IMPLEMENTATION OF PATIENT NAVIGATION IN RURAL AREAS AFTER AN ABNORMAL MAMMOGRAM

描述（由申请人提供）：农村地区妇女患乳腺癌死亡的风险高于城市地区妇女。城市/农村乳腺癌差异主要是由于卫生系统因素减少了获得护理的机会，患者因素降低了患者倡导其需求的能力。这些及时护理的障碍导致诊断为晚期乳腺癌和随后的低生存率。患者导航可以帮助妇女减少及时护理的障碍，从而提高乳腺癌患者的生存率。然而，关于卫生服务组织如何成功实施这一干预措施的证据有限。诸如认为干预措施无效、不支持的文化或资源不足等因素都可能导致实施失败。为了确定成功实施的有希望的做法，需要更多的信息来了解如何在农村地区使用这种干预措施。为了填补这一知识空白，我们与密苏里州东南部农村地区的主要利益相关者合作，以实现以下具体目标：1)评估在农村地区实施患者导航的程度，以帮助女性完成异常乳房x光检查后的随访护理；2)识别与患者导航实施相关的理论知情的组织特征（背景，促进过程，对证据的看法）；3)确定实施成功的有希望的战略。为了实现这些目标，我们将调查密苏里州东南部10个县的72个联邦合格卫生中心和农村卫生诊所，然后使用描述性统计来报告患者导航使用水平和实施成功的可变性（目标1）；建立多变量线性回归模型，以检查组织因素、患者导航使用水平和实施成功之间的关联（目标#2）。我们将使用目标2中的数据有目的地对四个组织进行抽样，以获得实施成功的最大变异性（两个高级别和两个低级别），然后对至少20个组织代表和20名最近有异常乳房x光检查的患者进行深入访谈。在用描述性统计（目标1）对访谈数据进行三角测量后，我们将进行潜在内容分析，这将使我们能够发现在一些组织中患者导航是如何以及为什么成功的。美国癌症协会资助我们进行目标#1，#2和组织访谈（目标#3）。该提案要求为患者调查和案例研究分析（目标#3）提供资金，以便我们以较低的边际成本增加研究结果的丰富性。我们的研究结果将为决策者提供有用的信息，并为一项实用的试验计划提供信息，以检查成功实施患者导航的有希望的策略的效果，以减少农村地区妇女乳腺癌诊断和治疗的延误。

DESCRIPTION (provided by applicant): Women in rural areas experience higher risk of breast cancer death than women in urban areas. The urban/rural breast cancer disparity is primarily due to a combination of health system factors that decrease access to care and patient factors that lower patients' capacity to advocate for their needs. These barriers to timely care contribute to advanced stage breast cancer at diagnosis and subsequent lower survival. Patient navigation can improve breast cancer survival by helping women reduce barriers to timely care. However, there is limited evidence to inform health service organizations how to successfully implement this intervention. Factors such as perceptions that an intervention is not effective, an unsupportive culture, or inadequate resources can result in failed implementation. To identify promising practices for successful implementation more information is needed to understand how this intervention is being used in rural areas. To fill this gap in knowledge, we have partnered with key stakeholders in rural southeast Missouri to address these specific aims: 1) assess the extent to which patient navigation is implemented in rural areas to assist women complete follow-up care after an abnormal mammogram; 2) identify theoretically informed organizational characteristics (context, facilitation processes, perceptions of the evidence) that are associated with implementation of patient navigation; 3) identify promising strategies for implementation success. To fulfill these aims we will survey 72 Federally Qualified Health Centers and Rural Health Clinics in 10 counties in southeast Missouri and then use descriptive statistics to report on variability in the level of patient navigation use and implementation success (Aim #1); build multivariable linear regression models to examine associations between organizational factors, level of patient navigation use and implementation success (Aim #2). We will use data from Aim #2 to purposefully sample four organizations for maximum variability of implementation success (two high-level and two low-level) then conduct in-depth interviews with a minimum 20 organizational representatives and 20 patients who recently had an abnormal mammogram. After triangulating interview data with descriptive statistics (Aim #1), we will conduct a latent content analysis that will enable us to discover how and why patient navigation is successful in some organizations. The American Cancer Society has funded us to conduct Aims #1, #2 and the organizational interviews (Aim #3). This proposal request funds for the patient surveys and case study analysis (Aim#3) so we increase the richness of our study results for a low marginal cost. The results from our study will provide decision-makers with useful information and inform plans for a pragmatic trial to examine the effect of promising strategies for successful implementation of patient navigation to reduce delays in breast cancer diagnosis and treatment for women in rural areas.