Tracy A. Battaglia

Patient navigation: State of the art or is it science?†

First implemented in 1990, patient navigation interventions are emerging today as an approach to reduce cancer disparities. However, there is lack of consensus about how patient navigation is defined, what patient navigators do, and what their qualifications should be. Little is known about the efficacy and cost‐effectiveness of patient navigation. For this review, the authors conducted a qualitative synthesis of published literature on cancer patient navigation. By using the keywords ‘navigator’ or ‘navigation’ and ‘cancer,’ 45 articles were identified in the PubMed database and from reference searches that were published or in press through October 2007. Sixteen studies provided data on the efficacy of navigation in improving timeliness and receipt of cancer screening, diagnostic follow‐up care, and treatment. Patient navigation services were defined and differentiated from other outreach services. Overall, there was evidence of some degree of efficacy for patient navigation in increasing participation in cancer screening and adherence to diagnostic follow‐up care after the detection of an abnormality. The reported increases in screening ranged from 10.8% to 17.1%, and increases in adherence to diagnostic follow‐up care ranged from 21% to 29.2% compared with control patients. There was less evidence regarding the efficacy of patient navigation in reducing either late‐stage cancer diagnosis or delays in the initiation of cancer treatment or improving outcomes during cancer survivorship. There were methodological limitations in most studies, such as a lack of control groups, small sample sizes, and contamination with other interventions. Although cancer‐related patient navigation interventions are being adopted increasingly across the United States and Canada, further research will be necessary to evaluate their efficacy and cost‐effectiveness in improving cancer care. Cancer 2008.

Improving follow-up to abnormal breast cancer screening in an urban population. A patient navigation intervention.

Delays in follow‐up after cancer screening contribute to racial/ethnic disparities in cancer outcomes. We evaluated a patient navigator intervention among inner‐city women with breast abnormalities. A full‐time patient navigator supported patients using the care management model. Female patients 18 years and above, referred to an urban, hospital‐based, diagnostic breast health practice from January to June 2000 (preintervention) and November 2001 to February 2003 (intervention), were studied. Timely follow‐up was defined as arrival to diagnostic evaluation within 120 days from the date the original appointment was scheduled. Data were collected via computerized registration, medical records, and patient interview. Bivariate and multivariate logistic regression analyses were conducted, comparing preintervention and intervention groups, with propensity score analysis and time trend analysis to address the limitations of the pre–post design. 314 patients were scheduled preintervention; 1018, during the intervention. Overall, mean age was 44 years; 40% black, 36% non‐Hispanic white, 14% Hispanic, 4% Asian, 5% other; 15% required an interpreter; 68% had no or only public insurance. Forty‐four percent of referrals originated from a community health center, 34% from a hospital‐based practice. During the intervention, 78% had timely follow‐up versus 64% preintervention (P < .0001). In adjusted analyses, women in the intervention group had 39% greater odds of having timely follow‐up (95% CI, 1.01–1.9). Timely follow‐up in the adjusted model was associated with older age (P = .0003), having private insurance (P = .006), having an abnormal mammogram (P = .0001), and being referred from a hospital‐based practice, as compared to a community health center (P = .003). Our data suggest a benefit of patient navigators in reducing delay in breast cancer care for poor and minority populations. Cancer 2007.

National Cancer Institute Patient Navigation Research Program: methods, protocol, and measures.

Patient, provider, and systems barriers contribute to delays in cancer care, a lower quality of care, and poorer outcomes in vulnerable populations, including low‐income, underinsured, and racial/ethnic minority populations. Patient navigation is emerging as an intervention to address this problem, but navigation requires a clear definition and a rigorous testing of its effectiveness. Pilot programs have provided some evidence of benefit, but have been limited by evaluation of single‐site interventions and varying definitions of navigation. To overcome these limitations, a 9‐site National Cancer Institute Patient Navigation Research Program (PNRP) was initiated.

