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2.
Value Health ; 26(10): 1494-1502, 2023 10.
Artículo en Inglés | MEDLINE | ID: mdl-37301367

RESUMEN

OBJECTIVES: A major strategy to reduce the impact of breast cancer (BC) among African Americans (AA) is patient navigation, defined here as individualized assistance for reducing barriers to healthcare use. The primary focus of this study was to estimate the added value of incorporating breast health promotion by navigated participants and the subsequent BC screenings that network members may obtain. METHODS: In this study, we compared the cost-effectiveness of navigation across 2 scenarios. First, we examine the effect of navigation on AA participants (scenario 1). Second, we examine the effect of navigation on AA participants and their networks (scenario 2). We leverage data from multiple studies in South Chicago. Our primary outcome (BC screening) is intermediate, given limited available quantitative data on the long-term benefits of BC screening for AA populations. RESULTS: When considering participant effects alone (scenario 1), the incremental cost-effectiveness ratio was $3845 per additional screening mammogram. When including participant and network effects (scenario 2), the incremental cost-effectiveness ratio was $1098 per additional screening mammogram. CONCLUSION: Our findings suggest that inclusion of network effects can contribute to a more precise, comprehensive assessment of interventions for underserved communities.


Asunto(s)
Neoplasias de la Mama , Navegación de Pacientes , Humanos , Femenino , Negro o Afroamericano , Mamografía , Neoplasias de la Mama/diagnóstico , Neoplasias de la Mama/prevención & control , Promoción de la Salud , Detección Precoz del Cáncer , Red Social
3.
J Gen Intern Med ; 37(16): 4103-4111, 2022 12.
Artículo en Inglés | MEDLINE | ID: mdl-35260961

RESUMEN

INTRODUCTION: Minority-serving hospitals (MSHs) need evidence-based strategies tailored to the populations they serve to improve patient-centered outcomes after hospitalization. METHODS: We conducted a pragmatic randomized clinical trial (RCT) from October 2014 to January 2017 at a MSH comparing the effectiveness of a stakeholder-supported Navigator intervention vs. Usual care on post-hospital patient experience, outcomes, and healthcare utilization. Community health workers and peer coaches delivered the intervention which included (1) in-hospital visits to assess barriers to health/healthcare and to develop a personalized Discharge Patient Education Tool (DPET); (2) a home visit to review the DPET; and (3) telephone-based peer coaching. The co-primary outcomes were between-group comparisons of 30-day changes in Patient-Reported Outcomes Measurement Information System (PROMIS) measures of anxiety and informational support (minimum important difference is 2 to 5 units change); a p-value <0.025 was considered significant using intention-to-treat analysis. Secondary outcomes included death, ED visits, or readmissions and measures of emotional, social, and physical health at 30 and 60 days. RESULTS: We enrolled 1029 adults hospitalized with heart failure (28%), pneumonia (22%), MI (10%), COPD (11%), or sickle cell disease (29%). Over 80% were non-Hispanic Black. Overall, there were no significant between-group differences in the 30-day change in anxiety (adjusted difference: -1.6, 97.5% CI -3.3 to 0.1, p=0.03), informational support (adjusted difference: -0.01, 97.5% CI -2.0 to 1.9, p=0.99), or any secondary outcomes. Exploratory analyses suggested the Navigator intervention improved anxiety among participants with COPD, a primary care provider, a hospitalization in the past 12 months, or higher baseline anxiety; among participants without health insurance, the intervention improved informational support (all p-values <0.05). CONCLUSIONS: In this pragmatic RCT at a MSH, the Navigator intervention did not improve post-hospital anxiety, informational support, or other outcomes compared to Usual care. Benefits observed in participant subgroups should be confirmed in future studies. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT02114515.


