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Hebdon M, Pool N, Yee R, Herrera-Theut K, Yee E, Allen LA, Hasan A, Lindenfeld J, Calhoun E, Sweitzer NK, Welling A, Breathett K. Bias in team decision-making for advanced heart failure therapies: model application. J Interprof Care 2024:1-10. [PMID: 38734870 DOI: 10.1080/13561820.2024.2346934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 04/17/2024] [Indexed: 05/13/2024]
Abstract
Bias in advanced heart failure therapy allocation results in inequitable outcomes for minoritized populations. The purpose of this study was to examine how bias is introduced during group decision-making with an interprofessional team using Breathett's Model of Heart Failure Decision-Making. This was a secondary qualitative descriptive analysis from a study focused on bias in advanced heart failure therapy allocation. Team meetings were recorded and transcribed from four heart failure centers. Breathett's Model was applied both deductively and inductively to transcripts (n = 12). Bias was identified during discussions about patient characteristics, clinical fragility, and prior clinical decision-making. Some patients were labeled as "good citizens" or as adherent/non-adherent while others benefited from strong advocacy from interprofessional team members. Social determinants of health also impacted therapy allocation. Interprofessional collaboration with advanced heart failure therapy allocation may be enhanced with the inclusion of patient advocates and limit of clinical decision-making using subjective data.
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Affiliation(s)
- Megan Hebdon
- School of Nursing, University of Texas-Austin, Austin, TX, USA
| | - Natalie Pool
- School of Nursing, University of Northern Colorado, Greeley, Colorado, USA
| | - Ryan Yee
- Sarver Heart Center Research, University of Arizona, Tucson, AZ, USA
| | - Kathryn Herrera-Theut
- College of Medicine, Departments of Medicine and Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Erika Yee
- College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Larry A Allen
- Division of Cardiovascular Medicine, University of Colorado, Denver, CO, USA
| | - Ayesha Hasan
- Division of Cardiovascular Medicine, Ohio State University, Columbus, Ohio, USA
| | - JoAnn Lindenfeld
- Division of Cardiovascular Medicine, Vanderbilt University, Nashville, TN, USA
| | - Elizabeth Calhoun
- Department of Population Health, University of Kansas, Lawrence, Kansas, USA
| | - Nancy K Sweitzer
- Division of Cardiovascular Medicine, Sarver Heart Center, University of Arizona, Tucson, AZ, USA
| | - Anna Welling
- School of Nursing, University of Texas-Austin, Austin, TX, USA
| | - Khadijah Breathett
- Division of Cardiovascular Medicine, Indiana University, Bloomington, IN, USA
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Ver Hoeve ES, Calhoun E, Hernandez M, High E, Armin JS, Ali-Akbarian L, Frithsen M, Andrews W, Hamann HA. Evaluating implementation of a community-focused patient navigation intervention at an NCI-designated cancer center using RE-AIM. BMC Health Serv Res 2024; 24:550. [PMID: 38685006 PMCID: PMC11059763 DOI: 10.1186/s12913-024-10919-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 03/28/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Patient navigation is an evidence-based intervention that reduces cancer health disparities by directly addressing the barriers to care for underserved patients with cancer. Variability in design and integration of patient navigation programs within cancer care settings has limited this intervention's utility. The implementation science evaluation framework, RE-AIM, allows quantitative and qualitative examination of effective implementation of patient navigation programs into cancer care settings. METHODS The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework was used to evaluate implementation of a community-focused patient navigation intervention at an NCI-designated cancer center between June 2018 and October 2021. Using a 3-month longitudinal, non-comparative measurement period, univariate and bivariate analyses were conducted to examine associations between participant-level demographics and primary (i.e., barrier reduction) and secondary (i.e., patient-reported outcomes) effectiveness outcomes. Mixed methods analyses were used to examine adoption and delivery of the intervention into the cancer center setting. Process-level analyses were used to evaluate maintenance of the intervention. RESULTS Participants (n = 311) represented a largely underserved population, as defined by the National Cancer Institute, with the majority identifying as Hispanic/Latino, having a household income of $35,000 or less, and being enrolled in Medicaid. Participants were diagnosed with a variety of cancer types and most had advanced staged cancers. Pre-post-intervention analyses indicated significant reduction from pre-intervention assessments in the average number of reported barriers, F(1, 207) = 117.62, p < .001, as well as significant increases in patient-reported physical health, t(205) = - 6.004, p < .001, mental health, t(205) = - 3.810, p < .001, self-efficacy, t(205) = - 5.321, p < .001, and satisfaction with medical team communication, t(206) = - 2.03, p = .029. Referral patterns and qualitative data supported increased adoption and integration of the intervention into the target setting, and consistent intervention delivery metrics suggested high fidelity to intervention delivery over time. Process-level data outlined a successful transition from a grant-funded community-focused patient navigation intervention to an institution-funded program. CONCLUSIONS This study utilized the implementation science evaluation framework, RE-AIM, to evaluate implementation of a community-focused patient navigation program. Our analyses indicate successful implementation within a cancer care setting and provide a potential guide for other oncology settings who may be interested in implementing community-focused patient navigation programs.
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Affiliation(s)
| | | | | | | | | | | | - Michael Frithsen
- Banner Health, Tucson, AZ, USA
- University of Arizona College of Medicine, Tucson, AZ, USA
| | - Wendy Andrews
- Banner Health, Tucson, AZ, USA
- University of Arizona College of Medicine, Tucson, AZ, USA
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Graboyes EM, Chappell M, Duckett KA, Sterba K, Halbert CH, Hill EG, Chera B, McCay J, Puram SV, Ramadan S, Sandulache VC, Kahmke R, Nussenbaum B, Alberg AJ, Paskett ED, Calhoun E. Patient Navigation for Timely, Guideline-Adherent Adjuvant Therapy for Head and Neck Cancer: A National Landscape Analysis. J Natl Compr Canc Netw 2023; 21:1251-1259.e5. [PMID: 38081134 PMCID: PMC10846494 DOI: 10.6004/jnccn.2023.7061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 07/24/2023] [Indexed: 12/18/2023]
Abstract
BACKGROUND Aligned with the NCCN Clinical Practice Guidelines in Oncology for Head and Neck Cancers, in November 2021 the Commission on Cancer approved initiation of postoperative radiation therapy (PORT) within 6 weeks of surgery for head and neck cancer (HNC) as its first and only HNC quality metric. Unfortunately, >50% of patients do not commence PORT within 6 weeks, and delays disproportionately burden racial and ethnic minority groups. Although patient navigation (PN) is a potential strategy to improve the delivery of timely, equitable, guideline-adherent PORT, the national landscape of PN for this aspect of care is unknown. MATERIALS AND METHODS From September through November 2022, we conducted a survey of health care organizations that participate in the American Cancer Society National Navigation Roundtable to understand the scope of PN for delivering timely, guideline-adherent PORT for patients with HNC. RESULTS Of the 94 institutions that completed the survey, 89.4% (n=84) reported that at least part of their practice was dedicated to navigating patients with HNC. Sixty-eight percent of the institutions who reported navigating patients with HNC along the continuum (56/83) reported helping them begin PORT. One-third of HNC navigators (32.5%; 27/83) reported tracking the metric for time-to-PORT at their facility. When estimating the timeframe in which the NCCN and Commission on Cancer guidelines recommend commencing PORT, 44.0% (37/84) of HNC navigators correctly stated ≤6 weeks; 71.4% (60/84) reported that they did not know the frequency of delays starting PORT among patients with HNC nationally, and 63.1% (53/84) did not know the frequency of delays at their institution. CONCLUSIONS In this national landscape survey, we identified that PN is already widely used in clinical practice to help patients with HNC start timely, guideline-adherent PORT. To enhance and scale PN within this area and improve the quality and equity of HNC care delivery, organizations could focus on providing better education and support for their navigators as well as specialization in HNC.
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Affiliation(s)
- Evan M. Graboyes
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina
| | - Michelle Chappell
- American Cancer Society National Navigation Roundtable, Cincinnati, Ohio
| | - Kelsey A. Duckett
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Katherine Sterba
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina
| | - Chanita Hughes Halbert
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, California
| | - Elizabeth G. Hill
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina
| | - Bhishamjit Chera
- Department of Radiation Oncology, Hollings Cancer Center, Medical University of South Carolina, Charleston, South Carolina
| | - Jessica McCay
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Sidharth V. Puram
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri
- Department of Genetics, Washington University School of Medicine, St. Louis, Missouri
| | - Salma Ramadan
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Vlad C. Sandulache
- Bobby R. Alford Department of Otolaryngology Head and Neck Surgery, Baylor College of Medicine, Houston, Texas
- ENT Section, Operative Care Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Russel Kahmke
- Department of Head and Neck Surgery and Communication Sciences, Duke University, Durham, North Carolina
| | - Brian Nussenbaum
- American Board of Otolaryngology - Head and Neck Surgery, Houston, Texas
| | - Anthony J. Alberg
- Department of Epidemiology and Biostatistics, University of South Carolina Arnold School of Public Health, Columbia, South Carolina
| | - Electra D. Paskett
- Division of Population Sciences, Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, Ohio
- Division of Cancer Prevention Control, Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, Ohio
| | - Elizabeth Calhoun
- Department of Population Health, University of Illinois Chicago, Chicago, Illinois
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Mudaranthakam DP, Hughes D, Johnson P, Mason T, Nollen N, Wick J, Welch DR, Calhoun E. Career disruption and limitation of financial earnings due to cancer. JNCI Cancer Spectr 2023; 7:pkad044. [PMID: 37326961 PMCID: PMC10359624 DOI: 10.1093/jncics/pkad044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 04/24/2023] [Accepted: 06/05/2023] [Indexed: 06/17/2023] Open
Abstract
PURPOSE This study investigated how cancer diagnosis and treatment lead to career disruption and, consequently, loss of income and depletion of savings. DESIGN This study followed a qualitative descriptive design that allowed us to understand the characteristics and trends of the participants. METHOD Patients recruited (n = 20) for this study were part of the University of Kansas Cancer Center patient advocacy research group (Patient and Investigator Voices Organizing Together). The inclusion criteria were that participants must be cancer survivors or co-survivors, be aged 18 years or older, be either employed or a student at the time of cancer diagnosis, have completed their cancer treatment, and be in remission. The responses were transcribed and coded inductively to identify themes. A thematic network was constructed based on those themes, allowing us to explore and describe the intricacies of the various themes and their impacts. RESULTS Most patients had to quit their jobs or take extended absences from work to handle treatment challenges. Patients employed by the same employer for longer durations had the most flexibility to balance their time between cancer treatment and work. Essential, actionable items suggested by the cancer survivors included disseminating information about coping with financial burdens and ensuring that a nurse and financial navigator were assigned to every cancer patient. CONCLUSIONS Career disruption is common among cancer patients, and the financial burden due to their career trajectory is irreparable. The financial burden is more prominent in younger cancer patients and creates a cascading effect that financially affects close family members.
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Affiliation(s)
- Dinesh Pal Mudaranthakam
- Department of Biostatistics & Data Science, University of Kansas Medical Center, Kansas City, KS, USA
- Department of Population Health, University of Kansas Medical Center, Kansas City, KS, USA
- University of Kansas Comprehensive Cancer Center, Kansas City, KS, USA
| | - Dorothy Hughes
- Department of Population Health, University of Kansas Medical Center, Kansas City, KS, USA
| | - Peggy Johnson
- Patient and Investigator Voices Organizing Together (PIVOT), University of Kansas Comprehensive Cancer Center, Kansas City, KS, USA
| | - Tracy Mason
- Patient and Investigator Voices Organizing Together (PIVOT), University of Kansas Comprehensive Cancer Center, Kansas City, KS, USA
| | - Nicole Nollen
- Department of Population Health, University of Kansas Medical Center, Kansas City, KS, USA
- University of Kansas Comprehensive Cancer Center, Kansas City, KS, USA
| | - Jo Wick
- Department of Population Health, University of Kansas Medical Center, Kansas City, KS, USA
- University of Kansas Comprehensive Cancer Center, Kansas City, KS, USA
| | - Danny R Welch
- University of Kansas Comprehensive Cancer Center, Kansas City, KS, USA
- Department of Cancer Biology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Elizabeth Calhoun
- Department of Population Health, University of Kansas Medical Center, Kansas City, KS, USA
- Population Health Sciences, University of Illinois Chicago, Chicago, IL, USA
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Mudaranthakam DP, Nollen N, Wick J, Hughes D, Welch D, Calhoun E. Evaluating Work Impairment as a Source of Financial Toxicity in Cancer Healthcare and Negative Impacts on Health Status. Cancer Res Commun 2023; 3:1166-1172. [PMID: 37415746 PMCID: PMC10321355 DOI: 10.1158/2767-9764.crc-23-0038] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 04/17/2023] [Accepted: 06/06/2023] [Indexed: 07/08/2023]
Abstract
How the socioeconomic factors intersect for a particular patient can determine their susceptibility to financial toxicity, what costs they will encounter during treatment, the type and quality of their care, and the potential work impairments they face. The primary goal of this study was to evaluate financial factors leading to worsening health outcomes by the cancer subtype. A logistic model predicting worsening health outcomes while assessing the most influential economic factors was constructed by the University of Michigan Health and Retirement Study. A forward stepwise regression procedure was implemented to identify the social risk factors that impact health status. Stepwise regression was done on data subsets based on the cancer types of lung, breast, prostate, and colon cancer to determine whether significant predictors of worsening health status were different or the same across cancer types. Independent covariate analysis was also conducted to cross-validate our model. On the basis of the model fit statistics, the two-factor model has the best fit, that is, the lowest AIC among potential models of 3270.56, percent concordance of 64.7, and a C-statistics of 0.65. The two-factor model used work impairment and out-of-pocket costs, significantly contributing to worsening health outcomes. Covariate analysis demonstrated that younger patients with cancer experienced more financial burdens leading to worsening health outcomes than elderly patients aged 65 years and above. Work impairment and high out-of-pocket costs were significantly associated with worsening health outcomes among cancer patients. Matching the participants who need the most financial help with appropriate resources is essential to mitigate the financial burden. Significance Among patients with cancer, work impairment and out-of-pocket are the two primary factors contributing to adverse health outcomes. Women, African American or other races, the Hispanic population, and younger individuals have encountered higher work impairment and out-of-pocket costs due to cancer than their counterparts.
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Affiliation(s)
- Dinesh Pal Mudaranthakam
- Department of Biostatistics & Data Science, University of Kansas Medical Center, Kansas City, Kansas
- Department of Population Health, University of Kansas Medical Center, Kansas City, Kansas
- University of Kansas Comprehensive Cancer Center, Kansas City, Kansas
| | - Nicole Nollen
- Department of Population Health, University of Kansas Medical Center, Kansas City, Kansas
- University of Kansas Comprehensive Cancer Center, Kansas City, Kansas
| | - Jo Wick
- Department of Population Health, University of Kansas Medical Center, Kansas City, Kansas
- University of Kansas Comprehensive Cancer Center, Kansas City, Kansas
| | - Dorothy Hughes
- Department of Population Health, University of Kansas Medical Center, Kansas City, Kansas
| | - Danny Welch
- University of Kansas Comprehensive Cancer Center, Kansas City, Kansas
| | - Elizabeth Calhoun
- Department of Population Health, University of Kansas Medical Center, Kansas City, Kansas
- Population Health Sciences, University of Illinois Chicago, Chicago, Illinois
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Pool N, Hebdon M, de Groot E, Yee R, Herrera-Theut K, Yee E, Allen LA, Hasan A, Lindenfeld J, Calhoun E, Carnes M, Sweitzer NK, Breathett K. A novel approach for assessing bias during team-based clinical decision-making. Front Public Health 2023; 11:1014773. [PMID: 37228737 PMCID: PMC10203455 DOI: 10.3389/fpubh.2023.1014773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 03/20/2023] [Indexed: 05/27/2023] Open
Abstract
Many clinical processes include multidisciplinary group decision-making, yet few methods exist to evaluate the presence of implicit bias during this collective process. Implicit bias negatively impacts the equitable delivery of evidence-based interventions and ultimately patient outcomes. Since implicit bias can be difficult to assess, novel approaches are required to detect and analyze this elusive phenomenon. In this paper, we describe how the de Groot Critically Reflective Diagnoses Protocol (DCRDP) can be used as a data analysis tool to evaluate group dynamics as an essential foundation for exploring how interactions can bias collective clinical decision-making. The DCRDP includes 6 distinct criteria: challenging groupthink, critical opinion sharing, research utilization, openness to mistakes, asking and giving feedback, and experimentation. Based on the strength and frequency of codes in the form of exemplar quotes, each criterion was given a numerical score of 1-4 with 1 representing teams that are interactive, reflective, higher functioning, and more equitable. When applied as a coding scheme to transcripts of recorded decision-making meetings, the DCRDP was revealed as a practical tool for examining group decision-making bias. It can be adapted to a variety of clinical, educational, and other professional settings as an impetus for recognizing the presence of team-based bias, engaging in reflexivity, informing the design and testing of implementation strategies, and monitoring long-term outcomes to promote more equitable decision-making processes in healthcare.
