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

尽管迫切需要长期的后续护理，但只有三分之一的儿童癌症幸存者(CCS)报告 接受以幸存者为重点的护理的人更少，接受降低风险咨询和适当筛查的人更少。 许多研究已经描述了CCS在个体层面上经历的障碍，这些障碍主要源于 社会经济因素。因此，高危人群从事长期跟踪的机会有限。 增加护理，使他们患上与治疗相关的疾病的风险更高。很少有研究能成功地测试 有效、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结局差异的因素。 如果不解决现有的健康障碍，就无法实现平等获得高质量的生存护理 护理利用情况。我们建议的目标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。AIM 1将利用 电子健康记录数据提取工具，从生活中的CCS中提取相关的社会人口数据， 已经完成了治疗。然后，我们将开发一种算法来识别CCS处于次优健康状态的风险 护理利用(定义为在完成治疗后四年内未进入长期跟踪护理)。 为了做到这一点，我们将使用我们之前发表的工作中预测存活不坚持的因素，以及 纳入以地区为基础的社会经济剥夺措施。对于目标2，我们将前瞻性地确定CCS 卫生保健利用率不佳且有资格接受长期随访的风险人群(至少3 治疗结束后数年)，尚未安排到长期幸存者(LTS)诊所就诊。一个 Survivship Navigator将联系高危CCS，以完成一项评估结构性障碍的调查，数据 将用于为LTS资源工具包的开发提供信息。对于AIM 3，幸存者导航员将 使用LTS资源工具包为他们在AIM中认可的障碍提供风险较高的CCS个性化解决方案 2.将通过比较每个符合条件的高危人群的首次LTS就诊率来评估干预的临床益处 CCS将利率从历史上的风险CCS控制。干预措施对成本效益的影响将是 根据人员在导航活动中花费的时间加上与工具包相关的费用计算得出 增加了LTS访问产生的收入。 我们预计这个项目将提高启动长期跟踪的符合条件的风险CCS的比例 在它的诊所里的护理。这项研究结果产生的证据将提供实用、可持续和 最重要的是，在高危CCS中最大限度地提高生存护理摄取率的通用解决方案。未来领域 调查包括评估这项干预对维持长期随访的影响 除了第一次探视之外的关爱。

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.