History and principles of patient navigation.
TL;DR: There is a disconnect between the nation’s discovery and delivery enterprises, suggesting that some Americans have not shared sufficiently in this progress as measured by higher mortality, lower survival, and 5-year cancer survival.
Abstract: In 1971 President Richard Nixon declared a war on cancer and signed the National Cancer Act. During the past several decades since this declaration, the nation has made extraordinary progress toward a far better understanding of the molecular, cellular, and genetic changes resulting in cancer. We have also seen significant declines in overall and site-specific cancer mortality1. This decline in mortality has been attributed to improved cancer prevention, screening, and detection measures as well as the application of more effective and more targeted cancer treatments.
However, some Americans (such as the poor, uninsured, and underinsured) have not shared sufficiently in this progress as measured by higher mortality, lower survival, and 5-year cancer survival2, 3. These findings suggest that there is a disconnect between the nation’s discovery and delivery enterprises; a disconnect between what we know and what we do (Fig 1).
Figure 1
Discovery-Delivery Disconnect
Disparities occur when beneficial medical interventions are not shared by all. Moreover, health disparities arise from a complex interplay of economic, social, and cultural factors. The model presented in (Fig. 2) illustrates the overlapping factors of poverty, culture, and social injustice as principal causes of health disparities. These causal factors impact on all aspects of the healthcare continuum from prevention, detection, diagnosis, treatment, and survival to the end of life. Disparities occur principally in individuals or populations who experience one or more of the following circumstances: insufficient resources, risk-promoting lifestyle and behavior, and social inequities. Approaches to reducing or eliminating disparities must necessarily take these factors into consideration.
Figure 2
Causes of Health Disparities
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TL;DR: Results show that Latino children were diagnosed almost one year later than White children, received fewer specialty services, and had higher unmet service needs, and factors that accounted for differences in the number of services received were maternal level of education and thenumber of sources of knowledge about autism.
Abstract: There is greater identification of children with autism spectrum disorders (ASD) and, as a result, more attention to specialty services to address the challenges children with ASD face. Along with the growth in identification of ASD is a growth in the population of Latino children, yet there is some evidence that disparities exist in diagnosis and services between Latino and non-Latino White children. This study further documents these disparities and investigates the mechanisms that may contribute to them. Diagnosis and specialty services were compared between 48 Latino and 56 non-Latino White children diagnosed with ASD, and factors that contribute to differences are explored. Results show that Latino children were diagnosed almost one year later than White children, received fewer specialty services, and had higher unmet service needs. Factors that accounted for differences in the number of services received were maternal level of education and the number of sources of knowledge about autism. Findings suggest that service providers need to work to provide greater awareness and knowledge about autism, and make services more accessible to Latino families.
252 citations
TL;DR: The review shows CHWs as paraprofessionals or lay individuals with an in-depth understanding of the community culture and language, have received standardised job-related training of a shorter duration than health professionals, and their primary goal is to provide culturally appropriate health services to the community.
Abstract: Background: Community health workers (CHWs) can play vital roles in increasing coverage of basic health services. However, there is a need for a systematic categorisation of CHWs that will aid common understanding among policy makers, programme planners, and researchers.Objective: To identify the common themes in the definitions and descriptions of CHWs that will aid delineation within this cadre and distinguish CHWs from other healthcare providers.Design: A systematic review of peer-reviewed papers and grey literature.Results: We identified 119 papers that provided definitions of CHWs in 25 countries across 7 regions. The review shows CHWs as paraprofessionals or lay individuals with an in-depth understanding of the community culture and language, have received standardised job-related training of a shorter duration than health professionals, and their primary goal is to provide culturally appropriate health services to the community. CHWs can be categorised into three groups by education and pre...
184 citations
TL;DR: This issue of CEBP focuses on patient navigation with specific emphasis on the findings of the National Cancer institute's PPNRP, designed to develop interventions to reduce the time to diagnosis and treatment of cancer after.
Abstract: This issue of CEBP focuses on patient navigation with specific emphasis on the findings of the National Cancer institute (NCI) Patient Navigation Research Program (PNRP). This research program was designed to develop interventions to reduce the time to diagnosis and treatment of cancer after
166 citations
Cites background from "History and principles of patient n..."