Asunto(s)
Transición del Hospital al Hogar , Adulto , Humanos , Hospitales , Evaluación del Resultado de la Atención al Paciente , Alta del Paciente
4.
J Urban Health ; 99(5): 813-828, 2022 10.
Artículo en Inglés | MEDLINE | ID: mdl-35941401

RESUMEN

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


Asunto(s)
Neoplasias de la Mama , Navegación de Pacientes , Negro o Afroamericano , Anciano , Neoplasias de la Mama/diagnóstico , Chicago , Detección Precoz del Cáncer , Femenino , Humanos , Mamografía , Persona de Mediana Edad , Navegación de Pacientes/métodos
5.
Support Care Cancer ; 30(3): 2487-2496, 2022 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-34783907

RESUMEN

BACKGROUND: Patient navigation is an increasingly widespread intervention to address the persistent, severe, and disproportionate breast cancer (BC) burden that African Americans (AA) face. Navigation may have more widespread effects than previously estimated due to patient-driven diffusion of BC information. METHODS: This pilot study examined the network effects of a randomized controlled trial via recruitment of navigated and non-navigated AA BC patients as well as their network members. We estimated study arm differences in patient BC promotion (i.e., number of individuals to whom BC patients promote BC screening) and network BC screening (i.e., % BC screening among network members). RESULTS: Among our sample of 100 AA BC patients, navigated patients promoted BC screening to more individuals than non-navigated patients. BC patients were more likely to promote BC screening to children and individuals with whom they communicated more frequently. Some models further suggested more network BC screening among "navigated" network members relative to "non-navigated" network members. CONCLUSIONS: Navigated AA patients promoted BC screening more widely throughout their networks than non-navigated AA BC patients. There were also suggestive findings regarding increased BC screening among their network members. Our pilot study highlights the potential for social network analysis to improve the precision of intervention effect estimates and to inform future innovations (e.g., integrating navigation and network-based interventions) with multilevel effects on cancer health disparities.


Asunto(s)
Neoplasias de la Mama , Navegación de Pacientes , Negro o Afroamericano , Niño , Femenino , Amigos , Humanos , Proyectos Piloto
6.
Rural Remote Health ; 21(3): 6357, 2021 07.
Artículo en Inglés | MEDLINE | ID: mdl-34215158

RESUMEN

INTRODUCTION: While cancer deaths have decreased nationally, declines have been much slower in rural areas than in urban areas. Previous studies on rural cancer service capacity are limited to specific points along the cancer care continuum (eg screening, diagnosis or treatment) and require updating to capture the current rural health landscape since implementation of the 2010 Affordable Care Act in the USA. The association between current rural cancer service capacity across the cancer care continuum and cancer incidence and death is unclear. This cross-sectional study explored the association between breast cancer service capacity and incidence and mortality in Arizona's low populous counties. METHODS: To measure county-level cancer capacity, clinical organizations operating within low populous areas of Arizona were surveyed to assess on-site breast cancer services provided (screening, diagnosis and treatment) and number of healthcare providers were pulled from Centers for Medicare and Medicaid Services National Provider Identifier database. The number of clinical sites and healthcare providers were converted to county-level per capita rates. Rural-Urban Continuum codes were used to designate rural or urban county status. Age-adjusted county-level breast cancer incidence and death rates from 2010 to 2016 were obtained from the Arizona Department of Health Services, Arizona Cancer Registry. Descriptive statistics were used to summarize the results. Multivariate regression was used to evaluate the association between cancer service capacity and incidence and mortality in 13 out of Arizona's 15 counties. RESULTS: Rural counties had more per capita clinical sites (20.4) than urban counties (8.9) (p=0.02). Urban counties had more per capita pathologists (1.0) than rural counties (0) (p≤0.01). In addition to zero pathologists, rural counties had zero medical oncologists. Rural county status was associated with a decrease in breast cancer incidence (β=-20.1, 95% confidence interval: -37.2-3.1). CONCLUSION: While Arizona's sparsely populated rural counties may have more physical infrastructure per capita, these services are dispersed over vast geographic areas. They lack specialists providing cancer services. Non-physician clinical providers may be more prevalent in rural areas and represent opportunities for improving access to cancer preventive services and care. Compared to urban counties, rural county status was associated with lower detected breast cancer incidence rates although there were no statistically significant differences in breast cancer mortality. Other factors may contribute to rural-urban differences in breast cancer incidence. Future research should explore these factors and the association between cancer capacity and local resources because the use of county-level data represents a challenge in Arizona, where counties average over 19 425 km2 (7500 square miles).


