Urban Latino African American Cancer (ULAAC) Disparities

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  • 1.Radiation Therapy Oncology Group (RTOG) Semi-Annual Meeting Tampa, Florida February 3, 2007
  • 2.Urban Latino African American Cancer (ULAAC) Disparities Project Michael L. Steinberg, MD, FACR Principal Investigator David Huang, MD Co-Investigator Nicole Harada, CCRC, CCRP Clinical Trials Coordinator/Data Manager
  • 3.Component Updates Administrative Navigation Clinical Trials Telesynergy/Telemedicine Quality Assurance Publications, Articles, and Presentations Work in Progress
  • 4.Administrative Component
  • 5.Our Partners Centinela Freeman Regional Medical Center Michael L. Steinberg, MD, FACR, Principal Investigator David Khan, MD, Co-Investigator David Huang, MD, Co-Investigator RAND Corporation Allen Fremont, MD, PhD Nell Forge, PhD , Co-Investigator USC Norris Comprehensive Cancer Center Oscar Streeter, MD , Co-Investigator UCSF Comprehensive Cancer Center Mack Roach, MD , Co-Investigator
  • 6.Infrastructure Project Staff: Debbie Karaman, MPH, Community Health Educator Erika Cobb, Program Administrative Assistant Herschel Knapp, PhD, MSSW Nicole Harada, Clinical Trials Coordinator Susan Richardson, RN, Oncology Nurse Keith Andre, MA, Project Administrator
  • 7.Community Liaison Community Advisory Board Meets two times per year Investigators’ Meeting Meets two times per year Medical Advisory Board Meets 6 times per year
  • 8.Navigation Component
  • 9.Our Patients
  • 10.Abnormal results Diagnosis Treatment ConcludeNavigation Cancer Disparities Research Partnership (CDRP) Patient Navigation Model Outreach Patient Navigation Rehabilitation Abnormal Results Diagnosis Treatment Abnormal Finding Resolution ConcludeNavigation Freeman, et.al., Cancer Practice, 1995. Cancer Diagnosis
  • 11. Patient Navigator Training Program The 9-hour navigator training course emphasizes: Investigating and implementing resources for patients in a timely fashion Listening compassionately and non-judgmentally Completing appropriate records of all interactions on behalf of patient Empowering patients to self-advocate in the healthcare realm
  • 12.Training Program
  • 13.Active Navigators
  • 14.Reasons for Navigator Attrition
  • 15.Gender of Active Navigators
  • 16.Ethnicity of Active Navigators
  • 17.Cancer Survivor Status of Active Patient Navigators
  • 18.Patient Data
  • 19.Patients Offered Navigation By Project Year
  • 20.Ethnicity of Patients Offered Navigation
  • 21.Percentage of each Ethnicity Accepting Navigation * Small sample size
  • 22.Percentage of Patients Accepting NavigationBy Ethnicity
  • 23.Measuring the Effectiveness of Barrier Solution Identification Patient-specific barriers to care are identified during the patient intake conducted by a navigator Records are maintained and audited to determine number of days to barrier solution identification Barrier solution includes assigning a navigator (psychosocial barriers) and identifying community resources (functional barriers)
  • 24.Premise Barriers to care increase the likelihood that the patient will not be able to comply with treatment and follow-up regimens Barriers to care increase the likelihood that the patient will not participate in a clinical trial Addressing barriers to care will increase compliance and likelihood of clinical trials participation
  • 25.6 Most Common Barriers
  • 26.Barriers to Care: Chart Audit
  • 27.Mean Number of Days to Barrier Solution Identification
  • 28.Percentage of Barriers Solutions Identified in One Day
  • 29.Clinical Trials
  • 30.Trials Open for Accrual
  • 31.Trials Closed to Accrual
  • 32.Patients Accrued to Trial
  • 33.Accrual to Trial by Ethnicity
  • 34.Clinical Trial Accrual/Navigation
  • 35.Telesynergy/Telemedicine
  • 36.Telesynergy Telemedicine
  • 37.Telesynergy Usage Tumor Boards Meetings with partners and mentoring institutions Meetings with CDRP sites
  • 38.Quality Assurance
  • 39.
  • 40.
