Clark Cheryl R, Baril Nashira, Hall Angela, Kunicki Marycarmen, Johnson Natacha, Soukup Jane, Lipsitz Stuart, Bigby Judyann
Center for Community Health Equity, Brigham and Women's Hospital, Commonwealth of Massachusetts, USA.
Prog Community Health Partnersh. 2011 Fall;5(3):235-47. doi: 10.1353/cpr.2011.0034.
The Boston REACH Coalition developed a case management intervention for Black women in primary care settings to identify and reduce medical and social obstacles to cervical cancer screening and following up abnormal results.
The 5-year intervention was evaluated among 732 Black women aged 18 to 75 who were at high risk for inadequate Pap smear screening and follow-up. Case managers provided social services referrals to address patient-identified social concerns (e.g., transportation, housing), as well as navigation to prompt screening and follow-up of abnormal tests. The three study aims were to (1) identify the social factors associated with Pap smear screening at baseline before intervention, (2) evaluate the correlation between exposure to case management intervention and achieving recommended Pap screening intervals, and (3) evaluate the correlation between exposure to case management intervention and having timely follow-up of abnormal Pap smear tests.
We found that a lack of a regular clinical provider, concerns communicating with providers, poor self-rated health, and having less than a high school education were important correlates of recent Pap smear screening before the case management intervention. During the case management intervention, we found a significant increase in achieving recommended Pap smear screening intervals among women with a recent Pap smear at study entry (increasing from 52% in the first year to 80% after 4 or more years; p < .01), but not among women who entered the study without a recent Pap smear (increasing from 31% in the first year to 44% after 4 or more years; p = .39). During case management intervention, having social support for childcare was associated with regular screening among women without a recent Pap smear (odds ratio [OR], 3.52; 95% confidence interval [CI], 1.28-9.69). Insurance status was the key factor in timely clinically indicated follow-up of abnormal results (uninsured OR, 0.27; 95% CI, 0.08-0.86), rather than case management intervention.
Exposure to case management was associated with regular Pap smear screening among women who recently engaged in screening. Future research should focus on systems changes to address social determinants of health, including strategies to facilitate screening for Black women without social support for childcare. To improve follow-up of abnormal results, financial access to care should be addressed.
波士顿REACH联盟针对基层医疗环境中的黑人女性制定了一项病例管理干预措施，以识别并减少宫颈癌筛查及对异常结果进行随访的医疗和社会障碍。
在732名年龄在18至75岁、巴氏涂片筛查及随访不足风险较高的黑人女性中对这项为期5年的干预措施进行了评估。病例管理人员提供社会服务转介，以解决患者确定的社会问题（如交通、住房），并提供引导，以促使进行筛查及对异常检查结果进行随访。三项研究目标分别为：（1）确定干预前基线时与巴氏涂片筛查相关的社会因素；（2）评估接受病例管理干预与达到推荐的巴氏筛查间隔之间的相关性；（3）评估接受病例管理干预与对异常巴氏涂片检查结果进行及时随访之间的相关性。
我们发现，缺乏固定的临床医生、与医生沟通存在顾虑、自我健康评价较差以及未接受过高中以上教育是病例管理干预前近期巴氏涂片筛查的重要相关因素。在病例管理干预期间，我们发现，在研究开始时近期进行过巴氏涂片检查的女性中，达到推荐的巴氏涂片筛查间隔的比例显著增加（从第一年的52%增至4年或更长时间后的80%；p < 0.01），但在研究开始时未近期进行过巴氏涂片检查的女性中则未显著增加（从第一年的31%增至4年或更长时间后的44%；p = 0.39）。在病例管理干预期间，有儿童保育社会支持与未近期进行过巴氏涂片检查的女性定期筛查相关（优势比[OR]，3.52；95%置信区间[CI]，1.28 - 9.69）。保险状况是对异常结果进行及时临床随访的关键因素（未参保者OR，0.27；95%CI，0.08 - 0.86），而非病例管理干预。
接受病例管理干预与近期进行过筛查的女性定期进行巴氏涂片筛查相关。未来研究应聚焦于系统变革，以解决健康的社会决定因素，包括促进对缺乏儿童保育社会支持的黑人女性进行筛查的策略。为改善对异常结果的随访，应解决医疗保健的经济可及性问题。
