The Impact of Patient Navigators on Overactive Bladder Care: Real-World Practice Patterns from a US National Database

Purpose/Objective(s): Black breast cancer patients have substantially decreased access to optimal breast conserving cancer care (postlumpectomy radiation therapy) than White patients. Patient navigation (originally implemented in the 1990s to address cancer disparities and medical mistrust) has demonstrated improvement in breast cancer survival, yet has never been formally implemented into the receipt of radiation therapy (RT) for Black patients. The Navigator-Assisted Hypofractionation (NAVAH) program is the first to formally assess the impact of patient navigation on RT in Black breast cancer patients. Here, we present the initial results from an ongoing Phase I trial assessing the impact of NAVAH on RT completion. Materials/Methods: NAVAH is a prospective single-arm Phase I pilot study. Patients of Black race age > 18 with pathologically confirmed breast cancer following operative resection are eligible. Patients referred for RT in multidisciplinary tumor board, seen by Radiation Oncology, and consented to receive RT were approached for trial participation. Participants were assigned a patient navigator to aid them throughout the course of radiation therapy and post-RT care, and were provided travel vouchers to offset the transportation cost of RT. The RT scheduled dose/fractionation, scheduled completion date, actual completion date, and verification of RT completion was recorded for each enrolled patient. Patients refusing trial participation were assessed to determine RT completion rate; Fisher’s exact test was used for statistical analysis with significance assigned as p<0.05. The primary trial endpoint is RT completion rate following initiation of patient navigation; this trial is registered at clinicaltrials.gov, NCT05978232. Results: Between March 27, 2024 and May 28, 2024, a total of 18 patients with scheduled CT simulation for RT planning were offered trial enrollment; 11 accepted and 7 declined. No patient had received navigation prior to being offered trial enrollment. Median fraction duration and total dose received (including boost) was 16 (range 5-20) and 40.05 Gy (range 26-52.56 Gy) among enrolled patients, and 16 (range 5-20) and 40.05 Gy (range 30-52.56 Gy) in those declining enrollment, with no significant difference in patient age or distance from RT facility between those who accepted versus declined trial enrollment. Of the 7 patients who declined trial enrollment, six (85.7%) completed RT (the seventh initially agreed to RT but subsequently failed to present for treatment); of these six, four (66.7%) completed RT without delay. Of the 11 patients who enrolled on trial, all (100%) completed RT, with eight (72.7%) completing RT without delay. The differences between groups were not statistically significant. Conclusion: Early results of an ongoing Phase I clinical trial reveal that incorporation of patient navigation following initial Radiation Oncology consultation is associated with 100% radiation therapy treatment completion for postoperative early-stage breast cancer in Black patients, compared with lower rates among patients not receiving navigation, as well as numerically superior rates of RT completion without delay. Further work examining incorporation of patient navigation earlier in the treatment course of patients is ongoing. Citation Format: Shearwood McClelland III, Ursula J Burnette, Louisa Onyewadume, Chesley W Cheatham, Tamika K Smith, Corey W Speers, Janice A Lyons. Impact of Patient Navigation on Radiation Therapy Completion in Black Breast Cancer Patients: Early Phase I Trial Results From the Navigator-Assisted Hypofractionation (NAVAH) Program [abstract]. In: Proceedings of the San Antonio Breast Cancer Symposium 2024; 2024 Dec 10-13; San Antonio, TX. Philadelphia (PA): AACR; Clin Cancer Res 2025;31(12 Suppl):Abstract nr P5-09-15.

Effect of Pharmacotherapy for Overactive Bladder on the Incidence of and Factors Related to Urinary Tract Infection: A Systematic Review and Meta-analysis.