...Below are listed the Principles of Patient Navigation that have been developed and vetted formore than 20years through the author’s experience (9)....
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TL;DR: This study found that the patient navigation intervention was associated with decreased odds of returning to the ED among less frequent PCR-ED users, and the savings associated with reduced PCR- ED visits were greater than the cost to implement the navigation program.
Abstract: Primary care-related emergency department (PCR-ED) utilization, including for conditions that are preventable or treatable with appropriate primary care, is associated with decreased efficiency of and increased costs to the health system. Many PCR-ED users experience actual or perceived problems accessing appropriate, ongoing sources of medical care. Patient navigation, an intervention used most often in the cancer care continuum, may help to address these barriers among medically underserved populations, such as those who are low income, uninsured, publicly insured, or recent U.S. immigrants. We examined a patient navigation program designed to promote appropriate primary care utilization and prevent or reduce PCR-ED use at Memorial Hermann Health System in Houston, Texas. The intervention is facilitated by bilingual, state-certified community health workers (CHWs) who are trained in peer-to-peer counseling and connect medically underserved patients with medical homes and related support services. The CHWs provide education about the importance of primary care, assist with appointment scheduling, and follow up with patients to monitor and address additional barriers. Our study found that the patient navigation intervention was associated with decreased odds of returning to the ED among less frequent PCR-ED users. Among patients who returned to the ED for PCR reasons, the pre/post mean visits declined significantly over a 12-month pre/post-observation period but not over a 24-month period. The savings associated with reduced PCR-ED visits were greater than the cost to implement the navigation program. Our findings suggest that an ED-based patient navigation program led by CHWs should be further evaluated as a tool to help reduce PCR-ED visits among vulnerable populations.
142 citations
Cites background from "History and principles of patient n..."
...…Showstack, Hunt, Colby, & Callaham, 2005). insurance and assistance programs) to health system related (appointment scheduling, referrals, and care coordination) to social support related (transportation and child care) (Freeman & Rodriguez, 2011; Natale-Pereira, Enard, Nevarez, & Jones, 2011)....
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...Patient navigation has been shown to be potentially useful in linking vulnerable patients to appropriate medical and support services, reducing disruptions in care, and increasing patient satisfaction (Freeman & Rodriguez, 2011; Solberg, Asche, Fontaine, Flottemesch, & Anderson, 2011)....
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...…patient navigation has been expanded to include the timely movement of individuals across the entire healthcare continuum—from preventive care, screening, and early diagnosis to treatment and end-of-life care—for cancers and other chronic diseases (Dohan & Schrag, 2005; Freeman & Rodriguez, 2011)....
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TL;DR: This article considers the challenges and proposes the key components of an integrated psychosocial service that could be implemented now and what the need to do next if the model is to succeed in providing better and more comprehensive care to patients.
Abstract: Despite substantial evidence that patients with cancer commonly have significant psychosocial problems, for which we have evidence-based treatments, many patients still do not receive adequate psychosocial care. This means that we risk prolonging life without adequately addressing the quality of that life. There are many challenges to improving the current situation, the major one of which is organizational. Many cancer centers lack a system of psychosocial care that is integrated with the cancer care of the patient. Psychosocial care encompasses a range of problems (emotional, social, palliative, and logistical). The integration must occur with the cancer care of the patient at all stages (from screening to palliative care) and across all clinical sites of care (inpatient and outpatient cancer services as well as primary care). In this article, we consider the challenges we face if we are to provide such integrated psychosocial services. We focus on the collaborative care service model. This model compri...
121 citations
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TL;DR: While the absolute number of cancer deaths decreased for the second consecutive year in the United States, much progress has been made in reducing mortality rates and improving survival, cancer still accounts for more deaths than heart disease in persons under age 85 years.
