The Integration of Value Assessment and Social Network Methods for Breast Health Navigation Among African Americans

OBJECTIVES

A major strategy to reduce the impact of breast cancer (BC) among African Americans (AA) is patient navigation, defined here as individualized assistance for reducing barriers to healthcare use. The primary focus of this study was to estimate the added value of incorporating breast health promotion by navigated participants and the subsequent BC screenings that network members may obtain.

METHODS

In this study, we compared the cost-effectiveness of navigation across 2 scenarios. First, we examine the effect of navigation on AA participants (scenario 1). Second, we examine the effect of navigation on AA participants and their networks (scenario 2). We leverage data from multiple studies in South Chicago. Our primary outcome (BC screening) is intermediate, given limited available quantitative data on the long-term benefits of BC screening for AA populations.

RESULTS

When considering participant effects alone (scenario 1), the incremental cost-effectiveness ratio was $3845 per additional screening mammogram. When including participant and network effects (scenario 2), the incremental cost-effectiveness ratio was $1098 per additional screening mammogram.

CONCLUSION

Our findings suggest that inclusion of network effects can contribute to a more precise, comprehensive assessment of interventions for underserved communities.

Head computerized tomography in emergency department evaluation of the geriatric patient with generalized weakness

Objective

Weakness in older emergency department (ED) patients presents a broad differential. Evaluation of these patients can be challenging, and the efficacy of head computed tomography (CT) imaging is unclear. This study assesses the usefulness of head CT as a diagnostic study of acute generalized weakness in older ED patients.

Methods

This retrospective review of patients aged 65 years and older presenting to 2 community EDs included patients with a chief complaint of generalized weakness who received a head CT. Patients presenting with a focal neurologic complaint, altered mental status, or trauma were excluded. Variables evaluated included additional triage chief complaints, dementia diagnosis, and deficits on physical examination. Primary outcome was acute intracranial finding on head CT. Secondary outcomes included neurology consultation, neurosurgical consultation, and neurosurgical intervention.

Results

Of 247 patients, 3.2% had an acute intracranial abnormality on head CT. Emergent consultations for neurology and neurosurgery occurred for 1.6% and 2.4% of patients, respectively. None required neurosurgical intervention. Patients with objective weakness or focal neurologic deficits on physical examination were more likely to have acute findings on head CT (8.5% vs. 2.0%, odds ratio 4.56, confidence interval 1.10-18.95). Additional characteristics did not predict acute intracranial abnormality or need for emergent consultation.

Conclusion

Few patients with generalized weakness evaluated with head CT had acutely abnormal intracranial findings. Patients with objective weakness or neurologic deficits were more likely to have acute abnormalities. Although head CT is frequently used to evaluate geriatric weakness, its utility is low, especially in patients with normal physical examinations.

Policy Recommendations for Improving Rural Cancer Services in the United States

Compared with urban residents, rural Americans have seen slower declines in cancer deaths, have lower incidence but higher death rates from cancers that can be prevented through screening, have lower screening rates, are more likely to present with later-stage cancers, and have poorer cancer outcomes and lower survival. Rural health provider shortages and lack of cancer services may explain some disparities. The literature was reviewed to identify factors contributing to rural health care capacity shortages and propose policy recommendations for improving rural cancer care. Uncompensated care, unfavorable payer mix, and low patient volume impede rural physician recruitment and retainment. Students from rural areas are more likely to practice there but are less likely to attend medical school because of lower graduation rates, grades, and Medical College Admission Test (MCAT) scores versus urban students. The cancer care infrastructure is costly and financially challenging in rural areas with high proportions of uninsured and publicly insured patients. A lack of data on oncology providers and equipment impedes coordinated efforts to address rural shortages. Graduate Medical Education funding greatly favors large, urban, tertiary care teaching hospitals over residency training in rural, critical access and community-based hospitals and clinics. Policies have the potential to transform rural health care. This includes increasing advanced practice provider postgraduate oncology training opportunities and expanding the scope of practice; improving health workforce and services data collection and aggregation; transforming graduate medical education subsidies to support rural student recruitment and rural training opportunities; and expanding federal and state financial incentives and payments to support the rural cancer infrastructure.

Pragmatic Clinical Trial to Improve Patient Experience Among Adults During Transitions from Hospital to Home: the PArTNER study

INTRODUCTION

Minority-serving hospitals (MSHs) need evidence-based strategies tailored to the populations they serve to improve patient-centered outcomes after hospitalization.

METHODS

We conducted a pragmatic randomized clinical trial (RCT) from October 2014 to January 2017 at a MSH comparing the effectiveness of a stakeholder-supported Navigator intervention vs. Usual care on post-hospital patient experience, outcomes, and healthcare utilization. Community health workers and peer coaches delivered the intervention which included (1) in-hospital visits to assess barriers to health/healthcare and to develop a personalized Discharge Patient Education Tool (DPET); (2) a home visit to review the DPET; and (3) telephone-based peer coaching. The co-primary outcomes were between-group comparisons of 30-day changes in Patient-Reported Outcomes Measurement Information System (PROMIS) measures of anxiety and informational support (minimum important difference is 2 to 5 units change); a p-value <0.025 was considered significant using intention-to-treat analysis. Secondary outcomes included death, ED visits, or readmissions and measures of emotional, social, and physical health at 30 and 60 days.

RESULTS

We enrolled 1029 adults hospitalized with heart failure (28%), pneumonia (22%), MI (10%), COPD (11%), or sickle cell disease (29%). Over 80% were non-Hispanic Black. Overall, there were no significant between-group differences in the 30-day change in anxiety (adjusted difference: -1.6, 97.5% CI -3.3 to 0.1, p=0.03), informational support (adjusted difference: -0.01, 97.5% CI -2.0 to 1.9, p=0.99), or any secondary outcomes. Exploratory analyses suggested the Navigator intervention improved anxiety among participants with COPD, a primary care provider, a hospitalization in the past 12 months, or higher baseline anxiety; among participants without health insurance, the intervention improved informational support (all p-values <0.05).

CONCLUSIONS

In this pragmatic RCT at a MSH, the Navigator intervention did not improve post-hospital anxiety, informational support, or other outcomes compared to Usual care. Benefits observed in participant subgroups should be confirmed in future studies.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT02114515.

Patient Navigation Can Improve Breast Cancer Outcomes among African American Women in Chicago: Insights from a Modeling Study

African American (AA) women experience much greater mortality due to breast cancer (BC) than non-Latino Whites (NLW). Clinical patient navigation is an evidence-based strategy used by healthcare institutions to improve AA women's breast cancer outcomes. While empirical research has demonstrated the potential effect of navigation interventions for individuals, the population-level impact of navigation on screening, diagnostic completion, and stage at diagnosis has not been assessed. An agent-based model (ABM), representing 50-74-year-old AA women and parameterized with locally sourced data from Chicago, is developed to simulate screening mammography, diagnostic resolution, and stage at diagnosis of cancer. The ABM simulated three counterfactual scenarios: (1) a control setting without any navigation that represents the "standard of care"; (2) a clinical navigation scenario, where agents receive navigation from hospital-affiliated staff; and (3) a setting with network navigation, where agents receive clinical navigation and/or social network navigation (i.e., receiving support from clinically navigated agents for breast cancer care). In the control setting, the mean population-level screening mammography rate was 46.3% (95% CI: 46.2%, 46.4%), the diagnostic completion rate was 80.2% (95% CI: 79.9%, 80.5%), and the mean early cancer diagnosis rate was 65.9% (95% CI: 65.1%, 66.7%). Simulation results suggest that network navigation may lead up to a 13% increase in screening completion rate, 7.8% increase in diagnostic resolution rate, and a 4.9% increase in early-stage diagnoses at the population-level. Results suggest that systems science methods can be useful in the adoption of clinical and network navigation policies to reduce breast cancer disparities.

Rates of Diabetes-Related Major Amputations Among Racial and Ethnic Minority Adults Following Medicaid Expansion Under the Patient Protection and Affordable Care Act

Importance

It is not known whether implementation of Medicaid expansion under the Patient Protection and Affordable Care Act (ACA) was associated with improvements in the outcomes among racial and ethnic minority adults at risk of diabetes-related major amputations.

Objective

To explore the association of early Medicaid expansion with outcomes of diabetic foot ulcerations (DFUs).

Design, Setting, and Participants

This cohort study included hospitalizations for DFUs among African American, Asian and Pacific Islander, American Indian or Alaska Native, and Hispanic adults as well as adults with another minority racial or ethnic identification aged 20 to 64 years. Data were collected from the State Inpatient Databases for 19 states and the District of Columbia for 2013 to the third quarter of 2015. The analysis was performed on December 4, 2019, and updated on November 9, 2021.

Exposures

States were categorized into early-adopter states (expansion by January 2014) and nonadopter states.

Main Outcomes and Measures

Poisson regression was performed to examine the associations of state type, time, and their combined association with the proportional changes of major amputation rate per year per 100 000 population.