Asunto(s)
Neoplasias de la Mama , Anciano , Arizona/epidemiología , Neoplasias de la Mama/epidemiología , Estudios Transversales , Femenino , Humanos , Incidencia , Medicare , Patient Protection and Affordable Care Act , Población Rural , Estados Unidos/epidemiología , Población Urbana
7.
Health Promot Pract ; 20(6): 914-921, 2019 11.
Artículo en Inglés | MEDLINE | ID: mdl-29907079

RESUMEN

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


Asunto(s)
Neoplasias de la Mama/psicología , Mamografía/psicología , Navegación de Pacientes/métodos , Poblaciones Vulnerables/psicología , Adulto , Neoplasias de la Mama/diagnóstico , Neoplasias de la Mama/prevención & control , Detección Precoz del Cáncer/psicología , Femenino , Estudios de Seguimiento , Disparidades en Atención de Salud , Humanos , Tamizaje Masivo/psicología , Área sin Atención Médica , Persona de Mediana Edad
8.
Cancer ; 124(22): 4350-4357, 2018 11 15.
Artículo en Inglés | MEDLINE | ID: mdl-30246241

RESUMEN

BACKGROUND: Black women are more likely to be diagnosed at a later stage of breast cancer in part due to barriers to timely screening mammography, resulting in poorer mortality and survival outcomes. Patient navigation that helps to overcome barriers to the early detection of breast cancer is an effective intervention for reducing breast cancer disparity. However, the ability to recognize and seek help to overcome barriers may be affected by gendered and racialized social expectations of women. METHODS: Data from a randomized controlled trial, the Patient Navigation in Medically Underserved Areas study, were used. The likelihood of obtaining a follow-up screening mammogram was compared between women who identified ≥1 barriers and those who did not. RESULTS: Of the 3754 women who received the Patient Navigation in Medically Underserved Areas navigation intervention, approximately 14% identified ≥ 1 barriers, which led to additional navigator contacts. Consequently, those women who reported barriers were more likely to obtain a subsequent screening mammogram. Black women, women living in poverty, and women with a higher level of distrust were less likely to report barriers. CONCLUSIONS: Minority women living in poverty have always been the source of social support for others. However, gendered and racialized social expectations may affect the ways in which women seek help for their own health needs. A way to improve the effectiveness of navigation would be to recognize how minority women's gender images and expectations could shape how they seek help and support. A report of no barriers does not always translate into no problems. Proactive approaches to identify potential barriers may be beneficial.


Asunto(s)
Neoplasias de la Mama/diagnóstico por imagen , Neoplasias de la Mama/etnología , Diagnóstico Tardío , Navegación de Pacientes/métodos , Negro o Afroamericano/estadística & datos numéricos , Chicago/etnología , Diagnóstico Tardío/estadística & datos numéricos , Detección Precoz del Cáncer , Femenino , Accesibilidad a los Servicios de Salud , Humanos , Mamografía/estadística & datos numéricos , Tamizaje Masivo , Área sin Atención Médica , Persona de Mediana Edad , Evaluación de Programas y Proyectos de Salud , Ensayos Clínicos Controlados Aleatorios como Asunto , Factores Socioeconómicos
9.
Health Expect ; 18(6): 2941-50, 2015 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-25308749