Abstract: Each year, the American Cancer Society (ACS) estimates the number of new cancer cases and deaths expected in the United States in the current year and compiles the most recent data on cancer incidence, mortality, and survival based on incidence data from the National Cancer Institute, Centers for Disease Control and Prevention, and the North American Association of Central Cancer Registries and mortality data from the National Center for Health Statistics This report considers incidence data through 2003 and mortality data through 2004 Incidence and death rates are age-standardized to the 2000 US standard million population A total of 1,444,920 new cancer cases and 559,650 deaths for cancers are projected to occur in the United States in 2007 Notable trends in cancer incidence and mortality rates include stabilization of the age-standardized, delay-adjusted incidence rates for all cancers combined in men from 1995 through 2003; a continuing increase in the incidence rate by 03% per year in women; and a 136% total decrease in age-standardized cancer death rates among men and women combined between 1991 and 2004 This report also examines cancer incidence, mortality, and survival by site, sex, race/ethnicity, geographic area, and calendar year, as well as the proportionate contribution of selected sites to the overall trends While the absolute number of cancer deaths decreased for the second consecutive year in the United States (by more than 3,000 from 2003 to 2004) and much progress has been made in reducing mortality rates and improving survival, cancer still accounts for more deaths than heart disease in persons under age 85 years Further progress can be accelerated by supporting new discoveries and by applying existing cancer control knowledge across all segments of the population
7,446 citations
01 Jan 2004
TL;DR: The number of new cancer cases for 2010, excluding basal and squamous cell skin cancers and in situ carcinomas except urinary bladder, is estimated as a rough guide and should be interpreted with caution.
Abstract: Estimated number of new cancer cases for 2010, excluding basal and squamous cell skin cancers and in situ carcinomas except urinary bladder. Note: State estimates are offered as a rough guide and should be interpreted with caution. State estimates may not add to US total due to rounding.
2,269 citations
Journal Article•
TL;DR: In this paper, expanded cancer screening in an inner-city public hospital and a patient navigator intervention were proposed, which acted as patient advocates for patients with abnormal screening findings, and navigators were significantly more likely to have seen patients with suspicious findings than patients with nonsuspicious findings.
Abstract: Blacks have the highest cancer incidences and mortality rates in the United States. Higher mortality rates appear due to higher incidence in some sites and to later-stage diagnoses in others. To address these problems, expanded cancer screening in an inner-city public hospital and a patient navigator intervention were proposed. Patient navigators acted as patient advocates for patients with abnormal screening findings. One thousand thirty-four females and 102 males were screened from July 1990 through November 1992; seven breast cancers and one cervical cancer were found. Patient navigators were significantly more likely to have seen patients with suspicious findings than patients with non-suspicious findings. However, even among those with suspicious findings, almost 70% were not seen by a patient navigator. Of those navigated, 87.5% completed recommended breast biopsies, compared with 56.6% of the non-navigated patients. Among those with a biopsy, navigated patients did so in significantly less time than those not navigated. Navigation is one of three phases proposed to reduce cancer mortality among medically underserved populations.
436 citations
"History and principles of patient n..." refers background in this paper
...ing and the resolution of the finding by further diagnosis and treatment.(6) Commonly experienced barriers to timely care in the Har-...
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TL;DR: It is concluded that for all cancer sites combined, residents of poorer counties have a higher cancer death rate than residents in more affluent counties and some racial groups (eg, African Americans and American Indians/Alaskan Natives have a lower five-year survival rate than non-Hispanic Whites).
