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Randomized Controlled Trial
. 2024 Aug 1;184(8):892-902.
doi: 10.1001/jamainternmed.2024.1662.

Patient Navigation for Lung Cancer Screening at a Health Care for the Homeless Program: A Randomized Clinical Trial

Travis P Baggett  1   2   3   4 , Nora Sporn  1 , Joana Barbosa Teixeira  1 , Elijah C Rodriguez  5 , Nillani Anandakugan  6 , Natalia Critchley  1 , Evangeline Kennedy  1 , Katherine Hart  1 , Andrea Joyce  1 , Yuchiao Chang  1   2   3 , Sanja Percac-Lima  1   2   3 , Elyse R Park  1   2   3 , Nancy A Rigotti  1   2   3
Affiliations
Randomized Controlled Trial

Patient Navigation for Lung Cancer Screening at a Health Care for the Homeless Program: A Randomized Clinical Trial

Travis P Baggett et al. JAMA Intern Med. .

Abstract

Importance: People experiencing homelessness die of lung cancer at rates more than double those in the general population. Lung cancer screening (LCS) with low-dose computed tomography (LDCT) reduces lung cancer mortality, but the circumstances of homelessness create barriers to LCS participation.

Objective: To determine whether patient navigation, added to usual care, improved LCS LDCT receipt at a large Health Care for the Homeless (HCH) program.

Design, setting, and participants: This parallel group, pragmatic, mixed-methods randomized clinical trial was conducted at Boston Health Care for the Homeless Program (BHCHP), a federally qualified HCH program that provides tailored, multidisciplinary care to nearly 10 000 homeless-experienced patients annually. Eligible individuals had a lifetime history of homelessness, had a BHCHP primary care practitioner (PCP), were proficient in English, and met the pre-2022 Medicare coverage criteria for LCS (aged 55-77 years, ≥30 pack-year history of smoking, and smoking within the past 15 years). The study was conducted between November 20, 2020, and March 29, 2023.

Intervention: Participants were randomized 2:1 to usual BHCHP care either with or without patient navigation. Following a theory-based, patient-centered protocol, the navigator provided lung cancer education, facilitated LCS shared decision-making visits with PCPs, assisted participants in making and attending LCS LDCT appointments, arranged follow-up when needed, and offered tobacco cessation support for current smokers.

Main outcomes and measures: The primary outcome was receipt of a 1-time LCS LDCT within 6 months after randomization, with between-group differences assessed by χ2 analysis. Qualitative interviews assessed the perceptions of participants and PCPs about the navigation intervention.

Results: In all, 260 participants (mean [SD] age, 60.5 [4.7] years; 184 males [70.8%]; 96 non-Hispanic Black participants [36.9%] and 96 non-Hispanic White participants [36.9%]) were randomly assigned to usual care with (n = 173) or without (n = 87) patient navigation. At 6 months after randomization, 75 participants in the patient navigation arm (43.4%) and 8 of those in the usual care-only arm (9.2%) had completed LCS LDCT (P < .001), representing a 4.7-fold difference. Interviews with participants in the patient navigation arm and PCPs identified key elements of the intervention: multidimensional social support provision, care coordination activities, and interpersonal skills of the navigator.

Conclusions and relevance: In this randomized clinical trial, patient navigation support produced a 4.7-fold increase in 1-time LCS LDCT completion among HCH patients in Boston. Future work should focus on longer-term screening participation and outcomes.

Trial registration: ClinicalTrials.gov Identifier: NCT04308226.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Baggett reported receiving royalties from UpToDate outside the submitted work. Dr Rigotti reported receiving a grant from Achieve Life Sciences, Inc, and personal fees from Achieve Life Sciences, Inc, and UpToDate outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. CONSORT Diagram
BHCHP indicates Boston Health Care for the Homeless Program; CT, computed tomography; and PCP, primary care practitioner. aIndividuals could be ineligible for more than 1 reason. bEligibility could not be determined because patients did not complete all screening items.
Figure 2.
Figure 2.. Lung Cancer Screening (LCS) Low-Dose Computed Tomography (LDCT) Completion
See this image and copyright information in PMC

Comment on

  • Progress in Lung Cancer Screening Adoption.
    Richman IB, Gross CP. Richman IB, et al. JAMA Intern Med. 2024 Aug 1;184(8):902-903. doi: 10.1001/jamainternmed.2024.1673. JAMA Intern Med. 2024. PMID: 38857025 No abstract available.

References

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    1. Baggett TP, Hwang SW, O’Connell JJ, et al. . Mortality among homeless adults in Boston: shifts in causes of death over a 15-year period. JAMA Intern Med. 2013;173(3):189-195. doi:10.1001/jamainternmed.2013.1604 - DOI - PMC - PubMed
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