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Affiliation(s)
- Natalie Pool
- School of Nursing, University of Northern Colorado, Greeley, CO, United States
| | - Megan Hebdon
- School of Nursing, University of Texas-Austin, Austin, TX, United States
| | - Esther de Groot
- Department of General Practice, University of Utrecht, Utrecht, Netherlands
| | - Ryan Yee
- Division of Cardiovascular Medicine Research Department, Indiana University, Indianapolis, IN, United States
| | - Kathryn Herrera-Theut
- College of Medicine, Department of Medicine and Pediatrics, University of Michigan, Ann Arbor, MI, United States
| | - Erika Yee
- College of Medicine, University of Arizona, Tucson, AZ, United States
| | - Larry A. Allen
- Division of Cardiovascular Medicine, University of Colorado, Denver, CO, United States
| | - Ayesha Hasan
- Division of Cardiovascular Medicine, Ohio State University, Columbus, OH, United States
| | - JoAnn Lindenfeld
- Division of Cardiovascular Medicine, Vanderbilt University, Nashville, TN, United States
| | - Elizabeth Calhoun
- Department of Population Health, University of Kansas, Kansas City, KS, United States
| | - Molly Carnes
- Department of Medicine, University of Wisconsin, Madison, WI, United States
| | - Nancy K. Sweitzer
- Division of Cardiovascular Medicine, Washington University in St. Louis, St. Louis, MO, United States
| | - Khadijah Breathett
- Division of Cardiovascular Medicine, Indiana University, Indianapolis, IN, United States
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Mudaranthakam DP, Pepper S, Fortney T, Alsup A, Woodward J, Sykes K, Calhoun E. The Effects of COVID-19 Pandemic Policy on Social Needs Across the State of Kansas and Western Missouri: Paired Survey Response Testing. JMIR Public Health Surveill 2023; 9:e41369. [PMID: 36977199 PMCID: PMC10132827 DOI: 10.2196/41369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 12/21/2022] [Accepted: 03/23/2023] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND Studying patients' social needs is critical to the understanding of health conditions and disparities, and to inform strategies for improving health outcomes. Studies have shown that people of color, low-income families, and those with lower educational attainment experience greater hardships related to social needs. The COVID-19 pandemic represents an event that severely impacted people's social needs. This pandemic was declared by the World Health Organization on March 11, 2020, and contributed to food and housing insecurity, while highlighting weaknesses in the health care system surrounding access to care. To combat these issues, legislators implemented unique policies and procedures to help alleviate worsening social needs throughout the pandemic, which had not previously been exerted to this degree. We believe that improvements related to COVID-19 legislature and policy have positively impacted people's social needs in Kansas and Missouri, United States. In particular, Wyandotte County is of interest as it suffers greatly from issues related to social needs that many of these COVID-19-related policies aimed to improve. OBJECTIVE The research objective of this study was to evaluate the change in social needs before and after the COVID-19 pandemic declaration based on responses to a survey from The University of Kansas Health System (TUKHS). We further aimed to compare the social needs of respondents from Wyandotte County from those of respondents in other counties in the Kansas City metropolitan area. METHODS Social needs survey data from 2016 to 2022 were collected from a 12-question patient-administered survey distributed by TUKHS during a patient visit. This provided a longitudinal data set with 248,582 observations, which was narrowed down into a paired-response data set for 50,441 individuals who had provided at least one response before and after March 11, 2020. These data were then bucketed by county into Cass (Missouri), Clay (Missouri), Jackson (Missouri), Johnson (Kansas), Leavenworth (Kansas), Platte (Missouri), Wyandotte (Kansas), and Other counties, creating groupings with at least 1000 responses in each category. A pre-post composite score was calculated for each individual by adding their coded responses (yes=1, no=0) across the 12 questions. The Stuart-Maxwell marginal homogeneity test was used to compare the pre and post composite scores across all counties. Additionally, McNemar tests were performed to compare responses before and after March 11, 2020, for each of the 12 questions across all counties. Finally, McNemar tests were performed for questions 1, 7, 8, 9, and 10 for each of the bucketed counties. Significance was assessed at P<.05 for all tests. RESULTS The Stuart-Maxwell test for marginal homogeneity was significant (P<.001), indicating that respondents were overall less likely to identify an unmet social need after the COVID-19 pandemic. McNemar tests for individual questions indicated that after the COVID-19 pandemic, respondents across all counties were less likely to identify unmet social needs related to food availability (odds ratio [OR]=0.4073, P<.001), home utilities (OR=0.4538, P<.001), housing (OR=0.7143, P<.001), safety among cohabitants (OR=0.6148, P<.001), safety in their residential location (OR=0.6172, P<.001), child care (OR=0.7410, P<0.01), health care access (OR=0.3895, P<.001), medication adherence (OR=0.5449, P<.001), health care adherence (OR=0.6378, P<.001), and health care literacy (0.8729, P=.02), and were also less likely to request help with these unmet needs (OR=0.7368, P<.001) compared with prepandemic responses. Responses from individual counties were consistent with the overall results for the most part. Notably, no individual county demonstrated a significant reduction in social needs relating to a lack of companionship. CONCLUSIONS Post-COVID-19 responses showed improvement across almost all social needs-related questions, indicating that the federal policy response possibly had a positive impact on social needs across the populations of Kansas and western Missouri. Some counties were impacted more than others and positive outcomes were not limited to urban counties. The availability of resources, safety net services, access to health care, and educational opportunities could play a role in this change. Future research should focus on improving survey response rates from rural counties to increase their sample size, and to evaluate other explanatory variables such as food pantry access, educational status, employment opportunities, and access to community resources. Government policies should be an area of focused research as they may affect the social needs and health of the individuals considered in this analysis.
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Affiliation(s)
- Dinesh Pal Mudaranthakam
- Department of Biostatistics & Data Science, University of Kansas Medical Center, Kansas City, KS, United States
| | - Sam Pepper
- Department of Biostatistics & Data Science, University of Kansas Medical Center, Kansas City, KS, United States
| | - Tanner Fortney
- Department of Population Health, University of Kansas Medical Center, Kansas City, KS, United States
| | - Alexander Alsup
- Department of Biostatistics & Data Science, University of Kansas Medical Center, Kansas City, KS, United States
| | - Jennifer Woodward
- Department of Family Medicine and Community Health, University of Kansas Medical Center, Kansas City, KS, United States
| | - Kevin Sykes
- Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, KS, United States
| | - Elizabeth Calhoun
- Department of Population Health, University of Kansas Medical Center, Kansas City, KS, United States
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8
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Breathett K, Yee RH, Pool N, Hebdon MC, Knapp SM, Calhoun E, Sweitzer NK, Carnes M. Pilot test of a Multi-Component Implementation Strategy for Equity in Advanced Heart Failure Allocation. Am J Transplant 2023:S1600-6135(23)00348-9. [PMID: 36931436 DOI: 10.1016/j.ajt.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/07/2023] [Accepted: 03/08/2023] [Indexed: 03/17/2023]
Abstract
Advanced heart failure (AHF) therapy allocation is vulnerable to bias related to subjective assessments and poor group dynamics. Our objective was to determine whether an implementation strategy for AHF team members could feasibly contribute to organizational and culture change supporting equity in AHF allocation. Using pretest-posttest design, the strategy included an 8-week multi-component training on bias reduction, standardized numerical social assessments, and enhanced group dynamics at an AHF center. Evaluations of organizational and cultural change included pretest-posttest AHF team member surveys, transcripts of AHF meetings to assess group dynamics using a standardized scoring system, and posttest interviews guided by framework for implementing a complex strategy. Results were analyzed with qualitative descriptive methods and Brunner-Munzel tests for relative effect (RE, RE >0.5 signals posttest improvement). The majority of survey metrics revealed potential benefit with RE >0.5. RE were >0.5 for 5 of 6 group dynamics metrics. Themes for implementation included: 1) promotes equitable distribution of scarce resources; 2) requires change in team members' time investment to correct bias and change meeting structure; 3) slows then accelerates the allocation process; 4) adaptable beyond AHF and reinforceable with semi-annual trainings. An implementation strategy for AHF equity demonstrated feasibility for organizational and culture change.
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Affiliation(s)
- Khadijah Breathett
- Division of Cardiovascular Medicine, Department of Medicine, Indiana University, Indianapolis, IN (Breathett).
| | - Ryan H Yee
- Division of Cardiovascular Medicine, Clinical Research Office, Indiana University, Indianapolis, IN (Yee)
| | - Natalie Pool
- School of Nursing, University of Northern Colorado, Greeley (Pool)
| | - Megan C Hebdon
- School of Nursing, University of Texas, San Antonio (Hebdon)
| | - Shannon M Knapp
- Statistics Consulting Lab, Bio5 Institute, University of Arizona, Tucson (Knapp)
| | | | - Nancy K Sweitzer
- Division of Cardiovascular Medicine, Department of Medicine, Sarver Heart Center, University of Arizona, Tucson (Sweitzer)
| | - Molly Carnes
- Department of Medicine, University of Wisconsin (Carnes)
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Breathett K, Yee R, Pool N, Thomas Hebdon MC, Knapp SM, Herrera-Theut K, de Groot E, Yee E, Allen LA, Hasan A, Lindenfeld J, Calhoun E, Carnes M, Sweitzer NK. Group Dynamics and Allocation of Advanced Heart Failure Therapies-Heart Transplants and Ventricular Assist Devices-By Gender, Racial, and Ethnic Group. J Am Heart Assoc 2023; 12:e027701. [PMID: 36846988 PMCID: PMC10111441 DOI: 10.1161/jaha.122.027701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
Background US regulatory framework for advanced heart failure therapies (AHFT), ventricular assist devices, and heart transplants, delegate eligibility decisions to multidisciplinary groups at the center level. The subjective nature of decision-making is at risk for racial, ethnic, and gender bias. We sought to determine how group dynamics impact allocation decision-making by patient gender, racial, and ethnic group. Methods and Results We performed a mixed-methods study among 4 AHFT centers. For ≈ 1 month, AHFT meetings were audio recorded. Meeting transcripts were evaluated for group function scores using de Groot Critically Reflective Diagnoses protocol (metrics: challenging groupthink, critical opinion sharing, openness to mistakes, asking/giving feedback, and experimentation; scoring: 1 to 4 [high to low quality]). The relationship between summed group function scores and AHFT allocation was assessed via hierarchical logistic regression with patients nested within meetings nested within centers, and interaction effects of group function score with gender and race, adjusting for patient age and comorbidities. Among 87 patients (24% women, 66% White race) evaluated for AHFT, 57% of women, 38% of men, 44% of White race, and 40% of patients of color were allocated to AHFT. The interaction between group function score and allocation by patient gender was statistically significant (P=0.035); as group function scores improved, the probability of AHFT allocation increased for women and decreased for men, a pattern that was similar irrespective of racial and ethnic groups. Conclusions Women evaluated for AHFT were more likely to receive AHFT when group decision-making processes were of higher quality. Further investigation is needed to promote routine high-quality group decision-making and reduce known disparities in AHFT allocation.
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Affiliation(s)
| | - Ryan Yee
- Division of Cardiovascular Medicine, Research Team Indiana University Indianapolis IN
| | - Natalie Pool
- School of Nursing University of Northern Colorado Greeley CO
| | | | - Shannon M Knapp
- Division of Cardiovascular Medicine Indiana University Indianapolis IN
| | | | - Esther de Groot
- Department of General Practice University Medical Center Utrecht Utrecht Netherlands
| | - Erika Yee
- School of Medicine University of Arizona Tucson AZ
| | - Larry A Allen
- Division of Cardiovascular Medicine University of Colorado Denver CO
| | - Ayesha Hasan
- Division of Cardiovascular Medicine The Ohio State University Columbus OH
| | - JoAnn Lindenfeld
- Division of Cardiovascular Medicine Vanderbilt University Nashville TN
| | | | - Molly Carnes
- Department of Medicine University of Wisconsin Madison WI
| | - Nancy K Sweitzer
- Division of Cardiovascular Medicine University of Washington at St Louis St Louis MO
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10
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Mudaranthakam DP, Wick J, Calhoun E, Gurley T. Financial burden among cancer patients: A national-level perspective. Cancer Med 2023; 12:4638-4646. [PMID: 35852258 PMCID: PMC9972087 DOI: 10.1002/cam4.5049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 05/26/2022] [Accepted: 07/08/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND This research study aimed to evaluate the financial burden among older cancer patients and its corresponding risk factors. Factors such as increasing treatment costs and work limitations often lead cancer patients to bankruptcy and poor quality of life. These consequences, in turn, can cause higher mortality rates among these patients. METHODS This retrospective cohort study utilized data from the Health Retirement Study (HRS), conducted by the University of Michigan (N = 18,109). Eligible participants had responses captured from years 2002 to 2016. Participants were classified according to any self-reported cancer diagnosis (yes or no) and were compared on the basis of financial, work, and health-related outcomes. Propensity score (PS) matching was applied to reduce the effects of potential confounding factors. Also only, individuals with an age ≥50 and ≤85 during Wave 6 were retained. RESULTS Multivariate analysis with random effects revealed several indicators of financial burden when comparing participants with a cancer diagnosis to those with no history of cancer. Mean out-of-pocket costs associated with a cancer diagnosis were $1058 higher when compared to participants with no history of cancer, suggesting that even cancer patients with insurance coverage faced out-of-pocket costs. Respondents with cancer patients had higher odds of encountering financial hardship if they are facing Work Limitations (OR = 2.714), Regular use of Medications (OR = 2.518), Hospital Stays (OR = 2.858), Declining Health (OR = 2.349), or were being covered under government health insurance (OR = 5.803) than respondents who did not have cancer, or suffered from mental health issues such as Depression (OR = 0.901). CONCLUSION Cancer patients contend with increasing financial costs during their treatment. However, most newly diagnosed patients are not aware of these costs and are given few resources to handle them.
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Affiliation(s)
- Dinesh Pal Mudaranthakam
- Department of Biostatistics & Data Science, University of Kansas Medical Center, Kansas City, Kansas, USA.,The University of Kansas Cancer Center, Kansas City, Kansas, USA.,Department of Population Health, Health Policy & Management, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Jo Wick
- Department of Biostatistics & Data Science, University of Kansas Medical Center, Kansas City, Kansas, USA.,The University of Kansas Cancer Center, Kansas City, Kansas, USA
| | - Elizabeth Calhoun
- The University of Kansas Cancer Center, Kansas City, Kansas, USA.,Department of Population Health, Health Policy & Management, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Tami Gurley
- The University of Kansas Cancer Center, Kansas City, Kansas, USA.,Department of Population Health, Health Policy & Management, University of Kansas Medical Center, Kansas City, Kansas, USA
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11
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Melton F, Palmer K, Solola S, Luy L, Herrera-Theut K, Zabala L, Knapp SM, Yee R, Yee E, Calhoun E, Hebdon MCT, Pool N, Sweitzer N, Breathett K. Race and Gender-Based Perceptions of Older Septuagenarian Adults. Womens Health Rep (New Rochelle) 2022; 3:944-956. [PMID: 36479377 PMCID: PMC9712052 DOI: 10.1089/whr.2022.0063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 10/07/2022] [Indexed: 06/17/2023]
Abstract
Objectives Older adults face racism, sexism, and ageism. As the U.S. population ages, it is important to understand how the current population views older adults. Methods Participants recruited through Amazon's Mechanical Turk provided perceptions of older Black and White models' photographs. Using mixed-effect models, we assessed interactions between race and gender of participants and models. Results Among Participants of Color and White participants (n = 712, 70% non-Hispanic White, 70% women, mean 37.81 years), Black models were perceived as more attractive, less threatening, and sadder than White models, but differences were greater for White participants (race-by-race interaction: attractive p = 0.003, threatening p = 0.009, sad p = 0.016). Each gender perceived their respective gender as more attractive (gender-by-gender interaction p < 0.0001). Male and female participants perceived male models as happier than female models, but differences were greater for male participants (p = 0.026). Irrespective of participant age group, women were perceived as more threatening (p = 0.012). Other perceptions were not significant. Discussion Participants had few biases toward older Black and White models, while gender biases favored men.
