Clinical benefit and cost-efficacy of risk-stratified survivorship navigation to overcome structural barriers to long-term follow-up care

尽管对长期随访护理的迫切需要，但只有三分之一的儿童癌症幸存者（CCS）报告说， 接受以幸存者为中心的护理，接受降低风险咨询和适当筛查的人更少。 许多研究描述了CCS在个人层面上遇到的障碍，这些障碍主要来自于 社会经济因素。因此，高危人群参与长期随访的机会有限- 增加护理，使他们面临更高的治疗相关疾病的风险。很少有研究成功地测试了 有效的，可持续的干预措施，以克服癌症中心环境中的结构性障碍， 通过限制获得生存护理而导致CCS结果差异的因素。 如果不消除现有的健康障碍，就无法公平获得高质量的生存护理 护理利用率我们建议的目的是评估医院的政策和程序， 不成比例地影响来自弱势背景的CCS，并确定消除， 规避或克服CCS进入长期随访护理的系统性障碍。目标1将利用 电子健康记录数据提取工具，从生活CCS中提取相关的社会人口数据， 已完成治疗。然后，我们将开发一种算法，用于识别处于次优健康风险中的CCS 护理利用（定义为在完成治疗后4年内未能进入长期随访护理）。 为了做到这一点，我们将使用我们以前发表的工作中预测生存率不依从的因素， 纳入基于地区的社会经济贫困措施。对于目标2，我们将前瞻性地确定CCS 存在次优医疗保健利用风险且符合进入长期随访的资格（至少3 治疗结束后的10年），尚未安排长期生存者（LTS）诊所的访视。一 Survivorship Navigator将联系处于风险中的CCS，以完成一项调查，评估结构性障碍， 将用于为LTS资源工具包的开发提供信息。对于目标3，生存导航器将 使用LTS资源工具包，为他们在Aim中认可的障碍提供风险CCS个性化解决方案 2.将通过比较每个合格风险患者的首次LTS访视率来评估干预的临床获益 CCS与历史风险CCS控制的比率。干预措施对成本效益的影响将是 根据导航活动所花费的人员时间加上工具包相关费用， LTS访问产生的收入增加。 我们预计该项目将提高启动长期随访的符合条件的高风险CCS的比例 在LTS诊所的护理。本研究结果产生的证据将提供实用的，可持续的， 最重要的是，可推广的解决方案，最大限度地提高生存护理吸收在风险CCS。未来领域 的调查包括评估这种干预对维持长期随访的影响 在初次访问之后的护理。

Despite a critical need for long-term follow-up care, only one-third of childhood cancer survivors (CCS) report receiving survivor-focused care, and even fewer receive risk-reduction counseling and appropriate screening. Numerous studies have described barriers experienced by CCS at the individual level, which largely stem from socioeconomic factors. As a result, at-risk populations have limited opportunities to engage in long-term follow- up care, placing them at higher risk for treatment-related morbidities. Few studies have successfully tested effective, sustainable interventions to overcome structural barriers within the cancer center environment, factors that contribute to CCS outcome disparities by limiting access to survivorship care. Equitable access to quality survivorship care cannot be achieved without addressing existing barriers to health care utilization. The objective of our proposal is to evaluate hospital policies and procedures that disproportionately impact CCS from disadvantaged backgrounds, and identify novel strategies that eliminate, circumvent, or overcome systematic barriers to CCS entry into long-term follow-up care. Aim 1 will leverage electronic health record data extraction tools to abstract relevant sociodemographic data from living CCS that have completed treatment. We will then develop an algorithm for identifying CCS at-risk for suboptimal health care utilization (defined as failure to enter long-term follow-up care by four years after completing treatment). To do this, we will use factors predictive of survivorship nonadherence from our previously published work, and incorporate area-based measures of socioeconomic deprivation. For Aim 2 we will prospectively identify CCS who are at-risk for suboptimal health care utilization and eligible for entry to long-term follow-up (at least 3 years from end of therapy) who have not yet scheduled a visit in the Long Term Survivor (LTS) Clinic. A Survivorship Navigator will contact at-risk CCS to complete a survey that assesses structural barriers, data that will be used to inform development of an LTS Resource Tool Kit. For Aim 3, the Survivorship Navigator will use the LTS Resource Tool Kit to offer at-risk CCS personalized solutions to the barriers they endorsed in Aim 2. Clinical benefit to the intervention will be assessed by comparing the rates of first LTS visit per eligible at-risk CCS to rates from historical at-risk CCS controls. The impact of the intervention on cost efficacy will be determined from the personnel time spent in navigation activities plus Tool Kit-related expenses to the resulting increase in revenue generated from LTS visits. We anticipate this project will improve the proportion of eligible at-risk CCS that initiate long-term follow-up care in the LTS Clinic. Evidence generated by the results of this study will provide practical, sustainable, and, most importantly, generalizable solutions that maximize survivorship care uptake in at-risk CCS. Future areas of investigation include assessment of the impact of this intervention on maintenance of long-term follow-up care beyond the initial visit.