Effectiveness and feasibility of three types of parent reminders to increase adolescent human papillomavirus (HPV) vaccination.

Parent reminders have produced modest improvements in human papillomavirus (HPV) vaccination among adolescents. However, little prior research has compared the effectiveness and feasibility of different HPV reminder types in resource-limited settings. We conducted a quasi-experimental study (2016-2017) to evaluate the effectiveness of three parent reminder types (mailed letters, robocalls, text messages) on next-dose HPV vaccine receipt among 12-year-olds in a large Federally Qualified Health Center in Los Angeles County. Six clinics were matched into three pairs: randomly assigning one clinic within each pair to intervention and control. Intervention clinics were randomly assigned to deliver one of the three parent reminder types. We calculated rates of next-dose vaccine receipt and assessed intervention effects using logistic regression models. We calculated the proportion of each type of reminder successfully delivered as a feasibility measure. The study sample comprised 877 12-year-olds due for an HPV vaccine dose (47% female, >85% Latino). At 4-month follow-up, 23% of intervention patients received an HPV vaccine dose compared to only 12% of control patients. Overall, receipt of any reminder increased rates of the next-needed HPV vaccine compared to usual care (p = 0.046). Significant improvements were observed for text reminders (p = 0.036) and boys (p = 0.006). Robocalls were the least feasible reminder type. Text message reminders are feasible and effective for promoting HPV vaccination. Future research is needed to assess the effectiveness and feasibility of reminders compared to other vaccine promotion strategies.

The Drug Shortage Crisis in the United States: Impact on Cancer Pharmaceutical Safety.

Drug shortages pose a significant public health concern in the United States, and cancer drugs are among those most affected. Shortages present serious safety risks for patients and substantial burden on providers and the healthcare system. Multifaceted drivers of this complex problem include manufacturing disruptions, raw material shortages, regulatory issues, market dynamics, and limited financial incentives that reward quality and production of off-patent drugs. Oncology drugs in short supply have resulted in substitution of less effective or more toxic alternatives, medication errors, and treatment delays, and are especially concerning for medications with no adequate substitute. Consequently, patient outcomes such as disease progression and survival have been adversely affected. Furthermore, emerging gray markets have contributed to cost-prohibitive markups and introduction of counterfeit products that compromise patient safety. The Food and Drug Administration plays a key role in preventing and managing pharmaceutical shortages, largely through regulations requiring early notification of manufacturing interruptions. Other proposed strategies similarly target upstream causes and center on reducing regulatory hurdles for manufacturers and increasing incentives for market entry and quality improvement. Despite progress in preventing supply disruptions, continued exploration of underlying systemic drivers remains critical to informing long-term solutions and alleviating the clinical and economic impact of drug shortages.

Behavioral and mental health risk factor profiles among diverse primary care patients.

Behavioral and mental health risk factors are prevalent among primary care patients and contribute substantially to premature morbidity and mortality and increased health care utilization and costs. Although prior studies have found most adults screen positive for multiple risk factors, limited research has attempted to identify factors that most commonly co-occur, which may guide future interventions. The purpose of this study was to identify subgroups of primary care patients with co-occurring risk factors and to examine sociodemographic characteristics associated with these subgroups. We assessed 12 behavioral health risk factors in a sample of adults (n=1628) receiving care from nine primary care practices across six U.S. states in 2013. Using latent class analysis, we identified four distinct patient subgroups: a 'Mental Health Risk' class (prevalence=14%; low physical activity, high stress, depressive symptoms, anxiety, and sleepiness), a 'Substance Use Risk' class (29%; highest tobacco, drug, alcohol use), a 'Dietary Risk' class (29%; high BMI, poor diet), and a 'Lower Risk' class (27%). Compared to the Lower Risk class, patients in the Mental Health Risk class were younger and less likely to be Latino/Hispanic, married, college educated, or employed. Patients in the Substance Use class tended to be younger, male, African American, unmarried, and less educated. African Americans were over 7 times more likely to be in the Dietary Risk versus Lower Risk class (OR 7.7, 95% CI 4.0-14.8). Given the heavy burden of behavioral health issues in primary care, efficiently addressing co-occurring risk factors in this setting is critical.