Results

Among the 115 071 hospitalizations among racial and ethnic minority adults with DFUs (64% of sample aged 50 to 64 years; 35%, female; 61%, African American; 25%, Hispanic; 14%, other racial and ethnic minority group), there were 36 829 hospitalizations (32%) for Medicaid beneficiaries and 10 500 hospitalizations (9%) for uninsured patients. Hospitalizations increased 3% (95% CI, 1% to 5%) in early-adopter states and increased 8% (95% CI, 6% to 10%) in nonadopter states after expansion, a significant difference (P for interaction < .001). Although there was no change in the amputation rate (0.08%; 95% CI, -6% to 7%) in early-adopter states after expansion, there was a 9% (95% CI, 3% to 16%) increase in nonadopter states, a significant change (P = .04). For uninsured adults, the amputation rate decreased 33% (95% CI, 10% to 50%) in early-adopter states and did not change (12%; 95% CI, -10% to 38%) in nonadopter states after expansion, a significant difference (P = .006). There was no difference in the change of amputation rate among Medicaid beneficiaries between state types after expansion.

Conclusions and Relevance

This study found a relative improvement in the major amputation rate among African American, Hispanic, and other racial and ethnic minority adults in early-expansion states compared with nonexpansion states, which could be because of the recruitment of at-risk uninsured adults into the Medicaid program during the first 2 years of ACA implementation. Future study is required to evaluate the long-term association of Medicaid expansion and the rates of amputation.

Abstract PO-208: The value of estimating spillover effects in health equity interventions: A case study to promote mammogram uptake among African American women and their social networks

Introduction: Standard economic evaluation methods may underestimate the value of health equity interventions by focusing exclusively on program costs and direct effects on participants' health. Yet, these interventions have spillover effects – wherein participants transition from being intervention recipients to becoming health advocates for their social networks. Consequently, interventions may improve the health of participants and other community members who are not directly connected with interventions. This study demonstrates the utility of incorporating spillover effects by comparing incremental cost-effectiveness ratios via a patient navigation intervention to promote mammography screening among African American (AA) women. Specifically, we compare the relative costs and cost-effectiveness when including mammography uptake of: (1) AA intervention participants (egos) only versus (2) AA intervention participants (egos) and their screening eligible social network members (alters). Methods: Our study draws from two studies: (1) an individual randomized trial to test the efficacy of patient navigation on mammography uptake (Patient Navigation in Medically Underserved Areas [PNMUA]) and (2) an observational ancillary study to test the effects of PNMUA on breast cancer survivor egos and their alters (Offering AA Survivors Increased Support [OASIS]). Overall, we used a healthcare system perspective. For 2021 cost data, we collected data from study records and expense reports. For effects data, we used: (1) medical record data for egos' mammography uptake, (2) self-report data from egos regarding their alters' mammography uptake, and (3) self-report data from alters about their own mammography uptake. We consequently computed incremental cost-effectiveness ratios (ICERs), using different data sources, to assess the impact of estimating spillover effects on economic evaluation of patient navigation. Results: Total cost of the intervention was $196,601. The greatest expense were breast cancer navigators' salaries and fringe rates ($126,745). In PNMUA, more navigated vs. non-navigated egos obtained biennial mammograms (45% vs. 39%). In terms of spillover effects, more navigation arm alters obtained biennial mammograms compared to alters in the non-navigated arm (ego self-report: n=1296 vs 949; alter self-report: n=1521 vs. 1195). Navigation had lower value when only incorporating participants' mammography uptake ($3,277 per each additional woman screened) versus when incorporating spillover effects ($2,027-$2,114 per each additional woman screened). Conclusion: Our results suggest breast cancer navigation programs may be more valuable when including spillover effects. This case study provides insight with real-world applicability into integrating spillover effects into economic evaluation. Our methods offer a new avenue for improved cost and effect estimates of health equity interventions, which may be useful for assessing future resource allocation in healthcare practice and policy.

Citation Format: Nyahne Bergeron, Veronica Fitzpatrick, Carl Asche, Karriem S. Watson, Aditya S. Khanna, Bridgette Hempstead, Elizabeth A. Calhoun, Jean McDougall, Yamilé Molina. The value of estimating spillover effects in health equity interventions: A case study to promote mammogram uptake among African American women and their social networks [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-208.

Development and Evaluation of a Navigation-Based, Multilevel Intervention to Improve the Delivery of Timely, Guideline-Adherent Adjuvant Therapy for Patients With Head and Neck Cancer

PURPOSE

More than half of patients with head and neck squamous cell carcinoma (HNSCC) experience a delay initiating guideline-adherent postoperative radiation therapy (PORT), contributing to excess mortality and racial disparities in survival. However, interventions to improve the delivery of timely, equitable PORT among patients with HNSCC are lacking. This study (1) describes the development of NDURE (Navigation for Disparities and Untimely Radiation thErapy), a navigation-based multilevel intervention (MLI) to improve guideline-adherent PORT and (2) evaluates its feasibility, acceptability, and preliminary efficacy.

METHODS

NDURE was developed using the six steps of intervention mapping (IM). Subsequently, NDURE was evaluated by enrolling consecutive patients with locally advanced HNSCC undergoing surgery and PORT (n = 15) into a single-arm clinical trial with a mixed-methods approach to process evaluation.

RESULTS

NDURE is a navigation-based MLI targeting barriers to timely, guideline-adherent PORT at the patient, healthcare team, and organizational levels. NDURE is delivered via three in-person navigation sessions anchored to case identification and surgical care transitions. Intervention components include the following: (1) patient education, (2) travel support, (3) a standardized process for initiating the discussion of expectations for PORT, (4) PORT care plans, (5) referral tracking and follow-up, and (6) organizational restructuring. NDURE was feasible, as judged by accrual (88% of eligible patients [100% Blacks] enrolled) and dropout (n = 0). One hundred percent of patients reported moderate or strong agreement that NDURE helped solve challenges starting PORT; 86% were highly likely to recommend NDURE. The rate of timely, guideline-adherent PORT was 86% overall and 100% for Black patients.

CONCLUSION

NDURE is a navigation-based MLI that is feasible, is acceptable, and has the potential to improve the timely, equitable, guideline-adherent PORT.

The association between breast cancer capacity and resources with incidence and mortality in Arizona's low populous counties

INTRODUCTION

While cancer deaths have decreased nationally, declines have been much slower in rural areas than in urban areas. Previous studies on rural cancer service capacity are limited to specific points along the cancer care continuum (eg screening, diagnosis or treatment) and require updating to capture the current rural health landscape since implementation of the 2010 Affordable Care Act in the USA. The association between current rural cancer service capacity across the cancer care continuum and cancer incidence and death is unclear. This cross-sectional study explored the association between breast cancer service capacity and incidence and mortality in Arizona's low populous counties.

METHODS

To measure county-level cancer capacity, clinical organizations operating within low populous areas of Arizona were surveyed to assess on-site breast cancer services provided (screening, diagnosis and treatment) and number of healthcare providers were pulled from Centers for Medicare and Medicaid Services National Provider Identifier database. The number of clinical sites and healthcare providers were converted to county-level per capita rates. Rural-Urban Continuum codes were used to designate rural or urban county status. Age-adjusted county-level breast cancer incidence and death rates from 2010 to 2016 were obtained from the Arizona Department of Health Services, Arizona Cancer Registry. Descriptive statistics were used to summarize the results. Multivariate regression was used to evaluate the association between cancer service capacity and incidence and mortality in 13 out of Arizona's 15 counties.

RESULTS

Rural counties had more per capita clinical sites (20.4) than urban counties (8.9) (p=0.02). Urban counties had more per capita pathologists (1.0) than rural counties (0) (p&le;0.01). In addition to zero pathologists, rural counties had zero medical oncologists. Rural county status was associated with a decrease in breast cancer incidence (&beta;=-20.1, 95% confidence interval: -37.2-3.1).

CONCLUSION

While Arizona's sparsely populated rural counties may have more physical infrastructure per capita, these services are dispersed over vast geographic areas. They lack specialists providing cancer services. Non-physician clinical providers may be more prevalent in rural areas and represent opportunities for improving access to cancer preventive services and care. Compared to urban counties, rural county status was associated with lower detected breast cancer incidence rates although there were no statistically significant differences in breast cancer mortality. Other factors may contribute to rural-urban differences in breast cancer incidence. Future research should explore these factors and the association between cancer capacity and local resources because the use of county-level data represents a challenge in Arizona, where counties average over 19 425 km2 (7500 square miles).

Comparison and impact of COVID-19 for patients with cancer: a survival analysis of fatality rate controlling for age, sex and cancer type

OBJECTIVES

Prior research has reported an increased risk of fatality for patients with cancer, but most studies investigated the risk by comparing cancer to non-cancer patients among COVID-19 infections, where cancer might have contributed to the increased risk. This study is to understand COVID-19's imposed HR of fatality while controlling for covariates, such as age, sex, metastasis status and cancer type.

METHODS

We conducted survival analyses of 4606 cancer patients with COVID-19 test results from 16 March to 11 October 2020 in UK Biobank and estimated the overall HR of fatality with and without COVID-19 infection. We also examined the HRs of 13 specific cancer types with at least 100 patients using a stratified analysis.

