[Author Name]. (2014, June). [Title of Presentation]. Podium presentation at the 7th Biennial Cancer Survivorship Research Conference, Atlanta, GA.

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1 June 18-20, 2014 Atlanta, Georgia Please Note: Reference to material from the following presentation should be acknowledged by citing the author, title of the presentation, and title of the conference as shown below. [Author Name]. (2014, June). [Title of Presentation]. Podium presentation at the 7th Biennial Cancer Survivorship Research Conference, Atlanta, GA.

2 Surviving an Abnormal Mammogram: Reducing Time Delays in Diagnostic Confirmation and Start of Treatment among Underserved Latinas The Role of Patient Navigation Amelie G. Ramirez, DRPH

3 Today s Talk: Patient Navigation (PN): What is it? Our Model Program: The Redes 6 Cities National Trial Codifying Success: The Redes PN Manual for Latino Audiences Lessons Learned, Future Directions, and the Evolution of PN

4 Patient Navigation (PN) Freeman s Care Management Model ( 80s) Facilitates access to screening, diagnosis, treatment in underserved populations Healthcare system Financial PN addresses Transportation Language/cultural norms Individual barriers Without it patients Miss appointments Delay cancer care ( til very sick) Seek alternative treatment Don t get right treatment Are lost in the system Navigation is a way to harness energy from a community that people can then use to help others in the community Harold Freeman PN Does not address Self-Efficacy ; i.e. patient motivation Freeman HP, Wasfie TJ. Cancer of the breast in poor black women. Cancer. June 1989;63(12): Freeman, HP, Muth BJ, Kerner JF. Expanding access to cancer screening and clinical follow up among the medically underserved. Cancer Pract. 1995; 3: Freeman HP, Rodriguez RL. History and Principles of Patient Navigation. Cancer 2011;117(15):

5 Redes En Acción: The National Latino Cancer Research Network N CTRL RNC, Chicago Frank Penedo PhD Eliseo Pérez- Stable MD NW RNC, San Francisco NE RNC, New York City Emilio Carrillo MD Greg Talavera MD SW RNC, San Diego Hawaii NNC/CTRL RNC San Antonio Amelie G. Ramirez DrPH Puerto Rico NW Region SW Region NNC/Ctrl Region N CTRL Region NE Region NNC/RCAG Mbrs NCI Designated Cancer Centers Virgin Islands

6 OUR PN WORK The Ecological Framework

7 Redes 6 Cities PN Study Based on 10 years prior research and publication, we did a randomized clinical trial to evaluate the impact of a PN (versed in both the medical system and cultural norms) to reduce Latinas time from breast cancer diagnosis to start of treatment DESIGN: Quasi-experimental (navigated v. control) ACCRUAL: Sampling via local health clinics; N=425 (PN=208, Control=217) NAVIGATORS: 6 bilingual, bicultural Latina PNs (ages 25-47) DUTIES: Emphasize adherence to diagnostic and treatment plans and goals, and offer culturally sensitive support/guidance Cancer patient navigator tasks across the cancer continuum. Braun KL, Kagawa-Singer M, Holden AE, Burhansstipanov L, Tran JH, Seals BF, Corbie-Smith G, Tsark JU, Harjo L, Foo MA, Ramirez AG. J Health Care Poor Underserved Feb;23(1): doi: /hpu

8 OUTCOMES OF INTEREST: Overall time from initial abnormal mammogram to definitive diagnosis, stratified by BI-RADS Proportions of women treated within 30 or 60 days of initial definitive cancer diagnosis Overall time from definitive diagnosis to initial treatment Reported barriers and PN activities PREDICTORS OF INTEREST: Patient Navigation (overall) Patient Navigator activities: o Accompaniment to appointments o Transportation arrangements o Telephone support o Appointment Scheduling o Family Support o o o o o Translation services Health Education System Intervention Records Assistance External Resources Referral

9 STUDY METHODS: Logistic Regression for dichotomous outcomes Kaplan-Meier and Cox proportional hazard analysis performed for entire 365 day follow-up period, with censoring for Time of Treatment Initiation (Time 2>365 days or missing data) Intent-to-Treat was imposed on all analyses Covariates: Age, gender, cancer type, stage at diagnosis, insurance status, language and marital status were equivalent between groups Chi-Square analysis for patient barriers and PN actions

10 Kaplan-Meir Time-to-Diagnosis Comparison, Navigated vs. Control Overall and Stratified by BIRADS Ramirez A, Perez-Stable E, Penedo F, Talavera G, Carrillo JE, Fernández M, Holden A, Munoz E, San Miguel S, Gallion K. Navigating Latinas with breast screen abnormalities to diagnosis: The Six Cities Study. Cancer 2012.