Trends in Cervical Cancer Screening in California's Family Planning Program.

OBJECTIVE: Guidelines recommend 3-year cervical cancer screening intervals to avoid unnecessary invasive procedures; however, regular testing remains critical. We evaluated trends in cervical cancer screening among low-income women receiving family planning-related services and their association with patient and provider characteristics. MATERIALS AND METHODS: Using claims and enrollment data from California's publicly funded family planning program, we identified 540,026 women with a clinician visit at 216 sites between 2011 and 2015. We calculated guideline adherent cervical cancer testing rates for 6-month periods among women aged 21 to 24, 25 to 29, and 30 to 64 years. We also calculated guideline adherent chlamydia testing for women aged 21 to 24 years. RESULTS: Having a 3-year cervical cancer screening test declined for all age groups. The odds of cervical cancer screening declined for women aged 21 to 24 years by an estimated 11% every 6 months (odds ratio [OR] = 0.90, 95% confidence interval [CI] = 0.89-0.90), a significantly greater decline than for the other age groups. Among women aged 21 to 29 years, the decrease was significantly larger for Latina (ratio of ORs = 0.95, 95% CI = 0.95-0.96) and Spanish-speaking (ratio of ORs = 0.95, 95% CI = 0.95-0.96) women compared with non-Latina and non-Spanish-speaking women. A smaller decline was seen for chlamydia screening. CONCLUSIONS: Changes in screening interval guidelines are associated with overall decreased screening. This trend was strongest among women aged 21 to 24 years, even as they continued to be screened appropriately for chlamydia, suggesting many missed opportunities. Efforts to reduce unnecessary cervical cancer screening should be monitored to maintain appropriate screening rates to avoid advanced-stage diagnoses and higher health care costs.

Obesity, physical activity, and dietary behaviors in an ethnically-diverse sample of cancer survivors with early onset disease.

PURPOSE: To assess weight status, physical activity, and dietary behaviors in an ethnically-diverse sample of breast and colorectal cancer survivors with early onset disease (≤ 50 years). METHODS: Breast and colorectal cancer survivors, diagnosed between 1999 and 2009 with early-stage cancer diagnosed by 50 years of age, were identified through a population-based cancer registry and surveyed. Descriptive and regression analyses were conducted to characterize the sample and identify correlates of lifestyle behaviors. FINDINGS: The majority of participants (n = 156) were female (83%), insured (84%), and racial/ethnic minorities (29% Asian, 24% Latino, 15% African American). Participants' mean age at response was 50 years and mean time since diagnosis was 9 years. Over half of survivors were overweight or obese. Few participants reported engaging in regular physical activity (31%) and adhering to minimum guidelines for fruit and vegetable consumption (32%). A substantial proportion of survivors consumed fast food in the past week (75%) and nearly half (48%) reported daily consumption of sugar-sweetened beverages. Lower income was associated with inadequate fruit and vegetable intake. Fast food and sugar-sweetened beverage consumption was significantly higher among racial/ethnic minority survivors compared to non-Latino whites. CONCLUSIONS: High prevalence of overweight and suboptimal adherence to recommended nutrition and physical activity behaviors were observed among cancer survivors with early onset disease. Cancer survivors diagnosed at a young age may benefit from targeted interventions to address overweight and suboptimal nutrition and physical activity.

The Affordable Care Act's Impacts on Access to Insurance and Health Care for Low-Income Populations.

The Patient Protection and Affordable Care Act (ACA) expands access to health insurance in the United States, and, to date, an estimated 20 million previously uninsured individuals have gained coverage. Understanding the law's impact on coverage, access, utilization, and health outcomes, especially among low-income populations, is critical to informing ongoing debates about its effectiveness and implementation. Early findings indicate that there have been significant reductions in the rate of uninsurance among the poor and among those who live in Medicaid expansion states. In addition, the law has been associated with increased health care access, affordability, and use of preventive and outpatient services among low-income populations, though impacts on inpatient utilization and health outcomes have been less conclusive. Although these early findings are generally consistent with past coverage expansions, continued monitoring of these domains is essential to understand the long-term impact of the law for underserved populations.