Background Despite CDC recommendations, areas with high HIV prevalence have not implemented routine HIV testing, stating among other concerns, inability to effectively link them to care. We implemented a routine HIV testing program in the Emergency Department (ED) at University Hospital in Newark, NJ that had 46,164 visits from July 2015 to November 2016 and looked at the impact of patient navigators (PN) on linkage to care (LTC) rates. Methods This was a retrospective study of all patients newly diagnosed (ND) with HIV or previously positive (PP) but lost to follow-up (LTFU) in select areas of the ED from July 2015 to November 2016. We collected information on demographics, HIV risk factor, and looked at the impact of PN on LTC by comparing months the PN was able to make personal contact compared with months when the PN was unavailable for substantial periods of time. Results A total of 9,511 individuals were screened, and 151 (1.6%) had a positive HIV test; 8 died and 2 were incarcerated. Of the remaining 141, 102 (72%) were LTC. The mean age was 49, 57% Male, 77% Black, 14% Hispanic, and 6% White. The reported HIV risk factors were 67% Heterosexual, 9% MSM, 6% IV drug use (IDU) and 18% Other. Of the patients with a positive HIV test, 60 (43%) were ND and 81 (57%) were PP. Only 52% ND patients were LTC, while 88% PP patients were LTC. Black and Hispanic patients tended to be PP (60% of both groups), while White patients tended to be ND (75% of white patients were ND). The risk factors for ND were 44% Heterosexual, 39% MSM, and 25% IDU. Average LTC while the PN was unavailable decreased from 78% to 56%. There were no demographic differences in the LTC group compared with the LTFU group. IDU had the highest rate of being LTFU at 37% followed by MSM and Heterosexual at approximately 23% each. The primary reason for LTFU was incorrect contact information in the medical record such as wrong address or phone number. PN would make 3 phone calls, send 2 letters and 1 outreach attempt. If all of those failed, the PN notified the state health department. Conclusion PN have a positive impact on LTC even in busy ED settings. Given limitations of staffing a busy ED 24/7, we need to develop strategies to link patients even if the PN is not present. To address this limitation, we plan on looking at the impact of involving medical residents to help with linkage to care after business hours. Disclosures S. Swaminathan, Gilead Sciences: Grant Investigator and Scientific Advisor, Consulting fee and Research grant

New ideas in urology: 2014 update

The Impact of Patient Navigation on Healthcare Utilization in Pediatric and Adolescent Gynecology: A Retrospective Cohort Study.

Anticholinergic drugs can cause cognitive impairment. The risk of dementia associated with anticholinergics compared to beta-3 agonists (mirabegron and vibegron) has not been extensively investigated in the super-aging society of Japan. This study evaluated the association between the dementia risk and anticholinergics compared to beta-3 agonists in older adults with overactive bladder in Japan. This study had 1,493,202 participants from the Longevity Improvement & Fair Evidence Study, which includes claim data in Japan from 2014 to 2022. The participants included 13,448 anticholinergic drug users and 24,669 beta-3 agonist users diagnosed with overactive bladder and aged ≥65years. The Cox proportional hazards regression model was used to calculate hazard ratios and 95% confidence intervals being adjusted for confounding variables to evaluate the impact of anticholinergic drugs compared to beta-3 agonists prescribed at index date to patients with overactive bladder. Among the beta-3 agonist and anticholinergic drug users, the mean (standard deviation) age was 78.9 (6.7) and 78.8 (7.0) years, and the percentage of men was 47.2% and 39.7%, respectively. In the beta-3 agonist group, 2130 participants were newly diagnosed with dementia during the 51,605 person-years of follow-up from the index date, whereas in the anticholinergic drug group, 1826 participants were diagnosed during the 34,929 person-years of follow-up. In the Cox proportional hazard regression model, there was an increased risk of dementia in the anticholinergic drug group compared to the beta-3 agonist group (adjusted hazard ratio [aHR]=1.22; 95% confidence interval [CI], 1.15-1.30). The increased risk remained identical when Inverse Probability Weighting (IPW) model was used for the analysis (aHR=1.19; 95% CI, 1.11-1.28). Compared to beta-3 agonists, anticholinergic drugs are associated with an increased risk of dementia in older adults with overactive bladder, in Japan. These findings suggest that beta-3 agonists may have a lower risk of dementia than anticholinergics and have potential to be a good alternative opinion for older people with OAB, which warrants further study.

INTRODUCTION: Anticholinergic (AC) and beta-3 agonist (B3) medications are the mainstay of pharmacotherapy to treat overactive bladder (OAB). Recent clinical guidelines recommend cautious use of ACs in elderly patients as ACs are associated with cognitive side effects. The primary objective of this study was to examine OAB prescribing patterns from 2020 to 2022. METHODS: This is an IRB-approved retrospective study at a single academic center between January 2020 and December 2022. Women aged at least 18 years, diagnosed with OAB, and newly prescribed ACs or B3s were included. Overactive bladder diagnosis was identified using ICD-9 and -10 codes and the electronic medical record queried for new OAB medication prescriptions in our system. Patient demographics and clinician specialty were abstracted from the medical record. Group comparisons were conducted using Student's t-test, and χ2, Fisher's exact tests were used as appropriate. RESULTS: Five thousand six hundred forty-eight women were prescribed an AC or B3 between 2020 and 2022. Anticholinergic medications were more commonly prescribed, comprising 58.3% of OAB prescriptions compared to B3s (41.7%). Beta-3 agonist prescriptions increased by 127% over the study period. In contrast, AC prescribing remained stable. Women prescribed B3 agonists were more likely to be older (P<.001). There were significant differences in OAB prescription trends by prescriber specialty (P<.001). Urogynecologists were the leading prescribers of B3s (38.3%), whereas primary care clinicians prescribed the most ACs (57.9%). CONCLUSION: Beta-3 agonist prescriptions increased while AC prescriptions were relatively unchanged from 2020 to 2022. Despite growing concern regarding AC risks, our study shows that ACs are still prescribed at high volume.