Abstract: In 1971, President Richard Nixon signed the National Cancer Act and declared a “War Against Cancer.” In the more than 30 years since this declaration of war, the nation has made extraordinary progress in our understanding of the causes of cancer, especially at the molecular level. We have also witnessed a dramatic evolution in the development of various therapeutic modalities resulting in more effective, more targeted, and less destructive cancer treatments. From a public health perspective, we have a seen a decline in the percentage of adults who smoke cigarettes. Note that tobacco is the cause of more than one third of cancer deaths. Related to this progress, an overall decline in cancer mortality has occurred in the last several years. However, some Americans have not fully benefited from this progress as evidenced by their higher cancer incidence, mortality, and lower survival. Stating this another way, there is a critical disconnect between what we discover and what we deliver, between what we know and what we do for all people (Figure 1). It is critical to accurately define which groups of Americans suffer a heavier burden of cancer, determine the causes, and apply interventions to eliminate the disparities. In this issue of CA, Ward and others highlight disparities in cancer incidence, mortality, and survival in relation to race/ethnicity and socioeconomic status. They conclude that for all cancer sites combined, residents of poorer counties have a higher cancer death rate than residents in more affluent counties. Ward further concludes that even when poverty rates are accounted for, some racial groups (eg, African Americans and American Indians/Alaskan Natives have a lower five-year survival rate than non-Hispanic Whites. Note also that within each racial/ethnic group, looked at separately, those living in poorer counties have the lowest survival rates according to Surveillance, Epidemiology, and End Results (SEER) Program data. For a better understanding of the issues raised by Ward et al., it is important to review the background of our current knowledge of cancer disparities. In 1973, Henschke noted an “alarming increase” in the cancer mortality in African Americans in the preceding 25 years. After the publication of this study, the National Cancer Institute (NCI) increased its focus on racial differences in cancer incidence, mortality, and survival. In 1986, based on a subcommittee’s findings, the American Cancer Society (ACS) issued a “Special Report on Cancer in the Economically Disadvantaged.” The report concluded that the poorer cancer outcome in African Americans compared with White Americans is primarily related to lower socioeconomic status in African Americans. The study concluded further that poor Americans, irrespective of race, have a 10% to 15% lower five-year survival. A pivotal report by Freeman in 1989 provided an analysis and broad overview of these findings. In 1989, the ACS issued its report “Cancer in the Poor: A Report to the Nation.” This report was the culmination of a series of fact-finding hearings held throughout the nation in collaboration with the NCI and Centers for Disease Control (CDC). Poor people with cancer of all racial and ethnic groups testified. The key findings were: Y Poor people lack access to quality health care and are more likely than others to die of cancer. Y Poor people endure greater pain and suffering from cancer than most Americans. Y Poor people face substantial obstacles to obtaining and using health insurance and often do not seek needed care if they cannot pay for it. Y Poor people and their families must make extraordinary personal sacrifices to obtain and pay for health care. Y Cancer education and outreach efforts are insensitive and irrelevant to many poor people. Y Fatalism about cancer prevails among the poor and prevents them from gaining quality health care. Dr. Freeman is Director, Center to Reduce Cancer Health Disparities, National Cancer Institute, Rockville, MD.
276 citations
TL;DR: The authors hypothesized that insurance payer and race would influence the care and outcomes for patients with breast carcinoma.
Abstract: BACKGROUND
The authors hypothesized that insurance payer and race would influence the care and outcomes for patients with breast carcinoma.
METHODS
The authors examined treatments and adjusted risk of death (through 1997) for all incident cases of breast carcinoma occurring in Florida in 1994 (n = 11,113) by using state tumor registry data.
RESULTS
Patients lacking health insurance were less likely to receive breast-conserving surgery (BCS) compared with patients who had private health insurance. Among patients insured by Medicare, those belonging to a health maintenance organization (HMO) were more likely to receive BCS but less likely to receive radiation therapy after BCS. Non-Hispanic African Americans had higher mortality rates even when stage at diagnosis, insurance payer, and treatment modalities used were adjusted in multivariate models (adjusted risk ratio [RR], 1.35; 95% confidence interval [CI], 1.12–1.61; P = 0.001). Patients who had HMO insurance had similar survival rates compared with those with fee-for-service (FFS) insurance. Among non-Medicare patients, mortality rates were higher for patients who had Medicaid insurance (RR, 1.58, 95% CI, 1.18–2.11; P = 0.002) and those who lacked health insurance (RR, 1.31; 95% CI, 1.03–1.68; P = 0.03) compared with patients who had commercial FFS insurance. There were no insurance-related differences in survival rates, however, once stage at diagnosis was controlled.
CONCLUSIONS
As a result of later stage at diagnosis, patients with breast carcinoma who were uninsured, or insured by Medicaid, had higher mortality rates. Mortality rates were also higher among non-Hispanic African Americans, a finding that was not fully explained by differences in stage at diagnosis, treatment modalities used, or insurance payer. Cancer 2000;89:2202–13. © 2000 American Cancer Society.
216 citations