UsingPatientNavigationtoImpactTrustintheHealthCareSystem

ARANTZARODRIGUEZ PUERTOS

MENTOR: CARMENE . GUERRA, M.D. , M.S .C .E . , F.A .C .P.

Outline

Introduction

DataandMethods

KeyFindingsandDiscussion

LessonsLearned

Q&A

2

Outline

Introduction BreastCancerDetectionandOutcomesPatientNavigationProgramProjectOverviewHealthCareSystemDistrust(HCSD)Scale

DataandMethods

KeyFindingsand

Discussion

LessonsLearned

Q&A

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BreastCancerDetectionandOutcomes

Earlydetectionleadstohighersurvivalrates

5yearsurvivalrate:99%forStageIvs.22%for

StageIV¹

However,thereisanunderutilizationofscreeningservices²

IntheUS,65.3%(2015)ofwomenage40+hadamammogramwithinthe

past2years

Insured(69.7%)vs.Uninsured(30%)

ComparedtoWhites,theBlackandHispanic

populationshaveloweroddsofutilizingscreeningmammographyservices.³

1. CANCER.NET 20172. CDC:HEALTH,UNITEDSTATES20163. AHMED.T.AHMED,ET.AL.RACIALDISPARITIESINSCREENINGMAMMOGRAPHYINTHEUNITEDSTATES:A SYSTEMATICREVIEWAND

META-ANALYSIS.20174

NavigationProgram•PatientnavigationwasaconceptfirstproposedbyDr.HaroldFreemanin1990•Maingoal:savelivesfromcancerby…• Educatingabouttheneedforbreastexaminations• Providingaccesstobreastcancerscreeningservices• Makingsurethatwomanwithpositivefindingsreceiveatimelydiagnosisandtreatment

•“ThemostimportantroleofPatientNavigationistoassurethatanindividualwithasuspiciouscancer-relatedfindingwillreceivetimelydiagnosisandtreatment.”•ThroughdozensofRCT,PatientNavigationProgramshaveshownthattheyeffectivelyreducedisparitiesinaccesstocancerscreeningtestsacrossdifferentpopulations,testsandhealthcaresystems

1.AMODELPATIENTNAVIGATIONPROGRAMBYDR.HAROLD FREEMAN 5

Penn’sPatientNavigationProgram

• PennMedicineBreastHealthInitiative(PMBHI)attheAbramsonCancerCenterWhere?

• Establishedin2014When?

• Freebreastcancerscreeningservicesandassistance(breasthealtheducation,schedulingappointments,transportation,translators)

What?

• Un/underinsuredwomaninthePhiladelphiaareaages40-64Who?

• Reducedisparitiesinbreastcancerdetectionandmortalityamongunderservedpopulationsbyovercomingaccessbarrierstoscreeningservices

Why?

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PMBHI’sNavigationProgram

Services Provided N

Totalpatientsserved

ScreeningmammogramsDiagnostic mammogramsBreastbiopsy

1022

83332564

DiagnosedBreastCancer

N

Stage0StageIStageIIStage3Stage4Total

3362216

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ProjectOverview

ResearchQuestion

• DoesaPatientNavigationProgramforbreastcancerscreeningimpacttrustintheHealthCareSystemforun/underinsuredwomeninthePhiladelphiaarea?

Hypothesis

• PatientNavigationProgramincreasestrustintheHealthCareSystem.

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HealthCareSystemDistrust(HCSD)Scale¹•WhyfocusonHCSD?• Suggestedasabarrier forseekingmedical care,adheringtopreventive healthcare,andparticipatinginmedicalresearch

•9questionsmeasuredona5pointLikertScale

•Scoresrangedfrom9-45• HighscoresmeanthighlevelofHCSD

•Measuredtrustontwodimensions:technicalcompetenceandvaluecongruence(honesty,motives,equity)

JUDYA.SHEA,ET.AL.DEVELOPMENTOFAREVISEDHEALTHCARESYSTEMDISTRUSTSCALE.20089

HealthCareSystemDistrust(HCSD)Scale¹

JUDYA.SHEA,ET.AL.DEVELOPMENTOFAREVISEDHEALTHCARESYSTEMDISTRUSTSCALE.200810

Outline

Introduction

DataandMethods

Methods

PatientEnrollmentFlowchart

PatientDemographics

KeyFindingsand

Discussion

LessonsLearned

Q&A

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MethodsRecruitment• NewPatientsoftheNavigationprogramwererecruitedbetween4/8/2016to8/14/2017• Byphoneormetattheirappointment• Allofthepatientsansweredademographicssurvey

Enrollment• PatientsenrolledansweredtheHCSDScalepreandpostparticipationinNavigationProgram

DataAnalysis• Myrolewastoperformasecondarydataanalysis• DatawasanalyzedusingStata15.0• Multivariateanalysiscontrollingforage,race/ethnicity,education,income,andmammographyoutcome.

