The Ohio Patient Navigation Research Program: does the American Cancer Society patient navigation model improve time to resolution in patients with abnormal screening tests?

BACKGROUND: Patient navigation (PN) has been suggested as a way to reduce cancer health disparities; however, many models of PN exist and most have not been carefully evaluated. The goal of this study was to test the Ohio American Cancer Society model of PN as it relates to reducing time to diagnostic resolution among persons with abnormal breast, cervical, or colorectal cancer screening tests or symptoms. METHODS: A total of 862 patients from 18 clinics participated in this group-randomized trial. Chart review documented the date of the abnormality and the date of resolution. The primary analysis used shared frailty models to test for the effect of PN on time to resolution. Crude HR were reported as there was no evidence of confounding. RESULTS: HRs became significant at 6 months; conditional on the random clinic effect, the resolution rate at 15 months was 65% higher in the PN arm (P = 0.012 for difference in resolution rate across arms; P = 0.009 for an increase in the HR over time). CONCLUSIONS: Participants with abnormal cancer screening tests or symptoms resolved faster if assigned to PN compared with those not assigned to PN. The effect of PN became apparent beginning six months after detection of the abnormality. IMPACT: PN may help address health disparities by reducing time to resolution after an abnormal cancer screening test.

Cancer-related lymphedema risk factors, diagnosis, treatment, and impact: a review.

PURPOSE Cancer-related lymphedema (LE) is an incurable condition associated with lymph-involved cancer treatments and is an increasing health, quality of life (QOL), and cost burden on a growing cancer survivor population. This review examines the evidence for causes, risk, prevention, diagnosis, treatment, and impact of this largely unexamined survivorship concern. METHODS PubMed and Medline were searched for cancer-related LE literature published since 1990 in English. The resulting references (N = 726) were evaluated for strength of design, methods, sample size, and recent publication and sorted into categories (ie, causes/prevention, diagnosis, treatment, and QOL). Sixty studies were included. Results Exercise and physical activity and sentinel lymph node biopsy reduce risk, and overweight and obesity increase risk. Evidence that physiotherapy reduces risk and that lymph node status and number of malignant nodes increase risk is less strong. Perometry and bioimpedence emerged as attractive diagnostic technologies, replacing the use of water displacement in clinical practice. Swelling can also be assessed by measuring arm circumference and relying on self-report. Symptoms can be managed, not cured, with complex physical therapy, low-level laser therapy, pharmacotherapy, and surgery. Sequelae of LE negatively affect physical and mental QOL and range in severity. However, the majority of reviewed studies involved patients with breast cancer; therefore, results may not be applicable to all cancers. CONCLUSION Research into causes, prevention, and effect on QOL of LE and information on LE in cancers other than breast is needed. Consensus on definitions and measurement, increased patient and provider awareness of signs and symptoms, and proper and prompt treatment/access, including psychosocial support, are needed to better understand, prevent, and treat LE.

Translating cancer prevention and control research into the community setting: workforce implications.

A gap exists between cancer prevention research and its translation into community practice. Two strategies to reduce this gap are community-based participatory research (CBPR) and dissemination research. CBPR offers an avenue to engage academic and community partners, thereby providing mechanisms for joint learning and application of knowledge. Dissemination research examines the movement of evidence-based public health and clinical innovations to practice settings. While applying these approaches may reduce the gap between research and practice, the cancer prevention workforce may be inadequate in size, insufficiently trained, lack resources and incentives, or face structural barriers to effectively participate in CBPR and disseminate evidence-based research findings into practice. Information on translating cancer prevention information to communities and workforce implications was obtained from a panel of experts and through a review of the literature on CBPR and dissemination research. The expert panel and literature review identified major barriers to successfully conducting CBPR and dissemination research in community settings. Barriers included inadequate policies; insufficient networking and communication infrastructures; unsupportive research cultures, climates, and mindsets; inadequate researcher and practitioner education; and limited CBPR and dissemination research with adequate study designs. No specific estimates of the cancer prevention workforce were found; however, indirect evidence for a shortfall were identified. We recommend expanding CBPR training for academic and community partners; increasing funding for dissemination research and practice; supporting proven partnerships; and providing strategic coordination for government agencies, research institutions, nongovernmental organizations, and the private sector to foster better dissemination of information and integration of community-based cancer prevention and control programs and practices. Specific challenges and needs that must be addressed to improve the translation of cancer prevention research into community settings were identified.

Trust and distrust among Appalachian women regarding cervical cancer screening: a qualitative study.