Evaluating a bilingual patient navigation program for uninsured women with abnormal screening tests for breast and cervical cancer: implications for future navigator research.

OBJECTIVES: The DuPage Patient Navigation Collaborative evaluated the Patient Navigation Research Program (PNRP) model for uninsured women receiving free breast or cervical cancer screening through the Illinois Breast and Cervical Cancer Program in DuPage County, Illinois. METHODS: We used medical records review and patient surveys of 477 women to compare median follow-up times with external Illinois Breast and Cervical Cancer Program and Chicago PNRP benchmarks of performance. We examined the extent to which we mitigated community-defined timeliness risk factors for delayed follow-up, with a focus on Spanish-speaking participants. RESULTS: Median follow-up time (29.0 days for breast and 56.5 days for cervical screening abnormalities) compared favorably to external benchmarks. Spanish-speaking patients had lower health literacy, lower patient activation, and more health care system distrust than did English-speaking patients, but despite the prevalence of timeliness risk factors, we observed no differences in likelihood of delayed (> 60 days) follow-up by language. CONCLUSIONS: Our successful replication and scaling of the PNRP navigation model to DuPage County illustrates a promising approach for future navigator research.

Access to care outcomes: a telephone interview study of a suburban safety net program for the uninsured.

Access DuPage (AD) currently provides primary care for about 14,000 low income, uninsured residents of suburban DuPage County, IL, an area with a very limited healthcare safety net infrastructure. A telephone interview survey evaluated health care utilization, satisfaction, and health status outcomes and compared recent enrollees to individuals in the program for at least 1 year. Sequential new AD enrollees (n = 158) were asked about the previous year when uninsured, while randomly selected established AD enrollees (n = 135) were asked the same questions about the previous year when actively enrolled in AD. Established enrollees reported being more likely to get 'any kind of tests or treatment' (96.3 vs. 46.2 %, p < 0.0001), fewer cost (78.5 vs. 21.3 %, p < 0.0001) and transportation barriers to care, more preventive and mental health services, and better self-management care. However, established enrollees also reported 14 % greater use of hospital inpatient and 9 % greater use of emergency room care, as well as continued difficulty in accessing needed specialty and dental care services. Despite more (diagnosed) conditions, established enrollees were over 2.5 times more likely to report good to excellent health status and over three times more likely to rate their satisfaction with health care as good to excellent. Findings illustrate the substantial benefits of assuring access to care for the uninsured, but do not reflect immediate savings from reduced hospital utilization. Access to care programs will be an important tool to address the needs of the 30 million people who will continue to be uninsured in the United States.

Interpretation of coefficients in segmented regression for interrupted time series analyses.

Background: Segmented regression, a common model for interrupted time series (ITS) analysis, primarily utilizes two equation parametrizations. Interpretations of coefficients vary between the two segmented regression parametrizations, leading to occasional user misinterpretations. Methods: To illustrate differences in coefficient interpretation between two common parametrizations of segmented regression in ITS analysis, we derived analytical results and present an illustration evaluating the impact of a smoking regulation policy in Italy using a publicly accessible dataset. Estimated coefficients and their standard errors were obtained using two commonly used parametrizations for segmented regression with continuous outcomes. We clarified coefficient interpretations and intervention effect calculations. Results: Our investigation revealed that both parametrizations represent the same model. However, due to differences in parametrization, the immediate effect of the intervention is estimated differently under the two approaches. The key difference lies in the interpretation of the coefficient related to the binary indicator for intervention implementation, impacting the calculation of the immediate effect. Conclusions: Two common parametrizations of segmented regression represent the same model but have different interpretations of a key coefficient. Researchers employing either parametrization should exercise caution when interpreting coefficients and calculating intervention effects.

