Elizabeth A. Calhoun

Achieving Health Equity: Closing The Gaps In Health Care Disparities, Interventions, And Research

In the United States, racial/ethnic minority, rural, and low-income populations continue to experience suboptimal access to and quality of health care despite decades of recognition of health disparities and policy mandates to eliminate them. Many health care interventions that were designed to achieve health equity fall short because of gaps in knowledge and translation. We discuss these gaps and highlight innovative interventions that help address them, focusing on cardiovascular disease and cancer. We also provide recommendations for advancing the field of health equity and informing the implementation and evaluation of policies that target health disparities through improved access to care and quality of care.

Calling for a bold new vision of health disparities intervention research

The author discusses the need for new health disparities intervention research based upon the experience of the Centers for Population Health and Health Disparities (CPHHD) Program. Topics include the effectiveness of interventions addressing social determinants of health to reduce health disparities, the potential use of genomic strategies to determine population health disparities, and the enhancement of communication and cultural competency in health professionals to improve healthcare equity.

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

OBJECTIVE A nationwide cross-sectional study was conducted to assess patient navigator, patient population, and work setting characteristics associated with performance of various patient navigation (PN) tasks. METHODS Using respondent-driven sampling, 819 navigators completed a survey assessing frequency of providing 83 PN services, along with information about themselves, populations they serve, and setting in which they worked. Analyses of variance and Pearson correlations were conducted to determine differences and associations in frequency of PN services provided by various patient, navigator, and work setting characteristics. RESULTS Nurse navigators and navigators with lower education provide basic navigation; social workers typically made arrangements and referrals; and individuals with higher education, social workers, and nurses provide treatment support and clinical trials/peer support. Treatment support and clinical trials/peer support are provided to individuals with private insurance. Basic navigation, arrangements and referrals, and care coordination are provided to individuals with Medicaid or no insurance. CONCLUSION Providing basic navigation is a core competency for patient navigators. There may be two different specialties of PN, one which seeks to reduce health disparities and a second which focuses on treatment and emotional support. PRACTICE IMPLICATIONS The selection and training of patient navigators should reflect the specialization required for a position.

Factors Related to Physician Clinical Decision-Making for African-American and Hispanic Patients: a Qualitative Meta-Synthesis

Clinical decision-making may have a role in racial and ethnic disparities in healthcare but has not been evaluated systematically. The purpose of this study was to synthesize qualitative studies that explore various aspects of how a patient’s African-American race or Hispanic ethnicity may factor into physician clinical decision-making. Using Ovid MEDLINE, Embase, and Cochrane Library, we identified 13 manuscripts that met inclusion criteria of usage of qualitative methods; addressed US physician clinical decision-making factors when caring for African-American, Hispanic, or Caucasian patients; and published between 2000 and 2017. We derived six fundamental themes that detail the role of patient race and ethnicity on physician decision-making, including importance of race, patient-level issues, system-level issues, bias and racism, patient values, and communication. In conclusion, a non-hierarchical system of intertwining themes influenced clinical decision-making among racial and ethnic minority patients. Future study should systematically intervene upon each theme in order to promote equitable clinical decision-making among diverse racial/ethnic patients.

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

BACKGROUND Past efforts to assess patient navigation on cancer screening utilization have focused on one-time uptake, which may not be sufficient in the long term. This is partially due to limited resources for in-person, longitudinal patient navigation. We examine the effectiveness of a low-intensity phone- and mail-based navigation on multiple screening episodes with a focus on screening uptake after receiving noncancerous results during a previous screening episode. METHODS The is a secondary analysis of patients who participated in a randomized controlled patient navigation trial in Chicago. Participants include women referred for a screening mammogram, aged 50-74 years, and with a history of benign/normal screening results. Navigation services focused on identification of barriers and intervention via shared decision-making processes. A multivariable logistic regression intent-to-treat model was used to examine differences in odds of obtaining a screening mammogram within 2 years of the initial mammogram (yes/no) between navigated and non-navigated women. Sensitivity analyses were conducted to explore patterns across subsets of participants (e.g., navigated women successfully contacted before the initial appointment; women receiving care at Hospital C). RESULTS The final sample included 2,536 women (741 navigated, 1,795 non-navigated). Navigated women exhibited greater odds of obtaining subsequent screenings relative to women in the standard care group in adjusted models and analyses including women who received navigation before the initial appointment. CONCLUSIONS Our findings suggest that low-intensity navigation services can improve follow-up screening among women who receive a noncancerous result. Further investigation is needed to confirm navigations impacts on longitudinal screening.

