Heather Pauls

Dissemination of patient navigation programs across the united states

OBJECTIVE To use diffusion and dissemination frameworks to describe how indicators of economic and health care disparity affect the location and type of patient navigation programs. METHODS A cross-sectional national Web-based survey conducted during 2009-2010 with support from 65 separate national and regional stakeholder organizations. PARTICIPANTS A total of 1116 self-identified patient navigators across the United States. MAIN OUTCOME MEASURE The location and characteristics of patient navigation programs according to economic and health care disparity indicators. RESULTS Patient navigation programs appear to be geographically dispersed across the United States. Program differences were observed in navigator type, population served, and setting by poverty level. Programs in high-poverty versus low-poverty areas were more likely to use lay navigators (P < .001) and to be located in community health centers and agencies with religious affiliations (50.6 vs 36.4%, and 21.5% vs 16.7%. respectively; P ≤ 0.01). CONCLUSION(S) Results suggest that navigation programs have spread beyond initial target inception areas and also serve as a potentially important resource in communities with higher levels of poverty and/or relatively low access to care. In addition, while nurse navigators have emerged as a significant component of the patient navigation workforce, lay health navigators serve a vital role in underserved communities. Other factors from dissemination frameworks may influence the spread of navigation and provide useful insights to support the dissemination of programs to areas of high need.

Implementation challenges and outcomes of a randomized controlled pilot study of a group prenatal care model in Malawi and Tanzania

To identify implementation challenges associated with conducting a randomized controlled trial (RCT) of group prenatal care (PNC) and report outcomes of the pilot.

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.

Physician Decisions to Defer Antiretroviral Therapy in Key Populations: Implications for Reducing HIV Incidence and Mortality in Malaysia.

Abstract Background Antiretroviral therapy (ART) is recommended for all people living with human immunodeficiency virus (HIV), yet physician attitudes and prescribing behaviors toward members of key risk populations may limit ART access and undermine treatment as prevention strategies. Methods Physicians in Malaysia (N = 214) who prescribe antiretroviral therapy (ART) responded in an Internet-based survey to hypothetical clinical scenarios of HIV patients, varying by key risk population and CD4+ T-cell count, on whether they would initiate or defer ART compared with a control patient with sexually acquired HIV. Results The proportion of physicians who would defer ART in patients with advanced HIV (CD4 = 17 cells/μL) was significantly higher (P < .0001) for 4 key populations, including people who inject drugs ([PWID] 45.3%) or consume alcohol (42.1%), released prisoners (35.0%), and those lacking social support (26.6%), compared with a control patient (4.2%). People who inject drugs with advanced HIV (CD4 = 17 cells/μL) were 19-fold (adjusted odds ratio [AOR] = 18.9; 95% confidence interval [CI], 9.8–36.5) more likely to have ART deferred compared with the control. This effect was partially mitigated for PWID receiving methadone (AOR = 2.9; 95% CI, 1.5–5.7). At the highest CD4+ T-cell count (CD4 = 470 cells/μL), sex workers (AOR = 0.55; 95% CI, .44–.70) and patients with an HIV-uninfected sexual partner (AOR = 0.43; 95% CI, .34–.57) were significantly less likely to have ART deferred. Conclusions Physicians who prescribe antiretroviral therapy in Malaysia may defer ART in some key populations including PWID and released prisoners, regardless of CD4+ T-cell count, which may help to explain very low rates of ART coverage among PWID in Malaysia. Reducing HIV incidence and mortality in Malaysia, where HIV is concentrated in PWID and other key populations, requires clinician-level interventions and monitoring physician adherence to international evidence-based treatment guidelines.

If you build it, they may not come: modifiable barriers to patient portal use among pre- and post-kidney transplant patients

Abstract Background Patient access to health information using electronic patient portals is increasingly common. Portal use has the potential to improve patients’ engagement with their health and is particularly important for patients with chronic illness; however, patients’ abilities, attitudes, and use of portals are poorly understood. Methods A single-center, cross-sectional survey was conducted of 240 consecutive pre- and post-kidney transplant patients of all levels of technological proficiency who presented to an urban transplant center in the United States. The investigator-developed Patient Information and Technology Assessment-Patient Portal was used to assess patients’ attitudes towards the use of patient portals. Results Most patients surveyed did not use the patient portal (n = 176, 73%). Patients were more likely to use the patient portal if they were White, highly educated, in the post-transplant period, more comfortable with technology, and reported being a frequent internet user (P < .05). The most common reasons for not using the patient portal included: (1) preference for traditional communication, (2) not being aware of the portal, (3) low technological proficiency, and (4) poor interoperability between the portal at the transplant center and the patient’s primary care center. Conclusions We identified several modifiable barriers to patient portal use. Some barriers can be addressed by patient education and training on portal use, and federal initiatives are underway to improve interoperability; however, a preference for traditional communications represents the most prominent barrier. Additional strategies are needed to improve portal adoption by encouraging acceptance of technologies as a way of clinical communication.

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.

Abstract A05: Does community-level access to healthcare moderate the adverse effect of community socioeconomic deprivation on prostate and colorectal cancer mortality rates?

Introduction and Objective: Some socioeconomically disadvantaged urban communities experience significantly higher mortality rates from cancer than more affluent areas, whereas others do not. This study explored whether community-level healthcare access-related factors in an urban setting modified the association of community socioeconomic disadvantage with increased cancer-related mortality. Methods: We used linear regression models to analyze the association of concentrated disadvantage (CD), a multidimensional area-based measure of SES, with age-adjusted prostate and colorectal cancer mortality rates in the 77 community areas of Chicago, Illinois before and after stratification by measures of community access to healthcare. For each community, we calculated a CD score using data from the 2000 U.S. census and the subsequent 5-year age-adjusted cumulative mortality rates from prostate and colorectal cancer using data from the Chicago Department of Public Health. We also characterized each community area with respect to the density of prostate and colorectal cancer-related physicians and medically underserved area/population (MUA/MUP) designation status as of 2000 using data from the American Medical Association and the U.S. Department of Health and Human Services-Health Resources and Services Administration (DHHS-HRSA), respectively. Results: Community area CD score was strongly associated with 5-year cumulative mortality rates from prostate and colorectal cancers (p < 0.0001, R2 = 0.440 and 0.223, respectively). Physician density did not modify the association. However, CD was not associated with increased prostate and colorectal cancer mortality rates in community areas with an MUA/MUP designation of 7 years or more (p = 0.31 and 0.87 for prostate and colorectal cancer, respectively). Moreover, the cancer mortality rates in communities with a long-standing MUA/MUP designation were not significantly higher than those of more affluent communities (p = 0.36 and 0.99 for prostate and colorectal cancer, respectively). Conclusion: Over time, an MUA/MUP designation may moderate the association between community-level socioeconomic disadvantage and increased mortality from prostate and colorectal cancers in socioeconomically deprived urban communities. A sustained increase in access to health care infrastructure, providers and services that usually follows a MUA/MUP designation through DHHS-HRSA could help explain this moderating effect. Citation Format: Vincent L. Freeman, Richard E. Barrett, Benjamin J. Booth, Sara L. McLafferty, Alisa Shockley, Joseph M. Simanis, Heather Pauls, Richard T. Campbell. Does community-level access to healthcare moderate the adverse effect of community socioeconomic deprivation on prostate and colorectal cancer mortality rates? [abstract]. In: Proceedings of the Fifth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2012 Oct 27-30; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(10 Suppl):Abstract nr A05.