RESULTS

COVID-19 resulted in an overall HR of 7.76 (95% CI 5.78 to 10.40, p<10-10) by following 4606 patients with cancer for 21 days after the tests. The HR varied among cancer type, with over a 10-fold increase in fatality rate (false discovery rate ≤0.02) for melanoma, haematological malignancies, uterine cancer and kidney cancer. Although COVID-19 imposed a higher risk for localised versus distant metastasis cancers, those of distant metastases yielded higher overall fatality rates due to their multiplicative effects.

DISCUSSION

The results confirmed prior reports for the increased risk of fatality for patients with COVID-19 plus hematological malignancies and demonstrated similar findings of COVID-19 on melanoma, uterine, and kidney cancers.

CONCLUSION

The results highlight the heightened risk that COVID-19 imposes on localised and haematological cancer patients and the necessity to vaccinate uninfected patients with cancer promptly, particularly for the cancer types most influenced by COVID-19. Results also suggest the importance of timely care for patients with localised cancer, whether they are infected by COVID-19 or not.

Barriers to the Delivery of Timely, Guideline-Adherent Adjuvant Therapy Among Patients With Head and Neck Cancer

PURPOSE

Delays initiating guideline-adherent postoperative radiation therapy (PORT) in head and neck squamous cell carcinoma (HNSCC) are common, contribute to excess mortality, and are a modifiable target for improving survival. However, the barriers that prevent the delivery of timely, guideline-adherent PORT remain unknown. This study aims to identify the multilevel barriers to timely, guideline-adherent PORT and organize them into a conceptual model.

MATERIALS AND METHODS

Semi-structured interviews with key informants were conducted with a purposive sample of patients with HNSCC and oncology providers across diverse practice settings until thematic saturation (n = 45). Thematic analysis was performed to identify the themes that explain barriers to timely PORT and to develop a conceptual model.

RESULTS

In all, 27 patients with HNSCC undergoing surgery and PORT were included, of whom 41% were African American, and 37% had surgery and PORT at different facilities. Eighteen clinicians representing a diverse mix of provider types from 7 oncology practices participated in key informant interviews. Five key themes representing barriers to timely PORT were identified across 5 health care delivery levels: (1) inadequate education about timely PORT, (2) postsurgical sequelae that interrupt the tight treatment timeline (both intrapersonal level), (3) insufficient coordination and communication during care transitions (interpersonal and health care team levels), (4) fragmentation of care across health care organizations (organizational level), and (5) travel burden for socioeconomically disadvantaged patients (community level).

CONCLUSION

This study provides a novel description of the multilevel barriers that contribute to delayed PORT. Interventions targeting these multilevel barriers could improve the delivery of timely, guideline-adherent PORT and decrease mortality for patients with HNSCC.

Abstract PO-231: Development and evaluation of a theory-based, multilevel intervention to improve the delivery of timely, guideline-adherent adjuvant therapy for patients with head and neck cancer

Background: Delays initiating guideline-adherent postoperative radiation therapy (PORT) in head and neck squamous cell carcinoma (HNSCC) occur in more than 50% of patients and are key drivers of excess mortality and racial disparities in survival. Theory-based multilevel interventions to address delays and racial disparities in timely PORT have not been described and effective interventions to improve timely, equitable PORT are lacking. Purpose: This study aims to describe the development of NDURE (Navigation for Disparities and Untimely Radiation Therapy), a novel theory- based, multilevel intervention to decrease delays starting PORT and evaluate its feasibility, acceptability, and preliminary clinical efficacy. Methods: An intervention mapping approach was used to develop NDURE. Consecutive patients with locally- advanced HNSCC undergoing surgery and PORT were enrolled into a single-arm clinical trial. Results: NDURE targets the determinants of timely, guideline-adherent PORT through the following core functions: 1) patient education, 2) standardization of the process for initiating the discussion of PORT, 3) PORT care plans, 4) provider role definition, 5) referral tracking and follow-up, and 6) transportation assistance.

NDURE was feasible, as judged by trial accrual (88% overall; 100% for African Americans) and dropout (n=0). 100% of patients reported moderate/strong agreement that NDURE helped solve challenges starting PORT; 86% were highly likely to recommend NDURE. The rate of timely, guideline-adherent PORT was 86% overall and 100% for African Americans. Conclusions: NDURE is a novel, theory-based, multilevel intervention targeting determinants of timely PORT among HNSCC patients. NDURE is feasible, acceptable, and has potential to improve the timely, equitable, guideline-adherent PORT. These results support conducting a randomized controlled trial to test NDURE’s clinical efficacy. clinicaltrials.gov number NCT04030130

Citation Format: Evan M. Graboyes, Katherine R. Sterba, Hong Li, Graham Warren, Anthony J. Alberg, Elizabeth A. Calhoun, Brian Nussenbaum, Jessica McCay, Courtney H. Marsh, David M. Neskey, John Kaczmar, Anand K. Sharma, Jennifer Harper, Terry A. Day, Chanita Hughes Halbert. Development and evaluation of a theory-based, multilevel intervention to improve the delivery of timely, guideline-adherent adjuvant therapy for patients with head and neck cancer [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-231.

Leveraging system sciences methods in clinical trial evaluation: An example concerning African American women diagnosed with breast cancer via the Patient Navigation in Medically Underserved Areas study

Background

Systems science methodologies offer a promising assessment approach for clinical trials by: 1) providing an in-silico laboratory to conduct investigations where purely empirical research may be infeasible or unethical; and, 2) offering a more precise measurement of intervention benefits across individual, network, and population levels. We propose to assess the potential of systems sciences methodologies by quantifying the spillover effects of randomized controlled trial via empirical social network analysis and agent-based models (ABM).

Design/methods

We will evaluate the effects of the Patient Navigation in Medically Underserved Areas (PNMUA) study on adult African American participants diagnosed with breast cancer and their networks through social network analysis and agent-based modeling. First, we will survey 100 original trial participants (50 navigated, 50 non-navigated) and 150 of members of their social networks (75 from navigated, 75 non-navigated) to assess if navigation results in: 1) greater dissemination of breast health information and breast healthcare utilization throughout the trial participants’ networks; and, 2) lower incremental costs, when incorporating navigation effects on trial participants and network members. Second, we will compare cost-effectiveness models, using a provider perspective, incorporating effects on trial participants versus trial participants and network members. Third, we will develop an ABM platform, parameterized using published data sources and PNMUA data, to examine if navigation increases the proportion of early stage breast cancer diagnoses.

Discussion

Our study results will provide promising venues for leveraging systems science methodologies in clinical trial evaluation.

Gendered and racialized social expectations, barriers, and delayed breast cancer diagnosis

BACKGROUND

Black women are more likely to be diagnosed at a later stage of breast cancer in part due to barriers to timely screening mammography, resulting in poorer mortality and survival outcomes. Patient navigation that helps to overcome barriers to the early detection of breast cancer is an effective intervention for reducing breast cancer disparity. However, the ability to recognize and seek help to overcome barriers may be affected by gendered and racialized social expectations of women.

METHODS

Data from a randomized controlled trial, the Patient Navigation in Medically Underserved Areas study, were used. The likelihood of obtaining a follow-up screening mammogram was compared between women who identified ≥1 barriers and those who did not.

RESULTS

Of the 3754 women who received the Patient Navigation in Medically Underserved Areas navigation intervention, approximately 14% identified ≥ 1 barriers, which led to additional navigator contacts. Consequently, those women who reported barriers were more likely to obtain a subsequent screening mammogram. Black women, women living in poverty, and women with a higher level of distrust were less likely to report barriers.

CONCLUSIONS

Minority women living in poverty have always been the source of social support for others. However, gendered and racialized social expectations may affect the ways in which women seek help for their own health needs. A way to improve the effectiveness of navigation would be to recognize how minority women's gender images and expectations could shape how they seek help and support. A report of no barriers does not always translate into no problems. Proactive approaches to identify potential barriers may be beneficial.

A Comparison of Different Intensities of Patient Navigation After Abnormal Mammography

Background. Patient navigation is a practice strategy to address barriers to timely diagnosis and treatment of cancer. The aim of this study was to examine the effectiveness of varying intensities of patient navigation and timely diagnostic resolution after abnormal mammography. Method. This is a secondary analysis of a subset of women with an abnormal screening or diagnostic mammogram who participated in the "patient navigation in medically underserved areas" 5-year randomized trial. We compared timely diagnostic resolution in women assigned to different intensities of patient navigation including, full navigation intervention, no contact with navigators, or limited contact with navigators. Results. The sample included 1,725 women with abnormal mammogram results. Women who interacted with patient navigators had significantly fewer days to diagnostic resolution after abnormal mammography compared with women who did not interact with patient navigators. Discussion. Results from our study suggest that even limited contact with navigators encourages women to seek more timely diagnostic resolution after an abnormal mammogram, which may offer a low-cost practice strategy to improve timely diagnosis for disadvantaged and underserved women.

What are patient navigators doing, for whom, and where? A national survey evaluating the types of services provided by patient navigators

OBJECTIVE

A nationwide cross-sectional study was conducted to assess patient navigator, patient population, and work setting characteristics associated with performance of various patient navigation (PN) tasks.