Consensus Support for the Role of Patient Navigation in the Nation’s Healthcare System

The current momentum in health care is to improve quality and access to care by empowering patients, regardless of socioeconomic level, education, race, or diagnosed disease, to take a leading role in their health care. Patient Navigation was initially developed to improve health outcomes of medically underserved populations by eliminating barriers to accessing and using the complex US health system. The field has evolved and Patient Navigation is now utilized along the entire cancer care continuum and in other chronic diseases in an effort to coordinate care for vulnerable patients. Numerous organizations have invested significant resources to fund Patient Navigation research and service delivery programs providing evidence that supports Patient Navigation improves health outcomes. The presence of Patient Navigation, however, is fragmented in the health system and is consistently misunderstood. The aim of this chapter is to outline recommendations for healthcare policy initiatives aimed at establishing Patient Navigators as a valuable professional in the healthcare delivery system team. While they serve on a multidisciplinary team, this literature distinguishes the roles of Patient Navigation from other health fields, such as community health workers (CHWs), and highlights the need for a definitive job description. The consensus also calls for development and maintenance of an accepted standardized training program with curriculum targeting core proficiencies and an evaluation process, leading to national accreditation and certification. The goal for Patient Navigation is to be recognition as a coverable service for both private and public payers through bundled payments and other payment mechanisms. There has been a sharp increase in the number of Patient Navigation programs, which has increased the number of patients who receive their services. Therefore, it is essential to continue the growth of Patient Navigation so it becomes a permanent part of the fabric of the healthcare delivery system.

Gendered and Racialized Social Expectations, Barriers, and Delayed Breast Cancer Diagnosis: Barriers to Diagnostic Mammography

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.

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

Purpose. Improving mammography among Latinas may improve ethnic disparities in stage at diagnosis, morbidity, and quality of life. In response, multiple interventions have been developed and assessed, including patient navigation. Little is known about how efficacy varies across socioenvironmental contexts. Such work is warranted for future comparative effectiveness research and clinical implementation. Objective. The study examined the interactive effects of patient navigation with contextual factors (facility and residential neighborhood characteristics) on mammography uptake among a Chicago-based sample of Latinas. Methods. The larger trial, “Patient Navigation in Medically Underserved Areas”, is a five year project to assess the effectiveness of primarily phone-based navigation services within 3 hospitals in South Chicago. The current study9s analytic sample includes 715 women who: 1) identified as Latina; 2) were referred for mammography; and 3) had age, insurance status, type of mammogram, and zipcode information documented in their medical records. We classified participants using an as-treated operationalization (navigated or not). The facility variable of interest was accreditation as a Breast Imaging Center of Excellence (BICOE; 1 yes and 2 no). The two neighborhood characteristics of interest were median household income and percent of Latino residents (%Latino) based on American Community Survey 2007-2011 data. The outcome of interest was days to mammography uptake, defined as days between randomization and attendance at the referred mammography appointment. Results. First, Cox regression survival models were conducted that adjusted for patient age, insurance status, and type of mammogram (screening or diagnostic) and incorporated main effects of facility and neighborhood characteristics. There were significant interaction effects of navigation with neighborhood %Latino (p The analysis next conducted models, wherein we stratified by tertiles for %Latino and by facility BICOE status (yes/no). For these models, it included covariates and the main effects of non-stratified contextual variables (e.g., neighborhood median income). Among residents of neighborhoods with the least %Latino, non-navigated women had a greater number of days to mammography uptake relative to navigated women, HR =2.8, 95%CI[1.6, 4.9], p Conclusions. The study suggests navigation may be particularly effective within more resourced facility settings and for Latinos living outside of ethnic enclaves. Future studies are warranted to confirm our findings and assess the potential of these services across diverse clinical settings. Citation Format: Yamile Molina, Yazmin San Miguel, Sage Kim, Anne Elizabeth Glassglow, Nerida Berrios, Julie S. Darnell, Elizabeth A. Calhoun. The effect of navigation on mammography uptake among Latinas: Effect modification by facility and neighborhood characteristics. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr C78.

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

Purpose: Despite its increasing popularity to address breast cancer disparities, existing efforts to assess the effect of patient navigation on regular breast cancer screening utilization among medically underserved groups have been cross-sectional or ecological in nature. Such work is warranted to examine the longitudinal benefits of patient navigation, given one-time utilization of cancer screening is not sufficient strategy for improving early detection of breast cancer. Objective: Our study had two objectives. First, we test the effectiveness of navigation on adherence to initial recommended screening mammography appointments among a population of medically underserved, largely African American women. Second, for women with normal screening results, we test the effectiveness of navigation on attainment of subsequent screening mammograms. Methods: The larger trial, Patient Navigation in Medically Underserved Areas, is a five year project to assess the effectiveness of multimodal, primarily phone-based, navigation services to timely diagnostic resolution after an abnormal screening result within three hospitals located in South Chicago. The current study focuses on secondary outcomes concerning the effectiveness of navigation for mammography screening. Our analytic sample includes 4185 women referred for mammography screening with available medical record data concerning demographic (age, race, insurance, miles to clinic, neighborhood median income) and healthcare information (insurance, screening patterns). Participants were classified by their assignment from randomization, which was focused on the primary outcome (diagnostic follow-up), and whether they interacted with staff prior to the initial appointment: navigated with contact; control with contact; navigated without contact; and control without contact. Results: After adjusting for demographic and healthcare insurance, navigated with contact, women obtained the initial screening mammogram within fewer days relative to other groups, HR= 0.7, 95%CI [0.6, 0.9], p = .001 and greater odds of obtaining screening mammograms, OR = 1.6, 95%CI [1.3, 1.9], p Conclusions: Our study adds to a growing body of work demonstrating the usefulness of patient navigation, including the impact of delivering services outside of in-person interaction. Future studies are warranted to confirm our findings and assess the potential of these services in real life settings. Citation Format: Yamile Molina, Sage Kim, Anne L. Glassgow, Nerida M. Berrios, Julie Darnell, Heather Pauls, Ganga Vijayasiri, Richard Warnecke, Elizabeth A. Calhoun. Effects of navigation on initial and repeat mammography screening among medically underserved women. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr B76.

