reports have studied the role of patient navigators during the cancer screening or diagnostic process, emerging evidence indicates the benefits of patient navigation during active cancer treatment.

DISCUSSION

Reports in the literature are conflicting on the impact of patient navigation during cancer care and on the benefits to timely or quality care in all populations. Recent sub-analyses of the Patient Navigation Research Program data demonstrated specifically the benefits of targeting patient navigation to the most vulnerable populations, including those with low educational attainment, low income and unstable housing, less social support, multiple comorbidities, and minority race/ethnicity.

CONCLUSION

The implications of the Patient Navigation Research Program are that this resource is best utilized when directed to support the care of patients at locations with known challenges to timely care and for specific patients with risk factors for delays in care, including comorbidities, low educational attainment and low income. Implementation of patient navigation programs requires the following processes: needs assessment, selection of a navigator to meet the community and care needs, supervision and integration of the navigator into clinical processes, and systems support to facilitate the identification and tracking of those patients requiring patient navigation. There is a need for ongoing research on methods to fund and sustain patient navigation programs.

Who is a community health worker? - a systematic review of definitions

BACKGROUND

Community health workers (CHWs) can play vital roles in increasing coverage of basic health services. However, there is a need for a systematic categorisation of CHWs that will aid common understanding among policy makers, programme planners, and researchers.

OBJECTIVE

To identify the common themes in the definitions and descriptions of CHWs that will aid delineation within this cadre and distinguish CHWs from other healthcare providers.

DESIGN

A systematic review of peer-reviewed papers and grey literature.

RESULTS

We identified 119 papers that provided definitions of CHWs in 25 countries across 7 regions. The review shows CHWs as paraprofessionals or lay individuals with an in-depth understanding of the community culture and language, have received standardised job-related training of a shorter duration than health professionals, and their primary goal is to provide culturally appropriate health services to the community. CHWs can be categorised into three groups by education and pre-service training. These are lay health workers (individuals with little or no formal education who undergo a few days to a few weeks of informal training), level 1 paraprofessionals (individuals with some form of secondary education and subsequent informal training), and level 2 paraprofessionals (individuals with some form of secondary education and subsequent formal training lasting a few months to more than a year). Lay health workers tend to provide basic health services as unpaid volunteers while level 1 paraprofessionals often receive an allowance and level 2 paraprofessionals tend to be salaried.

CONCLUSIONS

This review provides a categorisation of CHWs that may be useful for health policy formulation, programme planning, and research.

Racial/Ethnic Disparities in Cervical Cancer Screening and Outcomes

Invasive cervical cancer disproportionately affects women without sufficient access to care, with higher rates among minority groups in higher-income countries and women in low-resource regions of the world. Many elements contribute to racial/ethnic disparities in the cervical cancer continuum - from screening and diagnosis to treatment and outcome. Sociodemographic factors, access to healthcare, income and education level, and disease stage at diagnosis are closely linked to such inequities. Despite the identification of such elements, racial/ethnic disparities persist, and are widening in several minority subgroups, particularly in older women, who are ineligible for human papillomavirus (HPV) vaccination and are underscreened. Recent studies suggest that racial/ethnic differences in HPV infection exist and may also have a role in observed differences in cervical cancer. In this review, we provide an overview of the current literature on racial disparities in cervical cancer screening, incidence, treatment and outcome to inform future strategies to reduce persistent inequities.

Racial and ethnic differences in patient navigation: Results from the Patient Navigation Research Program

BACKGROUND

Patient navigation was developed to address barriers to timely care and reduce cancer disparities. The current study explored navigation and racial and ethnic differences in time to the diagnostic resolution of a cancer screening abnormality.

METHODS

The authors conducted an analysis of the multisite Patient Navigation Research Program. Participants with an abnormal cancer screening test were allocated to either navigation or control. The unadjusted median time to resolution was calculated for each racial and ethnic group by navigation and control. Multivariable Cox proportional hazards models were fit, adjusting for sex, age, cancer abnormality type, and health insurance and stratifying by center of care.

RESULTS

Among a sample of 7514 participants, 29% were non-Hispanic white, 43% were Hispanic, and 28% were black. In the control group, black individuals were found to have a longer median time to diagnostic resolution (108 days) compared with non-Hispanic white individuals (65 days) or Hispanic individuals (68 days) (P<.0001). In the navigated groups, black individuals had a reduction in the median time to diagnostic resolution (97 days) (P<.0001). In the multivariable models, among controls, black race was found to be associated with an increased delay to diagnostic resolution (hazard ratio, 0.77; 95% confidence interval, 0.69-0.84) compared with non-Hispanic white individuals, which was reduced in the navigated arm (hazard ratio, 0.85; 95% confidence interval, 0.77-0.94).

CONCLUSIONS

Patient navigation appears to have the greatest impact among black patients, who had the greatest delays in care. Cancer 2016. © 2016 American Cancer Society. Cancer 2016;122:2715-2722. © 2016 American Cancer Society.