METHODS

Using respondent-driven sampling, 819 navigators completed a survey assessing frequency of providing 83 PN services, along with information about themselves, populations they serve, and setting in which they worked. Analyses of variance and Pearson correlations were conducted to determine differences and associations in frequency of PN services provided by various patient, navigator, and work setting characteristics.

RESULTS

Nurse navigators and navigators with lower education provide basic navigation; social workers typically made arrangements and referrals; and individuals with higher education, social workers, and nurses provide treatment support and clinical trials/peer support. Treatment support and clinical trials/peer support are provided to individuals with private insurance. Basic navigation, arrangements and referrals, and care coordination are provided to individuals with Medicaid or no insurance.

CONCLUSION

Providing basic navigation is a core competency for patient navigators. There may be two different specialties of PN, one which seeks to reduce health disparities and a second which focuses on treatment and emotional support.

PRACTICE IMPLICATIONS

The selection and training of patient navigators should reflect the specialization required for a position.

Patient Navigation Improves Subsequent Breast Cancer Screening After a Noncancerous Result: Evidence from the Patient Navigation in Medically Underserved Areas Study

BACKGROUND

Past efforts to assess patient navigation on cancer screening utilization have focused on one-time uptake, which may not be sufficient in the long term. This is partially due to limited resources for in-person, longitudinal patient navigation. We examine the effectiveness of a low-intensity phone- and mail-based navigation on multiple screening episodes with a focus on screening uptake after receiving noncancerous results during a previous screening episode.

METHODS

The is a secondary analysis of patients who participated in a randomized controlled patient navigation trial in Chicago. Participants include women referred for a screening mammogram, aged 50-74 years, and with a history of benign/normal screening results. Navigation services focused on identification of barriers and intervention via shared decision-making processes. A multivariable logistic regression intent-to-treat model was used to examine differences in odds of obtaining a screening mammogram within 2 years of the initial mammogram (yes/no) between navigated and non-navigated women. Sensitivity analyses were conducted to explore patterns across subsets of participants (e.g., navigated women successfully contacted before the initial appointment; women receiving care at Hospital C).

RESULTS

The final sample included 2,536 women (741 navigated, 1,795 non-navigated). Navigated women exhibited greater odds of obtaining subsequent screenings relative to women in the standard care group in adjusted models and analyses including women who received navigation before the initial appointment.

CONCLUSIONS

Our findings suggest that low-intensity navigation services can improve follow-up screening among women who receive a noncancerous result. Further investigation is needed to confirm navigation's impacts on longitudinal screening.

Patient Navigation in Medically Underserved Areas study design: A trial with implications for efficacy, effect modification, and full continuum assessment

BACKGROUND

The Patient Navigation in Medically Underserved Areas study objectives are to assess if navigation improves: 1) care uptake and time to diagnosis; and 2) outcomes depending on patients' residential medically underserved area (MUA) status. Secondary objectives include the efficacy of navigation across 1) different points of the care continuum among patients diagnosed with breast cancer; and 2) multiple regular screening episodes among patients who did not obtain breast cancer diagnoses.

DESIGN/METHODS

Our randomized controlled trial was implemented in three community hospitals in South Chicago. Eligible participants were: 1) female, 2) 18+years old, 3) not pregnant, 4) referred from a primary care provider for a screening or diagnostic mammogram based on an abnormal clinical breast exam. Participants were randomized to 1) control care or 2) receive longitudinal navigation, through treatment if diagnosed with cancer or across multiple years if asymptomatic, by a lay health worker. Participants' residential areas were identified as: 1) established MUA (before 1998), 2) new MUA (after 1998), 3) eligible/but not designated as MUA, and 4) affluent/ineligible for MUA. Primary outcomes include days to initially recommended care after randomization and days to diagnosis for women with abnormal results. Secondary outcomes concern days to treatment initiation following a diagnosis and receipt of subsequent screening following normal/benign results.

DISCUSSION

This intervention aims to assess the efficacy of patient navigation on breast cancer care uptake across the continuum. If effective, the program may improve rates of early cancer detection and breast cancer morbidity.

Abstract C78: The effect of navigation on mammography uptake among Latinas: Effect modification by facility and neighborhood characteristics

Purpose. Improving mammography among Latinas may improve ethnic disparities in stage at diagnosis, morbidity, and quality of life. In response, multiple interventions have been developed and assessed, including patient navigation. Little is known about how efficacy varies across socioenvironmental contexts. Such work is warranted for future comparative effectiveness research and clinical implementation.

Objective. The study examined the interactive effects of patient navigation with contextual factors (facility and residential neighborhood characteristics) on mammography uptake among a Chicago-based sample of Latinas.

Methods. The larger trial, “Patient Navigation in Medically Underserved Areas”, is a five year project to assess the effectiveness of primarily phone-based navigation services within 3 hospitals in South Chicago. The current study's analytic sample includes 715 women who: 1) identified as Latina; 2) were referred for mammography; and 3) had age, insurance status, type of mammogram, and zipcode information documented in their medical records. We classified participants using an as-treated operationalization (navigated or not). The facility variable of interest was accreditation as a Breast Imaging Center of Excellence (BICOE; 1 yes and 2 no). The two neighborhood characteristics of interest were median household income and percent of Latino residents (%Latino) based on American Community Survey 2007-2011 data. The outcome of interest was days to mammography uptake, defined as days between randomization and attendance at the referred mammography appointment.

Results. First, Cox regression survival models were conducted that adjusted for patient age, insurance status, and type of mammogram (screening or diagnostic) and incorporated main effects of facility and neighborhood characteristics. There were significant interaction effects of navigation with neighborhood %Latino (p&lt;.0001) and facility BICOE status (p = .01). There was also a non-significant interaction with neighborhood median income (p =.08).

The analysis next conducted models, wherein we stratified by tertiles for %Latino and by facility BICOE status (yes/no). For these models, it included covariates and the main effects of non-stratified contextual variables (e.g., neighborhood median income). Among residents of neighborhoods with the least %Latino, non-navigated women had a greater number of days to mammography uptake relative to navigated women, HR =2.8, 95%CI[1.6, 4.9], p&lt;.0001. Navigation effects were not significant for residents of neighborhoods with greater %Latino (ps=.19-.23). Among BICOE patients, non-navigated women had a greater number of days to mammography uptake relative to navigated women, HR=2.5, 95%CI[1.5,4.5], p =.001. Navigation effects were not significant for patients attending non-BICOE facilities (p=.55).

Conclusions. The study suggests navigation may be particularly effective within more resourced facility settings and for Latinos living outside of ethnic enclaves. Future studies are warranted to confirm our findings and assess the potential of these services across diverse clinical settings.

Citation Format: Yamile Molina, Yazmin San Miguel, Sage Kim, Anne Elizabeth Glassglow, Nerida Berrios, Julie S. Darnell, Elizabeth A. Calhoun. The effect of navigation on mammography uptake among Latinas: Effect modification by facility and neighborhood characteristics. [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 C78.

Abstract B76: Effects of navigation on initial and repeat mammography screening among medically underserved women

Purpose: Despite its increasing popularity to address breast cancer disparities, existing efforts to assess the effect of patient navigation on regular breast cancer screening utilization among medically underserved groups have been cross-sectional or ecological in nature. Such work is warranted to examine the longitudinal benefits of patient navigation, given one-time utilization of cancer screening is not sufficient strategy for improving early detection of breast cancer.

Objective: Our study had two objectives. First, we test the effectiveness of navigation on adherence to initial recommended screening mammography appointments among a population of medically underserved, largely African American women. Second, for women with normal screening results, we test the effectiveness of navigation on attainment of subsequent screening mammograms.

Methods: The larger trial, Patient Navigation in Medically Underserved Areas, is a five year project to assess the effectiveness of multimodal, primarily phone-based, navigation services to timely diagnostic resolution after an abnormal screening result within three hospitals located in South Chicago. The current study focuses on secondary outcomes concerning the effectiveness of navigation for mammography screening. Our analytic sample includes 4185 women referred for mammography screening with available medical record data concerning demographic (age, race, insurance, miles to clinic, neighborhood median income) and healthcare information (insurance, screening patterns). Participants were classified by their assignment from randomization, which was focused on the primary outcome (diagnostic follow-up), and whether they interacted with staff prior to the initial appointment: navigated with contact; control with contact; navigated without contact; and control without contact.

Results: After adjusting for demographic and healthcare insurance, navigated with contact, women obtained the initial screening mammogram within fewer days relative to other groups, HR= 0.7, 95%CI [0.6, 0.9], p = .001 and greater odds of obtaining screening mammograms, OR = 1.6, 95%CI [1.3, 1.9], p &lt;.0001. Complex differences were found when comparing control with contact and navigated without contact to control without contact, indicating placebo effects on interaction with staff focused on breast healthcare.

Conclusions: Our study adds to a growing body of work demonstrating the usefulness of patient navigation, including the impact of delivering services outside of in-person interaction. Future studies are warranted to confirm our findings and assess the potential of these services in real life settings.

Citation Format: Yamile Molina, Sage Kim, Anne L. Glassgow, Nerida M. Berrios, Julie Darnell, Heather Pauls, Ganga Vijayasiri, Richard Warnecke, Elizabeth A. Calhoun. Effects of navigation on initial and repeat mammography screening among medically underserved women. [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 B76.