Abstract IA38: Patient navigation in medically underserved areas

Purpose: The Chicago Patient Navigation in Medically Underserved Areas Study, a large scale randomized trial of patient navigation, involving women who made appointments at one of three Chicago-area medical centers for either screening or diagnostic mammograms/services. The principal outcome measure is the time required to come to diagnostic resolution for women whose initial mammograms results in BIRAD values of 0,3,4 or 5. Our goal was to evaluate the effectiveness of patient navigation but also to investigate the effect of living in an officially designated Medically Underserved Area (MUA). Background: MUAs are designated by the Health Research Services Administration (HRSA). Areas to be considered for designation are defined as rational service areas (RSA), which in urban areas are composed of contiguous census tracts. Four elements are considered (1) the ratio of primary medical care physicians per 1,000 population, (2) the infant mortality rate, (3) the percentage of the population with income below the poverty level, and (4) the percent of the population 65 years and older. Each of the four elements is scored separately and then summed; the resulting score can range from 0 to 100. Areas with an IMU below 62 qualify for designation. Consideration for MUA status must be requested by representatives from the population of the eligible areas. Thus, designation requires that a local community organization advocates for establishment of the MUA. As a result, in Chicago, many census tracts are eligible for MUA status but are not so designated. Methods: All women who had an initial referral from a physician for screening or for diagnostic mammography following a clinical breast exam were randomly assigned to either the control or navigation arm of the study. Randomization was balanced by age group. Women assigned to navigation were recruited if they had a working telephone and gave informed consent. Electronic medical record (EMR) data were made available by the cooperating medical centers for all women. All women in the navigation arm and a small subsample of women in the control arm also responded to a series of questionnaires collecting background data and tracking their progress through the breast care cycle. Each woman9s address was geocoded and the census tract was coded for MUA status: (1) not eligible, (2) old MUA designated before the year 2000, (3) new MUA designated in 2000 or after and (4) eligible but not designated. For this analysis, the primary outcome variable is the number of days ensuing between the date of the initial examination and the date on which a firm diagnosis of cancer or no cancer was obtained. The analysis sample consisted of all women with initial BIRAD values of 0, 3, 4 or 5. Women with BIRAD 3 are normally asked to return for re-examination in six months and in their case the number of days till resolution was adjusted to count the number of days following the suggested return date. Over the course of the study some women were observed over several exam cycles. This analysis focuses on the first cycle only. All analysis were conducted using the Cox proportional hazard model. Analyses were stratified by the initial BIRAD value. Results: After excluding a small number of women with missing clinical data, 5660 cases were available for analysis. Of these, 3567 cases were excluded because their initial BIRAD value was 1 or 2. For the remaining 2093 cases involving 223022 person-days at risk we obtained resolution dates for 1810 and the remainder were lost to follow up in that we did not observe a diagnostic resolution date. These cases were considered to be censored. The maximum number of days observed was 741. Variables in the Cox model were indicator variables for navigated versus control and screening versus diagnostic, a set of indicator variables for MUA status (reference group New MUA), a set of indicator variables for insurance status (private, Medicare, Medicaid or uninsured, reference group private) and marital status (single, married, divorced/separated and widowed, reference group single). Age was found to be unrelated to the rate of resolution and was not included in the final model. Women who were navigated obtained diagnostic resolution more quickly (HR 1.13; CI 1.02, 1.24; p .017) than women in the control arm. Women seen for diagnostic mammography had much faster resolution times (HR 1.88, CI 1.67, 2.09; p . Conclusion: Despite years of gains in cancer screening, diagnosis, and treatment, certain populations continue to disproportionally suffer with poor outcomes and higher mortality. Patient navigation is a strategy to improve the equity in outcomes across populations. The field of navigation is maturing and solidifying the evidence for the efficacy pf patient navigation. There needs to be more efforts aimed at understanding which populations benefit the most from navigation. In addition, determining what type of navigation models works best in certain settings and with certain populations is still ripe for study. This study provides evidence supporting navigation as an effective tool to help women reach diagnostic resolution. Additionally analyses will be conducted to examine more fully the impact on how living in an MUA, having a medical home, and being actively engaged in your health care has on the patients9 ability to navigate themselves more effectively and help provide evidence to help deploy navigation in a sustainable and cost efficient manner. Citation Format: Elizabeth A. Calhoun, Heather Pauls, Ganga Vijayasiri, Julie S. Darnell, Yamile Molina, Nerida Berrios, Richard Warnecke, Richard Campbell. Patient navigation in medically underserved areas. [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr IA38.