RESUMEN

BACKGROUND: Medical mistrust is salient among African American women, given historic and contemporary racism within medical settings. Mistrust may influence satisfaction among navigated women by affecting women's perceptions of their health-care self-efficacy and their providers' roles in follow-up of abnormal test results. OBJECTIVES: To (i) examine whether general medical mistrust and health-care self-efficacy predict satisfaction with mammography services and (ii) test the mediating effects of health-related self-efficacy. DESIGN: The current study is a part of a randomized controlled patient navigation trial for medically underserved women who had received a physician referral to obtain a mammogram in three community hospitals in Chicago, IL. After consent, 671 African American women with no history of cancer completed questionnaires concerning medical mistrust and received navigation services. After their mammography appointment, women completed health-care self-efficacy and patient satisfaction questionnaires. RESULTS: Women with lower medical mistrust and greater perceived self-efficacy reported greater satisfaction with care. Medical mistrust was directly and indirectly related to patient satisfaction through self-efficacy. CONCLUSIONS: Preliminary findings suggest future programmes designed to increase health-care self-efficacy may improve patient satisfaction among African American women with high levels of medical mistrust. Our findings add to a growing body of literature indicating the importance of self-efficacy and active participation in health care, especially among the underserved.


Asunto(s)
Negro o Afroamericano/psicología , Mamografía/psicología , Navegación de Pacientes , Satisfacción del Paciente , Autoeficacia , Confianza/psicología , Chicago , Femenino , Humanos , Persona de Mediana Edad
10.
JCO Oncol Pract ; 19(5): 288-294, 2023 05.
Artículo en Inglés | MEDLINE | ID: mdl-36735900

RESUMEN

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


Asunto(s)
Neoplasias , Servicios de Salud Rural , Humanos , Estados Unidos/epidemiología , Educación de Postgrado en Medicina , Población Rural , Neoplasias/epidemiología , Neoplasias/terapia
11.
J Am Coll Emerg Physicians Open ; 4(4): e12998, 2023 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-37389326

RESUMEN

Objective: Weakness in older emergency department (ED) patients presents a broad differential. Evaluation of these patients can be challenging, and the efficacy of head computed tomography (CT) imaging is unclear. This study assesses the usefulness of head CT as a diagnostic study of acute generalized weakness in older ED patients. Methods: This retrospective review of patients aged 65 years and older presenting to 2 community EDs included patients with a chief complaint of generalized weakness who received a head CT. Patients presenting with a focal neurologic complaint, altered mental status, or trauma were excluded. Variables evaluated included additional triage chief complaints, dementia diagnosis, and deficits on physical examination. Primary outcome was acute intracranial finding on head CT. Secondary outcomes included neurology consultation, neurosurgical consultation, and neurosurgical intervention. Results: Of 247 patients, 3.2% had an acute intracranial abnormality on head CT. Emergent consultations for neurology and neurosurgery occurred for 1.6% and 2.4% of patients, respectively. None required neurosurgical intervention. Patients with objective weakness or focal neurologic deficits on physical examination were more likely to have acute findings on head CT (8.5% vs. 2.0%, odds ratio 4.56, confidence interval 1.10-18.95). Additional characteristics did not predict acute intracranial abnormality or need for emergent consultation. Conclusion: Few patients with generalized weakness evaluated with head CT had acutely abnormal intracranial findings. Patients with objective weakness or neurologic deficits were more likely to have acute abnormalities. Although head CT is frequently used to evaluate geriatric weakness, its utility is low, especially in patients with normal physical examinations.