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Affiliation(s)
- Forest Melton
- Department of Clinical Translational Sciences, College of Medicine, University of Arizona, Phoenix, Arizona, USA
| | - Kelly Palmer
- Department of Promotion Science, College of Public Health, University of Arizona, Tucson, Arizona, USA
| | - Sade Solola
- Division of Cardiology, Brown University, Providence, Rhode Island, USA
| | - Luis Luy
- University of Rochester, Rochester, New York, USA
| | - Kathryn Herrera-Theut
- Department of Internal Medicine and Pediatrics, College of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Leanne Zabala
- Department of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Shannon M. Knapp
- Division of Cardiovascular Medicine Statistics, College of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Ryan Yee
- Clinical Research Office, Indiana University, Indianapolis, Indiana, USA
| | - Erika Yee
- College of Medicine, University of Arizona, Tucson, Arizona, USA
| | - Elizabeth Calhoun
- College of Public Health, University of Illinois at Chicago, Chicago, Illinois, USA
| | | | - Natalie Pool
- School of Nursing, University of Northern Colorado, Greeley, Colorado, USA
| | - Nancy Sweitzer
- Division of Cardiology, Washington University, St. Louis, Missouri, USA
| | - Khadijah Breathett
- Division of Cardiovascular Medicine, College of Medicine, Krannert Institute of Cardiology, Indiana University, Indianapolis, Indiana, USA
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12
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Hentzen S, Alsman K, O'Neal A, Adams T, Calhoun E, Lowry BN. Understanding adult survivors of childhood cancers: An analysis of a survivorship transitions clinic. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.28_suppl.227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
227 Background: As the prevalence of patients with cancer increases and improvements to treatment continue, the population of childhood cancer survivors (CCS) will see remarkable growth in coming years. Care for CCS requires collaboration between oncologists and primary care practitioners (PCPs). Long term follow up calls for unique attention to survivorship guidelines, the late effects of treatment, and the risk of secondary malignancies. To meet these needs, the cancer center at the University of Kansas Health System partnered with internal medicine to establish a primary care based STC. This study aimed to describe and analyze the population of cancer survivors in this clinic. Methods: After obtaining IRB approval, a retrospective chart review was completed for patients established in the STC between 2014 and 2022. Subjects were de-identified and analysis was performed using Microsoft Excel. Results: The 261 patients were 57% (150) female and had an average age of 12 (2 months - 41 years) at the time of cancer diagnosis and an average age of 28 (18 – 61 years) at the time of of clinic establishment. Patients were from 9 states, 47 counties, and 139 unique zipcodes. We identified 42 different cancers among the patients with ALL (24.5%) and Hodgkin’s Lymphoma (19.2%) most common. We found that 244 (93.5%) received chemotherapy, 138 (52.9%) received radiation, and 41 (15.7%) underwent bone marrow transplant. Secondary cancers were diagnosed in 30 (11.5%) of the patients with breast (23.3%) and thyroid (23.3%) malignancies most common. Three of these patients had two secondary malignancies. Conclusions: Our CCS population was clinically diverse in malignancy and treatment regimen. Nearly half of the patients received therapy in combination, adding to the complexity of late effects risks and care monitoring. This is emphasized by the prevalence of secondary malignancies which enforces the need for close follow up and adherence to survivorship guidelines. We found that despite the young age of cancer diagnosis, many of the patients established care in our clinic well into adulthood which is concerning for a gap in survivorship care as patients transition from treatment to follow up. Finally, the wide catchment area of this clinic is unique and shows the success of rural survivorship care at a tertiary medical center.
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Affiliation(s)
| | | | - Alicia O'Neal
- University of Kansas School of Medicine, Kansas City, KS
| | - Taylor Adams
- Kansas University Medical Center, Kansas City, KS
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13
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Mwansa H, Barry I, Knapp SM, Mazimba S, Calhoun E, Sweitzer NK, Breathett K. Association Between the Affordable Care Act Medicaid Expansion and Receipt of Cardiac Resynchronization Therapy by Race and Ethnicity. J Am Heart Assoc 2022; 11:e026766. [PMID: 36129039 DOI: 10.1161/jaha.122.026766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Black and Hispanic patients are less likely to receive cardiac resynchronization therapy (CRT) than White patients. Medicaid expansion has been associated with increased access to cardiovascular care among racial and ethnic groups with higher prevalence of underinsurance. It is unknown whether the Medicaid expansion was associated with increased receipt of CRT by race and ethnicity. Methods and Results Using Healthcare Cost and Utilization Project Data State Inpatient Databases from 19 states and Washington, DC, we analyzed 1061 patients from early-adopter states (Medicaid expansion by January 2014) and 745 patients from nonadopter states (no implementation 2013-2014). Estimates of change in census-adjusted rates of CRT with or without defibrillator by race and ethnicity and Medicaid adopter status 1 year before and after January 2014 were conducted using a quasi-Poisson regression model. Following the Medicaid expansion, the rate of CRT did not significantly change among Black individuals from early-adopter states (1.07 [95% CI, 0.78-1.48]) or nonadopter states (0.79 [95% CI, 0.57-1.09]). There were no significant changes in rates of CRT among Hispanic individuals from early-adopter states (0.99 [95% CI, 0.70-1.38]) or nonadopter states (1.01 [95% CI, 0.65-1.57]). There was a 34% increase in CRT rates among White individuals from early-adopter states (1.34 [95% CI, 1.05-1.70]), and no significant change among White individuals from nonadopter states (0.77 [95% CI, 0.59-1.02]). The change in CRT rates among White individuals was associated with the timing of the Medicaid implementation (P=0.003). Conclusions Among states participating in Healthcare Cost and Utilization Project Data State Inpatient Databases, implementation of Medicaid expansion was associated with increase in CRT rates among White individuals residing in states that adopted the Medicaid expansion policy. Further work is needed to address disparities in CRT among Black and Hispanic patients.
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Affiliation(s)
- Hunter Mwansa
- Frankel Cardiovascular Center University of Michigan Ann Arbor MI
| | - Ibrahim Barry
- Division of Cardiovascular Medicine, Sarver Heart Center University of Arizona Tucson AZ
| | - Shannon M Knapp
- Statistics Consulting Lab Bio5 Institute, University of Arizona Tucson AZ.,Division of Cardiovascular Medicine Indiana University Indianapolis IN
| | - Sula Mazimba
- Division of Cardiovascular Medicine University of Virginia Health System Charlottesville VA
| | | | - Nancy K Sweitzer
- Division of Cardiovascular Medicine, Sarver Heart Center University of Arizona Tucson AZ.,Division of Cardiovascular Medicine Washington University St. Louis MO
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14
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Ver Hoeve ES, Simon MA, Danner SM, Washington AJ, Coples SD, Percac-Lima S, Whited EC, Paskett ED, Naughton MJ, Gray DM, Wenzel JA, Zabora JR, Hassoon A, Tolbert EE, Calhoun E, Barton DL, Friese CR, Titler MG, Hamann HA. Implementing patient navigation programs: Considerations and lessons learned from the Alliance to Advance Patient-Centered Cancer Care. Cancer 2022; 128:2806-2816. [PMID: 35579501 PMCID: PMC9261966 DOI: 10.1002/cncr.34251] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 01/31/2022] [Accepted: 04/04/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Six multidisciplinary cancer centers were selected and funded by the Merck Foundation (2017-2021) to collaborate in the Alliance to Advance Patient-Centered Cancer Care ("Alliance"), an initiative to improve patient access, minimize health disparities, and enhance the quality of patient-centered cancer care. These sites share their insights on implementation and expansion of their patient navigation efforts. METHODS Patient navigation represents an evidence-based health care intervention designed to enhance patient-centered care and care coordination. Investigators at 6 National Cancer Institute-designated cancer centers outline their approaches to reducing health care disparities and synthesize their efforts to ensure sustainability and successful transferability in the management of patients with cancer and their families in real-world health care settings. RESULTS Insights are outlined within the context of patient navigation program effectiveness and supported by examples from Alliance cancer center sites: 1) understand the patient populations, particularly underserved and high-risk patients; 2) capitalize on the existing infrastructure and institutional commitment to support and sustain patient navigation; and 3) build capacity by mobilizing community support outside of the cancer center. CONCLUSIONS This process-level article reflects the importance of collaboration and the usefulness of partnering with other cancer centers to share interdisciplinary insights while undergoing intervention development, implementation, and expansion. These collective insights may be useful to staff at other cancer centers that look to implement, enhance, or evaluate the effectiveness of their patient navigation interventions.
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Affiliation(s)
| | - Melissa A. Simon
- Northwestern University Feinberg School of Medicine, Robert H. Lurie Comprehensive Cancer Center, Chicago, Illinois
| | - Sankirtana M. Danner
- Northwestern University Feinberg School of Medicine, Robert H. Lurie Comprehensive Cancer Center, Chicago, Illinois
| | | | - Susan D. Coples
- Georgia Cancer Center for Excellence at Grady Health System, Atlanta, Georgia
| | | | | | | | | | - Darrell M. Gray
- The Ohio State University College of Medicine, Columbus, Ohio
| | - Jennifer A. Wenzel
- The Johns Hopkins University Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland
| | - James R. Zabora
- The Johns Hopkins University Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland
| | - Ahmed Hassoon
- The Johns Hopkins University Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland
| | - Elliott E. Tolbert
- The Johns Hopkins University Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland
| | | | - Debra L. Barton
- The University of Michigan School of Nursing, Ann Arbor, Michigan
| | | | - Marita G. Titler
- The University of Michigan School of Nursing, Ann Arbor, Michigan
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15
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Wells KJ, Wightman P, Cobian Aguilar R, Dwyer AJ, Garcia-Alcaraz C, Saavedra Ferrer EL, Mohan P, Fleisher L, Franklin EF, Valverde PA, Calhoun E. Comparing clinical and nonclinical cancer patient navigators: A national study in the United States. Cancer 2022; 128 Suppl 13:2601-2609. [PMID: 35699618 DOI: 10.1002/cncr.33880] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 06/08/2021] [Accepted: 07/30/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND A nationwide survey was conducted to examine differences between clinical and nonclinical oncology navigators in their service provision, engagement in the cancer care continuum, personal characteristics, and program characteristics. METHODS Using convenience sampling, 527 oncology navigators participated and completed an online survey. Descriptive statistics, χ2 statistics, and t tests were used to compare nonclinical (eg, community health worker) and clinical (eg, nurse navigators) navigators on the provision of various navigation services, personal characteristics, engagement in the cancer care continuum, and program characteristics. RESULTS Most participants were clinical navigators (76.1%). Compared to nonclinical navigators, clinical navigators were more likely to have a bachelor's degree or higher (88.6% vs 69.6%, P < .001), be funded by operational budgets (84.4% vs 35.7%, P < .001), and less likely to work at a community-based organization or nonprofit (2.0% vs 36.5%, P < .001). Clinical navigators were more likely to perform basic navigation (P < .001), care coordination (P < .001), treatment support (P < .001), and clinical trial/peer support (P = .005). Clinical navigators were more likely to engage in treatment (P < .001), end-of-life (P < .001), and palliative care (P = .001) navigation. CONCLUSIONS There is growing indication that clinical and nonclinical oncology navigators perform different functions and work in different settings. Nonclinical navigators may be more likely to face job insecurity because they work in nonprofit organizations and are primarily funded by grants.
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Affiliation(s)
- Kristen J Wells
- Department of Psychology, San Diego State University, San Diego, California.,San Diego State University/University of California San Diego Joint Doctoral Program in Clinical Psychology, San Diego, California
| | | | | | | | - Cristian Garcia-Alcaraz
- Department of Psychology, San Diego State University, San Diego, California.,San Diego State University/University of California San Diego Joint Doctoral Program in Clinical Psychology, San Diego, California
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16
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Dwyer AJ, Wender RC, Weltzien ES, Dean MS, Sharpe K, Fleisher L, Burhansstipanov L, Johnson W, Martinez L, Wiatrek DE, Calhoun E, Battaglia TA. Collective pursuit for equity in cancer care: The National Navigation Roundtable. Cancer 2022; 128 Suppl 13:2561-2567. [PMID: 35699616 DOI: 10.1002/cncr.34162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 11/11/2021] [Accepted: 01/08/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND The evidence continues to build in support of implementing patient navigation to reduce barriers and increase access to care. However, health disparities remain in cancer outcomes. The goal of the National Navigation Roundtable (NNRT) is to serve as a convener to help support the field of navigation to address equity. METHODS To examine the progress and opportunities for navigation, the NNRT submitted a collection of articles based on the results from 2 dedicated surveys and contributions from member organizations. The intent was to help inform what we know about patient navigation since the last dedicated examination in this journal 10 years ago. RESULTS The online survey of >700 people described navigators and examined sustainability and policy issues and the longevity, specific role and function, and impact of clinical and nonclinical navigators in addition to the role of training and supervision. In addition, a full examination of coronavirus disease 2019 and contributions from member organizations helped further define progress and future opportunities to meet the needs of patients through patient navigation. CONCLUSIONS To achieve equity in cancer care will demand the sustained action of virtually every component of the cancer care system. It is the hope and intent of the NNRT that the information presented in this supplement will be a catalyst for action in this collective action approach.
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Affiliation(s)
- Andrea J Dwyer
- Department of Community and Behavioral Health, The Colorado School of Public Health, University of Colorado, Aurora, Colorado
| | - Richard C Wender
- Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elsa S Weltzien
- Department of Community and Behavioral Health, The Colorado School of Public Health, University of Colorado, Aurora, Colorado
| | - Monica S Dean
- Academy of Oncology Nurse and Patient Navigators, Cranbury, New Jersey
| | | | - Linda Fleisher
- Cancer Prevention and Control, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | | | - Wenora Johnson
- Fight Colorectal Cancer Patient Advocate, Springfield, Missouri
| | | | | | - Elizabeth Calhoun
- Department of Population Health, University of Kansas School of Medicine, Kansas City, Kansas
| | - Tracy A Battaglia
- Women's Health Unit, Section of General Internal Medicine, Evans Department of Medicine, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
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17
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Garcia-Alcaraz C, Roesch SC, Calhoun E, Wightman P, Mohan P, Battaglia TA, Cobian Aguilar R, Valverde PA, Wells KJ. Exploring classes of cancer patient navigators and determinants of navigator role retention. Cancer 2022; 128 Suppl 13:2590-2600. [PMID: 35699613 DOI: 10.1002/cncr.33908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 08/02/2021] [Accepted: 08/03/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND In the current nationwide study, the authors used latent class analysis (LCA) to identify classes of cancer patient navigators (CPNs) and examined whether class membership and 12 indicators were related to navigator role retention. METHODS By using data from 460 CPNs in the United States, LCA identified classes (ie, homogenous subgroups) of CPNs with the following indicators: type of CPN (clinical vs nonclinical), education level, area(s) of the cancer care continuum in which the CPN provided patient navigation, region and urbanity where the CPN provided services, organizational work setting, and patient navigation program funding source. The associations of navigator retention with class membership and each indicator were examined using χ2 tests. RESULTS LCA identified 3 classes of CPNs. Classes 1 and 3 were conceptualized as distinct, homogeneous subgroups of clinical CPNs that appeared to differ mainly on their likelihood of engagement in outreach, survivorship, palliative care, and end-of-life patient navigation. Class 2 was conceptualized as a nonclinical CPN subgroup that was distinct primarily based on their high endorsement of employment in programs, which are at least partially funded by grants and engagement in earlier stages of patient navigation (eg, early detection). The provision of survivorship and treatment patient navigation was related to navigator role retention, with senior CPNs providing these patient navigation services more than novice CPNs. CONCLUSIONS The current study highlights 3 distinct classes of CPNs, provides initial information regarding determinants of navigator retention, and makes several recommendations for future patient navigation research.
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Affiliation(s)
- Cristian Garcia-Alcaraz
- San Diego State University/University of California San Diego Joint Doctoral Program in Clinical Psychology, San Diego, California.,Department of Psychology, San Diego State University, San Diego, California
| | - Scott C Roesch
- San Diego State University/University of California San Diego Joint Doctoral Program in Clinical Psychology, San Diego, California.,Department of Psychology, San Diego State University, San Diego, California
| | | | - Patrick Wightman
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona
| | - Prashanthinie Mohan
- Center for Population Science and Discovery, University of Arizona, Tucson, Arizona
| | - Tracy A Battaglia
- Boston Medical Center and Boston University Schools of Medicine and Public Health, Boston, Massachusetts
| | | | | | - Kristen J Wells
- San Diego State University/University of California San Diego Joint Doctoral Program in Clinical Psychology, San Diego, California.,Department of Psychology, San Diego State University, San Diego, California
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18
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Battaglia TA, Fleisher L, Dwyer AJ, Wiatrek DE, Wells KJ, Wightman P, Strusowski T, Calhoun E. Barriers and opportunities to measuring oncology patient navigation impact: Results from the National Navigation Roundtable survey. Cancer 2022; 128 Suppl 13:2568-2577. [PMID: 35699612 DOI: 10.1002/cncr.33805] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 05/28/2021] [Accepted: 06/04/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Patient navigation improves cancer care delivery for those most at risk for poor outcomes. Lack of sustainable funding threatens the full integration of navigation services into health care delivery systems. Standardized navigation metrics that document impact and identify best practices are necessary to support sustainability. METHODS The National Navigation Roundtable administered a web-based, cross-sectional survey to oncology patient navigation programs to identify barriers and facilitators to the use of navigation metrics. The 38-item survey asked about data-collection practices and specific navigation metrics used by the program. Exploratory and descriptive statistics were used to identify factors associated with data collection and reporting. RESULTS Seven hundred fifty respondents from across the country represented navigation programs across the continuum of care. Although 538 respondents (72%) reported participating in routine data collection, only one-half of them used data for reporting purposes. For the 374 programs that used electronic health records, only 40% had discrete, reportable navigation fields, and 25% had an identifier for navigated patients. Program funding was identified as the only characteristic associated with data collection, whereas the type of data collected was associated with work setting, participation in alternative payment models, and where on the continuum navigation services are provided. Respondents participating in an oncology accreditation program were more likely to collect specific outcome metrics across the continuum and to use those data for reporting purposes. The most common barriers to data collection were time (55%) and lack of support for complex data systems and/or platforms (50%). CONCLUSIONS Inconsistent data collection and reporting of oncology navigation programs remain a threat to sustainability. Aligning data collection with oncology accreditation, funding, and reimbursement is a viable path forward.