Navigating veterans with an abnormal prostate cancer screening test: a quasi-experimental study.

BACKGROUND: Prostate cancer disproportionately affects low-income and minority men. This study evaluates the impact of a patient navigation intervention on timeliness of diagnostic resolution and treatment initiation among veterans with an abnormal prostate cancer screen. METHODS: Participants were enrolled between 2006 and 2010. The intervention involved a social worker and lay health worker navigation team that assisted patients in overcoming barriers to care. For navigated (n = 245) versus control (n = 245) participants, we evaluated rates of diagnostic resolution and treatment and adjusted for race, age, and Gleason score. RESULTS: Of 490 participants, 68% were African American, 47% were ≥ 65 years old, and 35% had cancer. Among those with an abnormal screen, navigation did not have a significant effect on time to diagnostic resolution compared to controls (median days of 97 versus 111; adj. HR 1.17, 95% CI, 0.96-1.43, p = 0.12). On analysis of the period beyond 80 days, navigated men reached resolution faster than controls (median of 151 days versus 190 days; adj. HR 1.41, 95% CI, 1.07-1.86, p = 0.01). Among those with cancer, navigation did not have a significant effect on time to treatment initiation compared to controls (median of 93 days versus 87 days; adj. HR 1.15, 95% CI, 0.82-1.62, p = 0.41). CONCLUSION: Our navigation program did not significantly impact the overall time to resolution or treatment for men with prostate cancer compared to controls. The utility of navigation programs may extend beyond targeted navigation times, however, and future studies focusing on other outcomes measures are therefore needed.

Perceptions of patient-provider communication in breast and cervical cancer-related care: a qualitative study of low-income English- and Spanish-speaking women.

To explore patient perceptions of patient-provider communication in breast and cervical cancer-related care among low-income English- and Spanish-speaking women, we examined communication barriers and facilitators reported by patients receiving care at safety net clinics. Participants were interviewed in English or Spanish after receiving an abnormal breast or cervical cancer screening test or cancer diagnosis. Following an inductive approach, interviews were coded and analyzed by the language spoken with providers and patient-provider language concordance status. Of 78 participants, 53 % (n = 41) were English-speakers and 47 % (n = 37) were Spanish-speakers. All English-speakers were language-concordant with providers. Of Spanish-speakers, 27 % (n = 10) were Spanish-concordant; 38 % (n = 14) were Spanish-discordant, requiring an interpreter; and 35 % (n = 13) were Spanish mixed-concordant, experiencing both types of communication throughout the care continuum. English-speakers focused on communication barriers, and difficulty understanding jargon arose as a theme. Spanish-speakers emphasized communication facilitators related to Spanish language use. Themes among all Spanish-speaking sub-groups included appreciation for language support resources and preference for Spanish-speaking providers. Mixed-concordant participants accounted for the majority of Spanish-speakers who reported communication barriers. Our data suggest that, although perception of patient-provider communication may depend on the language spoken throughout the care continuum, jargon is lost when health information is communicated in Spanish. Further, the respective consistency of language concordance or interpretation may play a role in patient perception of patient-provider communication.

Design of a prostate cancer patient navigation intervention for a Veterans Affairs hospital.

