INTERVENTIONS DESIGNED TO REDUCE DISPARITIES IN CANCER OUTCOME
Although there has been an accumulation of studies indicating disparities in treatment, there is a dearth of studies focusing on strategies to reduce such disparities. One of the most well-known and very effective studies has been conducted by Bickell and her team (Bickell et al., 2008). They instituted a tracking and feedback registry across six unaffiliated hospitals in New York City, designed to target a cause of treatment under use that was more common among minority women. Their system tracked patients referred to oncologists by the surgeon and closed the loop by informing the surgeons’ office if the patient had kept the appointment. Surgeons were repeatedly reminded to call those patients who had not, thus spurring the surgical office to encourage the patients to follow up with their next stage of treatment. Overall, rates of oncology consultations, chemotherapy, and hormonal therapy were higher in the post-intervention groups. Among Black and Hispanic women, there was a significant increase in oncology consultations (86% before vs. 96% after the intervention), decreases in under-use of radiotherapy (23% before vs. 10% after), chemotherapy (26% before vs. 6% after), and hormonal therapy (27% before vs. 11% after). Overall rates of missing appointments dropped for all groups (from 34% to 14% in African American women, from 23% to 13% in Hispanic women, and from 17% to 14% in White women). This exciting study illustrates how a simple system, implemented to help all patients, but designed specifically to target causes of under treatment most common in minority women, was successful in reducing treatment under use and in eliminating racial disparity in adjuvant under use.
There are currently several studies examining the effectiveness of patient navigator programs in reducing health disparities during screening and treatment, but no data has been published yet on effectiveness on reducing disparities during treatment. Two published studies have examined the effectiveness of patient navigators in the diagnostic phase following mammography screening in minority populations. Both studies demonstrated the effectiveness of the patient navigator program in enhancing timely follow-up of breast abnormalities (Battaglia, Roloff, Posner, & Freund, 2007) and timeliness to diagnostic resolution (Ferrante, Chen, & Kim, 2008).
The Sisters Informing SistersSM intervention is a culturally appropriate empowerment model in which peers, African American women who had completed breast cancer treatment, were trained in T.A.L.K. Back!©, a shared decision-making approach. A very high degree of satisfaction was reported by patients; most (86%) reported that they found this model helped them communicate better with the provider, and that the program guidebook increased their understanding of treatment options.
DIRECTIONS FOR THE FUTURE
Disparities in treatment across ethnic groups in the United States have clearly been demonstrated. It is also clear that the factors that contribute to the less than optimal care received by some populations in the United States are multiple, complex, and potentially overlapping. What is not clear is why the path to finding solutions to rectify this morally reprehensible situation has not been more widely studied, and why effective strategies to eradicate inequities have not been widely implemented.
Key lessons for the future are apparent. The successful elimination of disparities in cancer care and outcomes will require change at multiple levels (Morris et al., 2010), with a concomitant need for (a) additional research dedicated to effective interventions, (b) specific application in clinical practice, and (c) implementation of transparent effective systems and policy change.
Future Research
Despite the numerous studies that have documented disparities, there is a need for several additional research directions. Although there are many reports comparing the treatment of African Americans with White groups, similar research focusing on the care of other ethnic groups, including Hispanics and Native Americans, is lacking and must be conducted. Research is needed to better clarify mechanisms of care that can be targeted for intervention with prospectively identified metrics. Studies that examine the effectiveness of interventions to reduce treatment disparities are imperative and urgent, yet rare. Systemic change in provider patterns, health care systems, and other contextual factors are more likely to be implemented once there is clear evidence that such interventions result in health equity. The funding of such studies by organizations such as the American Cancer Society and the National Cancer Institute should be a major priority.
Shift in Clinical Practice
Enhanced communication models, enhanced patient involvement, quality improvement techniques, real-time, point-of-care informatics, and other effective practices must be specifically applied in clinical practice to reduce cancer care disparities. Institutional and payer policies that align financial incentives around evidence-based care should include measures for equity in care. (a) Enhanced communication models: Poor doctor-patient communication has been demonstrated to negatively affect patient treatment choices, resulting in poorer outcome. The need to enhance provider-patient communication has been clearly demonstrated across multiple studies. The reality is that physicians are often encumbered by time constraints, so an alternative of a cancer educator has been recommended (Cykert, Dilworth-Anderson, et al., 2010). The teach-back method, proven to result in improved care in patients with low health (Paasche-Orlow et al., 2005; Wilson et al., 2008; Yin et al., 2008), is yet another effective strategy that is relatively simple to implement. Other such strategies exist; they simply need to be implemented. (b) Enhanced patient involvement: Prior studies have demonstrated that by increasing patient involvement in decisions and by increasing perceptions of being treated with dignity, improvements in care resulted (Beach et al., 2005; Clever et al., 2006). Extrapolating these to cancer treatment decisions should improve similarly. (c) Quality improvement and informatics: Audit and data feedback have been associated with improved patient outcomes in practice (Abreu, 1999). When coupled with quality improvement interventions, improved outcomes have been documented in the management of chronic diseases (Strand et al., 2007) and hospital care, including a reduction in mortality (Jamtvedt, Young, Kristoffersen, O’Brien, & Oxman, 2006; Sequist, Adams, Zhang, Ross-Degnan, & Ayanian, 2006). In the lung cancer setting where unidirectional, implicit bias has been insinuated, addressing this in a systematic manner beyond diversity training is needed, including standardization and transparency in the process of care.
Implementation of Systems Change
Current data suggest that health system and contextual factors, such as the location, accessibility, and quality of screening, diagnostic, and treatment facilities, are potentially some of the largest contributors to racial disparities in breast cancer mortality (Ansell et al., 2009). Other systemic changes needed include the following: (a) Access to high-quality facilities is therefore a crucial factor. (b) Accrual of race-specific data by institutions and provision of race-specific feedback has been demonstrated (Bickell et al., 2008) to overcome implicit bias—the collection of such data by all institutions that care for cancer patients is a necessary first step. (c) A tracking and feedback registry to increase patients’ connection with oncologists has demonstrated a significant decrease in under-use of appropriate treatment for breast cancer (Bickell et al., 2008). This system was implemented in multiple hospitals, including municipal hospitals, indicating that such implementation is possible across a variety of settings. (d) Patient navigator programs have been demonstrated to enhance timely resolution of abnormal mammographies (Battaglia et al., 2007; Ferrante et al., 2008) in minority, urban populations, and could be applied to reduce disparities in cancer control and cancer care. The American Cancer Society sponsors such programs in many areas around the country. We recognize that establishing such programs requires considerable planning and resources, and therefore encourage providers, health systems, patients, and communities to coordinate and optimize efforts. The informatics support provided by the HITECH portion of the American Recovery and Reinvestment Act and the expanded health insurance coverage and reimbursement changes provided by the Accountable Care Act should be leveraged as building blocks for these new systems of care. The guiding compass in implementing all future research, clinical care, and policy efforts should be our urgent quest to ensure that all members of our society receive equal and excellent medical care.