12.
JAMA Netw Open ; 5(3): e223991, 2022 03 01.
Artículo en Inglés | MEDLINE | ID: mdl-35323948

RESUMEN

Importance: It is not known whether implementation of Medicaid expansion under the Patient Protection and Affordable Care Act (ACA) was associated with improvements in the outcomes among racial and ethnic minority adults at risk of diabetes-related major amputations. Objective: To explore the association of early Medicaid expansion with outcomes of diabetic foot ulcerations (DFUs). Design, Setting, and Participants: This cohort study included hospitalizations for DFUs among African American, Asian and Pacific Islander, American Indian or Alaska Native, and Hispanic adults as well as adults with another minority racial or ethnic identification aged 20 to 64 years. Data were collected from the State Inpatient Databases for 19 states and the District of Columbia for 2013 to the third quarter of 2015. The analysis was performed on December 4, 2019, and updated on November 9, 2021. Exposures: States were categorized into early-adopter states (expansion by January 2014) and nonadopter states. Main Outcomes and Measures: Poisson regression was performed to examine the associations of state type, time, and their combined association with the proportional changes of major amputation rate per year per 100 000 population. Results: Among the 115 071 hospitalizations among racial and ethnic minority adults with DFUs (64% of sample aged 50 to 64 years; 35%, female; 61%, African American; 25%, Hispanic; 14%, other racial and ethnic minority group), there were 36 829 hospitalizations (32%) for Medicaid beneficiaries and 10 500 hospitalizations (9%) for uninsured patients. Hospitalizations increased 3% (95% CI, 1% to 5%) in early-adopter states and increased 8% (95% CI, 6% to 10%) in nonadopter states after expansion, a significant difference (P for interaction < .001). Although there was no change in the amputation rate (0.08%; 95% CI, -6% to 7%) in early-adopter states after expansion, there was a 9% (95% CI, 3% to 16%) increase in nonadopter states, a significant change (P = .04). For uninsured adults, the amputation rate decreased 33% (95% CI, 10% to 50%) in early-adopter states and did not change (12%; 95% CI, -10% to 38%) in nonadopter states after expansion, a significant difference (P = .006). There was no difference in the change of amputation rate among Medicaid beneficiaries between state types after expansion. Conclusions and Relevance: This study found a relative improvement in the major amputation rate among African American, Hispanic, and other racial and ethnic minority adults in early-expansion states compared with nonexpansion states, which could be because of the recruitment of at-risk uninsured adults into the Medicaid program during the first 2 years of ACA implementation. Future study is required to evaluate the long-term association of Medicaid expansion and the rates of amputation.


Asunto(s)
Diabetes Mellitus , Patient Protection and Affordable Care Act , Adulto , Amputación Quirúrgica , Estudios de Cohortes , Minorías Étnicas y Raciales , Etnicidad , Femenino , Humanos , Cobertura del Seguro , Masculino , Medicaid , Grupos Minoritarios , Estados Unidos/epidemiología
13.
BMJ Health Care Inform ; 28(1)2021 May.
Artículo en Inglés | MEDLINE | ID: mdl-33980502

RESUMEN

OBJECTIVES: Prior research has reported an increased risk of fatality for patients with cancer, but most studies investigated the risk by comparing cancer to non-cancer patients among COVID-19 infections, where cancer might have contributed to the increased risk. This study is to understand COVID-19's imposed HR of fatality while controlling for covariates, such as age, sex, metastasis status and cancer type. METHODS: We conducted survival analyses of 4606 cancer patients with COVID-19 test results from 16 March to 11 October 2020 in UK Biobank and estimated the overall HR of fatality with and without COVID-19 infection. We also examined the HRs of 13 specific cancer types with at least 100 patients using a stratified analysis. RESULTS: COVID-19 resulted in an overall HR of 7.76 (95% CI 5.78 to 10.40, p<10-10) by following 4606 patients with cancer for 21 days after the tests. The HR varied among cancer type, with over a 10-fold increase in fatality rate (false discovery rate ≤0.02) for melanoma, haematological malignancies, uterine cancer and kidney cancer. Although COVID-19 imposed a higher risk for localised versus distant metastasis cancers, those of distant metastases yielded higher overall fatality rates due to their multiplicative effects. DISCUSSION: The results confirmed prior reports for the increased risk of fatality for patients with COVID-19 plus hematological malignancies and demonstrated similar findings of COVID-19 on melanoma, uterine, and kidney cancers. CONCLUSION: The results highlight the heightened risk that COVID-19 imposes on localised and haematological cancer patients and the necessity to vaccinate uninfected patients with cancer promptly, particularly for the cancer types most influenced by COVID-19. Results also suggest the importance of timely care for patients with localised cancer, whether they are infected by COVID-19 or not.