Urinary anticholinergic (AC) medications are commonly prescribed for Overactive Bladder (OAB) syndrome. Although recent studies suggest a potential link between their use and an increased risk of dementia, this association remains debated. We conducted a systematic review and meta-analysis to evaluate the risk of dementia in patients receiving AC treatment for OAB syndrome. A comprehensive search of PubMed, Embase, and Cochrane databases was performed. Outcomes of interest included dementia risk and its association with age, sex distribution, treatment duration, and follow-up length. Two subgroup analyses were assessed: (1) AC vs. no drug therapy and (2) AC vs. mirabegron, a beta-3 agonist and current standard of care for OAB syndrome. Relative risk (RR) with p-value < 0.05 was considered statistically significant. Eight studies were included, comprising a total of 3,656,686 patients diagnosed with OAB syndrome, of whom 44.7% were exposed to urinary AC. The comparison between AC and no drug therapy showed a statistically significant higher risk of dementia in the exposed group (RR 1.2, 95% CI [1.09-1.32], I²=96%, p < 0.01). When the AC group was compared to patients who received Mirabegron, the AC use also presented a statistically significant increase in dementia risk (RR 1.28; 95% CI [1.03-1.58], I²=98%, p = 0.02). Patients who received urinary AC therapy for OAB syndrome were associated with an increased risk of dementia compared to both no drug therapy and medical therapy with mirabegron. These findings suggest that, for the long-term treatment of adult patients with OAB syndrome, alternative therapeutic options to AC should be considered, with Mirabegron emerging as a valid choice in clinical decision-making.

Insurance coverage of patient self-management devices like self-monitoring blood glucose (SMBG) equipment may help to reduce race-related barriers to effective care. We examined whether providing free home glucose monitors had greater impacts on self-monitoring among black versus white patients with diabetes. Using electronic medical record data (1992-1996), we used longitudinal survival analysis to examine racial differences in rates of initiation of SMBG after coverage and rates of discontinuation of SMBG 18 months after initiation. We used piecewise Cox models to compare relative rates of SMBG initiation between black and white patients before and after the policy. The study cohort included 2275 continuously enrolled adult patients with diabetes in a large, staff model HMO. Multivariate models were restricted to patients using oral therapy. Controlling for time-dependent and fixed effects, black patients were as likely to initiate SMBG as white patients before the policy (hazard ratio 1.14; 95% confidence interval 0.86-1.50) but more likely after the policy (hazard ratio 1.33; 95% confidence interval 1.01-1.76). Among postpolicy SMBG initiators, black patients were consistently at higher risk of SMBG discontinuation than white patients over time (P < 0.05). By the end of follow-up, discontinuation rates were 78% among black patients and 64% among white patients. The policy is effective in triggering additional diabetes patients to self-manage, particularly black patients. However, persistence after initiation of monitoring is short-lived. Although our results show the potential of such policies to narrow racial gaps in self-management among racial minority groups, further interventions may be needed to promote long-term adherence.

Hematopoietic Stem Cell Transplantation (HCST) Is Underutilized in Black Patients with Myeloid Neoplasms. Results from a Retrospective Study at Chicago's Leading Minority-Serving Hospital

Introduction

Patient navigation for lung cancer screening in an urban safety-net system: Protocol for a pragmatic randomized clinical trial

