Does patient navigation improve
satisfaction with health care and reduce
medical mistrust among Native
American cancer patients in the
Northern Plains?
B. Ashleigh Guadagnolo, MD, MPH
Assistant Professor
The University of Texas M.D. Anderson Cancer Center
Kristin Cina, BS and Daniel G. Petereit, MD
John T. Vecurevich Cancer Care Institute, Rapid City,
South Dakota
Background
In the most recent report to the nation on the
status of cancer by
y the Centers for Disease
Control, analyses of cancer death rates from
1975-2004 revealed declining trends in
cancer death rates for all ethnic groups
except American Indians and Alaska Natives
for whom death rate trends remained level.
Espey,
p y, et al. Annual report
p
to the nation on the status of cancer,,
1975-2004, featuring cancer in American Indians and Alaska
Natives. Cancer 2007; 110: 119-52.
Background
g
• American Indians in the U.S. Northern Plains,
where many large reservations are located,
have mortality rates that are significantly
higher than those for whites for which an
effective screening test exits.
• Specifically: 79% higher for cervical cancer,
cancer
58% higher for colorectal cancer.
Espey, et al
Espey
al. II.H.S.
H S Publication 97-614-28.
97 614 28 Rockville
Rockville, MD
MD, Indian Health
Service, 2003.
Study support
• National Cancer Institute, Cancer Disparities
Research Partnership grant issued in 2002,
renewed in 2009 (PI: Daniel G. Petereit, MD)
• Multi-faceted effort
–
–
–
–
Partner with communities
Research causes and ways to mitigate disparities
Increase clinical trial availability
Extensive patient navigation program
Medical mistrust and satisfaction
with health care
- Native Americans expressed significantly higher levels
of mistrust (p
(p=0
0.0001)
0001) and lower levels of satisfaction
with health care (p = 0.0001)
- IIn multivariable
li
i bl analyses,
l
NA race was the
h only
l factor
f
found to be significantly predictive of higher mistrust
(p=0.001)) and lower satisfaction with healthcare
(p
(p=0.0001), even when adjusting for income, education,
and geographic remoteness.
•
Guadagnolo A, Petereit D, et al. Medical mistrust and less satisfaction with health
g Native Americans p
presenting
g for cancer treatment. Journal of Health
care among
Care for the Poor and Underserved. Feb;20(1):210-26, 2009.
Study design
• Pre-post
Pre post survey study of cohort receiving
patient navigation during cancer treatment
• Survey
Su ey scales
sca es were
e e tthe
e sa
same
e as tthose
ose from
o
the published report showing baseline higher
mistrust and lower health care satisfaction.
satisfaction
• Recruitment was hospital-based
Population studied
• 52 adult Native American cancer patients
undergoing
g g treatment at a regional
g
care
center in Rapid City, SD
• Native populations served by the center:
– Pine Ridge/Oglala Sioux Tribe
– Rosebud Sioux
– Cheyenne River Sioux
– Rapid
R id Ci
City (Si
(Sioux S
San))
Patient navigation program
• Culturally-competent navigators assist pts
with:
– Navigating cancer therapy
– Obtaining medications
– Insurance/payor issues
– Communicating with medical providers
– Travel and lodging
g g logistics
g
– Psycho-social, educational, and advocacy support
– Provide Lakota language materials and services
The Instrument-Measuring
mistrust and satisfaction
• Scales developed through modification of
existing
i ti
scales
l (e.g.,
(
Medical
M di l Mistrust
Mi t
t Index;
I d
LaVeist, et al.) and novel items with NA
participation
ti i ti
in
i development
d
l
t to
t assure cultural
lt
l
appropriateness and engagement. (Iterative
process. Several
S
l meetings.)
ti
)
• Multi-item Likert-type scales to assess domains
of mistrust and satisfaction with health care.
LaVeist, et al. Medical Care Research and Review, Vol. 57 Suppl 1, (2000), 146-161.
Evaluating the survey instrument
• Content validity verified through focus
groups (NA and non-NA cancer patients
and research program staff).
ff)
• Good internal consistency of scales,
C
Cronbach’s
b h’ alpha
l h was 0.80
0 80 for
f mistrust
i t
t
scale and 0.87 for satisfaction scale.
• Study period: March 2008
2008-February
February 2010.
2010
Socio demographics
Socio-demographics
M di age
Median
62 yrs ((range 24
24-79
79 yrs))
Gender
Male
Female
60% (31)
40% (21)
Education
Less than H.S.
Hi h school/GED
High
h l/GED or more
23% (12)
77% (40)
Socio demographics
Socio-demographics
M di income
Median
i
$16 900 ((range, 0
$16,900
0-$100,000)
$100 000)
Below
B
l
Federal
F d
l poverty
t level
l
l
Yes
No
46% (23)
54% (27)
Primary payor of medical bills
Medicare
Veterans Administration
Indian Health Service
Medicaid
Private insurer
31% (16)
22% (11)
20% (10)
16% (8)
12% (6)
Mean scale scores for mistrust and
satisfaction pre- and post- navigation
Scale
Satisfaction*
pre
4.12
Change in mean score (95% CI)
Medical mistrust**
2.38
Change in mean score (95% CI)
post
4.53
p-value †
<0.0001
+0.41 (0.22-0.60)
2.23
0.13
-0.13 (-0.28-0.03)
Wilcoxon signed ranks test (non-parametric)
* a higher score corresponds to higher level of satisfation
**a higher score corresponds to a higher level of medical mistrust
†
Conclusions
• Native American cancer patients who
received patient navigation during
treatment showed improvement in
satisfaction with health care compared
p
with
pre-navigation baseline scores.
• No improvements were observed in levels
of medical mistrust after patient navigation.
Implications for policy, delivery
or practice
• Pt navigation may improve quality of health
care experience for Native American
patients (previously shown relatively low
satisfaction).
• Research is needed into whether this
improvement in satisfaction translates to
better treatment adherence or improved
outcomes.
Implications for policy, delivery
or practice
• Pt navigation by culturally and linguistically
competent
p
navigators
g
did not significantly
g
y reduce
medical mistrust in this cohort.
• Adjustments being implemented in staffing and
program to improve trust between navigators/staff
and patients.
patients
• Research is needed into both the role mistrust
plays in contributing to health disparities and
factors that may
y mitigate
g
it in this vulnerable
population.