Survivors of Intimate Partner Violence Speak Out: Trust in the Patient-provider Relationship

OBJECTIVE: To identify characteristics that facilitate trust in the patient-provider relationship among survivors of intimate partner violence (IPV). DESIGN: Semistructured, open-ended interviews were conducted to elicit participants’ beliefs and attitudes about trust in interactions with health care providers. Using grounded theory methods, the transcripts were analyed for common themes. A community advisory group, composed of advocates, counselors and IPV survivors, helped interpret themes and interview exerpts. Together, key components of trust were identified. SETTING: Eastern Massachusetts. PARTICIPANTS: Twenty-seven female survivors of IPV recruited from community-based IPV organizations. MAIN RESULTS: Participants’ ages ranged from 18 to 56 years, 36% were African American, 32% Hispanic, and 18% white. We identified 5 dimensions of provider behavior that were uniquely important to the development of trust for these IPV survivors: 1) communication about abuse: provider was willing to openly discuss abuse; 2) professional competency: provider asked about abuse when appropriate and was familiar with medical and social histories; 3) practice style: provider was consistently accessible, respected confidentiality, and shared decision making; 4) caring: provider demonstrated personal concern beyond biomedical role through nonjudgmental and compassionate gestures, empowering statements, and persistent, committed behaviors; 5) emotional equality: provider shared personal information and feelings and was perceived by the participant as a friend. CONCLUSIONS: These IPV survivors identified dimensions of provider behavior that facilitate trust in their clinical relationship. Strengthening these provider behaviors may increase trust with patients and thus improve disclosure of and referral for IPV.

BOSTON PATIENT NAVIGATION RESEARCH PROGRAM: The Impact of Navigation on Time to Diagnostic Resolution after Abnormal Cancer Screening

Background: There is a need for controlled studies to assess the impact of patient navigation in vulnerable cancer populations. Methods: Boston Patient Navigation Research Program conducted a quasi-experimental patient navigation intervention across six federally qualified inner-city community health centers, three assigned to a breast cancer navigation intervention and three assigned to a cervical cancer navigation intervention; each group then served as the control for the other. Eligible women had an abnormal breast or cervical cancer screening test conducted at one of the participating health centers during a baseline (2004–2005) or intervention period (2007–2008). Kaplan–Meier survival curves and proportional hazards regression examined the effect of patient navigation on time to definitive diagnosis, adjusting for covariates, clustering by clinic and differences between the baseline and intervention period. Results: We enrolled 997 subjects in the baseline period and 3,041 subjects during the intervention period, of whom 1,497 were in the navigated arm, and 1,544 in the control arm. There was a significant decrease in time to diagnosis for subjects in the navigated group compared with controls among those with a cervical screening abnormality [aHR 1.46; 95% confidence interval (CI), 1.1–1.9]; and among those with a breast cancer screening abnormality that resolved after 60 days (aHR 1.40; 95% CI, 1.1–1.9), with no differences before 60 days. Conclusions: This study documents a benefit of patient navigation on time to diagnosis among a racially/ethnically diverse inner city population. Impact: Patient navigation may address cancer health disparities by reducing time to diagnosis following an abnormal cancer-screening event. Cancer Epidemiol Biomarkers Prev; 21(10); 1645–54. ©2012 AACR.

Disclosing intimate partner violence to health care clinicians - what a difference the setting makes: a qualitative study.

BackgroundDespite endorsement by national organizations, the impact of screening for intimate partner violence (IPV) is understudied, particularly as it occurs in different clinical settings. We analyzed interviews of IPV survivors to understand the risks and benefits of disclosing IPV to clinicians across specialties.MethodsParticipants were English-speaking female IPV survivors recruited through IPV programs in Massachusetts. In-depth interviews describing medical encounters related to abuse were analyzed for common themes using Grounded Theory qualitative research methods. Encounters with health care clinicians were categorized by outcome (IPV disclosure by patient, discovery evidenced by discussion of IPV by clinician without patient disclosure, or non-disclosure), attribute (beneficial, unhelpful, harmful), and specialty (emergency department (ED), primary care (PC), obstetrics/gynecology (OB/GYN)).ResultsOf 27 participants aged 18–56, 5 were white, 10 Latina, and 12 black. Of 59 relevant health care encounters, 23 were in ED, 17 in OB/GYN, and 19 in PC. Seven of 9 ED disclosures were characterized as unhelpful; the majority of disclosures in PC and OB/GYN were characterized as beneficial. There were no harmful disclosures in any setting. Unhelpful disclosures resulted in emotional distress and alienation from health care. Regardless of whether disclosure occurred, beneficial encounters were characterized by familiarity with the clinician, acknowledgement of the abuse, respect and relevant referrals.ConclusionWhile no harms resulted from IPV disclosure, survivor satisfaction with disclosure is shaped by the setting of the encounter. Clinicians should aim to build a therapeutic relationship with IPV survivors that empowers and educates patients and does not demand disclosure.