Background: Overactive bladder (OAB) syndrome is defined as urinary urgency, with or without urge incontinence in the absence of an underlying pathological or metabolic cause. Treatment for OAB involves anti-muscarinic agents and beta 3-adrenoceptor agonists. As a previous study showed that treatment may increase the risk of urinary tract infection (UTI), we conducted a nationwide, population-based, retrospective study to assess UTI risk associated with OAB medication adherence, and different types of OAB medication. Methods: The source of data was medical records from National Health Insurance Research Database (NHIRD). Patients who were diagnosed with OAB in outpatient records from January 1, 2014 to December 31, 2016 were included. Outpatient visits included an attendance at primary care or the emergency department. The index date was the first prescription medication for OAB treatment after diagnosis. The targeted population was those diagnosed with OAB, and targeted drugs were anti-muscarinic agent (including flavoxate, oxybutynin, propiverine, solifenacin, tolterodine, and trospium) and mirabegron. Adherence was assessed based on the proportion of days covered in 12 months among mirabegron and anti-muscarinic agents. A multivariate Cox proportional-hazards model was used to compare the risk of UTI with OAB medication adherence, and different types of OAB medication. Results: There were 39,975 outpatients diagnosed with OAB in the database from 2014 to 2016. Excluding those younger than 20 years old and for whom the information was incomplete in the database, 21,869 patients were included in the final OAB cohort. Overall, risk of UTI was not influenced by the targeted drugs or adherence during the follow-up period, regardless of UTI history or sex. Conclusion: OAB is a common problem in Taiwan. After 12 months of follow-up, there was no difference between anticholinergic medications and beta-3 agonists, nor between high and low adherence in the risk of UTI.

Overactive bladder (OAB) is a common clinical problem with associated morbidities both in men and women. Although real-life management strategies have been examined among urologists (URO), treatment choices may differ between different specialties. In the present study, an online survey was conducted to determine and compare the management strategies and clinical preferences of UROs, obstetricians/gynecologists (OB/GYN), and geriatricians (GER) in the treatment of OAB in their daily practices. Between December 2020 and February 2021, an online questionnaire was sent to URO, OB/GYN, and GER specialists/residents. Current strategies and attitudes toward treatment of OAB in patients &lt;65 years were compared between URO and OB/GYN, whereas the responses were compared between all three specialties in patients ≥65 years. A total of 733 specialists/physicians (433 URO, 236 OB/GYN, and 64 GER) completed the online survey. Patients with OAB were more likely to present to URO compared to OB/GYN and GER (p = 0.001). A combination of behavioral modification and pharmacotherapy (antimuscarinics and/or beta-3 agonists) were chosen for the initial treatment of patients with OAB in both specialties with a significantly higher proportion by URO than by OB/GYN (51.9% vs. 38.1%; p = 0.001). Antimuscarinics were the most frequently prescribed medications by both the URO and OB/GYN specialties (81.8% vs. 78.4%; p = 0.27). Combination therapy with antimuscarinics was preferred more often by URO (91.5% vs. 77.1%; p = 0.001) when no or an inadequate response after initial treatment occurred. Multiple medication use, comorbidities, and risk of cognitive side effects affected medication preference by all specialists, especially by GER (p = 0.018). Patients with OAB present to UROs, OB/GYN and GER more frequently compared to other specialities. Although antimuscarinics and beta-3 adrenoceptor agonists are equally recommended as first-line pharmacotherapy for OAB, antimuscarinics were preferred for most patients as the initial molecule by all specialties. Beta-3 agonists are increasingly preferred for elderly patients.

Interstitial cystitis/bladder pain syndrome (IC/BPS) is prevalent, difficult to treat, and has close symptom overlap with overactive bladder (OAB). A review of the pathophysiology, assessment, and treatment of IC/BPS patients with overlapping OAB symptoms has not been summarized recently in the published literature. A review of the published literature on the overlap of IC/BPS and OAB was conducted using MeSH terminology (1992-2022). The pathophysiology of IC/BPS is not fully understood. Animal research has found the bladder trigone and base are richly populated by afferent fibers, including many small unmyelinated C-fibers that may be upregulated in IC/BPS. Successful therapies with multimodal effects on OAB symptoms in patients with IC/BPS are likely to exert beneficial effects on both pain and lower urinary tract symptoms. Potentially efficacious therapies for the treatment of OAB in IC/BPS include pelvic floor physical therapy, oral pharmacotherapy (antimuscarinics and beta-3 agonists), sacral neuromodulation, percutaneous tibial nerve stimulation, and botulinum toxin A (BTA). Antimuscarinics and beta-3 agonists have yielded partial efficacy in IC/BPS, although may help differentiate symptoms of OAB from those associated with IC/BPS. The transvaginal trigone treatment (T3) intradetrusor injection approach allows for delivery of therapeutics to the bladder without the need for a cystoscope and appears to be feasible. Further research is needed to understand the pathophysiology of IC/BPS and symptom overlap with OAB, which in turn should enable the development of more personalized therapeutics.