A human papillomavirus vaccination program for low-income postpartum women

BACKGROUND

Effective interventions are needed to address the low rate of human papillomavirus (HPV) vaccination in the United States, particularly among girls and women 16-26 years old. Counseling and offering the vaccine to postpartum patients could be an effective strategy to increase uptake among young women who did not complete the 3-dose series at an earlier age.

OBJECTIVE

The purpose of this evaluation was to assess the effectiveness of a multicomponent program designed for postpartum women that used patient navigators (PNs) and reminders for follow-up visits to improve uptake and completion of the HPV vaccine series.

STUDY DESIGN

As part of standard care, patients ≤26 years of age from Galveston County, Texas, who delivered an infant from November 2012 through June 2014 at a public hospital were counseled and offered the HPV vaccine postpartum. PNs assisted with scheduling follow-up injections during postpartum or well-child visits. A program evaluation was conducted after 20 months.

RESULTS

Of 1038 patients approached, only 161 (15.5%) had previously completed the vaccine series. Of the 877 patients who had not completed the series, 661 (75.4%) received at least 1 dose postpartum, with 575 patients receiving their first dose and 86 receiving their second or third doses. By April 2015, initiation rates had increased as a result of this program from 25.4% before the program was initiated to 80.8% and completion rates from 15.5-65.1%. Missed appointments for injections were less likely among those who received text message reminders and more likely among those with ≥2 prior pregnancies. Those who were Hispanic or had received an influenza vaccination in the last year were more likely to initiate and complete the series through this program. Patients who missed ≥1 follow-up appointments were less likely to complete the vaccine series.

CONCLUSION

Offering the HPV vaccine postpartum dramatically increased initiation rates among postpartum patients. PN and text messages ensured that a high percentage completed all 3 doses.

Cancer Care Delivery and Women's Health: The Role of Patient Navigation

Background

Patient navigation (PN) is a patient-centered health-care service delivery model that assists individuals, particularly the medically underserved, in overcoming barriers (e.g., personal, logistical, and system) to care across the cancer care continuum. In 2012, the American College of Surgeons Commission on Cancer (CoC) announced that health-care facilities seeking CoC-accreditation must have PN processes in place starting January 1, 2015. The CoC mandate, in light of the recent findings from centers within the Patient Navigation Research Program and the influx of PN interventions, warrants the present literature review.

Methods

PubMed and Medline were searched for studies published from January 2010 to October 2015, particularly those recent articles within the past 2 years, addressing PN for breast and gynecological cancers, and written in English. Search terms included patient navigation, navigation, navigator, cancer screening, clinical trials, cancer patient, cancer survivor, breast cancer, gynecological cancer, ovarian cancer, uterine cancer, vaginal cancer, and vulvar cancer.

Results

Consistent with prior reviews, PN was shown to be effective in helping women who receive cancer screenings, receive more timely diagnostic resolution after a breast and cervical cancer screening abnormality, initiate treatment sooner, receive proper treatment, and improve quality of life after cancer diagnosis. However, several limitations were observed. The majority of PN interventions focused on cancer screening and diagnostic resolution for breast cancer. As observed in prior reviews, methodological rigor (e.g., randomized controlled trial design) was lacking.

Conclusion

Future research opportunities include testing PN interventions in the post-treatment settings and among gynecological cancer patient populations, age-related barriers to effective PN, and collaborative efforts between community health workers and patient navigators as care goes across segments of the cancer control continuum. As PN programs continue to develop and become a standard of care, further research will be required to determine the effectiveness of cancer PN across the cancer care continuum, and in different patient populations.

Impact of Patient Navigation Interventions on Timely Diagnostic Follow Up for Abnormal Cervical Screening

OBJECTIVE

As part of the Patient Navigation Research Program, we examined the effect of patient navigation versus usual care on timely diagnostic follow-up, defined as clinical management for women with cervical abnormalities within accepted time frames.

METHODS

Participants from four Patient Navigation Research Program centers were divided into low- and high-risk abnormality groups and analyzed separately. Low-risk participants (n = 2088) were those who enrolled with an initial Pap test finding of atypical squamous cells of undetermined significance (ASCUS) with a positive high-risk human papillomavirus (HPV) serotype, atypical glandular cells, or low-grade squamous intraepithelial lesion (LGSIL). High-risk participants were those with an initial finding of high-grade squamous intraepithelial lesion (HGSIL) (n = 229). A dichotomous outcome of timely diagnostic follow-up within 180 days was used for the low-risk abnormality group and timely diagnostic follow-up within 60 days for the high-risk group, consistent with treatment guidelines. A logistic mixed-effects regression model was used to evaluate the intervention effect using a random effect for study arm within an institution. A backward selection process was used for multivariable model building, considering the impact of each predictor on the intervention effect.

RESULTS

Low-risk women in the patient navigation arm showed an improvement in the odds of timely diagnostic follow-up across all racial groups, but statistically significant effects were only observed in non-English-speaking Hispanics (OR 5.88, 95% CI 2.81-12.29). No effect was observed among high-risk women.

CONCLUSION

These results suggest that patient navigation can improve timely diagnostic follow-up among women with low-risk cervical abnormalities, particularly in non-English-speaking Hispanic women.