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FlowchartofPatient

Enrollment

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PatientDemographics(n=65)

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Demographics(n=65)

MeanAge 51

Race

Black 13(20%)

Hispanic 26(40%)

Other 22(34%)

White 4(6%)

Interpreter

Yes 44(68%)

No 21(32%)

Education

<thanHS 36(55%)

>thanHS 25(36%)

Income

<than$15,000/year 40(64%)

>than$15,000/year 25(36%)

Outline

Introduction

DataandMethods

KeyFindingsand

Discussion

GeneralDataAnalysis

MultipleRegressionModel

FindingsandConclusions

Limitations

LessonsLearned

Q&A

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PreliminaryGeneralDataAnalysisThedifferenceinscores(post-pre):• Wasonaverage-0.75points(5.67=st. dev.)lowerfortheposttestthanthepretest• Rangedfrom-24to10points

T-testbetweenprescorevs.postscorenotsignificantlydifferent(p=0.203)• Notsignificanteitherforprecompetencevs.postcompetence(p=0.0788)andprevaluesvs.postvalues(p=0.487)

So,overalltherewasnosignificantchangeintrust.But…

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PreliminaryMultivariateAnalysisDependentvariable:Differenceinscore(posttest– pretest)

Controlledforsuspiciousmammographyresult,race,age,useofinterpreterandeducation

AND…

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Variable DifferenceinDistrustScore

SuspiciousDiagnosis -5.27*(p=-.042)

Black -2.21Hispanic 2.96Other 1.46Age 0.07

Usedaninterpreter -2.19

Hadaneducationlevellowerthanhighschol -0.83

DemographicsForSuspicious(n=6) Total(n=65)MeanAge 45.5 51RaceBlack 0 13(20%)Hispanic 4(67%) 26(40%)Other 2(33%) 22(34%)White 0 4(6%)InterpreterYes 4(67%) 44(68%)No 2(33%) 21(32%)Education<thanHS 2(33%) 36(55%)>thanHS 4(67%) 25(36%)Income<than$15,000/year 5(83%) 40(64%)>than$15,000/year 1(17%) 25(36%)

FindingsandConclusions

SubgroupanalysisbyBIRADSCategorydemonstratedthatforpatientswithasuspiciousmammographydiagnosisdistrustinthehealthcaresystemdecreasedby5.27points

Womenwithasuspiciousdiagnosishadmoreencounterswiththenavigatorandwiththenavigationprogramasawhole

Oneofthefirststudiesthatdocumentsthatpatientnavigationincreasestrustinthehealthcaresystem

Significantfindingbecausealotofliteraturementionsthattrustisreallydifficulttochange

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Limitations•Additionalvariabilityfromuseoftranslatorsfrom67%ofpatients

•Missingdatagiventhatpatientshadtobecontactedattwodifferentpoints

•Conclusionsarelimitedtooverallhealthcaresystemdistrustratherthanindividualproviderdistrust

•Smallsamplesize(n=6)

•Singleurbaninstitutionandgeographiclocation(HUP,Philadelphia)

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Outline

Introduction

DataandMethods

KeyFindingsand

Discussions

LessonsLearned

StataAnalysis

Research

Medicine

Business

Q&A

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LessonsLearned

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Stataanalysis Useresearchskillstodevelop

programsthathelpunderservedpopulations

Medicineasawayofsavingalife

Adequatefinancialmanagementiskeyforthesuccessofsuchprograms

AcknowledgementsDr.CarmenGuerra

PatriciaHernandez

EmilyVerderame

AndreaNicholson

BrendaBryant

Dr.FrankLeone

JoanneLevyandSafaBrowne

SUMRCohort

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Q&A

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