Risk factors for nonadherence to outpatient appointments in lung cancer patients and a review of the patient navigation system: a case-control study
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BACKGROUND: There is a need to identify the populations at high risk of nonadherence to outpatient lung cancer appointments in order to reduce the delay from diagnosis to treatment. The patient navigation system, which helps patients with barriers navigate the health care system, was examined to see if the correct high-risk groups were being addressed. METHODS: A case-control study with 195 subjects from the lung cancer clinics at Boston Medical Center (BMC) was conducted examining three nonadherence case groups: no-shows (n=40), cancelations (n=64) and combined (n=20). Nonadherence was defined as any patient who was a no-show for at least one appointment or who canceled more than one appointment over the three month study period. The combined group incorporated both of these factors. The patients were stratified by 10 patient characteristics, including patient navigation. Odds ratios (ORs) and 95% confidence intervals (CIs) were used for the analysis. A second analysis was done on patients in the patient navigation program (n=33) to determine if the high risk groups identified were being addressed. This was done using ORs and 95% CIs. RESULTS: This study has shown that there are certain patient groups in the lung cancer clinics at BMC that are at higher risk of being nonadherent to lung cancer outpatient appointments. Among those are Hispanic/Latino patients, Spanish and Haitian Creole speaking patients, small cell lung cancer (SCLC) patients, and those patients who have Medicaid, and with late stage lung cancer patients at significantly higher risk (no-shows: OR-5.26 (1.85, 14.95), cancelations: OR-2.49 (1.12, 5.54), combined: OR-12.49 (1.48, 105.46)). Patients in the patient navigation system were also found to be at significantly higher risk of nonadherence (no-shows: OR-3.85 (1.72, 8.65), cancelations: OR-4.13 (1.89, 9.00), combined: OR-5.15 (1.93, 13.72)) than those not in the program. Some patients were also found to be at significantly decreased odds of nonadherence, including those who were: 1000-1999 days post diagnosis (no-shows: OR-0.14 (0.03, 0.59), cancelations: OR-0.20 (0.06, 0.65), combined: OR-0.07 (0.01, 0.64)); 2000-2999 days post diagnosis (no-shows: OR-0.09 (0.01, 0.80), cancelations: OR-0.06 (0.01, 0.50)); aged 71-75 (cancelations: OR-0.25 (0.08, 0.79)). The subset analysis with the patient navigation data yielded no statistically significant results. CONCLUSIONS: The study identified high-risk populations within the total lung cancer population at BMC that should be addressed by the patient navigation program. This study demonstrated that while the program does have its flaws, it is decreasing the odds of nonadherence of many of the high-risk populations.