BACKGROUND: Patient navigation programs have been launched nationwide in an attempt to reduce racial/ethnic and socio-demographic disparities in cancer care, but few have evaluated outcomes in the prostate cancer setting. The National Cancer Institute-funded Chicago Patient Navigation Research Program (C-PNRP) aims to implement and evaluate the efficacy of a patient navigation intervention for predominantly low-income minority patients with an abnormal prostate cancer screening test at a Veterans Affairs (VA) hospital in Chicago. METHODS/DESIGN: From 2006 through 2010, C-PNRP implemented a quasi-experimental intervention whereby trained social worker and lay health navigators worked with veterans with an abnormal prostate screen to proactively identify and resolve personal and systems barriers to care. Men were enrolled at a VA urology clinic and were selected to receive navigated versus usual care based on clinic day. Patient navigators performed activities to facilitate timely follow-up such as appointment reminders, transportation coordination, cancer education, scheduling assistance, and social support as needed. Primary outcome measures included time (days) from abnormal screening to diagnosis and time from diagnosis to treatment initiation. Secondary outcomes included psychosocial and demographic predictors of non-compliance and patient satisfaction. Dates of screening, follow-up visits, and treatment were obtained through chart audit, and questionnaires were administered at baseline, after diagnosis, and after treatment initiation. At the VA, 546 patients were enrolled in the study (245 in the navigated arm, 245 in the records-based control arm, and 56 in a subsample of surveyed control subjects). DISCUSSION: Given increasing concerns about balancing better health outcomes with lower costs, careful examination of interventions aimed at reducing healthcare disparities attain critical importance. While analysis of the C-PNRP data is underway, the design of this patient navigation intervention will inform other patient navigation programs addressing strategies to improve prostate cancer outcomes among vulnerable populations.

Increasing HPV Vaccination among Low-Income, Ethnic Minority Adolescents: Effects of a Multicomponent System Intervention through a County Health Department Hotline.

BACKGROUND: Introduction of the human papillomavirus (HPV) vaccine in 2006 was a game-changing advance in cancer control. Despite the vaccine's potential cancer prevention benefits, uptake remains low. We utilized a randomized design to evaluate a multicomponent intervention to improve HPV vaccine uptake among low-income, ethnic minority adolescents seeking services through a county health department telephone hotline. METHODS: Hotline callers who were caregivers of never-vaccinated adolescents (11-17 years) were randomized by call-week to intervention or control conditions. The intervention included brief telephone and print education, delivered in multiple languages, and personalized referral to a low-cost/free vaccine provider. Participants completed baseline (n = 238), 3-month (n = 215), and 9-month (n = 204) telephone follow-up surveys. RESULTS: HPV vaccine initiation rates increased substantially by 9-month follow-up overall, although no differences were observed between intervention and control groups (45% vs. 42%, respectively, P > 0.05). We also observed significant improvements in perceived HPV risk, barriers to vaccination, and perceived knowledge in both study conditions (P < 0.05). CONCLUSIONS: A low-intensity county hotline intervention did not produce a greater increase in HPV vaccination rates than routine practice. However, 44% of unvaccinated adolescents in both conditions received at least one dose of the vaccine, which can be viewed as a successful public health outcome. Future studies should evaluate more intensive interventions that address accessing and utilizing services in complex safety net settings. IMPACT: Study results suggest the need for investigators to be aware of the potential priming effects of study participation, which may obscure the effect of low-intensity interventions.

Impact of a Multi-Level, Multi-Component, System Intervention on HPV Vaccination in a Federally Qualified Health Center.

BACKGROUND: Human papillomavirus (HPV) vaccines can significantly reduce the burden of HPV-associated cancers, but remain underutilized. We evaluated a multi-component, system-level intervention to improve HPV vaccination in a large Federally Qualified Health Center (FQHC) that serves a primarily low income Latino population. METHODS: From January 2015 through March 2017, we evaluated the effectiveness of a multi-component, system-level intervention to improve HPV vaccination rates in eight clinics randomly assigned to study condition (four intervention, four usual care). The intervention included parent reminders for HPV vaccine series completion, provider training, clinic-level audit and feedback, and workflow modifications to reduce missed opportunities for vaccination. Using a difference-in-differences approach, we compared HPV vaccination rates among patients, ages 11 to 17 during a 12-month preintervention period and a 15-month intervention period. Linear mixed models were used to estimate intervention effects on vaccine initiation and completion. RESULTS: The sample included approximately 15,000 adolescents each quarter (range 14,773-15,571; mean age 14 years; 51% female, 88% Latino). A significantly greater quarterly increase in HPV vaccine initiation was observed for intervention compared with usual care clinics (0.75 percentage point greater increase, P < 0.001), corresponding to 114 additional adolescents vaccinated per quarter. The intervention led to a greater increase in HPV vaccine completion rates among boys (0.65 percentage point greater increase, P < 0.001), but not girls. CONCLUSIONS: Our system-level intervention was associated with modest improvements in HPV vaccine initiation overall and completion among boys. IMPACT: Study findings have implications for reducing HPV-related cancers in safety net populations.