  • 41.Instruments *Patient Satisfaction Survey *Cancer Post Treatment Survey *Clinical Trial Questionnaire Rand Process Instrument – In Process
  • 42. 1. The patient navigator was courteous. 2. The patient navigator was sensitive. 3. The patient navigator was respectful. 4. The patient navigator was friendly. 5. The patient navigator was thorough. 6. I valued working with the navigator. 7. The education materials I received were helpful. 8. Support services referrals met my needs. 9. I received financial information (if needed).10. I would recommend this service to others.Response: 5 point Likert Scale Strongly Agree = 5, Strongly Disagree = 1 N/A option offered on each question Patient Satisfaction Survey
  • 43.Sample method Each month, 10% of patients are randomly selected for telephone navigator service satisfaction survey.
  • 44.Q: Does the navigator’s cancer history predict patient satisfaction? In other words: Do you have to have had cancer in order to provide effective cancer navigation?
  • 45.Navigators without a hx. of CA outperformed navigators w/ CA hx. on 60% of patient satisfaction metrics.
  • 46.Statistically Significant Differences Individual ANOVA test revealed a statistically significant difference on question 7 (only).
  • 47. Overall patient satisfaction exceeds 90% with navigator services regardless of navigator’s cancer history (p = .953). Note: 5-point Likert scale scores presented as satisfaction percentages
  • 48.Would you like to continue with the Patient Navigator Program?  I would like to continue working with my navigator.  I would like to have a different navigator assigned to me.  I would like to discontinue receiving navigation. Final Question on Survey
  • 49.94.7% of patients surveyed chose to continue navigation. Navigator’s CA hx. does not predict patient satisfaction (X2: p = .329.)
  • 50.Provisional Findings Overall, there is no statistically significant difference in patient satisfaction when comparing navigators who have had cancer to navigators who have not had cancer. In other words: All helping hands are good hands and 95% of patients were satisfied and wished to continue navigation
  • 51.Further analysis pending accumulating n Correlative analyses to explore navigator / patient metrics: Navigator characteristics: age, gender, education, race / ethnicity,marital status, number of patients Patient post-tx metrics: navigated vs. not-navigated, age, gender, race / ethnicity, education, religion, marital status, income, geography, treatment satisfaction, well-being metrics: physical, social, emotional, functional, spiritual).
  • 52.Cancer Post-Treatment Survey Reason(s) for refusing navigation Demographics Treatment satisfaction scale FACIT (Functional Assessment of Chronic Illness Therapy) instrument Compares patients who accepted / refused navigation services at four levels:
  • 53.Sample characteristics 107 patients were offered navigation 45 (42.1%) accepted navigation 62 (57.9%) refused navigation
  • 54.Reasons for refusing navigation 85% I am an independent person 68% I have a supportive family 47% I am a private person 44% I have supportive friend(s) 42% I am a spiritual / religious person 23% Navigation seemed unnecessary 13% I was unclear on what the navigator would do 8% The role of the navigator seemed intrusive to me
  • 55.Demographics No significant differences (p > .05) Race Education Religion Marital status Living conditions Income
  • 56.Treatment Satisfaction No significant differences (p > .05) on 8 of 9 metrics using a 1 – 4 Likert scale (1 = never, 4 = always): During my cancer treatment, I had good communication with my care providers. Accepted navigation: 2.85 Refused navigation: 2.54 (p = .037) }
  • 57.FACIT instrument Physical 7 questions Social / Family 7 questions Emotional 6 questions Functional 7 questions Spiritual 12 questions Patient self-evaluation multi-scale instrument Measures 5 areas of well being using 5 point Likert scales (1 = not at all, 5 = very much)
  • 58.FACIT Scores No significant differences (p > .05) on 3 of 5 scales: Physical Social / Family Spiritual
  • 59.FACIT Scores Emotional Well-Being Accepted navigation: 20.65 Refused navigation: 17.91 Functional Well-Being Accepted navigation: 21.85 Refused navigation: 17.13 } (p = .025) } (p = .012)
  • 60.Do Navigators Make a Difference in Acceptance of Clinical Trials? Challenges: Small n the reality of the number of patients eligible for clinical trial in a community hospital process change required to ensured the early presence of a navigator in CT discussions