Medical mistrust and patient satisfaction with mammography: the mediating effects of perceived self-efficacy among navigated African American women

BACKGROUND

Medical mistrust is salient among African American women, given historic and contemporary racism within medical settings. Mistrust may influence satisfaction among navigated women by affecting women's perceptions of their health-care self-efficacy and their providers' roles in follow-up of abnormal test results.

OBJECTIVES

To (i) examine whether general medical mistrust and health-care self-efficacy predict satisfaction with mammography services and (ii) test the mediating effects of health-related self-efficacy.

DESIGN

The current study is a part of a randomized controlled patient navigation trial for medically underserved women who had received a physician referral to obtain a mammogram in three community hospitals in Chicago, IL. After consent, 671 African American women with no history of cancer completed questionnaires concerning medical mistrust and received navigation services. After their mammography appointment, women completed health-care self-efficacy and patient satisfaction questionnaires.

RESULTS

Women with lower medical mistrust and greater perceived self-efficacy reported greater satisfaction with care. Medical mistrust was directly and indirectly related to patient satisfaction through self-efficacy.

CONCLUSIONS

Preliminary findings suggest future programmes designed to increase health-care self-efficacy may improve patient satisfaction among African American women with high levels of medical mistrust. Our findings add to a growing body of literature indicating the importance of self-efficacy and active participation in health care, especially among the underserved.

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.

Abstract IA38: Patient navigation in medically underserved areas

Purpose: The Chicago Patient Navigation in Medically Underserved Areas Study, a large scale randomized trial of patient navigation, involving women who made appointments at one of three Chicago-area medical centers for either screening or diagnostic mammograms/services. The principal outcome measure is the time required to come to diagnostic resolution for women whose initial mammograms results in BIRAD values of 0,3,4 or 5. Our goal was to evaluate the effectiveness of patient navigation but also to investigate the effect of living in an officially designated Medically Underserved Area (MUA).

Background: MUAs are designated by the Health Research Services Administration (HRSA). Areas to be considered for designation are defined as rational service areas (RSA), which in urban areas are composed of contiguous census tracts. Four elements are considered (1) the ratio of primary medical care physicians per 1,000 population, (2) the infant mortality rate, (3) the percentage of the population with income below the poverty level, and (4) the percent of the population 65 years and older. Each of the four elements is scored separately and then summed; the resulting score can range from 0 to 100. Areas with an IMU below 62 qualify for designation. Consideration for MUA status must be requested by representatives from the population of the eligible areas. Thus, designation requires that a local community organization advocates for establishment of the MUA. As a result, in Chicago, many census tracts are eligible for MUA status but are not so designated.

Methods: All women who had an initial referral from a physician for screening or for diagnostic mammography following a clinical breast exam were randomly assigned to either the control or navigation arm of the study. Randomization was balanced by age group. Women assigned to navigation were recruited if they had a working telephone and gave informed consent. Electronic medical record (EMR) data were made available by the cooperating medical centers for all women. All women in the navigation arm and a small subsample of women in the control arm also responded to a series of questionnaires collecting background data and tracking their progress through the breast care cycle. Each woman's address was geocoded and the census tract was coded for MUA status: (1) not eligible, (2) old MUA designated before the year 2000, (3) new MUA designated in 2000 or after and (4) eligible but not designated. For this analysis, the primary outcome variable is the number of days ensuing between the date of the initial examination and the date on which a firm diagnosis of cancer or no cancer was obtained. The analysis sample consisted of all women with initial BIRAD values of 0, 3, 4 or 5. Women with BIRAD 3 are normally asked to return for re-examination in six months and in their case the number of days till resolution was adjusted to count the number of days following the suggested return date. Over the course of the study some women were observed over several exam cycles. This analysis focuses on the first cycle only. All analysis were conducted using the Cox proportional hazard model. Analyses were stratified by the initial BIRAD value.

Results: After excluding a small number of women with missing clinical data, 5660 cases were available for analysis. Of these, 3567 cases were excluded because their initial BIRAD value was 1 or 2. For the remaining 2093 cases involving 223022 person-days at risk we obtained resolution dates for 1810 and the remainder were lost to follow up in that we did not observe a diagnostic resolution date. These cases were considered to be censored. The maximum number of days observed was 741. Variables in the Cox model were indicator variables for navigated versus control and screening versus diagnostic, a set of indicator variables for MUA status (reference group New MUA), a set of indicator variables for insurance status (private, Medicare, Medicaid or uninsured, reference group private) and marital status (single, married, divorced/separated and widowed, reference group single). Age was found to be unrelated to the rate of resolution and was not included in the final model. Women who were navigated obtained diagnostic resolution more quickly (HR 1.13; CI 1.02, 1.24; p .017) than women in the control arm. Women seen for diagnostic mammography had much faster resolution times (HR 1.88, CI 1.67, 2.09; p .&lt;.000) than women initially seen for screening. Women who lived in areas designated as MUAs prior to 2000 experienced slower rates of diagnostic resolution than women in the reference group (HR .81; CI .67, .97;p .025). Other groups did not differ. Relative to women with private insurance, uninsured women or those on Medicaid had slower times to resolution (HR .78; CI .65, .95; p .011). None of the marital status groups differed from the reference group (single) at p &lt;= .05 however married or divorced or separated women experienced marginally faster resolution times (p = .062 and .079 respectively).

Conclusion: Despite years of gains in cancer screening, diagnosis, and treatment, certain populations continue to disproportionally suffer with poor outcomes and higher mortality. Patient navigation is a strategy to improve the equity in outcomes across populations. The field of navigation is maturing and solidifying the evidence for the efficacy pf patient navigation. There needs to be more efforts aimed at understanding which populations benefit the most from navigation. In addition, determining what type of navigation models works best in certain settings and with certain populations is still ripe for study.

This study provides evidence supporting navigation as an effective tool to help women reach diagnostic resolution. Additionally analyses will be conducted to examine more fully the impact on how living in an MUA, having a medical home, and being actively engaged in your health care has on the patients' ability to navigate themselves more effectively and help provide evidence to help deploy navigation in a sustainable and cost efficient manner.

Citation Format: Elizabeth A. Calhoun, Heather Pauls, Ganga Vijayasiri, Julie S. Darnell, Yamile Molina, Nerida Berrios, Richard Warnecke, Richard Campbell. Patient navigation in medically underserved areas. [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr IA38.

Abstract B87: Healthcare distrust, medical advocacy, and patient satisfaction: A mediation model for African American navigated patients

Background. African American women experience poorer breast cancer outcomes, partially due to delays in care. Recent efforts have sought to mitigate disparities through patient navigation. Given its growing popularity, research is warranted to understand patient satisfaction and improve service use, including understanding the contributions of neighborhood, socio-demographic, and psychosocial factors. These associations may be influenced by targeted outcomes of patient navigation, such as increased confidence in patients' ability to understand and act on health information and with healthcare staff (medical advocacy). Certain groups of women may perceive themselves to have greater medical advocacy as a result of navigation and consequently report greater satisfaction.

Purpose. The current study has two objectives: 1) to assess predictors of satisfaction in a group of African American women who received navigation services; and 2) to assess the mediating role of medical advocacy.

Methods. This study includes 877 African American women who were referred for diagnostic mammograms and were identified by trained Patient Navigators in the Patient Navigation in Medically Underserved Areas Project associated with the University of Illinois-Chicago's Center for Population Health and Health Disparities. Consenting women completed socio-demographic information and the Health Care Distrust Scale (Cronbach's α = 0.60). Prior to appointments, navigators utilized a “teach back” method to ensure comprehension for their upcoming breast health care exams and to recommend patients contact health care staff for further information as needed. After the appointment, participants completed questionnaires regarding medical advocacy (Cronbach's α = 0.84) and patient satisfaction (Cronbach's α = 0.94). Addresses abstracted from electronic medical records were matched to census tract data from the American Community Survey 2005-2009. We conducted HLM models to identify predictors and Preacher and Hayes and Sobel methods to test mediation models.

Results. There was substantial variation in patient satisfaction (Range: 34-140). Neighborhood factors (racial/ethnic composition, poverty) were not associated with patient satisfaction. Patient satisfaction was associated with age (B = -0.11, 95%CI [-0.19, -0.03], p = .008) and education (B = 0.61, 95%CI [0.002, 1.22], p =.05), but not with income, insurance status, self-rated health, medical home, or type of mammogram recommended. Lower satisfaction was also reported by women with higher levels of healthcare distrust, B = -0.64, 95%CI [-0.85, -0.43], p &lt;.0001. Mediation models revealed medical advocacy partially mediated relationships between healthcare distrust and satisfaction (15% Mediated Effect, Z = -3.55, p = .0004), but not education or age effects. Women with higher levels of healthcare distrust reported lower levels of perceived medical advocacy, which resulted in lower patient satisfaction.

Conclusions: Evidence suggests variation in satisfaction with navigation services among African American women that relate to age, education, and healthcare distrust. Refinement of patient navigation systems should target intrapersonal components related to medical advocacy, especially among women with higher levels of healthcare distrust. Future research should further characterize socio-demographic differences in satisfaction as well as assess the impact of satisfaction on subsequent healthcare utilization.