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Affiliation(s)
- Tracy A Battaglia
- Women's Health Unit, Section of General Internal Medicine, Evans Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts
| | - Linda Fleisher
- Cancer Prevention and Control, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Andrea J Dwyer
- Department of Community and Behavioral Health, The Colorado School of Public Health, University of Colorado, Aurora, Colorado
| | | | - Kristen J Wells
- Department of Psychology, San Diego State University, San Diego, California
| | - Patrick Wightman
- Center for Population Health Sciences, Arizona Health Sciences, University of Arizona, Tucson, Arizona
| | | | - Elizabeth Calhoun
- Department of Population Health, University of Kansas School of Medicine, Kansas City, Kansas
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Breathett KK, Xu H, Sweitzer NK, Calhoun E, Matsouaka RA, Yancy CW, Fonarow GC, DeVore AD, Bhatt DL, Peterson PN. Is the affordable care act medicaid expansion associated with receipt of heart failure guideline-directed medical therapy by race and ethnicity? Am Heart J 2022; 244:135-148. [PMID: 34813771 PMCID: PMC8727506 DOI: 10.1016/j.ahj.2021.11.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 09/17/2021] [Accepted: 11/16/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Uninsurance is a known contributor to racial/ethnic health inequities. Insurance is often needed for prescriptions and follow-up appointments. Therefore, we determined whether the Affordable Care Act(ACA) Medicaid Expansion was associated with increased receipt of guideline-directed medical treatment(GDMT) at discharge among patients hospitalized with heart failure(HF) by race/ethnicity. METHODS Using Get With The Guidelines-HF registry, logistic regression was used to assess odds of receiving GDMT(HF medications; education; follow-up appointment) in early vs non-adopter states before(2012 - 2013) and after ACA Medicaid Expansion(2014 - 2019) within each race/ethnicity, accounting for patient-level covariates and within-hospital clustering. We tested for an interaction(p-int) between GDMT and pre/post Medicaid Expansion time periods. RESULTS Among 271,606 patients(57.5% early adopter, 42.5% non-adopter), 65.5% were White, 22.8% African American, 8.9% Hispanic, and 2.9% Asian race/ethnicity. Independent of ACA timing, Hispanic patients were more likely to receive all GDMT for residing in early adopter states compared to non-adopter states (P <.0001). In fully-adjusted analyses, ACA Medicaid Expansion was associated with higher odds of receipt of ACEI/ARB/ARNI in Hispanic patients [before ACA:OR 0.40(95%CI:0.13,1.23); after ACA:OR 2.46(1.10,5.51); P-int = .0002], but this occurred in the setting of an immediate decline in prescribing patterns, particularly among non-adopter states, followed by an increase that remained lowest in non-adopter states. The ACA was not associated with receipt of GDMT for other racial/ethnic groups. CONCLUSIONS Among GWTG-HF hospitals, Hispanic patients were more likely to receive all GDMT if they resided in early adopter states rather than non-adopter states, independent of ACA Medicaid Expansion timing. ACA implementation was only associated with higher odds of receipt of ACEI/ARB/ARNI in Hispanic patients. Additional steps are needed for improved GDMT delivery for all.
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Affiliation(s)
- Khadijah K. Breathett
- Division of Cardiovascular Medicine, Sarver Heart Center,
University of Arizona, Tucson, AZ
| | - Haolin Xu
- Department of Biostatistics and Bioinformatics, Duke University,
Durham, NC
| | - Nancy K. Sweitzer
- Division of Cardiovascular Medicine, Sarver Heart Center,
University of Arizona, Tucson, AZ
| | - Elizabeth Calhoun
- Center for Population Science and Discovery, University of Arizona,
Tucson, AZ
| | | | - Clyde W. Yancy
- Division of Cardiology, Northwestern University Feinberg School of
Medicine, Chicago, IL
| | - Gregg C. Fonarow
- Division of Cardiology, University of California Los Angeles,
CA
| | | | - Deepak L. Bhatt
- Division of Cardiovascular Medicine, Brigham and Women’s
Hospital Heart & Vascular Center, Harvard Medical School, Boston,
MA
| | - Pamela N. Peterson
- Division of Cardiology, University of Colorado, Anschutz Medical
Campus, Aurora, CO and Division of Cardiology, Denver Health Medical Center,
Denver, CO
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20
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Jennings N, Garcia DO, Eng H, Calhoun E. Utilization and cost sharing for preventive cancer screenings. Health Policy OPEN 2021. [DOI: 10.1016/j.hpopen.2021.100044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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21
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Affiliation(s)
- Khadijah Breathett
- Division of Cardiovascular Medicine Sarver Heart Center University of Arizona Tucson AZ
| | - Shannon M Knapp
- Statistics Consulting Lab Bio5 InstituteUniversity of Arizona Tucson AZ
| | - Molly Carnes
- Department of Medicine University of Wisconsin Madison WI
| | - Elizabeth Calhoun
- Center for Population Health Sciences University of Arizona Tucson AZ
| | - Nancy K Sweitzer
- Division of Cardiovascular Medicine Sarver Heart Center University of Arizona Tucson AZ
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22
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Mudaranthakam DP, Gajewski B, Krebill H, Coulter J, Springer M, Calhoun E, Hughes D, Mayo M, Doolittle G. Barriers to clinical trial participation: a comparative study between rural and urban participants (Preprint). JMIR Cancer 2021; 8:e33240. [PMID: 35451964 PMCID: PMC9073606 DOI: 10.2196/33240] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 11/21/2021] [Accepted: 03/26/2022] [Indexed: 02/02/2023] Open
Abstract
Background The National Clinical Trials Network program conducts phase 2 or phase 3 treatment trials across all National Cancer Institute’s designated cancer centers. Participant accrual across these clinical trials is a critical factor in deciding their success. Cancer centers that cater to rural populations, such as The University of Kansas Cancer Center, have an additional responsibility to ensure rural residents have access and are well represented across these studies. Objective There are scant data available regarding the factors that act as barriers to the accrual of rural residents in these clinical trials. This study aims to use electronic screening logs that were used to gather patient data at several participating sites in The Kansas University of Cancer Center’s Catchment area. Methods Screening log data were used to assess what clinical trial participation barriers are faced by these patients. Additionally, the differences in clinical trial participation barriers were compared between rural and urban participating sites. Results Analysis revealed that the hospital location rural urban category, defined as whether the hospital was in an urban or rural setting, had a medium effect on enrolment of patients in breast cancer and lung cancer trials (Cohen d=0.7). Additionally, the hospital location category had a medium effect on the proportion of recurrent lung cancer cases at the time of screening (d=0.6). Conclusions In consideration of the financially hostile nature of cancer treatment as well as geographical and transportation barriers, clinical trials extended to rural communities are uniquely positioned to alleviate the burden of nonmedical costs in trial participation. However, these options can be far less feasible for patients in rural settings. Since the number of patients with cancer who are eligible for a clinical trial is already limited by the stringent eligibility criteria required of such a complex disease, improving accessibility for rural patients should be a greater focus in health policy.
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Affiliation(s)
| | - Byron Gajewski
- University of Kansas Medical Center, Kansas City, KS, United States
| | - Hope Krebill
- University of Kansas Medical Center, Kansas City, KS, United States
| | - James Coulter
- University of Kansas Medical Center, Kansas City, KS, United States
| | | | | | - Dorothy Hughes
- University of Kansas Medical Center, Kansas City, KS, United States
| | - Matthew Mayo
- University of Kansas Medical Center, Kansas City, KS, United States
| | - Gary Doolittle
- University of Kansas Medical Center, Kansas City, KS, United States
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Breathett K, Knapp SM, Carnes M, Calhoun E, Sweitzer NK. Imbalance in Heart Transplant to Heart Failure Mortality Ratio Among African American, Hispanic, and White Patients. Circulation 2021; 143:2412-2414. [PMID: 34125563 DOI: 10.1161/circulationaha.120.052254] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Khadijah Breathett
- Division of Cardiovascular Medicine, Sarver Heart Center (K.B., N.K.S.), University of Arizona, Tucson
| | - Shannon M Knapp
- Statistics Consulting Laboratory, Bio5 Institute (S.M.K.), University of Arizona, Tucson
| | - Molly Carnes
- Department of Medicine, University of Wisconsin, Madison (M.C.)
| | - Elizabeth Calhoun
- Center for Population Health Sciences (E.C.), University of Arizona, Tucson
| | - Nancy K Sweitzer
- Division of Cardiovascular Medicine, Sarver Heart Center (K.B., N.K.S.), University of Arizona, Tucson
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Solola S, Luy L, Herrera-Theut K, Zabala L, Torabzadeh E, Bedrick EJ, Yee E, Larsen A, Stone J, McEwen M, Calhoun E, Crist JD, Hebdon M, Pool N, Carnes M, Sweitzer N, Breathett K. Race and Gender-Based Perceptions of Older Adults: Will the Youth Lead the Way? J Racial Ethn Health Disparities 2020; 8:1415-1423. [PMID: 33145664 DOI: 10.1007/s40615-020-00903-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 09/13/2020] [Accepted: 10/20/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Older individuals encounter the greatest racial/gender biases. It is unknown whether younger generations, who often lead culture shifts, have racial and gender biases against older populations. METHODS Using Amazon's Mechanical Turk's crowdsourcing, we identified how an individual's race and gender are associated with perceptions of individuals aged mid-60s. Participants were asked to rate photograph appearances on Likert Scale (1-10). Interactions between participant and photograph race and gender were assessed with mixed effects models. Delta represents rating differences (positive value higher rating for Whites or women, negative value higher rating for African-Americans or men). RESULTS Among 1563 participants (mean 35 years ± 12), both non-Hispanic White (WP) and all Other race/ethnicity (OP) participants perceived African-American photos as more trustworthy [Delta WP -0.60(95%CI-0.83, - 0.37); Delta OP - 0.51(- 0.74,-0.28), interaction p = 0.06], more attractive [Delta non-Hispanic White participants - 0.63(- 0.97, - 0.29); Delta Other race/ethnicity participants - 0.40 (- 0.74, - 0.28), interaction p < 0.001], healthier [Delta WP -0.31(- 0.53, - 0.08); Delta OP -0.24(- 0.45, -0.03), interaction p = 1.00], and less threatening than White photos [Delta WP 0.79(0.36,1.22); Delta OP 0.60(0.17,1.03), interaction p < 0.001]. Compared with OP, WP perceived African-American photos more favorably for intelligence (interaction p < 0.001). Both genders perceived photos of women as more trustworthy [Delta Women Participants (WmP) 0.50(0.27,0.73); Delta Men Participants(MnP) 0.31(0.08,0.54); interaction p < 0.001] and men as more threatening [Delta WmP -0.84(-1.27, -0.41), Delta MnP - 0.77(- 1.20, - 0.34), interaction p = 0.93]. Compared with MnP, WmP perceived photos of women as happier and more attractive than men (interaction p < 0.001). Compared with WmP, MnP perceived men as healthier than women (interaction p < 0.001). CONCLUSIONS Among a young generation, older African-Americans were perceived more favorably than Whites. Gender perceptions followed gender norms. This suggests a decline in implicit bias against older minorities, but gender biases persist. Future work should investigate whether similar patterns are observed in healthcare.
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Affiliation(s)
- Sade Solola
- Department of Medicine, University of Arizona, Tucson, AZ, USA
| | - Luis Luy
- University of Rochester, Rochester, NY, USA
| | | | - Leanne Zabala
- University of Arizona College of Medicine, Tucson, AZ, USA
| | - Elmira Torabzadeh
- Statistics Consulting Lab, Bio5 Institute, University of Arizona, Tucson, AZ, USA
| | - Edward J Bedrick
- Statistics Consulting Lab, Bio5 Institute, University of Arizona, Tucson, AZ, USA
| | - Erika Yee
- Sarver Heart Center, Clinical Research Office, University of Arizona, Tucson, AZ, USA
| | - Ashley Larsen
- Sarver Heart Center, Clinical Research Office, University of Arizona, Tucson, AZ, USA
| | - Jeff Stone
- Department of Psychology, University of Arizona, Tucson, AZ, USA
| | - Marylyn McEwen
- Department of Nursing, University of Arizona, Tucson, AZ, USA
| | - Elizabeth Calhoun
- Center for Population Health Sciences, University of Arizona, Tucson, AZ, USA
| | - Janice D Crist
- Department of Nursing, University of Arizona, Tucson, AZ, USA
| | - Megan Hebdon
- Department of Nursing, University of Arizona, Tucson, AZ, USA
| | - Natalie Pool
- Department of Nursing, University of Arizona, Tucson, AZ, USA
| | - Molly Carnes
- Department of Medicine, University of Wisconsin, Madison, WI, USA
| | - Nancy Sweitzer
- Division of Cardiology, Department of Medicine, Sarver Heart Center, University of Arizona, 1501 North Campbell Avenue, PO Box 245046, Tucson, AZ, 85724, USA
| | - Khadijah Breathett
- Division of Cardiology, Department of Medicine, Sarver Heart Center, University of Arizona, 1501 North Campbell Avenue, PO Box 245046, Tucson, AZ, 85724, USA.
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Howell CM, Breathett K, Arrington A, Knapp S, Siracuse J, Calhoun E, Zhou W, Tan TW. Medicaid Expansion and Lower Extremity Amputation Among Urban and Rural Beneficiaries With Chronic Limb-Threatening Ischemia. J Vasc Surg 2020. [DOI: 10.1016/j.jvs.2020.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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26
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Breathett K, Yee E, Pool N, Hebdon M, Crist J, Yee R, Knapp S, Solola S, Luy L, Herrera‐Theut K, Zabala L, Stone J, McEwen M, Calhoun E, Sweitzer N. Sex and Race Biases in Allocation of Advanced Heart Failure Therapies. Health Serv Res 2020. [DOI: 10.1111/1475-6773.13397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
| | - E. Yee
- University of Arizona Tucson AZ United States
| | - N. Pool
- University of Arizona Tucson AZ United States
| | - M. Hebdon
- University of Arizona Tucson AZ United States
| | - J. Crist
- University of Arizona Tucson AZ United States
| | - R. Yee
- University of Arizona Tucson AZ United States
| | - S. Knapp
- University of Arizona Tucson AZ United States
| | - S. Solola
- University of Arizona Tucson AZ United States
| | - L. Luy
- University of Rochester Rochester NY United States
| | | | - L. Zabala
- University of Arizona Tucson AZ United States
| | - J. Stone
- University of Arizona Tucson AZ United States
| | - M. McEwen
- University of Arizona Tucson AZ United States
| | - E. Calhoun
- University of Arizona Tucson AZ United States
| | - N. Sweitzer
- University of Arizona Tucson AZ United States
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Tan TW, Armstrong DG, Concha-Moore KC, Marrero DG, Zhou W, Calhoun E, Chang CY, Lo-Ciganic WH. Association between race/ethnicity and the risk of amputation of lower extremities among medicare beneficiaries with diabetic foot ulcers and diabetic foot infections. BMJ Open Diabetes Res Care 2020; 8:8/1/e001328. [PMID: 32843499 PMCID: PMC7449291 DOI: 10.1136/bmjdrc-2020-001328] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 07/14/2020] [Accepted: 07/23/2020] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION This study aimed to examine the association of race and ethnicity on the risk of lower extremity amputations among Medicare beneficiaries with diabetic foot ulcers (DFUs) and diabetic foot infections (DFIs). RESEARCH DESIGN AND METHODS A retrospective study included 2011-2015 data of a 5% sample of fee-for-service Medicare beneficiaries with a newly diagnosed DFU and/or DFI. The primary outcome was the time to the first major amputation episode after a DFU and/or DFI were identified using the diagnosis and procedure codes. We used multivariable Cox proportional hazards models to estimate the risk of time to the first major amputation across races, adjusting for sociodemographic and health status factors. Adjusted hazard ratios (aHRs) with a 95% CI were reported. RESULTS Among 92 929 Medicare beneficiaries newly diagnosed with DFUs and/or DFIs, 77% were whites, 14.3% African Americans (AAs), 3.3% Hispanics, 0.7% Native Americans (NAs), and 4.0% were other races. The incidence rates of major amputation were 0.02 person-years for NAs, 0.02 person-years for AAs, 0.01 person-years for Hispanics, 0.01 person-years for other races, and 0.01 person-years for whites (p<0.05). Multivariable analysis showed that AAs (aHR=1.9, 95% CI 1.7 to 2.2, p<0.0001) and NAs (aHR=1.8, 95% CI 1.3 to 2.6, p=0.001) were associated with an increased risk of major amputation compared with whites. Beneficiaries with DFUs and/or DFIs diagnosed by a podiatrist or primary care physician (aHR=0.7, 95% CI 0.6 to 0.8, p<0.0001, specialists as reference) or at an outpatient visit (aHR=0.3, 95% CI 0.3 to 0.3, p<0.0001, inpatient stay as reference) were associated with a decreased risk of major amputation. CONCLUSIONS Racial and ethnic disparities in the risk of lower extremity amputations appear to exist among fee-for-service Medicare beneficiaries with diabetic foot problems. AAs and NAs with DFUs and/or DFIs were associated with an increased risk of major amputations compared with white Medicare beneficiaries.