Asunto(s)
COVID-19/mortalidad , Estado de Salud , Neoplasias/mortalidad , Vigilancia en Salud Pública , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Neoplasias/patología , Medición de Riesgo , Factores de Riesgo , Análisis de Supervivencia , Adulto Joven
14.
JCO Oncol Pract ; 17(10): e1512-e1523, 2021 10.
Artículo en Inglés | MEDLINE | ID: mdl-33689399

RESUMEN

PURPOSE: More than half of patients with head and neck squamous cell carcinoma (HNSCC) experience a delay initiating guideline-adherent postoperative radiation therapy (PORT), contributing to excess mortality and racial disparities in survival. However, interventions to improve the delivery of timely, equitable PORT among patients with HNSCC are lacking. This study (1) describes the development of NDURE (Navigation for Disparities and Untimely Radiation thErapy), a navigation-based multilevel intervention (MLI) to improve guideline-adherent PORT and (2) evaluates its feasibility, acceptability, and preliminary efficacy. METHODS: NDURE was developed using the six steps of intervention mapping (IM). Subsequently, NDURE was evaluated by enrolling consecutive patients with locally advanced HNSCC undergoing surgery and PORT (n = 15) into a single-arm clinical trial with a mixed-methods approach to process evaluation. RESULTS: NDURE is a navigation-based MLI targeting barriers to timely, guideline-adherent PORT at the patient, healthcare team, and organizational levels. NDURE is delivered via three in-person navigation sessions anchored to case identification and surgical care transitions. Intervention components include the following: (1) patient education, (2) travel support, (3) a standardized process for initiating the discussion of expectations for PORT, (4) PORT care plans, (5) referral tracking and follow-up, and (6) organizational restructuring. NDURE was feasible, as judged by accrual (88% of eligible patients [100% Blacks] enrolled) and dropout (n = 0). One hundred percent of patients reported moderate or strong agreement that NDURE helped solve challenges starting PORT; 86% were highly likely to recommend NDURE. The rate of timely, guideline-adherent PORT was 86% overall and 100% for Black patients. CONCLUSION: NDURE is a navigation-based MLI that is feasible, is acceptable, and has the potential to improve the timely, equitable, guideline-adherent PORT.


Asunto(s)
Neoplasias de Cabeza y Cuello , Terapia Combinada , Neoplasias de Cabeza y Cuello/terapia , Humanos , Derivación y Consulta , Carcinoma de Células Escamosas de Cabeza y Cuello/terapia
16.
Health Promot Pract ; 11(2): 205-15, 2010 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-19116415

RESUMEN

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


Asunto(s)
Agentes Comunitarios de Salud/educación , Accesibilidad a los Servicios de Salud/organización & administración , Disparidades en Atención de Salud , Área sin Atención Médica , Neoplasias/terapia , American Cancer Society , Centers for Medicare and Medicaid Services, U.S. , Competencia Cultural , Curriculum , Accesibilidad a los Servicios de Salud/economía , Humanos , National Cancer Institute (U.S.) , Neoplasias/diagnóstico , Neoplasias/etnología , Factores Socioeconómicos , Estados Unidos
17.
JCO Oncol Pract ; 16(12): e1417-e1432, 2020 12.
Artículo en Inglés | MEDLINE | ID: mdl-32853120