Citation Format: Yamile Molina, Elizabeth A. Calhoun, Nerida Barrios, Beti Thompson, Seijeoung Kim. Healthcare distrust, medical advocacy, and patient satisfaction: A mediation model for African American navigated patients. [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 B87. doi:10.1158/1538-7755.DISP13-B87

Utilizing Exploratory Spatial Data Analysis to Examine Health and Environmental Disparities in Disadvantaged Neighborhoods

Health disparities research has focused primarily on racial and socioeconomic differences in health outcomes. Although neighborhood characteristics and the concept of built environment have been shown to affect individual health, measuring the effects of environmental risks on health has been a less developed area of disparities research. To examine spatial associations and the distribution of geographic patterns of sociodemographic characteristics, environmental cancer risk, and cancer rates, we utilized existing data from multiple sources. The findings from our initial analysis, which concerned with proximity to environmental hazards and at-risk communities, were consistent with results of previous studies, which often reported mixed relationships between health disparity indicators and environmental burden. However, further analysis with refined models showed that several key demographic and subdomains of cancer risk measures were shown to have spatial components. With the application of exploratory spatial data analysis, we were able to identify areas with both high rates of poverty and racial minorities to further examine for possible associations to environmental cancer risk. Global spatial autocorrelation found spatial clustering with percent black, percent poverty, point and non-point cancer risks requiring further spatial analysis to determine relationship of significance based on geography. This methodology was based upon particular assumptions associated with data and applications, which needed to be met. We conclude that careful assessment of the data and applications were required to properly interpret the findings in understanding the relationship between vulnerable populations and environmental burden.

Patient barriers to follow-up care for breast and cervical cancer abnormalities

BACKGROUND

Women with breast or cervical cancer abnormalities can experience barriers to timely follow-up care, resulting in delays in cancer diagnosis. Patient navigation programs that identify and remove barriers to ensure timely receipt of care are proliferating nationally. The study used a systematic framework to describe barriers, including differences between African American and Latina women; to determine recurrence of barriers; and to examine factors associated with barriers to follow-up care.

METHODS

Data originated from 250 women in the intervention arm of the Chicago Patient Navigation Research Program (PNRP). The women had abnormal cancer screening findings and navigator encounters. Women were recruited from a community health center and a publicly owned medical center. After describing proportions of African American and Latina women experiencing particular barriers, logistic regression was used to explore associations between patient characteristics, such as race/ethnicity, and type of barriers.

RESULTS

The most frequent barriers occurred at the intrapersonal level (e.g., insurance issues and fear), while institutional-level barriers such as system problems with scheduling care were the most commonly recurring over time (29%). The majority of barriers (58%) were reported in the first navigator encounter. Latinas (81%) reported barriers more often than African American women (19%). Differences in race/ethnicity and employment status were associated with types of barriers. Compared to African American women, Latinas were more likely to report an intrapersonal level barrier. Unemployed women were more likely to report an institutional level barrier.

CONCLUSION

In a sample of highly vulnerable women, there is no single characteristic (e.g., uninsured) that predicts what kinds of barriers a woman is likely to have. Nevertheless, navigators appear able to easily resolve intrapersonal-level barriers, but ongoing navigation is needed to address system-level barriers. Patient navigation programs can adopt the PNRP barriers framework to assist their efforts in assuring timely follow-up care.

Follow-up and timeliness after an abnormal cancer screening among underserved, urban women in a patient navigation program

BACKGROUND

We evaluated the efficacy of a Chicago-based cancer patient navigation program developed to increase the proportion of patients reaching diagnostic resolution and reduce the time from abnormal screening test to definitive diagnostic resolution.

METHODS

Women with an abnormal breast (n = 352) or cervical (n = 545) cancer screening test were recruited for the quasi-experimental study. Navigation subjects originated from five federally qualified health center sites and one safety net hospital. Records-based concurrent control subjects were selected from 20 sites. Control sites had similar characteristics to the navigated sites in terms of patient volume, racial/ethnic composition, and payor mix. Mixed-effects logistic regression and Cox proportional hazard regression analyses were conducted to compare navigation and control patients reaching diagnostic resolution by 60 days and time to resolution, adjusting for demographic covariates and site.

RESULTS

Compared with controls, the breast navigation group had shorter time to diagnostic resolution (aHR = 1.65, CI = 1.20-2.28) and the cervical navigation group had shorter time to diagnostic resolution for those who resolved after 30 days (aHR = 2.31, CI = 1.75-3.06), with no difference before 30 days (aHR = 1.42, CI = 0.83-2.43). Variables significantly associated with longer time to resolution for breast cancer screening abnormalities were being older, never partnered, abnormal mammogram and BI-RADS 3, and being younger and Black for cervical abnormalities.

CONCLUSIONS

Patient navigation reduces time from abnormal cancer finding to definitive diagnosis in underserved women.

IMPACT

Results support efforts to use patient navigation as a strategy to reduce cancer disparities among socioeconomically disadvantaged women.

Abstract FO02-03: Breast cancer control in federally qualified health centers

Patient Navigation is a patient-centric health care service delivery intervention, with the goal of eliminating barriers, which may occur across the health care continuum, from screening, to timely diagnosis and treatment of cancer, and through survivorship. Pioneered in Harlem, NY, patient navigation is being widely replicated nationally and is receiving considerable support for demonstration projects and research to test its effectiveness. Patient navigation has evolved as a strategy to reduce cancer health disparities by eliminating barriers to timely diagnosis and treatment of cancer. The largest and longest effort to test the efficacy of PN is the $25 million, five-year Patient Navigation Research Program (PNRP) undertaken by the National Cancer Institute (NCI). The Chicago patient navigation program, for example, was funded through the NCI PNRP to increase the proportion of patients reaching diagnostic resolution and reduce the time from abnormal screening test to definitive diagnostic resolution among low income underserved women with abnormal breast (n=352) or cervical (n=545) screening results. We found that compared to control subjects who received usual care, a higher percentage of navigated subjects reached a diagnostic resolution by 60 days (83.0% vs. 52.7%) for breast and by 365 days (98.7% vs. 81.0%) for cervical cancer. But, the effects of patient navigation are defined and measured in different ways across programs. In order to make meaningful comparisons across diverse programs, outcome measures must be concordant. Therefore, in March 2010, the National Patient Navigation Leadership Summit comprised of cancer clinicians, researchers, practicing public health and measurement experts, funders, and patient navigators, met to develop a national consensus on common outcomes to solidify the scientific evidence and efficacy of patient navigation using a principles from community-based participatory research. The goal of the Summit was to develop and propose core metrics to measure outcomes of navigation on individuals as well as populations across the continuum. The process used to engage all key stakeholders and current national efforts will be discussed along with the outcomes of this approach.

Funding: The Chicago Patient Navigation grant was supported by the National Institute of Health grant 1 U01 CA116875-01. The leadership conference and Cancer supplement were cosponsored by Pfizer Oncology, Livestrong (Lance Armstrong Foundation), Susan G. Komen for the Cure, the Oncology Nursing Society (ONS), the American College of Surgeons Commission on Cancer, the American Cancer Society, and AstraZeneca.

Citation Format: Elizabeth A. Calhoun. Breast cancer control in federally qualified health centers. [abstract]. In: Proceedings of the Fifth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2012 Oct 27-30; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(10 Suppl):Abstract nr FO02-03.

Are breast cancer navigation programs cost-effective? Evidence from the Chicago Cancer Navigation Project

OBJECTIVES

One of the aims of the Chicago Cancer Navigation Project (CCNP) is to reduce the interval of time between abnormal breast cancer screening and definitive diagnosis in patients who are navigated as compared to usual care. In this article, we investigate the extent to which total costs of breast cancer navigation can be offset by survival benefits and savings in lifetime breast cancer-attributable costs.

METHODS

Data sources for the cost-effectiveness analysis include data from published literature, secondary data from the NCI's Surveillance Epidemiology and End Results (SEER) program, and primary data from the CCNP.

RESULTS

If women enrolled in CCNP receive breast cancer diagnosis earlier by 6 months as compared to usual care, then navigation is borderline cost-effective for $95,625 per life-year saved. Results from sensitivity analyses suggest that the cost-effectiveness of navigation is sensitive to: the interval of time between screening and diagnosis, percent increase in number of women who receive cancer diagnosis and treatment, women's age, and the positive predictive value of a mammogram.

CONCLUSIONS

In planning cost-effective navigation programs, special considerations should be made regarding the characteristics of the disease, program participants, and the initial screening test that determines program eligibility.

A survey of primary care physician practices in the diagnosis and management of women with interstitial cystitis/painful bladder syndrome

OBJECTIVES

To describe the practice patterns among primary care physicians' (PCPs) managing patients with symptoms suggestive of interstitial cystitis/painful bladder syndrome (IC/PBS).

METHODS

We developed a clinical vignette describing a woman with typical IC/PBS symptoms to elicit questions about etiology, management strategies, and familiarity with this syndrome. We mailed the questionnaire to 556 PCPs, including academicians and community physicians, in Boston, Los Angeles, and Chicago.