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Affiliation(s)
- Tze-Woei Tan
- University of Arizona Health Sciences Center, Tucson, Arizona, USA
| | - David G Armstrong
- Surgery, University of Southern California, Los Angeles, California, USA
| | | | - David G Marrero
- University of Arizona Health Sciences Center, Tucson, Arizona, USA
| | - Wei Zhou
- University of Arizona Health Sciences Center, Tucson, Arizona, USA
| | | | - Ching-Yuan Chang
- Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida Health, Gainesville, Florida, USA
| | - Wei-Hsuan Lo-Ciganic
- Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida Health, Gainesville, Florida, USA
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Breathett K, Yee E, Pool N, Hebdon M, Crist JD, Yee RH, Knapp SM, Solola S, Luy L, Herrera-Theut K, Zabala L, Stone J, McEwen MM, Calhoun E, Sweitzer NK. Association of Gender and Race With Allocation of Advanced Heart Failure Therapies. JAMA Netw Open 2020; 3:e2011044. [PMID: 32692370 PMCID: PMC7412827 DOI: 10.1001/jamanetworkopen.2020.11044] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Importance Racial bias is associated with the allocation of advanced heart failure therapies, heart transplants, and ventricular assist devices. It is unknown whether gender and racial biases are associated with the allocation of advanced therapies among women. Objective To determine whether the intersection of patient gender and race is associated with the decision-making of clinicians during the allocation of advanced heart failure therapies. Design, Setting, and Participants In this qualitative study, 46 US clinicians attending a conference for an international heart transplant organization in April 2019 were interviewed on the allocation of advanced heart failure therapies. Participants were randomized to examine clinical vignettes that varied 1:1 by patient race (African American to white) and 20:3 by gender (women to men) to purposefully target vignettes of women patients to compare with a prior study of vignettes of men patients. Participants were interviewed about their decision-making process using the think-aloud technique and provided supplemental surveys. Interviews were analyzed using grounded theory methodology, and surveys were analyzed with Wilcoxon tests. Exposure Randomization to clinical vignettes. Main Outcomes and Measures Thematic differences in allocation of advanced therapies by patient race and gender. Results Among 46 participants (24 [52%] women, 20 [43%] racial minority), participants were randomized to the vignette of a white woman (20 participants [43%]), an African American woman (20 participants [43%]), a white man (3 participants [7%]), and an African American man (3 participants [7%]). Allocation differences centered on 5 themes. First, clinicians critiqued the appearance of the women more harshly than the men as part of their overall impressions. Second, the African American man was perceived as experiencing more severe illness than individuals from other racial and gender groups. Third, there was more concern regarding appropriateness of prior care of the African American woman compared with the white woman. Fourth, there were greater concerns about adequacy of social support for the women than for the men. Children were perceived as liabilities for women, particularly the African American woman. Family dynamics and finances were perceived to be greater concerns for the African American woman than for individuals in the other vignettes; spouses were deemed inadequate support for women. Last, participants recommended ventricular assist devices over transplantation for all racial and gender groups. Surveys revealed no statistically significant differences in allocation recommendations for African American and white women patients. Conclusions and Relevance This national study of health care professionals randomized to clinical vignettes that varied only by gender and race found evidence of gender and race bias in the decision-making process for offering advanced therapies for heart failure, particularly for African American women patients, who were judged more harshly by appearance and adequacy of social support. There was no associated between patient gender and race and final recommendations for allocation of advanced therapies. However, it is possible that bias may contribute to delayed allocation and ultimately inequity in the allocation of advanced therapies in a clinical setting.
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Affiliation(s)
- Khadijah Breathett
- Sarver Heart Center, Division of Cardiology, Department of Medicine, University of Arizona, Tucson
| | - Erika Yee
- Sarver Heart Center, Clinical Research Office, University of Arizona, Tucson
| | - Natalie Pool
- College of Nursing, University of Arizona, Tucson
| | - Megan Hebdon
- College of Nursing, University of Utah, Salt Lake City
| | | | - Ryan H Yee
- Sarver Heart Center, Clinical Research Office, University of Arizona, Tucson
| | - Shannon M Knapp
- Statistics Consulting Lab, Bio5 Institute, University of Arizona, Tucson
| | - Sade Solola
- Department of Medicine, University of Arizona, Tucson
| | - Luis Luy
- University of Rochester, New York
| | | | - Leanne Zabala
- Department of Medicine, University of California, Los Angeles
| | - Jeff Stone
- Department of Psychology, University of Arizona, Tucson
| | | | - Elizabeth Calhoun
- Center for Population Health Sciences, University of Arizona, Tucson
| | - Nancy K Sweitzer
- Sarver Heart Center, Division of Cardiology, Department of Medicine, University of Arizona, Tucson
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Tan TW, Eslami MH, Knapp S, Howell C, Siracuse JJ, Zhou W, Armstrong D, Calhoun E. The Association of Medicaid Expansion and Reduced Lower Extremity Amputation Among Minorities With Chronic Limb-Threatening Ischemia. J Vasc Surg 2020. [DOI: 10.1016/j.jvs.2020.04.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Ford ME, Bryant DC, Cartmell KB, Sterba K, Burshell DR, Hill EG, Kim J, De Toma A, Knight KD, Reed T, Weaver K, Calhoun E, Esnaola NF. Abstract A085: Challenges and successes in recruiting African Americans with early-stage, non-small cell lung cancer to an NIMHD-funded, NCORP-based patient navigation trial. Cancer Epidemiol Biomarkers Prev 2020. [DOI: 10.1158/1538-7755.disp18-a085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Abstract
Background: Enrollment of early-stage lung cancer patients to randomized trials has historically been challenging. The STARS Trial enrolled 36 of 1,030 intended patients from 28 sites, while the ROSEL Trial recruited 22 of 960 intended patients from 10 sites. Unfortunately, evidence shows African Americans with early-stage NSCLC are significantly less likely than their European American counterparts to undergo resection and may also be less likely to participate in lung cancer trials as well.
Purpose: The purpose of this research is to describe interim recruitment results from an NIMHD-funded, NCI NCORP-based patient navigation trial conducted with African Americans with early-stage, probable/proven non-small cell lung cancer (NSCLC).
Design: The protocol-driven, barriers-focused patient navigation intervention is being conducted in the context of a two-arm cluster-randomized trial testing the effectiveness of the intervention in increasing rates of lung-directed curative-intent therapy (surgery and SBRT) in African Americans with Stage I-II NSCLC. The 2 study arms consist of the protocol-driven, intensive navigation intervention vs. usual care. The trial includes 20 study sites in 11 US states. Specific activities to enhance recruitment in the present trial include reaching out to referring physicians (e.g., primary care, pulmonologists, radiologists) to increase referrals of African American patients to the participating NCORP sites, and partnering with the leaders of community engagement activities at the sites to raise community-level awareness of the trial.
Results/Conclusions: To date, 200 African American patients have been recruited and the trial is now on target to meet its expected accrual goal of 222 patients. The majority of potential participants were ineligible due to receipt of surgical resection or radiation therapy prior to enrollment (24%), not having been told that they had probable/proven NSCLC prior to study contact (22%), or a previous history of lung cancer (10%). The median age of the 200 participants is 65 years (range 40-86 years). Most are unmarried (70%) and have a high school diploma or less (71%). The number of enrolled-to-date African American participants in this ongoing trial exceeds the total number of participants recruited to the STARS Trial or to the ROSEL Trial.
Citation Format: Marvella E. Ford, Debbie C. Bryant, Kathleen B. Cartmell, Katherine Sterba, Dana R. Burshell, Elizabeth G. Hill, Joanne Kim, Allan De Toma, Kendrea D. Knight, Ta'Myiah Reed, Kathryn Weaver, Elizabeth Calhoun, Nestor F. Esnaola. Challenges and successes in recruiting African Americans with early-stage, non-small cell lung cancer to an NIMHD-funded, NCORP-based patient navigation trial [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr A085.
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Affiliation(s)
| | | | | | | | | | | | - Joanne Kim
- 1Medical University of South Carolina, Charleston, SC,
| | | | | | - Ta'Myiah Reed
- 1Medical University of South Carolina, Charleston, SC,
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Breathett KK, Xu H, Sweitzer NK, Calhoun E, Matsouaka R, Yancy CW, Fonarow GC, Devore AD, Bhatt DL, Peterson P. Abstract 22: Affordable Care Act Medicaid Expansion Then and Now: Racial/Ethnic Differences in Receipt of Guideline-Directed Medical Therapy During Heart Failure Hospitalizations. Circ Cardiovasc Qual Outcomes 2020. [DOI: 10.1161/hcq.13.suppl_1.22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Uninsurance is a known contributor to racial/ethnic minority health inequities. Insurance is needed for prescription medications and follow-up visits with specialists. Among racial/ethnic minority patients hospitalized with heart failure (HF), it is not well studied whether the Affordable Care Act (ACA) Medicaid Expansion was associated with increased receipt of guideline-directed medical treatment (GDMT) on discharge from HF hospitalization.
Methods:
Using Get With The Guidelines-HF registry, logistic regression models were used to assess the odds of receiving GDMT [angiotensin converting enzyme inhibitor(ACE)/ angiotensin receptor blocker (ARB)/ angiotensin receptor-neprilysin inhibitor(ARNI); beta blocker; aldosterone antagonist; hydralazine/nitrate; HF education; HF follow-up appointment] in early adopter versus non-adopter states in the periods before (2012-2013) and after ACA Medicaid Expansion (2014-2019) within each race/ethnicity. Models were adjusted for patient-level covariates and generalized estimating equations addressed within-hospital clustering. The interaction (p-int) between adopter state status and timing of ACA Medicaid Expansion (2014) was evaluated.
Results:
Among 271,606 patients (57.5% early adopter, 42.5% non-adopter states), 65.5% were White, 22.8% were African-American, 8.9% were Hispanic, and 2.9% were Asian. In fully adjusted analyses, ACA Medicaid Expansion was associated with significant likelihood of receipt of ACE/ARB/ARNI at discharge in Hispanics [before ACA: OR 0.40 (95% CI: 0.13, 1.23); after ACA: OR 2.46 (95% CI 1.10, 5.51); p-int <0.01]. Asians were more likely to receive a HF follow-up appointment [before ACA: OR 0.64 (0.20, 2.06); after ACA: OR 1.44 (0.50, 4.15); p-int 0.03]. No significant differences were found in receipt of GDMT at the time of ACA Medicaid Expansion for other racial/ethnic groups. Independent of timing of ACA, Hispanics were more likely to receive all GDMT if they resided in an early adopter state compared to non-adopter state (p<0.01). Individual evidence-based treatments varied by state group independent of ACA timing for other racial/ethnic groups. With the exception of ACE/ARB/ARNI, beta blockers, and HF follow-up, <60% of patients in both state groups received other forms of GDMT despite eligibility.
Conclusions:
Among patients hospitalized with HF at centers voluntarily participating in a national quality improvement program, the ACA Medicaid Expansion was associated with increased receipt of ACE/ARB/ARNI in Hispanics, and increased receipt of follow-up appointments in Asians. Independent of the ACA, Hispanics residing in early adopter states were more likely to receive GDMT than Hispanics in non-adopter states. Futher expansion of ACA may reduce racial/ethnic disparities in HF; however, additional steps must be taken to overcome barriers to prescribing GDMT to all.
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Affiliation(s)
| | - Haolin Xu
- Duke Clinical Rsch Institute, Durham, NC
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Breathett KK, Xu H, Sweitzer NK, Calhoun E, Matsouaka R, Yancy CW, Fonarow GC, Devore AD, Bhatt DL, Peterson P. Abstract 384: Affordable Care Act Medicaid Expansion Then and Now: Racial/Ethnic Differences in Receipt of Guideline-Directed Medical Therapy During Heart Failure Hospitalizations. Circ Cardiovasc Qual Outcomes 2020. [DOI: 10.1161/hcq.13.suppl_1.384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Uninsurance is a known contributor to racial/ethnic minority health inequities. Insurance is needed for prescription medications and follow-up visits with specialists. Among racial/ethnic minority patients hospitalized with heart failure (HF), it is not well studied whether the Affordable Care Act (ACA) Medicaid Expansion was associated with increased receipt of guideline-directed medical treatment (GDMT) on discharge from HF hospitalization.
Methods:
Using Get With The Guidelines-HF registry, logistic regression models were used to assess the odds of receiving GDMT [angiotensin converting enzyme inhibitor(ACE)/ angiotensin receptor blocker (ARB)/ angiotensin receptor-neprilysin inhibitor(ARNI); beta blocker; aldosterone antagonist; hydralazine/nitrate; HF education; HF follow-up appointment] in early adopter versus non-adopter states in the periods before (2012-2013) and after ACA Medicaid Expansion (2014-2019) within each race/ethnicity. Models were adjusted for patient-level covariates and generalized estimating equations addressed within-hospital clustering. The interaction (p-int) between adopter state status and timing of ACA Medicaid Expansion (2014) was evaluated.
Results:
Among 271,606 patients (57.5% early adopter, 42.5% non-adopter states), 65.5% were White, 22.8% were African-American, 8.9% were Hispanic, and 2.9% were Asian. In fully adjusted analyses, ACA Medicaid Expansion was associated with significant likelihood of receipt of ACE/ARB/ARNI at discharge in Hispanics [before ACA: OR 0.40 (95% CI: 0.13, 1.23); after ACA: OR 2.46 (95% CI 1.10, 5.51); p-int <0.01]. Asians were more likely to receive a HF follow-up appointment [before ACA: OR 0.64 (0.20, 2.06); after ACA: OR 1.44 (0.50, 4.15); p-int 0.03]. No significant differences were found in receipt of GDMT at the time of ACA Medicaid Expansion for other racial/ethnic groups. Independent of timing of ACA, Hispanics were more likely to receive all GDMT if they resided in an early adopter state compared to non-adopter state (p<0.01). Individual evidence-based treatments varied by state group independent of ACA timing for other racial/ethnic groups. With the exception of ACE/ARB/ARNI, beta blockers, and HF follow-up, <60% of patients in both state groups received other forms of GDMT despite eligibility.
Conclusions:
Among patients hospitalized with HF at centers voluntarily participating in a national quality improvement program, the ACA Medicaid Expansion was associated with increased receipt of ACE/ARB/ARNI in Hispanics, and increased receipt of follow-up appointments in Asians. Independent of the ACA, Hispanics residing in early adopter states were more likely to receive GDMT than Hispanics in non-adopter states. Futher expansion of ACA may reduce racial/ethnic disparities in HF; however, additional steps must be taken to overcome barriers to prescribing GDMT to all.
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Affiliation(s)
| | - Haolin Xu
- Duke Clinical Rsch Institute, Durham, NC
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Breathett KK, Knapp SM, Wightman P, Desai A, Mazimba S, Calhoun E, Sweitzer NK. Is the Affordable Care Act Medicaid Expansion Linked to Change in Rate of Ventricular Assist Device Implantation for Blacks and Whites? Circ Heart Fail 2020; 13:e006544. [PMID: 32233662 DOI: 10.1161/circheartfailure.119.006544] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The Affordable Care Act (ACA) has been associated with increased heart transplant listings among blacks, who are disproportionately uninsured. It is unclear whether the ACA is also associated with increased ventricular assist device implantation in blacks. METHODS Using Healthcare Cost and Utilization Project Data State Inpatient Databases from 19 states and Washington DC, we analyzed 1157 patients from early-adopter states (ACA Medicaid expansion by January 2014) and 785 patients from nonadopter states (no implementation from 2013 to 2014). Piecewise Poisson regression with a discontinuity was used to estimate change in census-adjusted rates of ventricular assist device implants by race and ACA adopter status 1 year before and after January 2014. RESULTS Following the ACA Medicaid expansion, the proportional change in rate increased significantly among blacks from early adopter (1.40 [95% CI, 1.12-1.75], pre 0.57/100 000 to post-ACA 0.80/100 000) but not nonadopter states (1.25 [95% CI, 0.98-1.58], pre 0.40/100 000 to post-ACA 0.50/100 000). However, the early and nonadopter changes in implantation rates were not statistically different from each other (P=0.50). There were no immediate changes in whites in either state group following the ACA Medicaid expansion (early adopter, 1.12 [95% CI, 0.98-1.29], pre 0.27/100 000 to post-ACA 0.30/100 000; nonadopter, 0.98 [95% CI, 0.82-1.16], pre 0.27/100 000 to post-ACA 0.26/100 000). CONCLUSIONS Among eligible states participating in Healthcare Cost and Utilization Project Data State Inpatient Databases, the ACA was not associated with immediate changes in ventricular assist device implantation rates by race. Although a significant increase in implantation rate was observed among blacks from early-adopter states, the change was not statistically different from the change seen in nonadopter states.