Human papillomavirus (HPV) vaccination in the transition between adolescence and adulthood.

PURPOSE: Young adulthood is characterized by changes in health care decision-making, insurance coverage, and sexual risk. Although the human papillomavirus (HPV) vaccine is now approved for adults up to age 45, and catch-up vaccination is currently recommended up through age 26, vaccination rates remain low in young adults. This study explored perspectives on HPV vaccination among young adults receiving care at the student health center of a large public university. METHODS: We conducted semi-structured interviews (n = 27) and four focus groups with female and male undergraduate and graduate students (n = 18) and semi-structured interviews with health care providers (n = 6). Interviews and focus groups explored perceived risk of HPV infection, benefits of the HPV vaccine, and motivations for and barriers to HPV vaccination. RESULTS: Many young adults cited their parents' views and recommendations from medical providers as influential on their decision-making process. Students perceived that cervical cancer prevention was a main benefit of the HPV vaccine and sexual activity was a risk factor for HPV infection. Students often lacked knowledge about the vaccine's benefits for males and expressed some concerns about the safety and side effects of a vaccine perceived as new. Logistical barriers to vaccination included uncertainty over vaccination status and insurance coverage for the vaccine, and concerns about balancing the vaccine schedule with school obligations. Providers' vaccine recommendations were impacted by health system factors, including clinical infrastructure, processes for recommending and documenting vaccination, and office visit priorities. Suggested vaccination promotion strategies included improving the timing and messaging of outreach efforts on campus and bolstering clinical infrastructure. CONCLUSIONS: Although college may be an opportune time to reach young adults for HPV vaccination, obstacles including navigating parental influence and independent decision-making, lack of awareness of vaccination status, and numerous logistical and system-level barriers may impede vaccination during this time.

Cancer surveillance and preventive services in a diverse sample of breast and colorectal cancer survivors.

PURPOSE: Cancer survivors diagnosed at an early age remain at risk for cancer recurrence and other chronic diseases. This study assessed engagement in surveillance for recurrence, cancer screening, and other recommended preventive health services among breast and colorectal cancer survivors with early-onset disease (≤ 50 years) who were diagnosed in California. METHODS: Breast and colorectal cancer survivors diagnosed with early-onset cancer between 1999 and 2009 were identified through the California Cancer Registry, the state-based cancer registry, and surveyed. Multivariable regression analyses were used to assess correlates of receipt of cancer surveillance, cancer screening, and other preventive health services. RESULTS: Of the 497 survivors that were invited to participate in the study, 156 completed the survey for a response rate of 31%. The sample was 50 years of age on average (range 32-69 years) with a mean time since diagnosis of 9 years. The majority of the sample (71%) was a racial/ethnic minority (24% Latino, 15% African American, 29% Asian). Overall, 80% received appropriate surveillance for recurrence, and 72% received recommended screening for early detection of other cancers (breast, cervical, colorectal). Increasing age was associated with lower likelihood of early detection screening (adjusted odds ratio (aOR) 0.28, 95% confidence interval (CI) 0.11-0.69), and higher income was associated with a greater likelihood (aOR 4.89, 95% CI 1.62-14.81). Screening rates were highest for blood pressure (96%), cholesterol (86%), and diabetes (81%), followed by dental visits (64%) and flu vaccination (35%). Greater use of recommended preventive health services was associated with increasing age, female sex, higher education level, and having health insurance. CONCLUSIONS: Although the majority of survivors received appropriate surveillance for recurrence, engagement in other preventive health services varied substantially. IMPLICATIONS FOR CANCER SURVIVORS: Efforts are needed to address gaps in the use of recommended cancer screening and preventive health services among cancer survivors, particularly survivors with early-onset disease who may be at increased risk for additional cancers and common chronic conditions over their lifetime.