11 Predictors of Timely Diagnosis within 30 and 60 Days of Breast Abnormality In our Cox Regression to assess factors associated with breast cancer diagnosis within 30 and 60 days of abnormality detection, only these factors were identified: Fewer missed appointments Patient navigation In sub-analyses, there was no difference between patients reporting barriers and patients reporting no barriers In our study, all barriers were resolved successfully Ramirez A, Perez-Stable E, Penedo F, Talavera G, Carrillo JE, Fernández M, Holden A, Munoz E, San Miguel S, Gallion K. Navigating Latinas with breast screen abnormalities to diagnosis: The Six Cities Study. Cancer 2012.

12 Time to Start of Treatment Hazard Ratio = 1.45 p = Median days 95% CI Mean days 95% CI Navigated (n=42) Controls (n=57) TOTAL Conclusion: Treatment initiation occurred faster among navigated vs. nonnavigated Latinas Ramirez A, Perez-Stable E, Penedo F, Talavera G, Carrillo JE, Fernández M, Holden A, Munoz E, San Miguel S, Gallion K. Reducing time-totreatment in underserved Latinas with breast cancer: The Six Cities Study. Cancer Nov 12. doi: /cncr PMID:

13 Proportion of Participants with Initial Treatment within 30 and 60 days of Diagnosis* 30 Days 60 Days Group treated % P treated % P Navigated n = Controls n = Conclusions: Faster treatment initiation among navigated Latinas Associated with several unique PN activities *Based on intent-to-treat. A lost navigated case (sought a second opinion) is considered untreated within the time frame specified. Ramirez A, Perez-Stable E, Penedo F, Talavera G, Carrillo JE, Fernández M, Holden A, Munoz E, San Miguel S, Gallion K. Reducing time-totreatment in underserved Latinas with breast cancer: The Six Cities Study. Cancer Nov 12. doi: /cncr PMID:

14 Earlier Start of Treatment FREQUENCY OF PATIENT NAVIGATOR LOGGED ACTIVITIES, SHOWING ACTIVITIES SIGNIFICANTLY ASSOCIATED WITH INITIATION OF TREATMENT WITHIN 30 DAYS 70 % 60 P 50 A T 40 I E 30 N T 20 S Mean Days to Treatment Ramirez, A.G., et al. Barriers and actions of patient navigators of Latinas with abnormal breast screening: The Six Cities Study. In preparation, Psycho-Oncology, 2014.

15 Barriers and (%) Accommodated by Navigator Actions (Partial) Barrier Action Total Arrangements Accompaniment Phone Support Scheduling Translation System Intervention Total Support 33 5 (9.3) 0 19 (20.4) 0 1 (3.1) 1 ( 4.2) Translation (55.6) 16 (59.3) 31 (33.3) 7 (35.0) 98 (45.6) 20 (83.3) Health Education 26 2 (3.7) 3 (11.1) 5 (5.4) 1 ( 5.0) 5 (15.5) 0 Insurance 20 3 (5.6) 1 (3.7) 2 (2.2) 1 ( 5.0) 7 (35.0) 1 (4.2) Fear 70 3 (5.6) 3 (11.1) 25 (26.9) 1 ( 5.0) 12 (44.4) 1 ( 4.2) Beliefs 32 1 (1.9) 3 (11.1) 6 (6.5) 1 (5.0) 9 (33.3) 1 (4.2) Ramirez, A.G., et al. Barriers and actions of patient navigators of Latinas with abnormal breast screening: The Six Cities Study. In preparation, Psycho-Oncology, 2014.

16 Codifying Success: PN Manual The Patient Navigator Manual: Developing and Implementing a Patient Navigator Program Section 1: What is PN? Section 2: Is PN right for your organization? Section 3: How do you build/implement a PN program? Templates/Resources Find manual at:

17 Codifying Success: PN Manual 6-Step Decision Guide: Is PN Right for Your Group? 1. Assessing Organizational Need 2. Budgeting (i.e., navigator s salary, supplies, phone, mileage, educational materials) 3. Training 4. Developing Internal Systems 5. Developing Navigation Support Materials 6. Navigation Accountability Find manual at:

18 Future Directions Questions WILL PN MAKE IMPROVE HEALTH CARE? Which barriers are vital? Address, resolve all barriers? Can PN be applied to other areas of health care? Can PN be standardized for diverse groups? Can PN be successfully integrated into the health care system? Concierge medicine?

19 Next Study: PN & Survivor QoL Redes RCT to test PN on improving general and diseasespecific QoL and treatment compliance among Latino breast, colorectal and prostate survivors 2 groups: PN vs. PN+Livestrong Navigation Services N=300 at two sites: San Antonio and Chicago Hypothesis: Group Assignment communication + health behaviors self-efficacy preparedness for med. visits Satisfaction with care General & Disease- Specific QOL & Treatment Compliance unmet cancer needs psych. distress Relevant Covariates

20 The Evolution of Patient Navigation Integration of Motivational Interviewing PN solves problems PN is navigator-focused (navigator is the active person in survivornavigator dyad) Traditional PN Services Motivational Interviewing Evolved PN! Motivate the survivor? Incorporation of adapted Motivational Interviewing techniques into PN

21 Muchismas gracias, Mil Gracias por su attencion! Google us: Redes En Acción Follow us on Social

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