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Affiliation(s)
- Khadijah K Breathett
- Division of Cardiovascular Medicine, Sarver Heart Center (K.K.B., N.K.S), University of Arizona, Tucson
| | - Shannon M Knapp
- Statistics Consulting Lab, Bio5 Institute (S.M.K.), University of Arizona, Tucson
| | - Patrick Wightman
- Center for Population Sciences (P.W., E.C.), University of Arizona, Tucson
| | - Archita Desai
- Division of Gastroenterology, Indiana University, Indianapolis (A.D.)
| | - Sula Mazimba
- Division of Cardiovascular Medicine, University of Virginia, Charlottesville (S.M.)
| | - Elizabeth Calhoun
- Center for Population Sciences (P.W., E.C.), University of Arizona, Tucson
| | - Nancy K Sweitzer
- Division of Cardiovascular Medicine, Sarver Heart Center (K.K.B., N.K.S), University of Arizona, Tucson
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Ilori TO, Viera E, Wilson J, Moreno F, Menon U, Ehiri J, Peterson R, Vemulapalli T, StimsonRiahi SC, Rosales C, Calhoun E, Sokan A, Karnes JH, Reiman E, Ojo A, Theodorou A, Ojo T. Approach to High Volume Enrollment in Clinical Research: Experiences from an All of Us Research Program Site. Clin Transl Sci 2020; 13:685-692. [PMID: 32004412 PMCID: PMC7359931 DOI: 10.1111/cts.12759] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 01/20/2020] [Indexed: 11/29/2022] Open
Abstract
Clinical trials and cohort studies are required to meet target recruitment of study participants within stipulated timelines, especially when the priority is to include populations traditionally unrepresented in biomedical research. By the third quarter of 2019, the University of Arizona‐Banner Health Provider Organization (UA‐Banner HPO) has enrolled > 30,000 core participants into the All of Us Research Program (AoURP), the research cohort of the Precision Medicine Initiative. The majority of enrolled participants meet the criteria for individuals under‐represented in biomedical research. The enrollment goals were calculated based on a target of 20,000 as set by the National Institutes of Health and our health provider organization achieved enrollment numbers between 17% and 86% above the targeted daily enrollment. We evaluated enrollment methods and challenges to enrollments encountered by the UA‐Banner Health Provider Organization into the AoURP. Challenges to enrollment centered around the need for high‐touch engagement methods, time investment necessary for stakeholder inclusion, and the use of purely digital enrollment methods especially in populations under‐represented in biomedical research. These challenges occurred at the level of the individual, provider, institutions, and community, and cumulatively impacted participant enrollment. Successful strategies for engagement and enrollment leveraged provider partners as advocates for the program. For high‐volume enrollment in clinical research, it is important to engage leaders in the healthcare setting, patient providers, and tailor engagement and enrollment to potential participant needs. We emphasize the need for precision engagement and enrollment methods tailored to individual needs.
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Affiliation(s)
- Titilayo O Ilori
- Renal Section, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Emma Viera
- Division of Public Health Practice and Translational Research, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, USA
| | - Jillian Wilson
- Department of Internal Medicine, Kansas University Medical Center, Kansas City, Kansas, USA
| | - Francisco Moreno
- Department of Psychiatry, College of Medicine, University of Arizona, Tucson, Arizona, USA
| | - Usha Menon
- College of Nursing, University of South Florida, Tampa, Florida, USA
| | - John Ehiri
- Department of Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, USA
| | | | - Tejo Vemulapalli
- Department of Medicine, College of Medicine Tucson, University of Arizona, Tucson, Arizona, USA
| | - Sara C StimsonRiahi
- Department of Medicine, College of Medicine Phoenix, University of Arizona, Tucson, Arizona, USA
| | - Cecilia Rosales
- Division of Public Health Practice and Translational Research, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, USA
| | - Elizabeth Calhoun
- Division of Community, Environment, and Policy of the UA Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, USA
| | - Amanda Sokan
- Division of Public Health Practice and Translational Research, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, USA
| | - Jason H Karnes
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, Arizona, USA
| | - Eric Reiman
- Banner Alzheimer's Institute, Phoenix, Arizona, USA
| | - Akinlolu Ojo
- Kansas University Medical Center, Kansas City, Kansas, USA
| | - Andreas Theodorou
- Department of Pediatrics, University of Arizona, Tucson, Arizona, USA.,Banner University Medical Group, Tucson, Arizona, USA
| | - Tammy Ojo
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Kansas University Medical Center, Kansas City, Kansas, USA
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MacPherson AH, Gomez J, Calhoun E, Borders M, Fitzpatrick K, Prado Y, Bezies-Lopez D, Hsu CH. Abstract P6-11-13: Identification of barriers to breast cancer screening that affect compliance. Cancer Res 2020. [DOI: 10.1158/1538-7445.sabcs19-p6-11-13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: In 2015, the latest year for which the Center for Disease Control (CDC) has incidence data, 242,476 new cases of Female Breast Cancer were reported, and 41,523 women died of Female Breast Cancer in the United States. For every 100,000 women, 125 new Female Breast Cancer cases were reported and 20 died of cancer. In Arizona, breast was the leading site of new cancers in 2015, with 110.9 new breast cancer diagnoses per 100,000 women, and is second for cancer deaths, reporting 19 deaths per 100,000 women. This study specifically addresses low screening rates among women in Pima County in Southern Arizona through a telephone navigation program with the goal of increasing follow-up mammograms and recommended breast imaging. Our short-term goal is to increase both initial screening and diagnostic resolution rates among women in Southern Arizona. Our long-term plan is to develop a sustainable model to increase breast cancer screening among women that is expected to inform programs state-wide and nationally. Specific aims are: 1) to increase adherence or repeat screening rate by 20% for women lost to follow-up; 2) Establish the framework for a community-academic partnership that can be replicated in other Hispanic-based areas. Methods: Potential study participants were identified using Electronic Health Records and categorized by Breast Imaging-Reporting and Data System (BI-RADS) 0 to 5. Inclusion criteria include non-compliant women of any race/ethnicity between the ages of 40 and 75 who have been referred to, or seen at a breast imaging clinic in Tucson, Arizona (Pima County) from January 1, 2014 to September 30, 2017. Of those non-compliant, 47% had a BI-RADS 0,3,4, or 5. With IRB approval from University of Arizona, we adapted a questionnaire validated for use in colon cancer to measure screening knowledge, motivations and barriers to adherence, and self-efficacy. Two navigators reached out to participants to recruit and re-engage them in the care process. Results: The sample is n=9661 of noncompliant patients from a clinic in Southern Arizona, 26% were Hispanic and 65% non-Hispanic, with 10% with 9% requiring an interpreter. From this sample, 123 study participants have been recruited (300 target accrual) with a 21% recruitment rate, 46% unable to reach rate, and a 47% decline rate. Notably, of those who declined, 66% reported being compliant at another clinic. The participants were 46% non-Hispanic and 52% Hispanic, with 25% requiring an English/Spanish interpreter. Nearly half had less than or a high school degree and similarly, nearly half had a monthly family income of $2000 or less. On the questionnaire section of knowledge, there were no statistically significant results indicating extensive knowledge, except for how often one should have a mammogram, in which 93% answered correctly. On the Barriers to Getting a Mammogram section, when the data was disaggregated by ethnicity, there was statistically significant (P⇒.05) responses. One barrier identified was financial reasons (P=.05), but interestingly no (0) Hispanics reported financial reasons to be a barrier. Conclusion: The high number of declined due to compliant elsewhere points to the need to develop a business case to sustain lay navigators across the breast cancer continuum, from screening to diagnostic resolution, treatment, survivorship, and/or palliative care. Further, breast cancer and breast screening education materials will be developed in the next phase of this study and interventions to address financial reasons. For more information on this study, please contact Drs. Jorge Gomez (Jorgejgomez@email.arizona.edu), Allison Huff MacPherson (allison7@email.arizona.edu).
Citation Format: Allison Huff MacPherson, Jorge Gomez, Elizabeth Calhoun, Marisa Borders, Kimberly Fitzpatrick, Yessenia Prado, Dora Bezies-Lopez, Chiu-Hsieh Hsu. Identification of barriers to breast cancer screening that affect compliance [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P6-11-13.
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Breathett K, Yee E, Pool N, Hebdon M, Crist JD, Knapp S, Larsen A, Solola S, Luy L, Herrera-Theut K, Zabala L, Stone J, McEwen MM, Calhoun E, Sweitzer NK. Does Race Influence Decision Making for Advanced Heart Failure Therapies? J Am Heart Assoc 2019; 8:e013592. [PMID: 31707940 PMCID: PMC6915287 DOI: 10.1161/jaha.119.013592] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Race influences medical decision making, but its impact on advanced heart failure therapy allocation is unknown. We sought to determine whether patient race influences allocation of advanced heart failure therapies. Methods and Results Members of a national heart failure organization were randomized to clinical vignettes that varied by patient race (black or white man) and were blinded to study objectives. Participants (N=422) completed Likert scale surveys rating factors for advanced therapy allocation and think‐aloud interviews (n=44). Survey results were analyzed by least absolute shrinkage and selection operator and multivariable regression to identify factors influencing advanced therapy allocation, including interactions with vignette race and participant demographics. Interviews were analyzed using grounded theory. Surveys revealed no differences in overall racial ratings for advanced therapies. Least absolute shrinkage and selection operator regression selected no interactions between vignette race and clinical factors as important in allocation. However, interactions between participants aged ≥40 years and black vignette negatively influenced heart transplant allocation modestly (−0.58; 95% CI, −1.15 to −0.0002), with adherence and social history the most influential factors. Interviews revealed sequential decision making: forming overall impression, identifying urgency, evaluating prior care appropriateness, anticipating challenges, and evaluating trust while making recommendations. Race influenced each step: avoiding discussing race, believing photographs may contribute to racial bias, believing the black man was sicker compared with the white man, developing greater concern for trust and adherence with the black man, and ultimately offering the white man transplantation and the black man ventricular assist device implantation. Conclusions Black race modestly influenced decision making for heart transplant, particularly during conversations. Because advanced therapy selection meetings are conversations rather than surveys, allocation may be vulnerable to racial bias.
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Affiliation(s)
- Khadijah Breathett
- Division of Cardiovascular Medicine Department of Medicine Sarver Heart Center University of Arizona Tucson AZ
| | - Erika Yee
- Sarver Heart Center, Clinical Research Office University of Arizona Tucson AZ
| | - Natalie Pool
- College of Nursing University of Arizona Tucson AZ
| | - Megan Hebdon
- College of Nursing University of Arizona Tucson AZ
| | | | - Shannon Knapp
- Statistics Consulting Lab Bio5 Institute University of Arizona Tucson AZ
| | - Ashley Larsen
- Sarver Heart Center, Clinical Research Office University of Arizona Tucson AZ
| | - Sade Solola
- Department of Medicine University of Arizona Tucson AZ
| | - Luis Luy
- University of Rochester Rochester New York U.S
| | | | | | - Jeff Stone
- Department of Psychology University of Arizona Tucson AZ
| | | | - Elizabeth Calhoun
- Center for Population Health Sciences University of Arizona Tucson AZ
| | - Nancy K Sweitzer
- Division of Cardiovascular Medicine Department of Medicine Sarver Heart Center University of Arizona Tucson AZ
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Prieto-Centurion V, Basu S, Bracken N, Calhoun E, Dickens C, DiDomenico RJ, Gallardo R, Gordeuk V, Gutierrez-Kapheim M, Hsu LL, Illendula S, Joo M, Kazmi U, Mutso A, Pickard AS, Pittendrigh B, Sullivan JL, Williams M, Krishnan JA. Design of the patient navigator to Reduce Readmissions (PArTNER) study: A pragmatic clinical effectiveness trial. Contemp Clin Trials Commun 2019; 15:100420. [PMID: 31440690 PMCID: PMC6700266 DOI: 10.1016/j.conctc.2019.100420] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 06/03/2019] [Accepted: 07/18/2019] [Indexed: 11/29/2022] Open
Abstract
Previous work indicates the potential for community health workers and peer coaches serving as patient navigators to improve processes of care and health outcomes during care transitions, but have not been sufficiently tested to determine if such programs improve measures of patient experience in minority serving institutions. The objectives of the Patient Navigator to Reduce Readmissions (PArTNER) study was to: 1) conduct a pragmatic clinical effectiveness trial comparing a multi-faceted, stakeholder-supported Navigator intervention (in-person CHW visits in the hospital and after hospital discharge, plus telephone-based peer coaching) versus usual care on the experience of hospital-to-home care transitions in patients hospitalized with heart failure, pneumonia, chronic obstructive pulmonary disease, myocardial infarction, or sickle cell disease; 2) examine the effectiveness of the Navigator intervention in patient subgroups; and 3) understand the barriers and facilitators of successfully implementing the Navigator intervention across patient populations. The co-primary outcomes are the 30-day changes in: 1) Patient Reported Outcomes Measurement Information System (PROMIS) emotional distress-anxiety, and 2) PROMIS informational support. Secondary outcomes at 30 and 60 days include other PROMIS health measures and hospital readmissions. Innovative features of the PArTNER study include early and continuous engagement of patients, their caregivers, clinicians, health system administrators, and other stakeholders to inform the design and implementation of the Navigator intervention. In this report, we describe the design of the PArTNER study.
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Affiliation(s)
- Valentin Prieto-Centurion
- Breathe Chicago Center, Department of Medicine, College of Medicine, University of Illinois at Chicago, United States
| | - Sanjib Basu
- Department of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, United States
| | - Nina Bracken
- Population Health Sciences Program and Breathe Chicago Center, Department of Medicine, College of Medicine, University of Illinois at Chicago, United States
| | | | - Carolyn Dickens
- Department of Medicine, College of Medicine, University of Illinois at Chicago, United States
| | - Robert J. DiDomenico
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, United States
| | - Richard Gallardo
- Population Health Sciences Program, University of Illinois at Chicago, United States
| | - Victor Gordeuk
- Department of Medicine, College of Medicine, University of Illinois at Chicago, United States
| | - Melissa Gutierrez-Kapheim
- Department of Community Health Sciences, School of Public Health, University of Illinois at Chicago, United States
| | - Lewis L. Hsu
- Department of Pediatrics, College of Medicine, University of Illinois at Chicago, United States
| | - Sai Illendula
- Population Health Sciences Program, University of Illinois at Chicago, United States
| | - Min Joo
- Department of Medicine, College of Medicine, University of Illinois at Chicago, United States
| | - Uzma Kazmi
- American Academy of Sleep Medicine, United States
| | - Amelia Mutso
- College of Medicine, University of Illinois at Chicago, United States
| | - A. Simon Pickard
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, United States
| | | | | | | | - Jerry A. Krishnan
- Population Health Sciences Program, And the Breathe Chicago Center, Department of Medicine, College of Medicine, University of Illinois at Chicago, United States
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Breathett K, Allen LA, Helmkamp L, Colborn K, Daugherty SL, Blair IV, Jones J, Khazanie P, Mazimba S, McEwen M, Stone J, Calhoun E, Sweitzer NK, Peterson PN. Temporal Trends in Contemporary Use of Ventricular Assist Devices by Race and Ethnicity. Circ Heart Fail 2019; 11:e005008. [PMID: 30021796 DOI: 10.1161/circheartfailure.118.005008] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 06/25/2018] [Indexed: 01/14/2023]
Abstract
BACKGROUND The proportion of racial/ethnic minorities receiving ventricular assist devices (VADs) has previously been less than expected. It is unclear if trends have changed since the broadening of access to insurance in 2014 and the rapid adoption of VAD technology. METHODS AND RESULTS Using the Interagency Registry of Mechanically Assisted Circulatory Support, we analyzed time trends by race/ethnicity for 10 795 patients (white, 67.4%; African-American, 24.8%; Hispanic, 6.3%; Asian, 1.5%) who had a VAD implanted between 2012 and 2015. Linear models were fit to the annual census-adjusted rate of VAD implantation for each racial/ethnic group, stratified by sex and age group. From 2012 to 2015, African-Americans had an increase in the census-adjusted annual rate of VAD implantation per 100 000 (0.26 [95% confidence interval, 0.17-0.34]) while other ethnic groups exhibited no significant changes (white: 0.06 [-0.03 to 0.14]; Hispanic: 0.04 [-0.05 to 0.12]; Asian: 0.04 [-0.04 to 0.13]). Stratified by sex, rates increased in both African-American men and women (P<0.05), but the change in rate was highest among African-American men (men 0.37 [0.28-0.46]; women 0.16 [0.07-0.25]; interaction with sex P=0.004). Stratified by age group, rates increased in African-Americans aged 40 to 69 years and Asians aged 50 to 59 years (P<0.05). The observed differential change in VAD implantation rate by age group was significant among African-Americans (interaction with age, P<0.01) and Asians (interaction with age, P=0.02). CONCLUSIONS From 2012 to 2015, VAD implantation rates increased among African-Americans but not other racial/ethnic groups. The greatest increase in rate was observed among middle-aged African-American men, suggesting a decline in racial disparities. Further investigation is warranted to reduce disparities among women and older racial/ethnic minorities.
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Affiliation(s)
| | - Larry A Allen
- University of Arizona, Tucson. Division of Cardiology, Anschutz Medical Campus (L.A.A., S.L.D., P.K., P.N.P.)
| | - Laura Helmkamp
- University of Colorado, Aurora. University of Colorado Adult and Child Consortium for Health Outcomes Research and Delivery Science, Aurora (L.H.)
| | - Kathryn Colborn
- Department of Biostatistics and Informatics, Colorado School of Public Health, Anschutz Medical Campus (K.C.)
| | - Stacie L Daugherty
- University of Arizona, Tucson. Division of Cardiology, Anschutz Medical Campus (L.A.A., S.L.D., P.K., P.N.P.)
| | | | | | - Prateeti Khazanie
- University of Arizona, Tucson. Division of Cardiology, Anschutz Medical Campus (L.A.A., S.L.D., P.K., P.N.P.)
| | - Sula Mazimba
- Division of Cardiology, University of Virginia Health System, Charlottesville (S.M.)
| | - Marylyn McEwen
- Division of Community and Systems Health Science, Department of Nursing (M.M.)
| | | | | | - Nancy K Sweitzer
- Division of Cardiovascular Medicine, Sarver Heart Center (K.B., N.K.S.)
| | - Pamela N Peterson
- University of Arizona, Tucson. Division of Cardiology, Anschutz Medical Campus (L.A.A., S.L.D., P.K., P.N.P.)