Disparities in parental human papillomavirus (HPV) vaccine awareness and uptake among adolescents.

Trends in HPV vaccine awareness among parents of adolescent girls and boys (ages 13-17) and HPV vaccine uptake (≥1 dose) among girls (ages 13-17) were evaluated in Los Angeles County, California. Between 2007 and 2011, parental HPV vaccine awareness increased from 72% to 77% overall, with significant increases among mothers, Latinos, and respondents with daughters and Medi-Cal insured children. In 2011, parents who were male, older, less educated, Asian/Pacific Islander, and had sons remained significantly less likely to be aware. HPV vaccine initiation among daughters nearly doubled from 25% in 2007 to 48% in 2011, and girls who were older, uninsured, and had access-related barriers showed the largest improvements. In 2011, daughters who were younger and who had older and African American parents were at risk for low uptake. Thus, initiatives targeting male and younger adolescents, culturally-relevant information, and access to vaccination may help to reduce identified disparities.

Cost considerations in the management of cancer in the older patient.

Patients aged 65 years and older represent 12% of the US population yet account for approximately 56% of cancer cases and 69% of all cancer mortalities. The overall cost of cancer in 2005 was $209.9 billion--$74 billion for direct medical costs and $118.4 billion for indirect mortality costs. This paper considers the direct, indirect, and out-of-pocket expenditures incurred by cancer patients > or = 50 years of age. Several major empirical studies on supportive care for older patients and cancer-related costs were reviewed. Insurance coverage, hematologic malignancies, squamous cell carcinoma of the head and neck, and cancers of the breast, prostate, colorectum, and lung were evaluated. Major sources of direct medical expenditures covered by third-party insurers for patients aged 65 years and older include extended length of hospital stay, home health assistance following hospital discharge, adjuvant prescription medications, lower-risk treatment (for prostate cancer), and advent of new pharmaceuticals (for colorectal cancer). The mean total direct medical cost for breast cancer is $35,164, and the cumulative cost for prostate cancer is $42,570. Emerging targeted cancer drug costs range from $20,000 to $50,000 annually per patient. Additional clinical trials and cost-effective treatments are needed for older patients to ameliorate the disproportionate economic burden among older individuals with cancer. Additional research about cancer costs may also lead to reforms in cancer care reimbursement, and therefore provide access to affordable health care for older patients.

Public Funds Account for Over 70 Percent of Health Care Spending in California.

In California, personal health care expenditures are estimated to total more than $367 billion in 2016. Approximately 71 percent of these expenditures will be paid for with public funds (i.e., taxpayer dollars). This estimated contribution of public funds to health care expenditures is much higher than estimates that include only major health insurance programs such as Medicare and Medicaid. Several additional public funding sources also contribute to health care expenditures in the state, including government spending for public employee health benefits, tax subsidies for employer-sponsored insurance and the Affordable Care Act (ACA) insurance exchange, and county health care expenditures. As health care reform continues to take effect, it will be important to monitor the public versus private contributions to state health care expenditures to ensure that funds are being distributed both efficiently and equitably.

Patient Navigators: Agents of Creating Community-Nested Patient-Centered Medical Homes for Cancer Care.

Patient navigation is an internationally utilized, culturally grounded, and multifaceted strategy to optimize patients' interface with the health-care team and system. The DuPage County Patient Navigation Collaborative (DPNC) is a campus-community partnership designed to improve access to care among uninsured breast and cervical cancer patients in DuPage County, IL. Importantly, the DPNC connects community-based social service delivery with the patient-centered medical home to achieve a community-nested patient-centered medical home model for cancer care. While the patient navigator experience has been qualitatively documented, the literature pertaining to patient navigation has largely focused on efficacy outcomes and program cost effectiveness. Here, we uniquely highlight stories of women enrolled in the DPNC, told from the perspective of patient navigators, to shed light on the myriad barriers that DPNC patients faced and document the strategies DPNC patient navigators implemented.