RESULTS

We received 290 completed questionnaires (response rate, 52%). Nineteen percent of respondents reported they had "never" seen a patient like the one described in the vignette. Two-thirds of respondents correctly identified the hallmark symptom of IC/PBS (bladder pain/pressure). Regarding etiology, 90% correctly indicated that IC/PBS was a noninfectious disease, 76% correctly reported that it was not caused by a sexually transmitted infection, and 61% correctly indicated that it was not caused by a psychiatric illness. Common treatments included antibiotics and nonsteroidal anti-inflammatory agents. Referrals were often made to a specialist.

CONCLUSIONS

Although most PCPs indicate familiarity with IC/PBS, they manage the condition infrequently. They also appear to have significant knowledge deficits about the clinical characteristics of IC/PBS, and they indicate variable practice patterns in the diagnosis and treatment of the condition. Educational efforts directed at PCPs will likely improve the care of patients with IC/PBS.

Beyond the black box: drug- and device-associated hypersensitivity events

Background:

Drug- and device-associated hypersensitivity reactions are serious toxicities that can result in respiratory failure or acute cardiac ischemic events, or even severe hypersensitivity syndromes such as Stevens–Johnson syndrome. These toxicities are usually poorly described in the “black box” warnings section of the product labels.

Methods:

Adverse event reports contained in databases maintained by the Project on Medical Research on Adverse Drug Events and Reports (Med-RADAR), product labels, safety advisories disseminated by pharmaceutical manufacturers, the Food and Drug Administration (FDA), and the Centers for Disease Control and Prevention (CDC) were reviewed.

Results:

Adverse event reports identified three health care workers who developed nevirapine-associated Stevens–Johnson syndrome following occupational exposure to HIV-infected blood or blood products; four persons with localized hypersensitivity and fatal cardiac events associated with rapamycin- or paclitaxel-coated coronary artery stent placements; and six persons with breast cancer who developed severe or fatal anaphylaxis after receiving adjuvant chemotherapy with Cremophor-EL containing paclitaxel. Safety advisories from the FDA, CDC, and the relevant pharmaceutical manufacturers were ambiguous in their description in “black box” warning sections of package inserts describing these serious and potentially fatal toxicities.

Conclusion:

Improvements are needed in pharmacovigilance and subsequent dissemination of safety advisories for drug/device-associated hypersensitivity reactions.

Prevalence and severity of undiagnosed urinary incontinence in women

BACKGROUND

Urinary incontinence is a highly prevalent condition in aging women that results in significant morbidity. Less than half of women who suffer from urinary incontinence seek treatment, resulting in a significant proportion of clinically relevant urinary incontinence remaining undiagnosed. Therefore, the purpose of this study was to quantify the prevalence of urinary incontinence in undiagnosed women in a managed care population.

METHODS

There were 136,457 women aged 25-80 years enrolled in Kaiser Permanente Northwest who were free of genitourinary diagnoses, including urinary incontinence, who were included in this study. Of the 2118 women who were mailed questionnaires ascertaining information on demographic and urinary incontinence characteristics, 875 completed the survey. A chart review of the 234 women who reported moderate to severe urinary incontinence was performed.

RESULTS

The prevalence of undiagnosed urinary incontinence was 53% in the preceding year, and 39% in the preceding week. The prevalence of undiagnosed stress, mixed, and urge incontinence was found to be 18.7%, 12.0%, and 6.8%, respectively. Quality of life was found to significantly decrease with increasing urinary incontinence severity. Of the 234 chart-reviewed women, 5% were found to have physician-documented urinary incontinence.

CONCLUSIONS

These results suggest that a significant proportion of women in this managed care population are suffering from urinary incontinence that remains undiagnosed. Efforts should be made to encourage women and physicians to initiate conversations about urinary incontinence symptoms in order to decrease the unnecessary burden of this disease.

Validation of a modified National Institutes of Health chronic prostatitis symptom index to assess genitourinary pain in both men and women

OBJECTIVES

To date, separate condition-specific instruments have been used to assess severity of symptoms, in men and women with urological pain conditions. We developed a single instrument that can be used to assess treatment response in clinical trials and cohort studies that involve both genders.

METHODS

We developed the Genitourinary Pain Index (GUPI) by modifying and adding questions to the National Institutes of Health-Chronic Prostatitis Symptom Index. To assess discriminant validity, concurrent validity, and reliability, we administered the GUPI to 1653 men and 1403 women in a large managed care population. To assess responsiveness, we administered the GUPI to 47 men and women who completed a National Institutes of Health-sponsored trial of pelvic floor physical therapy.

RESULTS

The GUPI discriminated between men with chronic prostatitis or interstitial cystitis, those with other symptomatic conditions (dysuria, frequency, chronic cystitis), and those with none of these diagnoses (P <.05). It also discriminated between women with interstitial cystitis, those with incontinence, and those with none of these diagnoses (P <.05). The GUPI demonstrated good internal consistency within subscale domains, and GUPI scores correlated highly with scores on the Interstitial Cystitis Symptom Index and Problem Index. The GUPI was highly responsive to change, and the change in score was similar in both male and female responders. A reduction of 7 points robustly predicted being a treatment responder (sensitivity 100%, specificity 76%).

CONCLUSIONS

The GUPI is a valid, reliable, and responsive instrument that can be used to assess the degree of symptoms in both men and women with genitourinary pain complaints.

Rescoring the NIH chronic prostatitis symptom index: nothing new

The NIH-Chronic Prostatitis Symptom Index (NIH-CPSI) is a commonly used 13-item questionnaire for the assessment of symptom severity in men with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). For each item, score ranges are 0–1 (6 items), 0–3 (2 items), 0–5 (3 items), 0–6 (1 item), and 0–10 (1 item). This scoring system is straightforward, but items with wider score ranges are de facto weighted more, which could adversely affect the performance characteristics of the questionnaire. We rescored the NIH-CPSI so that equal weights were assigned to each item, and compared the performance of the standard and rescored questionnaires using the original validation dataset. Both the original and revised versions of the scoring algorithm discriminated similarly among groups of men with chronic prostatitis (n=151), benign prostatic hyperplasia (n=149), and controls (n=134). Internal consistency of the questionnaire was slightly better with the revised scoring, but values with the standard scoring were sufficiently high (Cronbach’s alpha ≥0.80). We conclude that although the rescored NIH-CPSI provides better face validity than the standard scoring algorithm, it requires additional calculation efforts and yields only marginal improvements in performance.

Comparison of economic impact of chronic prostatitis/chronic pelvic pain syndrome and interstitial cystitis/painful bladder syndrome

OBJECTIVES

To perform a comparison of the economic impact of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) and interstitial cystitis/painful bladder syndrome (IC/PBS) because limited information is available. Furthermore, no direct comparisons of the costs of these 2 conditions have been performed. Such a comparison is relevant because the distinction between the 2 conditions is not always clear.

METHODS

We recruited 62 men with CP/CPPS and 43 women with IC/PBS from a tertiary care outpatient urology clinic. Information about hospitalizations, laboratory tests, physician visits, telephone calls, medication use, and lost productivity was obtained from written questionnaires. Direct medical cost estimates were determined from hospital cost accounting data, the 2005 Physician Fee Schedule Book, and the 2005 Redbook for pharmaceuticals. Indirect costs were determined from patient-reported annual income and patient-reported hours lost from work during the most recent 3-month period.

RESULTS

Using Medicare rates, the annualized direct costs per person were $3631 for IC/PBS and $3017 for CP/CPPS. Using non-Medicare rates for outpatient visits and tests/procedures, the annual per person costs increased substantially to $7043 for IC/PBS and $6534 for CP/CPPS. Sixteen patients with CP/CPPS (26%) and 8 with IC/PBS (19%) reported lost wages as a result of their condition in the previous 3 months.

CONCLUSIONS

Both CP/CPPS and IC/PBS have very similar and substantial direct and indirect costs. The greater costs reflected by the non-Medicare rates may more accurately reflect the true costs, given that a large proportion of these patients were <65 years old.

A national patient navigator training program

Patient Navigation is an intervention aimed at addressing cancer health disparities by eliminating barriers to diagnosis, treatment, and services. Three major patient navigation (PN) programs (The National Cancer Institute, The American Cancer Society &The Center for Medicare and Medicaid Services) are underway to address the needs of medically underserved cancer patients. There has not been national training with a defined curriculum for patient navigators (PNs). Curriculum for training the PNs was created by experts from the three programs. The efficacy of training was evaluated using a pre- and posttest. The data show that overall the posttest scores improved from the pretest. In addition, having a high school education or greater or having more years of work experience were significantly related to improvements on the posttest. The first successful standardized national training program was attended by 116 PNs representing 85 cities with the goal to reduce health disparities for medically underserved.

Evaluating the supportive care costs of severe radiochemotherapy-induced mucositis and pharyngitis : results from a Northwestern University Costs of Cancer Program pilot study with head and neck and nonsmall cell lung cancer patients who received care at a county hospital, a Veterans Administration hospital, or a comprehensive cancer care center

BACKGROUND

Few studies have examined the costs of supportive care for radiochemotherapy-induced mucosits/pharyngitis among patients with head and neck cancer (HNC) or lung cancers despite the documented negative clinical impact of these complications.