- Denver Health Medical Center, CO (P.N.P.)
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Huff AJ, Gomez J, Calhoun E, Hsu CH, Chalasani P, Fitzpatrick K, Borders M, Lang L, Prado Y. Abstract P5-13-19: Addressing non-adherence for breast cancer screening across ethnicity in southern Arizona. Cancer Res 2019. [DOI: 10.1158/1538-7445.sabcs18-p5-13-19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background In Arizona, female breast cancer has the highest incidence rate and the second highest death rate compared to all other cancers. This ongoing single arm intervention study investigates non-adherence with recommended annual mammography or follow-up breast imaging. Data collected for this study is both retrospective, using the university Electronic Health Record (EHR) system (January 1, 2014 to September 30, 2017), and prospective, implementing a questionnaire during the intervention phase. Potential study participants were identified using EHR and categorized by BI-RADS (Breast Imaging-Reporting and Data System) 0 to 5. With IRB approval from University of Arizona, we designed a questionnaire to measure barriers to adherence and we navigate participants to schedule and attend follow-up appointments. This study's overall specific aims are to increase first time mammography screening by 25% among women in Southern Arizona; increase adherence or repeat screening rate by 20% among women lost to follow-up; establish the framework for a community- academic partnership in ethnically diverse areas. Women, age 40 and older who are not compliant with recommended annual mammograms or recommended follow-up screenings after a suspicious finding are eligible to participate in this study. Men and children, as well as women for whom breast imaging is not recommended are excluded from participating in this study. Results Patient's age was summarized by mean ± standard deviation for continuous variables and frequency and the associated percentage for categorical variables. BI-RADS scores were classified into Negative, Benign, Possible Malignancy and Proven Malignancy and compared between ethnic and racial groups using Fisher's exact test. Of 8823 non-compliant woman over nearly 4 years of data, 0.2% are BI-RADS 4 and 5, 2.2% are BI-RADS 3, 96% are BI-RADS 1 and 2, and 0.3% are BI-RADS 0. The mean age is 61.59 years, with 25% reporting as Hispanic, 66% reporting as non-Hispanic women (NHW), and 10% preferring to receive care in Spanish. Initial data shows only .24% with proven malignancies. Further, the data reveals that Hispanics have a slightly higher rate of possible malignancy (.36%) than NHW (.18%); however, NHW show a slightly higher rate of proven malignancy (.27% compared to .18%, respectively). Discussion These data provide valuable information for the direction of this study; in particular, understanding the disparity between Hispanic and NHW malignancies and developing culturally competent interventions and education materials to increase compliance with breast cancer screening recommendations. Further, these data indicate our focus should be on screening compliance for BI-RADS 1 and 2. These data also point to a possible high non-compliance issue. Comparing non-compliance data from other regional clinics will continue to shape this study's direction. The target sample size for this study is 300 participants. We accept a 95% confidence level and a 5% margin of error. Out of 420 recruitment letters mailed, the navigators have reached 152 potential participants by phone and have a 26% study recruitment rate (n=40).
Citation Format: Huff AJ, Gomez J, Calhoun E, Hsu C-H, Chalasani P, Fitzpatrick K, Borders M, Lang L, Prado Y. Addressing non-adherence for breast cancer screening across ethnicity in southern Arizona [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-13-19.
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Affiliation(s)
- AJ Huff
- University of Arizona, Tucson, AZ
| | - J Gomez
- University of Arizona, Tucson, AZ
| | | | - C-H Hsu
- University of Arizona, Tucson, AZ
| | | | | | | | - L Lang
- University of Arizona, Tucson, AZ
| | - Y Prado
- University of Arizona, Tucson, AZ
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Ford ME, Bryant DC, Cartmell KB, Sterba K, Burshell DR, Hill EG, Toma AD, Knight KD, Weaver K, Calhoun E, Esnaola NF. Abstract A23: Interim Recruitment Outcomes in an NCORP-Based Patient Navigation Trial for African Americans with Early Stage Lung Cancer. Cancer Epidemiol Biomarkers Prev 2018. [DOI: 10.1158/1538-7755.disp17-a23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Abstract
Background: Enrollment of early-stage lung cancer patients to randomized trials has historically been challenging. The STARS Trial enrolled 36 of 1,030 intended patients from 28 sites, while the ROSEL Trial recruited 22 of 960 intended patients from 10 sites. Unfortunately, evidence shows African Americans with early-stage non-small cell lung cancer (NSCLC) are significantly less likely than their European American counterparts to undergo resection and may also be less likely to participate in lung cancer trials as well.
Purpose: The purpose of this research is to describe interim recruitment results from an NIMHD-funded, NCI NCORP-based patient navigation trial conducted with African Americans with early-stage, probable/proven NSCLC.
Design: The protocol-driven, barriers-focused patient navigation intervention is being conducted in the context of a two-arm cluster-randomized trial testing the effectiveness of the intervention in increasing rates of lung-directed curative-intent therapy (surgery and SBRT) in African Americans with Stage I-II NSCLC. The two study arms consist of the protocol-driven, intensive navigation intervention vs. usual care. The trial includes 24 study sites in 13 U.S. states. Specific activities to enhance recruitment in the present trial include reaching out to referring physicians (e.g., primary care, pulmonologists, radiologists) to increase referrals of African American patients to the participating NCORP sites, and partnering with the leaders of community-engagement activities at the sites to raise community-level awareness of the trial.
Results/Conclusions: To date, 90 African American patients have been recruited and the trial is now on target to meet its expected accrual goal of 200 patients. The majority of potential participants were ineligible due to receipt of surgical resection or radiation therapy prior to enrollment (27%), not having been told that they had probable/proven NSCLC prior to study contact (32%), or a previous history of lung cancer (10%). Only 13 potential participants have refused trial participation. The median age of the 90 participants is 66 years (range 51-86 years). Most are unmarried (64%) and have a high school diploma or less (73%). Only 10 of the participants (24%) have no comorbidities. The number of enrolled-to-date African American participants in this ongoing trial exceeds the total number of participants recruited to the STARS Trial or to the ROSEL Trial.
Citation Format: Marvella E. Ford, Debbie C. Bryant. Kathleen B. Cartmell, Katherine Sterba, Dana R. Burshell, Elizabeth G. Hill, Allan De Toma, Kendrea D. Knight, Kathryn Weaver Elizabeth Calhoun, Nestor F. Esnaola. Interim Recruitment Outcomes in an NCORP-Based Patient Navigation Trial for African Americans with Early Stage Lung Cancer [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr A23.
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Affiliation(s)
- Marvella E. Ford
- 1Medical University of South Carolina (MUSC), Charleston, SC,
- 2MUSC Hollings Cancer Center, Charleston, SC,
| | - Debbie C. Bryant
- 1Medical University of South Carolina (MUSC), Charleston, SC,
- 2MUSC Hollings Cancer Center, Charleston, SC,
- 3MUSC College of Nursing, Charleston, SC,
| | - Kathleen B. Cartmell
- 1Medical University of South Carolina (MUSC), Charleston, SC,
- 2MUSC Hollings Cancer Center, Charleston, SC,
- 3MUSC College of Nursing, Charleston, SC,
| | - Katherine Sterba
- 1Medical University of South Carolina (MUSC), Charleston, SC,
- 2MUSC Hollings Cancer Center, Charleston, SC,
| | - Dana R. Burshell
- 1Medical University of South Carolina (MUSC), Charleston, SC,
- 2MUSC Hollings Cancer Center, Charleston, SC,
- 3MUSC College of Nursing, Charleston, SC,
| | - Elizabeth G. Hill
- 1Medical University of South Carolina (MUSC), Charleston, SC,
- 2MUSC Hollings Cancer Center, Charleston, SC,
| | - Allan De Toma
- 1Medical University of South Carolina (MUSC), Charleston, SC,
- 2MUSC Hollings Cancer Center, Charleston, SC,
| | - Kendrea D. Knight
- 1Medical University of South Carolina (MUSC), Charleston, SC,
- 2MUSC Hollings Cancer Center, Charleston, SC,
- 3MUSC College of Nursing, Charleston, SC,
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Valverde PA, Calhoun E, Esparza A, Wells KJ, Risendal BC. The early dissemination of patient navigation interventions: results of a respondent-driven sample survey. Transl Behav Med 2018; 8:456-467. [PMID: 29800405 DOI: 10.1093/tbm/ibx080] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Patient navigators (PNs) coordinate medical services and connect patients with resources to improve outcomes, satisfaction, and reduce costs. Little national information is available to inform workforce development. We analyzed 819 responses from an online PN survey conducted in 2009-2010. Study variables were mapped to the five Consolidated Framework for Implementation Research (CFIR) constructs to explore program variations by type of PN. Five logistic regression models compared each PN type to all others while adjusting for covariates. Thirty-five percent of respondents were nurse navigators, 28% lay navigators, 20% social work (SW)/counselor navigators, 7% allied health navigators, and 10% were "other" types of PNs. Most were non-Hispanic White (71%), female (94%), and at least college educated (70%). The primary differences were observed among: the core intervention tasks; position structure; work setting; health conditions navigated; navigator race/ethnicity; personal cancer experiences; navigation training; and patient populations served. Lay PNs had fewer odds of identifying as Hispanic, work in rural settings and assist underserved populations compared to others. Nurse navigators showed greater odds of clinical responsibilities, work in hospital or government settings and fewer odds of navigating minority populations compared to others. SW/counselor navigators also had additional duties, provided greater assistance to Medicare patient populations, and less odds of navigating underserved populations than others. In summary, our survey indicates that the type of PN utilized is an indicator of other substantial differences in program implementation. CFIR provides a robust method to compare differences and should incorporate care coordination outcomes in future PN research.
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Affiliation(s)
- Patricia A Valverde
- Department of Community and Behavioral Health, School of Public Health, Aurora, CO
| | - Elizabeth Calhoun
- University of Arizona, Office of the Senior Vice President for Health Sciences, Vice President for Population Health Sciences, Executive Director, Center for Population Science and Discovery, Roy P. Drachman Hall, Tucson, AZ
| | - Angelina Esparza
- Executive Staff Analyst/Chief Program Officer, Houston Department for Health and Human Services, Houston, TX
| | - Kristen J Wells
- Department of Psychology, San Diego State University, San Diego, CA
| | - Betsy C Risendal
- Department of Community and Behavioral Health, Colorado School of Public Health, Aurora, CO
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Ursan ID, Krishnan JA, Pickard AS, Calhoun E, DiDomenico R, Prieto-Centurion V, Sullivan JB, Valentino L, Williams MV, Joo M. Engaging Patients and Caregivers to Design Transitional Care Management Services at a Minority Serving Institution. J Health Care Poor Underserved 2018; 27:352-365. [PMID: 27763474 DOI: 10.1353/hpu.2016.0026] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Limited socioeconomic resources contribute to high readmission rates at minority serving institutions (MSIs). A better understanding of patient-level factors and need for patient navigators could inform approaches to enhance care transitions tailored to these vulnerable patient populations. We sought to understand the perspectives of patients and their caregivers about hospital to home transitions from an MSI, as well as their attitudes about patient navigators to facilitate care transitions. We conducted qualitative research using focus groups (FGs)-five disease-specific patient FGs and two caregiver FGs, including 23 patients and 10 caregivers. Findings support the need for additional services to address: (1) gaps in the hospital discharge; (2) socioeconomic resources; (3) access to post-discharge care; (4) patient's health care seeking behaviors; (5) patient anxiety; (6) self-management education; and (7) social supports for patients and caregivers. While caregivers uniformly expressed interest in patient navigators, support for navigators among patients was more variable.
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Ford ME, Bryant DC, Cartmell KB, Sterba K, Burshell DR, Hill EG, Toma AD, Knight KD, Weaver K, Calhoun E, Esnaola NF. Abstract A72: Interim Recruitment Outcomes in an NCORP-Based Patient Navigation Trial for African Americans with Early Stage Lung Cancer. Cancer Epidemiol Biomarkers Prev 2017. [DOI: 10.1158/1538-7755.disp16-a72] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Abstract
BACKGROUND: Enrollment of early stage lung cancer patients to randomized trials has historically been challenging. The STARS Trial enrolled 36 of 1,030 intended patients from 28 sites, while the ROSEL Trial recruited 22 of 960 intended patients from 10 sites. Unfortunately, evidence shows African Americans with early stage, NSCLC are significantly less likely than their European American counterparts to undergo resection and may also be less likely to participate in lung cancer trials as well.
PURPOSE: The purpose of this research is to describe interim recruitment results from an NIMHD-funded, NCI NCORP-based patient navigation trial conducted with African Americans with early stage, probable/proven non-small cell lung cancer (NSCLC).
DESIGN: The protocol-driven, barriers-focused patient navigation intervention is being conducted in the context of a two-arm cluster-randomized trial testing the effectiveness of the intervention in increasing rates of lung-directed curative-intent therapy (surgery and SBRT) in African Americans with Stage I-II NSCLC. The 2 study arms consist of the protocol-driven, intensive navigation intervention vs. usual care. The trial includes 24 study sites in 13 US states. Specific activities to enhance recruitment in the present trial include reaching out to referring physicians (e.g., primary care, pulmonologists, radiologists) to increase referrals of African American patients to the participating NCORP sites, and partnering with the leaders of community engagement activities at the sites to raise community-level awareness of the trial.
RESULTS/CONCLUSIONS: To date, 64 African American patients have been recruited and the trial is now on target to meet its expected accrual goal of 200 patients. The majority of potential participants were ineligible due to receipt of surgical resection or radiation therapy prior to enrollment (32%), not having been told that they had probable/proven NSCLC prior to study contact (13%) or a previous history of lung cancer (13%). Only 9 potential participants have refused trial participation. The median age of the 64 participants is 64 years (range 37-86 years). Most are unmarried (64%) and have a high school diploma or less (72%). Only 13 of the participants (20%) have no comorbidities. The number of enrolled-to-date African American participants in this ongoing trial exceeds the total number of participants recruited to the STARS Trial or to the ROSEL Trial.
Citation Format: Marvella E. Ford, Debbie C. Bryant, Kathleen B. Cartmell, Katherine Sterba, Dana R. Burshell, Elizabeth G. Hill, Allan De Toma, Kendrea D. Knight, Kathryn Weaver, Elizabeth Calhoun, Nestor F. Esnaola. Interim Recruitment Outcomes in an NCORP-Based Patient Navigation Trial for African Americans with Early Stage Lung Cancer. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr A72.
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Affiliation(s)
- Marvella E. Ford
- 1Medical University of South Carolina (MUSC) Hollings Cancer Center, Charleston, SC,
| | - Debbie C. Bryant
- 2Medical University of South Carolina (MUSC) College of Nursing, Charleston, SC,
| | - Kathleen B. Cartmell
- 2Medical University of South Carolina (MUSC) College of Nursing, Charleston, SC,
| | - Katherine Sterba
- 1Medical University of South Carolina (MUSC) Hollings Cancer Center, Charleston, SC,
| | - Dana R. Burshell
- 2Medical University of South Carolina (MUSC) College of Nursing, Charleston, SC,
| | - Elizabeth G. Hill
- 1Medical University of South Carolina (MUSC) Hollings Cancer Center, Charleston, SC,
| | - Allan De Toma
- 1Medical University of South Carolina (MUSC) Hollings Cancer Center, Charleston, SC,
| | - Kendrea D. Knight
- 1Medical University of South Carolina (MUSC) Hollings Cancer Center, Charleston, SC,
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Gunn C, Battaglia TA, Parker VA, Clark JA, Paskett ED, Calhoun E, Snyder FR, Bergling E, Freund KM. What Makes Patient Navigation Most Effective: Defining Useful Tasks and Networks. J Health Care Poor Underserved 2017; 28:663-676. [DOI: 10.1353/hpu.2017.0066] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Battaglia TA, Darnell JS, Ko N, Snyder F, Paskett ED, Wells KJ, Whitley EM, Griggs JJ, Karnad A, Young H, Warren-Mears V, Simon MA, Calhoun E. The impact of patient navigation on the delivery of diagnostic breast cancer care in the National Patient Navigation Research Program: a prospective meta-analysis. Breast Cancer Res Treat 2016; 158:523-34. [PMID: 27432417 PMCID: PMC5216421 DOI: 10.1007/s10549-016-3887-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 06/17/2016] [Indexed: 11/26/2022]
Abstract
Patient navigation is emerging as a standard in breast cancer care delivery, yet multi-site data on the impact of navigation at reducing delays along the continuum of care are lacking. The purpose of this study was to determine the effect of navigation on reaching diagnostic resolution at specific time points after an abnormal breast cancer screening test among a national sample. A prospective meta-analysis estimated the adjusted odds of achieving timely diagnostic resolution at 60, 180, and 365 days. Exploratory analyses were conducted on the pooled sample to identify which groups had the most benefit from navigation. Clinics from six medical centers serving vulnerable populations participated in the Patient Navigation Research Program. Women with an abnormal breast cancer screening test between 2007 and 2009 were included and received the patient navigation intervention or usual care. Patient navigators worked with patients and their care providers to address patient-specific barriers to care to prevent delays in diagnosis. A total of 4675 participants included predominantly racial/ethnic minorities (74 %) with public insurance (40 %) or no insurance (31 %). At 60 days and 180 days, there was no statistically significant effect of navigation on achieving timely diagnostic care, but a benefit of navigation was seen at 365 days (aOR 2.12, CI 1.36-3.29). We found an equal benefit of navigation across all groups, regardless of race/ethnicity, language, insurance status, and type of screening abnormality. Patient navigation resulted in more timely diagnostic resolution at 365 days among a diverse group of minority, low-income women with breast cancer screening abnormalities. Trial registrations clinicaltrials.gov Identifiers: NCT00613275, NCT00496678, NCT00375024, NCT01569672.