OBJECTIVE: To explore Appalachian women's perceptions of trust and distrust of healthcare providers and the medical care system as they relate to views about cervical cancer and screening. METHODS: Thirty-six Ohio Appalachia female residents participated in community focus groups conducted by trained facilitators. Discussion topics included factors related to cervical cancer, and the issues of trust and distrust in medical care. The tape-recorded focus groups were transcribed and analyzed to identify salient themes. RESULTS: Five themes emerged related to trust in healthcare. Patient-centered communication and encouragement from a healthcare provider led women to trust their physicians and the medical care system. In contrast, lack of patient-centered communication by providers and perceptions of poor quality of care led to distrust. Physician gender concordance also contributed to trust as women reported trust of female physicians and distrust of male physicians; trust in male physicians was reported to be increased by the presence of a female nurse. CONCLUSIONS: Important factors associated with trust and distrust of providers and the medical care system may impact health-seeking behaviors among underserved women. PRACTICE IMPLICATIONS: Opportunities to improve patient-centered communication around the issues of prevention and cervical cancer screening (such as providing patient-focused information about access to appropriate screening tests) could be used to improve patient care and build patients' trust.

Cancer survivorship research: a review of the literature and summary of current NCI-designated cancer center projects.

The number of cancer survivors and the amount of cancer survivorship research have grown substantially during the past three decades. This article provides a review of interventional and observational cancer survivorship research efforts as well as a summary of current cancer survivorship research projects being conducted by National Cancer Institute-designated cancer centers in an effort to identify areas that need further attention.

Patient navigation: an update on the state of the science.

Although patient navigation was introduced 2 decades ago, there remains a lack of consensus regarding its definition, the necessary qualifications of patient navigators, and its impact on the continuum of cancer care. This review provides an update to the 2008 review by Wells et al on patient navigation. Since then, there has been a significant increase in the number of published studies dealing with cancer patient navigation. The authors of the current review conducted a search by using the keywords "navigation" or "navigator" and "cancer." Thirty-three articles published from November 2007 through July 2010 met the search criteria. Consistent with the prior review, there is building evidence of some degree of efficacy of patient navigation in terms of increasing cancer screening rates. However, there is less recent evidence concerning the benefit of patient navigation with regard to diagnostic follow-up and in the treatment setting, and a paucity of research focusing on patient navigation in cancer survivorship remains. Methodological limitations were noted in many studies, including small sample sizes and a lack of control groups. As patient navigation programs continue to develop across North America and beyond, further research will be required to determine the efficacy of cancer patient navigation across all aspects of the cancer care continuum.

Perceived efficiency impacts following electronic health record implementation: an exploratory study of an urban community health center network.

PURPOSE: Faced with an increasingly complex patient population and growing demand for services, community health centers (CHCs) are recognizing that electronic health records (EHRs) may help their efforts to improve efficiency in care delivery. Yet little is known about the benefits, challenges, and specific impacts of EHR implementation in the often resource-constrained CHC environment, especially from users' perspectives. The objective of this study was to explore EHR users' perspectives about the EHR implementation process and impact in a CHC network. METHODS: We performed an exploratory case study following EHR implementation in a multi-site, urban CHC network. Data were collected through semi-structured interviews with 39 key informants across four sites. Key informants included physicians, clinical staff and administrators. We used both deductive and inductive approaches to code the transcribed interview data and to identify themes in our analyses. RESULTS: A key theme that emerged involved perceptions of efficiency related to the EHR implementation. While the EHR was widely credited with improving the efficiency of several clinical processes (e.g., lab ordering), it also created new challenges. Some of the early efficiency challenges we identified were common to EHR implementation in general (e.g., system interface issues), but others were unique to the CHC context (e.g., issues related to compliance with complex regulatory and reporting requirements). Further, constrained organizational resources for training and ongoing IT support were widely noted as challenges that may have exacerbated, or precluded early resolution of, efficiency issues. While limited to a single CHC network, our findings highlight important issues for CHCs to consider about EHRs. CONCLUSIONS: These findings suggest that CHCs face difficult and often unique barriers related to EHR implementation and use, and the resultant efficiency impacts should not be overlooked.

Ohio Appalachian women's perceptions of the cost of cervical cancer screening.

BACKGROUND: Despite evidence of the importance of cervical cancer screening, screening rates in the United States remain below national prevention goals. Women in the Appalachia Ohio region have higher cervical cancer incidence and mortality rates along with lower cancer screening rates. This study explored the expectations of Appalachian Ohio women with regard to Papanicolaou (Pap) test cost and perceptions of cost as a barrier to screening. METHODS: Face-to-face interviews were conducted with 571 women who were part of a multilevel, observational community-based research program in Appalachia Ohio. Eligible women were identified through 14 participating health clinics and asked questions regarding Pap test cost and perceptions of cost as a barrier to screening. Estimates of medical costs were compared with actual costs reported by clinics. RESULTS: When asked about how much a Pap test would cost, 80% of the women reported they did not know. Among women who reportedly believed they knew the cost, 40% overestimated test cost. Women who noted cost as a barrier were twice as likely to not receive a test within screening guidelines as those who did not perceive a cost barrier. Furthermore, uninsured women were more than 8.5 times as likely to note cost as a barrier than women with private insurance. CONCLUSIONS: Although underserved women in need of cancer screening commonly report cost as a barrier, the findings of the current study suggest that women may have a very limited and often inaccurate understanding concerning Pap test cost. Providing women with this information may help reduce the impact of this barrier to screening.