METHODS

The authors identified a retrospective cohort of patients with HNC or nonsmall lung cancer (NSCLC) who had received radiochemotherapy at 1 of 3 Chicago hospitals (a Veterans Administration hospital, a county hospital, or a tertiary care hospital). Charts were reviewed for the presence/absence of severe mucositis/pharyngitis and the medical resources that were used. Resource estimates were converted into cost units obtained from standard sources (hospital bills, Medicare physician fee schedule, Red Book). Estimates of resources used and direct medical costs were compared for patients who did and patients who did not develop severe mucositis/pharyngitis.

RESULTS

Severe mucositis/pharyngitis occurred in 70.1% of 99 patients with HNC and in 37.5% of 40 patients with NSCLC during radiochemotherapy. The total median medical costs per patient were USD 39,313 for patients with mucositis/pharyngitis and USD 20,798 for patients without mucositis/pharyngitis (P = .007). Extended inpatient hospitalization accounted for USD 12,600 of the increased medical costs (median 14 days [USD 19,600] with severe mucositis/pharyngitis vs 5 days [USD 7,000] without; P = .017). For patients who had HNC with mucositis/pharyngitis, incremental inpatient hospitalization costs were USD 14,000, and total medical costs were USD 17,244. For patients who had NSCLC with mucositis/pharyngitis, these costs were USD 11,200 and USD 25,000, respectively.

CONCLUSIONS

In the current study, the medical costs among the patients with HNC and NSCLC who received radiochemotherapy were greater for those who developed severe mucositis/pharyngitis than for those who did not.

Mental health diagnoses in patients with interstitial cystitis/painful bladder syndrome and chronic prostatitis/chronic pelvic pain syndrome: a case/control study

PURPOSE

We compared the rate of mental health disorders in male and female patients with pelvic pain and control subjects.

MATERIALS AND METHODS

Male patients with chronic prostatitis/chronic pelvic pain syndrome (174) and female patients with interstitial cystitis/painful bladder syndrome (111) were identified from a urology tertiary care clinic population. A control group consisting of 72 men and 175 women was also recruited. Subjects completed self-administered questionnaires that included items about demographics, medical history, medication use and urological symptoms. The Patient Health Questionnaire was used to identify depression and panic disorder. Multiple logistic regression was used to determine odds ratios for the presence of a mental health diagnosis.

RESULTS

Mental health disorders were identified in 13% of the chronic prostatitis/chronic pelvic pain syndrome cases and 4% of male controls (OR 2.0, p = 0.04), as well as in 23% of interstitial cystitis/painful bladder syndrome cases and 3% of female controls (OR 8.2, p <0.0001). Disease status (case vs control) (OR 10.4, p = 0.001) and income greater than $50,000 (OR 0.34, p = 0.008) were the only 2 variables independently predictive of the presence of a mental health diagnosis. Age, gender, race/ethnicity and education were not predictive. Medications for anxiety, depression or stress were being taken by 18% of patients with chronic prostatitis/chronic pelvic pain syndrome, 37% of those with interstitial cystitis/painful bladder syndrome, 7% of male controls and 13% of female controls.

CONCLUSIONS

Depression and panic disorder are significantly more common in men and women with pelvic pain conditions than in controls. Medication use data suggest that anxiety and depression may be more difficult to treat in patients with urological pain syndromes than in controls.

Incidence and clinical characteristics of interstitial cystitis in the community

We utilized physician-coded diagnoses and chart reviews to estimate the incidence of interstitial cystitis (IC) in women. A computer search of the Kaiser Permanente database was performed to identify newly coded diagnoses of IC (ICD-9 code 595.1) between May 2002 and May 2005. Chart reviews were performed and patient demographics, diagnosing physicians, and symptom characteristics were recorded. The IC incidence rate was 15 per 100,000 women per year. The mean age of the patients was 51 years (range 31-81 years). The most common presenting symptoms were frequency (70%), dysuria (52%), urgency (50%), suprapubic pain (50%), nocturia (35%), and dyspareunia (13%). Cases diagnosed by primary care physicians had a shorter median symptom duration (9 months) compared with those diagnosed by urologists (1 year) and gynecologists (3 years). IC is an uncommon diagnosis in the community setting, with an incidence rate of 15 per 100,000 women per year.

Prevalence of and risk factors for prostatitis: population based assessment using physician assigned diagnoses

PURPOSE

Previous studies to assess risk factors for prostatitis used patient self-reported data and, therefore, they were subject to recall bias. We 1) used coded physician diagnoses to calculate the prevalence of prostatitis and 2) compared these patients with matched controls to identify medical conditions that are associated with prostatitis. Subjects were male enrollees in the Kaiser Permanente Northwest, Portland, Oregon health maintenance organization.

MATERIALS AND METHODS

A computer search of the Kaiser Permanente Northwest administrative database was performed for May 1, 1998 to April 30, 2004 to identify men with a coded diagnosis of prostatitis. Prostatitis cases were each age matched with 3 controls and the medical diagnoses (using 3-digit International Classification of Diseases, 9th Revision codes) assigned to these 2 groups were compared.

RESULTS

A prostatitis diagnosis was present in 4.5% of the male population. There were 37 diagnoses that were significantly more common in cases than in controls (p <0.0001). Most of them were other urological codes to describe prostatitis symptoms, unexplained physical symptoms in other organ systems and psychiatric diagnoses. The strongest observed associations were with benign prostatic hyperplasia (OR 2.7), functional digestive disorders (OR 2.6), dyspepsia (OR 2.1), anxiety disorders (OR 2.0), other soft tissue disorders (OR 2.0), esophageal reflux (OR 1.8) and mood disorders (OR 1.8).

CONCLUSIONS

Prostatitis is a commonly diagnosed condition in the community setting, affecting approximately 1/22 men. The diagnosis is associated with multiple other unexplained physical symptoms and certain psychiatric conditions. Studies to explore possible biological explanations for these associations are needed.

Overlap of voiding symptoms, storage symptoms and pain in men and women

PURPOSE

We quantified the degree of symptomatic overlap in individuals who reported urological symptoms and compared these patterns between men and women.

MATERIALS AND METHODS

A questionnaire was mailed to a random sample of the Kaiser Permanente Northwest membership with no medical record evidence of pelvic malignancy or neurological disease. The questionnaire included the International Prostate Symptom Scale, Interstitial Cystitis Symptom Index and Problem Index, and National Institutes of Health Chronic Prostatitis Symptom Index. The 701 men and 745 women who reported urological symptoms were selected for analysis. The degree of overlap of storage symptoms, voiding symptoms and pain symptoms was assessed. Multiple logistic regression was used to determine symptom predictors.

RESULTS

There was a high degree of overlap among the 3 symptom categories with few observed differences between men and women. Of individuals with storage or voiding symptoms 34% of men and 43% of women also had pain symptoms. Of those with pain 90% of men and 94% of women also had voiding or storage symptoms. Logistic regression results indicated that frequency, urgency and any storage symptoms were statistically more common in women than in men, while a slow stream was more common in men than in women.

CONCLUSIONS

As previously reported, there are limited differences in the degree and distribution of lower urinary tract symptoms in men and women. To our knowledge the novel finding of this study is that pain symptoms commonly coincide with voiding and storage symptoms in the 2 genders. This suggests that categorizing patients into disease categories, such as lower urinary tract symptoms or bladder conditions, may ignore the pain components of symptoms. A symptom based classification symptom may more accurately identify and address all patient complaints.

Evaluating the total costs of chemotherapy-induced febrile neutropenia: results from a pilot study with community oncology cancer patients

PURPOSE

While cancer chemotherapy-related febrile neutropenia affects patients' activities and medical expenditures, few studies have reported on the total costs of this condition. Here, we evaluate the feasibility of obtaining detailed and comprehensive cost information on patients who experience febrile neutropenia during cancer chemotherapy treatment.

METHODS

Community oncology cancer patients who experienced chemotherapy-associated febrile neutropenia recorded information about use of medical care, tests, devices, medications, and lost productivity. Direct cost estimates were derived from Medicare Physician Fee Schedules and cost-to-charge ratios. Indirect cost estimates were based on modified Labor Force, Employment, and Earnings data for employed patients and wages earned by paid caregivers. Multivariate regression models evaluated predictors of higher direct, indirect, and total costs.

RESULTS

Outpatients' mean direct and indirect costs were 5,704 dollars and 1,201 dollars (lymphoma), 1,094 dollars and 1,530 dollars (breast cancer), and 1,329 dollars and 1,325 dollars (lung cancer and myeloma), respectively. The mean direct and indirect costs were three- to tenfold and 1.5- to threefold greater for inpatients, respectively. Factors associated with higher direct costs of care included diagnosis of lymphoma and inpatient care; higher indirect costs, male versus female gender; higher total costs, lymphoma diagnosis and inpatient care.

CONCLUSION

Estimation of the total costs of cancer-related neutropenia is feasible. Indirect costs appear to account for as much as half of the total supportive care costs when febrile neutropenia is managed in the outpatient setting and about one fifth of the total supportive care costs in the inpatient setting.