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Affiliation(s)
- Tracy A Battaglia
- Women's Health Unit, Section of General Internal Medicine, Boston Medical Center and Boston University School of Medicine, 801 Massachusetts Avenue, Crosstown Building 1st Floor, Boston, MA, 02118, USA.
| | - Julie S Darnell
- Department of Public Health Sciences, Stritch School of Medicine, Loyola University Chicago, 2160 S. First Avenue, Bldg 115, Room 556, Maywood, IL, 60153, USA
| | - Naomi Ko
- Section of Hematology Oncology, Boston University School of Medicine, 801 Massachusetts Avenue, First Floor, Boston, MA, 02118, USA
| | - Fred Snyder
- NOVA Research Company, 801 Roeder Road, Suite 700, Silver Spring, MD, 20910, USA
| | - Electra D Paskett
- Division of Cancer Prevention and Control, Department of Internal Medicine, College of Medicine and Comprehensive Cancer Center, The Ohio State University, 1590 North High Street, Columbus, OH, 43201, USA
| | - Kristen J Wells
- Department of Psychology, San Diego State University, 6363 Alvarado Ct., Ste. 103, San Diego, CA, 92120-4913, USA
| | - Elizabeth M Whitley
- Colorado Department of Public Health and Environment, 4300 Cherry Creek Drive South, Denver, CO, 80246, USA
| | - Jennifer J Griggs
- University of Michigan School of Public Health, 2800 Plymouth Road, Building 16, 116 W, Ann Arbor, MI, 48109, USA
| | - Anand Karnad
- Division of Hematology-Oncology, Cancer Therapy & Research Center (CTRC), UT Health Science Center, 7979 Wurzbach Rd., San Antonio, TX, 78229, USA
| | - Heather Young
- George Washington University Cancer Institute, 950 New Hampshire Ave. NW 5th Floor, Washington, DC, 20052, USA
| | - Victoria Warren-Mears
- Northwest Portland Area Indian Health Board, 2121 SW Broadway, Suite 300, Portland, OR, 97201, USA
| | - Melissa A Simon
- Northwestern University Feinberg School of Medicine, 633 N. St Clair, Suite 1800, Chicago, IL, 60611, USA
| | - Elizabeth Calhoun
- University of Arizona Health Sciences, 550 East Van Buren, Phoenix, AZ, 85004-2230, USA
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Esnaola NF, Bryant DC, Cartmell KB, Calhoun E, Sterba K, Burshell DR, Hill EG, Wahlquist AE, Knight KD, Ford ME. Abstract C45: A patient navigation model to increase rates of lung-directed therapy with curative intent (LDTCI) in African Americans with early stage non-small cell lung cancer (NSCLC). Cancer Epidemiol Biomarkers Prev 2016. [DOI: 10.1158/1538-7755.disp15-c45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Abstract
Background: LDTCI (i.e., surgical resection or stereotactic body radiation therapy [SBRT] in patients who are not surgical candidates]) is the standard of care for patients with early stage NSCLC. Unfortunately, African Americans with early stage, NSCLC are significantly less likely than their European American counterparts to undergo resection.
Purpose: This presentation will describe the design of an NIH/NIMHD-funded, NCORP-sponsored, cluster-randomized trial testing the effectiveness of a barriers-focused, protocol-driven patient navigation intervention on increasing rates of LDTCI in African Americans with early stage, probable/proven NSCLC.
Design: The trial is currently being conducted at 13 study sites across the United States. The investigators developed an electronic, web-based version of the NIH/NCI Patient Navigation Barrier Checklist. Patient navigators at each intervention site use the electronic Checklist to identify patient barriers to care and guide their interactions with patients. The navigators then enter the data from these interactions into a secure, web-based electronic data management system.
Results/Conclusions: Most of the African American patients at the study sites are ineligible for study participation due to advanced stage at diagnosis. Of the 2,529 patients who have been pre-screened for study eligibility to date, only 43 (1.7%) were determined to be African American with likely/proven stage I-II NSCLC. Of this number, 34 (79.1%) were consented for the study, and 29 are currently enrolled. During this presentation, the investigators will present de-identified case examples of barriers experienced by patients and the strategies used by the navigators to overcome these barriers. Plans are underway to add study sites to increase the denominator of potentially eligible participants.
Citation Format: Nestor F. Esnaola, Debbie C. Bryant, Kathleen B. Cartmell, Elizabeth Calhoun, Katherine Sterba, Dana R. Burshell, Elizabeth G. Hill, Amy E. Wahlquist, Kendrea D. Knight, Marvella E. Ford. A patient navigation model to increase rates of lung-directed therapy with curative intent (LDTCI) in African Americans with early stage non-small cell lung cancer (NSCLC). [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr C45.
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Affiliation(s)
| | - Debbie C. Bryant
- 2Medical University of South Carolina (MUSC) Hollings Cancer Center, Charleston, SC,
| | - Kathleen B. Cartmell
- 3Medical University of South Carolina (MUSC) College of Nursing, Charleston, SC,
| | | | - Katherine Sterba
- 2Medical University of South Carolina (MUSC) Hollings Cancer Center, Charleston, SC,
| | - Dana R. Burshell
- 3Medical University of South Carolina (MUSC) College of Nursing, Charleston, SC,
| | - Elizabeth G. Hill
- 2Medical University of South Carolina (MUSC) Hollings Cancer Center, Charleston, SC,
| | - Amy E. Wahlquist
- 2Medical University of South Carolina (MUSC) Hollings Cancer Center, Charleston, SC,
| | - Kendrea D. Knight
- 2Medical University of South Carolina (MUSC) Hollings Cancer Center, Charleston, SC,
| | - Marvella E. Ford
- 2Medical University of South Carolina (MUSC) Hollings Cancer Center, Charleston, SC,
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Kim S, Molina Y, Glassgow AE, Berrios N, Guadamuz J, Calhoun E. The effects of navigation and types of neighborhoods on timely follow-up of abnormal mammogram among black women. ACTA ACUST UNITED AC 2015; 2015. [PMID: 26949738 DOI: 10.18103/mra.v0i3.111] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Despite the availability of relatively simple and inexpensive screening tools, minority women are more often diagnosed at a late stage of breast cancer, in part due to delays in follow-up of abnormal screening result. One of the key factors for timely follow-up of abnormal mammogram may be neighborhood characteristics. Patient Navigation (PN) programs aim to diminish barriers, but its differential effects by neighborhood have not been fully examined. The current study examines the effect of types of neighborhoods on time to follow-up of abnormal mammogram, and the differential effects of PN by neighborhood characteristics. METHODS We examined data from a total of 1,696 randomized patients from a randomized controlled trial, "the Patient Navigation in Medically Underserved Areas" study that explored the effect of navigation on breast health outcomes. We categorized participants' neighborhoods into three categories and compared the effect of navigation between these neighborhood types. RESULTS Navigated women in mixed race neighborhoods had a shorter time to follow-up compared with non-navigated women in the neighborhoods. Black women living in mixed neighborhoods had a significant longer time to follow-up of abnormal mammogram, compared with black women living in middle class black neighborhoods. CONCLUSION Patient navigation interventions improve timely follow-up of abnormal mammogram. Patient navigation may be particularly beneficial for minority women who reside in racially heterogeneous neighborhoods which may be less likely to have access to affordable health clinics and social services. Health policies concerning breast cancer early detection for minority women need to pay further attention to those who might potentially be excluded from health services due to the characteristics of neighborhoods. Socioeconomic conditions of neighborhood may affect individual health through multiple interlinked mechanisms. Neighborhood characteristics, such as poverty, segregation, access to resources, and social cohesion, cannot be fully understood with simplistic measures of neighborhood disadvantage.
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Kim S, Molina Y, Berriors N, Calhoun E. Abstract B72: Timely breast cancer diagnostic resolution: Effects of individual and neighborhood characteristics. Cancer Epidemiol Biomarkers Prev 2014. [DOI: 10.1158/1538-7755.disp13-b72] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Abstract
Background: Disparities occur throughout the breast cancer continuum. African American women are more likely to be diagnosed with cancer at later stages, which results in poorer outcomes. In fact, despite lower incidence, the mortality rates are higher among black women.
While timely follow-up of abnormal breast cancer diagnostic test results could lead to early diagnosis and better treatment outcomes, a myriad of factors may influence timely diagnostic resolution, even with patient navigation in place. Individual and neighborhood socioeconomic characteristics affect access to care, quality, and timeliness of care, which consequently affect health outcomes.
In this study, we focus on the effects of neighborhood racial composition and poverty on timeliness of diagnostic test in African American women living in relatively poor neighborhoods in Chicago, IL.
Purpose: The purpose of this study is to examine the effects of individual and neighborhood characteristics on timely resolution of breast cancer diagnostic tests among African American women who received breast cancer screening and diagnostic tests from three community hospitals in disadvantaged neighborhoods in Chicago.
Methods: The analysis utilized a total of 405 African American women who participated in the Patient Navigation in Medically Underserved Areas Project in Chicago. Participating women were recruited from three hospitals. We created an indicator variable for timely diagnostic resolution (completion of follow-up tests within 60 days). We geo-coded participants' home addresses, and calculated distance from home to clinic in miles. We added census tract level data from the American Community Survey 2005-2009, including racial composition and % poverty. In addition, we used Medically Underserved Area (MUA) designation (affluent; MUA designated poor; MUA undesignated poor). Individual characteristics were: age, education, distance to clinic, marital status, and health care distrust. We used Hierarchical Linear Model (HLM) to perform two-level models explaining diagnostic resolution timeliness.
Results: The average age of participants was 60 years old. Over 92% completed high school education and 81% lived in MUA designated and undesignated but poor areas (vs. 19% living in affluent areas that are not eligible for MUA). On average, women traveled 5.5 miles to clinics. The mean % whites and % poverty were respectively 11% and 32%, respectively, which differed from overall % whites (32%) and % poverty in Chicago (21%). Women living in areas with a higher % of white residents were more likely to complete diagnostic tests within 60 days, controlling for all other variables. On the other hand, women living in areas with a higher % of African American residents were less likely to have timely diagnostic resolution, controlling for % poverty and all other individual level characteristics. Neighborhood poverty level was not significantly associated with diagnostic test completion.
Conclusions: Even though all participants were African American women, living in neighborhoods with a higher proportion of whites was associated with timely diagnostic test resolution. Ethnic minority women seem to benefit from living in more racially integrated neighborhood environment, regardless of the level of poverty or MUA designation. While MUA designation and poverty are known to affect access to care, which is expected to influence timeliness of diagnostic test, racial composition of neighborhoods was shown to have a significant independent effect on timeliness of diagnostic test. The mechanisms of racial residential segregation on timeliness of diagnostic tests need to be further evaluated.
Citation Format: Seijeoung Kim, Yamile Molina, Nerida Berriors, Elizabeth Calhoun. Timely breast cancer diagnostic resolution: Effects of individual and neighborhood characteristics. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr B72. doi:10.1158/1538-7755.DISP13-B72
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Ko NY, Darnell JS, Calhoun E, Freund KM, Wells KJ, Shapiro CL, Dudley DJ, Patierno SR, Fiscella K, Raich P, Battaglia TA. Can patient navigation improve receipt of recommended breast cancer care? Evidence from the National Patient Navigation Research Program. J Clin Oncol 2014. [PMID: 25071111 DOI: 10.1200/jco.2013.53.6037.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Poor and underserved women face barriers in receiving timely and appropriate breast cancer care. Patient navigators help individuals overcome these barriers, but little is known about whether patient navigation improves quality of care. The purpose of this study is to examine whether navigated women with breast cancer are more likely to receive recommended standard breast cancer care. PATIENTS AND METHODS Women with breast cancer who participated in the national Patient Navigation Research Program were examined to determine whether the care they received included the following: initiation of antiestrogen therapy in patients with hormone receptor-positive breast cancer; initiation of postlumpectomy radiation therapy; and initiation of chemotherapy in women younger than age 70 years with triple-negative tumors more than 1 cm. This is a secondary analysis of a multicenter quasi-experimental study funded by the National Cancer Institute to evaluate patient navigation. Multiple logistic regression was performed to compare differences in receipt of care between navigated and non-navigated participants. RESULTS Among participants eligible for antiestrogen therapy, navigated participants (n = 380) had a statistically significant higher likelihood of receiving antiestrogen therapy compared with non-navigated controls (n = 381; odds ratio [OR], 1.73; P = .004) in a multivariable analysis. Among the participants eligible for radiation therapy after lumpectomy, navigated participants (n = 255) were no more likely to receive radiation (OR, 1.42; P = .22) than control participants (n = 297). CONCLUSION We demonstrate that navigated participants were more likely than non-navigated participants to receive antiestrogen therapy. Future studies are required to determine the full impact patient navigation may have on ensuring that vulnerable populations receive quality care.
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Affiliation(s)
- Naomi Y Ko
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO.
| | - Julie S Darnell
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO
| | - Elizabeth Calhoun
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO
| | - Karen M Freund
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO
| | - Kristin J Wells
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO
| | - Charles L Shapiro
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO
| | - Donald J Dudley
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO
| | - Steven R Patierno
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO
| | - Kevin Fiscella
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO
| | - Peter Raich
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO
| | - Tracy A Battaglia
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO
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Ko NY, Darnell JS, Calhoun E, Freund KM, Wells KJ, Shapiro CL, Dudley DJ, Patierno SR, Fiscella K, Raich P, Battaglia TA. Can patient navigation improve receipt of recommended breast cancer care? Evidence from the National Patient Navigation Research Program. J Clin Oncol 2014; 32:2758-64. [PMID: 25071111 DOI: 10.1200/jco.2013.53.6037] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Poor and underserved women face barriers in receiving timely and appropriate breast cancer care. Patient navigators help individuals overcome these barriers, but little is known about whether patient navigation improves quality of care. The purpose of this study is to examine whether navigated women with breast cancer are more likely to receive recommended standard breast cancer care. PATIENTS AND METHODS Women with breast cancer who participated in the national Patient Navigation Research Program were examined to determine whether the care they received included the following: initiation of antiestrogen therapy in patients with hormone receptor-positive breast cancer; initiation of postlumpectomy radiation therapy; and initiation of chemotherapy in women younger than age 70 years with triple-negative tumors more than 1 cm. This is a secondary analysis of a multicenter quasi-experimental study funded by the National Cancer Institute to evaluate patient navigation. Multiple logistic regression was performed to compare differences in receipt of care between navigated and non-navigated participants. RESULTS Among participants eligible for antiestrogen therapy, navigated participants (n = 380) had a statistically significant higher likelihood of receiving antiestrogen therapy compared with non-navigated controls (n = 381; odds ratio [OR], 1.73; P = .004) in a multivariable analysis. Among the participants eligible for radiation therapy after lumpectomy, navigated participants (n = 255) were no more likely to receive radiation (OR, 1.42; P = .22) than control participants (n = 297). CONCLUSION We demonstrate that navigated participants were more likely than non-navigated participants to receive antiestrogen therapy. Future studies are required to determine the full impact patient navigation may have on ensuring that vulnerable populations receive quality care.
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Affiliation(s)
- Naomi Y Ko
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO.
| | - Julie S Darnell
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO
| | - Elizabeth Calhoun
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO
| | - Karen M Freund
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO
| | - Kristin J Wells
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO
| | - Charles L Shapiro
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO
| | - Donald J Dudley
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO
| | - Steven R Patierno
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO
| | - Kevin Fiscella
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO
| | - Peter Raich
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO
| | - Tracy A Battaglia
- Naomi Y. Ko and Tracy A. Battaglia, Boston University School of Medicine; Karen M. Freund, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, MA; Julie S. Darnell and Elizabeth Calhoun, School of Public Health, University of Illinois at Chicago, Chicago, IL; Kristin J. Wells, San Diego State University and Moores Cancer Center, San Diego, CA; Charles L. Shapiro, Ohio State University Comprehensive Cancer Center and Wexner Medical Center, Columbus, OH; Donald J. Dudley, University of Texas Health Science Center, San Antonio, TX; Steven R. Patierno, The George Washington University Cancer Institute, Washington, DC; Steven R. Patierno, Duke Cancer Institute, Durham, NC; Kevin Fiscella, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; and Peter Raich, Denver Health and University of Colorado Denver, Denver, CO
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