  • 61.Do Navigators Make a Difference in Acceptance of Clinical Trials? Preliminary impressions suggest that early inclusion of a navigator in discussions with patients about clinical trials is associated with an increase rate of participation
  • 62.Do Navigators Make a Difference in Acceptance of Clinical Trials? Of patients eligible for a trial who have a navigator present at CT discussions 80% accept 20% decline n = 5 Only 1*/9 pts who declined had navigator input * perception of non coverage by insurance (managed care)
  • 63."Will get closer follow-up" as primary reason for patient accepting CT (navigator observation) Patients who accepted CT with a navigator present at CT discussions gave as stated reason for acceptance Of eligible patients who do not have a navigator present at CT discussions: 0% give “Will get closer follow up” as their primary reason for participating
  • 64.Presentations, Articles, and Publications
  • 65. Publications Lay Patient Navigator Program Implementation For Equal Access To Cancer Care And Clinical Trials: Essential Steps And Initial Challenges Cancer, Volume 107, Issue 11 , Pages 2669 – 2677 Preliminary results and evaluation of MammoSite® balloon brachytherapy for partial breast irradiation for pure ductal carcinoma in situ: A phase II clinical study In press, The American Journal of Surgery
  • 66.Presentations “National Leadership Summit on Eliminating Racial Disparities in Health” January 9-11, 2006 Washington, D.C. “Prophylactic Post-Operative Antibiotics for Prostate Brachytherapy” Presented at the 2006 Prostate Cancer Symposium at ASCO in 2006
  • 67.Presentations Preliminary results and evaluation of MammoSite® balloon brachytherapy for partial breast irradiation for pure ductal carcinoma in situ: A phase II clinical study Presented at the American Society of Breast Surgeons Meeting, April 2006 Developing a Lay Patient Navigator Program Addressing Barriers to Care and Participation in Clinical Trials Presented at the Cancer REACH 2010 Conference, May 2006 Using Telesynergy® to Improve Access to Clinical Trials at an Underserved Community Based Hospital Submitted to ASTRO, November 2006
  • 68.Presentations The Use of Lay Patient Navigators to Improve Quality of Care and Accrual to Clinical Trials for Radiation Oncology Patients Who Are Minorities or of Low Socioeconomic Status Presented at ASTRO 2006,   Philadelphia, PA, Nov. 5-9, 2006 Do Navigators Make a Difference in Acceptance of Clinical Trials? Presented at ASTRO 2006, Philadelphia, PA, Nov. 5-9, 2006 Disparity in Cancer Treatment and Outcome Presented at Mid-Winter Oncology Meeting, Los Angeles, Ca. Jan 23,2007
  • 69.Poster Presentations A Lay Patient Navigator Program as Part of a Clinical Trials Infrastructure in a Community Hospital Serving Minority and Low Income Patients Poster Presentation at the Cancer Health Disparities Summit 2006, Bethesda, MD, July 17-19, 2006 Lay patient navigator program for equal access to cancer care and clinical trials Poster presentation at ASTRO Health Services/Outcomes Research In Radiation Oncology, San Diego, CA September 15, 2006
  • 70.Work in Progress
  • 71.Work in Progress Spanish Support Group: To provide comfort, support, and education for Latinos undergoing cancer treatment in the community Susan B. Komen Foundation Grant: To train monolingual Latino navigators for the Breast Center at Centinela Campus, to help Spanish-speaking women access resources for treatment, to establish continuity of care, and to promote annual screening NCCCP: To establish a comprehensive cancer center of excellence and to incorporate navigation in medical oncologists’, pathologists’, and surgeons’ medical practices to facilitate pre-treatment barrier reduction
  • 72.Work in Progress Relocation of ULAAC Office to Centinela Campus: To capture oncology patients for navigation and to help them access resources for treatment Telesynergy/Telemedicine: To relocate to Centinela Campus for better utilization HRSA Nursing Workforce Grant: To train nurses of all discipline to close the shortage gap. Also to encourage professional nurses to enhance and refine their training and education
  • 73. Disparity is about Poverty and Lack of Infrastructure designed to Deal With the Indigent Patient’s Needs
  • 74.Contact Us Urban Latino African American Cancer (ULAAC) Disparities Project at Centinela Freeman Regional Medical Center, Memorial Campus 333 North Prairie AvenueInglewood, CA 90301 Telephone: (310) 674-7050, extension 4661 Fax: (310) 671-8299 Email: mls@cccma.com Principal Investigator: Michael L. Steinberg, MD, FACR