Massachusetts General Hospital, Division of General Medicine, Boston2Massachusetts General Hospital, Chelsea HealthCare Center, Chelsea3Harvard Medical School, Boston, Massachusetts.
Massachusetts General Hospital, Division of General Medicine, Boston3Harvard Medical School, Boston, Massachusetts.
JAMA Intern Med. 2016 Jul 1;176(7):930-7. doi: 10.1001/jamainternmed.2016.0841.
Patient navigation (PN) to improve cancer screening in low-income and racial/ethnic minority populations usually focuses on navigating for single cancers in community health center settings.
We evaluated PN for breast, cervical, and colorectal cancer screening using a population-based information technology (IT) system within a primary care network.
DESIGN, SETTING, AND PARTICIPANTS: Randomized clinical trial conducted from April 2014 to December 2014 in 18 practices in an academic primary care network. All patients eligible and overdue for cancer screening were identified and managed using a population-based IT system. Those at high risk for nonadherence with completing screening were identified using an electronic algorithm (language spoken, number of overdue tests, no-show visit history), and randomized to a PN intervention (n = 792) or usual care (n = 820). Navigators used the IT system to track patients, contact them, and provide intense outreach to help them complete cancer screening.
Mean cancer screening test completion rate over 8-month trial for each eligible patient, with all overdue cancer screening tests combined using linear regression models. Secondary outcomes included the proportion of patients completing any and each overdue cancer screening test.
Among 1612 patients (673 men and 975 women; median age, 57 years), baseline patient characteristics were similar among randomized groups. Of 792 intervention patients, patient navigators were unable to reach 151 (19%), deferred 246 (38%) (eg, patient declined, competing comorbidity), and navigated 202 (32%). The mean proportion of patients who were up to date with screening among all overdue screening examinations was higher in the intervention vs the control group for all cancers combined (10.2% vs 6.8%; 95% CI [for the difference], 1.5%-5.2%; P < .001), and for breast (14.7% vs 11.0%; 95% CI, 0.2%-7.3%; P = .04), cervical (11.1% vs 5.7%; 95% CI, 0.8%-5.2%; P = .002), and colon (7.6% vs 4.6%; 95% CI, 0.8%-5.2%; P = .01) cancer compared with control. The proportion of overdue patients who completed any cancer screening during follow-up was higher in the intervention group (25.5% vs 17.0%; 95% CI, 4.7%-12.7%; P < .001). The intervention group had more patients completing screening for breast (23.4% vs 16.6%; 95% CI, 1.8%-12.0%; P = .009), cervical (14.4% vs 8.6%; 95% CI, 1.6%-10.5%; P = .007), and colorectal (13.7% vs 7.0%; 95% CI, 3.2%-10.4%; P < .001) cancer.
Patient navigation as part of a population-based IT system significantly increased screening rates for breast, cervical, and colorectal cancer in patients at high risk for nonadherence with testing. Integrating patient navigation into population health management activities for low-income and racial/ethnic minority patients might improve equity of cancer care.
clinicaltrials.gov Identifier: NCT02553538.
重要性：为改善低收入和少数族裔人群的癌症筛查，患者导航（PN）通常专注于在社区卫生中心环境中针对单一癌症进行导航。
目的：我们使用基于人群的信息技术（IT）系统评估在初级保健网络中进行乳腺癌、宫颈癌和结直肠癌筛查的 PN。
设计、地点和参与者：这是一项 2014 年 4 月至 2014 年 12 月在学术初级保健网络的 18 个实践中进行的随机临床试验。使用基于人群的 IT 系统识别和管理所有符合条件且筛查逾期的患者。使用电子算法（语言、逾期测试数量、未就诊史）识别出非依从性高的高危患者，并随机分为 PN 干预组（n=792）或常规护理组（n=820）。导航员使用 IT 系统跟踪患者、联系他们，并提供密集的外展服务，以帮助他们完成癌症筛查。
主要结果和测量：每位符合条件的患者在 8 个月的试验期间完成癌症筛查测试的平均比率，使用线性回归模型综合所有逾期的癌症筛查测试。次要结果包括完成任何和每次逾期癌症筛查测试的患者比例。
结果：在 1612 名患者（673 名男性和 975 名女性；中位数年龄为 57 岁）中，随机分组的患者特征在基线时相似。在 792 名干预患者中，患者导航员无法联系到 151 名患者（19%），推迟了 246 名患者（38%）（例如，患者拒绝、合并并存疾病），并为 202 名患者提供了导航服务（32%）。在所有逾期筛查检查中，与对照组相比，干预组中所有癌症筛查及时的患者比例更高（10.2% vs 6.8%；95%CI[差异]，1.5%-5.2%；P<0.001），乳腺癌（14.7% vs 11.0%；95%CI，0.2%-7.3%；P=0.04）、宫颈癌（11.1% vs 5.7%；95%CI，0.8%-5.2%；P=0.002）和结肠癌（7.6% vs 4.6%；95%CI，0.8%-5.2%；P=0.01）。与对照组相比，在随访期间完成任何癌症筛查的逾期患者比例在干预组中更高（25.5% vs 17.0%；95%CI，4.7%-12.7%；P<0.001）。干预组中有更多患者完成了乳腺癌（23.4% vs 16.6%；95%CI，1.8%-12.0%；P=0.009）、宫颈癌（14.4% vs 8.6%；95%CI，1.6%-10.5%；P=0.007）和结直肠癌（13.7% vs 7.0%；95%CI，3.2%-10.4%；P<0.001）筛查。
结论和相关性：作为基于人群的 IT 系统的一部分，患者导航显著提高了高危患者乳腺癌、宫颈癌和结直肠癌的筛查率。将患者导航纳入低收入和少数族裔患者的人群健康管理活动中，可能会提高癌症护理的公平性。
试验注册：clinicaltrials.gov 标识符：NCT02553538。