RESUMEN

PURPOSE: Delays initiating guideline-adherent postoperative radiation therapy (PORT) in head and neck squamous cell carcinoma (HNSCC) are common, contribute to excess mortality, and are a modifiable target for improving survival. However, the barriers that prevent the delivery of timely, guideline-adherent PORT remain unknown. This study aims to identify the multilevel barriers to timely, guideline-adherent PORT and organize them into a conceptual model. MATERIALS AND METHODS: Semi-structured interviews with key informants were conducted with a purposive sample of patients with HNSCC and oncology providers across diverse practice settings until thematic saturation (n = 45). Thematic analysis was performed to identify the themes that explain barriers to timely PORT and to develop a conceptual model. RESULTS: In all, 27 patients with HNSCC undergoing surgery and PORT were included, of whom 41% were African American, and 37% had surgery and PORT at different facilities. Eighteen clinicians representing a diverse mix of provider types from 7 oncology practices participated in key informant interviews. Five key themes representing barriers to timely PORT were identified across 5 health care delivery levels: (1) inadequate education about timely PORT, (2) postsurgical sequelae that interrupt the tight treatment timeline (both intrapersonal level), (3) insufficient coordination and communication during care transitions (interpersonal and health care team levels), (4) fragmentation of care across health care organizations (organizational level), and (5) travel burden for socioeconomically disadvantaged patients (community level). CONCLUSION: This study provides a novel description of the multilevel barriers that contribute to delayed PORT. Interventions targeting these multilevel barriers could improve the delivery of timely, guideline-adherent PORT and decrease mortality for patients with HNSCC.


Asunto(s)
Neoplasias de Cabeza y Cuello , Terapia Combinada , Atención a la Salud , Neoplasias de Cabeza y Cuello/terapia , Humanos , Carcinoma de Células Escamosas de Cabeza y Cuello/terapia
18.
Contemp Clin Trials Commun ; 15: 100411, 2019 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-31406947

RESUMEN

BACKGROUND: Systems science methodologies offer a promising assessment approach for clinical trials by: 1) providing an in-silico laboratory to conduct investigations where purely empirical research may be infeasible or unethical; and, 2) offering a more precise measurement of intervention benefits across individual, network, and population levels. We propose to assess the potential of systems sciences methodologies by quantifying the spillover effects of randomized controlled trial via empirical social network analysis and agent-based models (ABM). DESIGN/METHODS: We will evaluate the effects of the Patient Navigation in Medically Underserved Areas (PNMUA) study on adult African American participants diagnosed with breast cancer and their networks through social network analysis and agent-based modeling. First, we will survey 100 original trial participants (50 navigated, 50 non-navigated) and 150 of members of their social networks (75 from navigated, 75 non-navigated) to assess if navigation results in: 1) greater dissemination of breast health information and breast healthcare utilization throughout the trial participants' networks; and, 2) lower incremental costs, when incorporating navigation effects on trial participants and network members. Second, we will compare cost-effectiveness models, using a provider perspective, incorporating effects on trial participants versus trial participants and network members. Third, we will develop an ABM platform, parameterized using published data sources and PNMUA data, to examine if navigation increases the proportion of early stage breast cancer diagnoses. DISCUSSION: Our study results will provide promising venues for leveraging systems science methodologies in clinical trial evaluation.

19.
Clin Transl Gastroenterol ; 10(7): e00062, 2019 07.
Artículo en Inglés | MEDLINE | ID: mdl-31343469

RESUMEN

INTRODUCTION: The prevalence of cirrhosis is increasing despite advances in therapeutics, and it remains an expensive medical condition. Studies examining the healthcare burden of inpatient cirrhosis-related care regardless of etiology, stage, or severity are lacking. This study aims to describe the current drivers of cost, length of stay (LOS), and mortality in hospitalized patients with cirrhosis. METHODS: Using the National Inpatient Sample (NIS) data from 2008 to 2014, we categorized admissions into decompensated cirrhosis (DC), compensated cirrhosis (CC), and NIS without cirrhosis. Descriptive statistics and regression analysis were used to analyze the association between patient characteristics, comorbidities, complications, and procedures with costs, LOS, and mortality in each group. RESULTS: The hospitalization costs for patients with cirrhosis increased 30.2% from 2008 to 2014 to $7.37 billion. Cirrhosis admissions increased by 36% and 24% in the DC and CC groups, respectively, compared with 7.7% decrease in the NIS without cirrhosis group. DC admissions contributed to 58.6% of total cirrhotic admissions by 2014. Procedures increased costs in both DC and CC groups by 15%-152%, with mechanical ventilation being associated with high cost increase and mortality increase. Complications are also key drivers of costs and LOS, with renal and infectious complications being associated with the highest increases in the DC group and infections and nonportal hypertensive gastrointestinal bleeding for the CC group. DISCUSSION: Economic burden of hospitalized patients with cirrhosis is increasing with more admissions and longer LOS in DC and CC groups. Important drivers include procedures and portal hypertensive and nonportal hypertensive complications.