Patient Navigation: Development of a Protocol for Describing What Navigators Do

OBJECTIVE To develop a structured protocol for observing patient navigators at work, describing and characterizing specific activities related to their goals. DATA SOURCES/SETTING Fourteen extended observations of navigators at three programs within a national trial of patient navigation. STUDY DESIGN Preliminary observations were guided by a conceptual model derived from the literature and expert consensus, then coded to develop and refine observation categories. These findings were then used to develop the protocol. METHODS Observation fieldnotes were coded, using both a priori codes and new codes based on emergent themes. Using these codes, the team refined the model and constructed an observation tool that enables consistent categorization of the observed range of navigator actions. FINDINGS Navigator actions across a wide variety of settings can be categorized in a matrix with two dimensions. One dimension categorizes the individuals and organizational entities with whom the navigator interacts; the other characterizes the types of tasks carried out by the navigators in support of their patients. CONCLUSIONS Use of this protocol will enable researchers to systematically characterize and compare navigator activities within and across programs.

Predictors of Timely Follow-Up After Abnormal Cancer Screening Among Women Seeking Care at Urban Community Health Centers

We sought to measure time and identify predictors of timely follow‐up among a cohort of racially/ethnically diverse inner city women with breast and cervical cancer screening abnormalities.

The influence of black race on treatment and mortality for early-stage breast cancer.

Background:Black Americans have higher mortality from breast cancer than white Americans. This study explores the influence of socioeconomic factors and black race on treatment and mortality for early-stage breast cancer. Methods:A cohort of 21,848 female black and white, non-Hispanic subjects from the Massachusetts Cancer Registry diagnosed with stage I or II breast cancer between 1999–2004 was studied. Subjects with tumors larger than 5 cm were excluded. We used mixed modeling methods to assess the impact of race on guideline concordant care (GCC), defined as receipt of mastectomy or breast conserving surgery plus radiation. Cox proportional hazard regression was used to assess disease-specific mortality. Results:Blacks were less likely to receive GCC after adjusting for age and clinical variables (OR: 0.75; 95% CI: 0.61, 0.92). Marital status and insurance were predictors of receipt of GCC. After adjustment for all covariates, there were no longer significant differences between black and white women regarding the receipt of GCC. Nevertheless, black women were more likely to die of early-stage breast cancer than white women after adjusting for clinical, treatment, socioeconomic variables, and reporting hospital (HR: 1.6; 95% CI: 1.1–2.1). Conclusions:Socioeconomic factors are mediators of racial differences in treatment outcomes. Significant racial differences exist in disease-specific mortality for women with early-stage breast cancer. Attention to reducing socioeconomic barriers to care may influence racial differences in breast cancer treatment and mortality.

Can Patient Navigation Improve Receipt of Recommended Breast Cancer Care? Evidence From the National Patient Navigation Research Program

PURPOSE Poor and underserved women face barriers in receiving timely and appropriate breast cancer care. Patient navigators help individuals overcome these barriers, but little is known about whether patient navigation improves quality of care. The purpose of this study is to examine whether navigated women with breast cancer are more likely to receive recommended standard breast cancer care. PATIENTS AND METHODS Women with breast cancer who participated in the national Patient Navigation Research Program were examined to determine whether the care they received included the following: initiation of antiestrogen therapy in patients with hormone receptor-positive breast cancer; initiation of postlumpectomy radiation therapy; and initiation of chemotherapy in women younger than age 70 years with triple-negative tumors more than 1 cm. This is a secondary analysis of a multicenter quasi-experimental study funded by the National Cancer Institute to evaluate patient navigation. Multiple logistic regression was performed to compare differences in receipt of care between navigated and non-navigated participants. RESULTS Among participants eligible for antiestrogen therapy, navigated participants (n = 380) had a statistically significant higher likelihood of receiving antiestrogen therapy compared with non-navigated controls (n = 381; odds ratio [OR], 1.73; P = .004) in a multivariable analysis. Among the participants eligible for radiation therapy after lumpectomy, navigated participants (n = 255) were no more likely to receive radiation (OR, 1.42; P = .22) than control participants (n = 297). CONCLUSION We demonstrate that navigated participants were more likely than non-navigated participants to receive antiestrogen therapy. Future studies are required to determine the full impact patient navigation may have on ensuring that vulnerable populations receive quality care.