Asunto(s)
Hospitalización/economía , Tiempo de Internación/economía , Cirrosis Hepática/economía , Cirrosis Hepática/etiología , Anciano , Anciano de 80 o más Años , Estudios de Casos y Controles , Comorbilidad , Costo de Enfermedad , Bases de Datos Factuales , Femenino , Hospitalización/estadística & datos numéricos , Humanos , Tiempo de Internación/tendencias , Cirrosis Hepática/epidemiología , Cirrosis Hepática/mortalidad , Masculino , Persona de Mediana Edad , Prevalencia , Respiración Artificial/economía , Respiración Artificial/mortalidad , Respiración Artificial/estadística & datos numéricos
20.
J Urol ; 180(4): 1378-82, 2008 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-18707716

RESUMEN

PURPOSE: We compared the rate of mental health disorders in male and female patients with pelvic pain and control subjects. MATERIALS AND METHODS: Male patients with chronic prostatitis/chronic pelvic pain syndrome (174) and female patients with interstitial cystitis/painful bladder syndrome (111) were identified from a urology tertiary care clinic population. A control group consisting of 72 men and 175 women was also recruited. Subjects completed self-administered questionnaires that included items about demographics, medical history, medication use and urological symptoms. The Patient Health Questionnaire was used to identify depression and panic disorder. Multiple logistic regression was used to determine odds ratios for the presence of a mental health diagnosis. RESULTS: Mental health disorders were identified in 13% of the chronic prostatitis/chronic pelvic pain syndrome cases and 4% of male controls (OR 2.0, p = 0.04), as well as in 23% of interstitial cystitis/painful bladder syndrome cases and 3% of female controls (OR 8.2, p <0.0001). Disease status (case vs control) (OR 10.4, p = 0.001) and income greater than $50,000 (OR 0.34, p = 0.008) were the only 2 variables independently predictive of the presence of a mental health diagnosis. Age, gender, race/ethnicity and education were not predictive. Medications for anxiety, depression or stress were being taken by 18% of patients with chronic prostatitis/chronic pelvic pain syndrome, 37% of those with interstitial cystitis/painful bladder syndrome, 7% of male controls and 13% of female controls. CONCLUSIONS: Depression and panic disorder are significantly more common in men and women with pelvic pain conditions than in controls. Medication use data suggest that anxiety and depression may be more difficult to treat in patients with urological pain syndromes than in controls.


Asunto(s)
Cistitis Intersticial/psicología , Salud Mental , Dolor Pélvico/psicología , Prostatitis/psicología , Calidad de Vida , Adulto , Distribución por Edad , Anciano , Ansiedad/epidemiología , Ansiedad/etiología , Estudios de Casos y Controles , Enfermedad Crónica , Cistitis Intersticial/complicaciones , Cistitis Intersticial/diagnóstico , Depresión/epidemiología , Depresión/etiología , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Trastorno de Pánico/epidemiología , Trastorno de Pánico/etiología , Dolor Pélvico/complicaciones , Dolor Pélvico/diagnóstico , Probabilidad , Pronóstico , Prostatitis/complicaciones , Prostatitis/diagnóstico , Valores de Referencia , Medición de Riesgo , Índice de Severidad de la Enfermedad , Distribución por Sexo , Encuestas y Cuestionarios
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