The cost of implementing a 2-1-1 call center-based cancer control navigator program
Introduction
The Federal Communications Commission (FCC) assigned the 2-1-1 telephone code for accessing community information and referral services. Referral services provided by 2-1-1 traditionally focused on basic needs, such as employment opportunity, food assistance, aging parent assistance, addiction prevention, and affordable housing assistance. Capitalizing on the existing 2-1-1 infrastructure, the 2-1-1 cancer prevention and control referral and navigation program was developed with evidence-based strategies for reducing the morbidity and mortality from breast, cervical and colorectal cancer in Texas. The program expanded referral services to include proactive screening of 2-1-1 callers’ unmet needs for cancer prevention and control services, and thereby addressed the FCC's original objectives to ensure the greatest public use of the 2-1-1 centers (What We Do, 2012).
The theoretical basis for the intervention development was guided by cognitive and psychosocial constructs identified in Fishbein et al.’s (Fishbein, 2008) integrated theoretical model. The patient navigation intervention also uses an evidence-based approach to behavior change entitled Motivation and Problem Solving (MAPS) (Vidrine et al., 2011). MAPS integrates two empirically validated approaches (motivational interviewing and problem solving) into a coordinated and comprehensive intervention (Miller & Rollnick, 2002). Telephone-based navigation provides ongoing logistic and personalized support to help callers overcome barriers to achieving basic needs, such as accessing health services. A state-wide randomized study documented the feasibility and referral contact effectiveness of providing cancer control and prevention services by 2-1-1 call centers. The most intensive strategy included a navigation component and demonstrated a larger referral contact rate at 1 month post intervention (34%) than the standard verbal referral plus tailored mailed reminder (24%) or verbal referral only (18%) (Kreuter et al., 2012). Studies have not provided evidence of cancer service completion caused by 2-1-1 call center cancer control interventions. Previous randomized studies have shown that telephone interventions can change callers’ use of mammography (Williams-Piehota et al., 2006, Williams-Piehota et al., 2005) and colorectal cancer screening (Jandorf et al., 2005, Lasser et al., 2009, Marcus et al., 2005).
Given the extensive network and the exceptional volume growth rate in the 2-1-1 call centers in the last decade (Vidrine et al., 2011), integrating the cancer promotion and navigation program with 2-1-1 services could reach a larger disadvantaged population than is currently feasible with existing cancer control methods. A majority of the 2-1-1 calls are from disproportionately low income or minority groups which suffer cancer prevention and treatment disparities (Eddens & Kreuter, 2011). The embedded 2-1-1 cancer prevention program includes a cancer risk assessment to understand the callers’ cancer screening or prevention needs, education about cancer screening or prevention, and referrals to affordable and accessible services. This cancer prevention program therefore responds to the Texas Cancer Plan's call for developing efforts to identify and reduce barriers to prevention services at a community level, particularly among diverse and medically underserved populations (Andersen et al., 2012).
The aim of the study was to determine the incremental annual total and per participant cost of implementing and maintaining a 2-1-1 call center-based cancer control navigator program in metropolitan areas, and to examine the cost of providing navigation to services in addition to the basic cancer screening and referral information. Other aims were to examine components of cost and the effects of scale of operations. Our study provides important cost information for program evaluators, planners and funding agencies. This study was the first step in a full economic evaluation of this innovative strategy for increasing cancer screening in low income and minority communities.
Section snippets
Trial and interventions
This cost study was conducted concurrent to a community based randomized trial of the 2-1-1 call center cancer control program. A primary aim of this ongoing trial was to assess effectiveness of the cancer control navigation (CCN) compared with a 2-1-1 cancer control referral-only (usual care). Call centers in Houston and Weslaco, TX, were selected to implement the cancer control navigator programs. Inclusion criteria for the study were 18–75 years of age, speak English or Spanish, not be in a
Participants
The demographic information of participants is shown in Table 1. Female callers represented 90% of the program participants. Hispanic or Latino participants were 41%. The study population also included 66% with high school degree or lower education and 77% with household income lower than $20,000. About 6% of the participants refused to give information on household income and less than 1% of participants refused to answer at least one of the demographic questions. The mean risk assessment time
Discussion
We conducted a cost analysis alongside a randomized trial of a 2-1-1 hotline based cancer control program in two Texas cities. The average cost was $36 per participant who received risk assessment and referral and $295 per participant who received risk assessment, referral, and navigation. About 63% of the cost was for time spent by the program staff, especially the information specialists, and the time the participants engaged in the communication. About 6.4% of the cost was for start-up,
Acknowledgements
This research was funded by the Cancer Prevention Research Institute of Texas (CPRIT, PP100077). The authors would like to thank David Jobe and David Smith from United Way of Greater Houston 2-1-1 Helpline Program, and Abby Torre from the 2-1-1 Weslaco Helpline Program for their help and support. We also appreciate the dedicated assistance of the navigators and information specialists.
David R. Lairson, PhD, is a health economist and co-director of the Center for Health Services Research at the University of Texas School of Public Health in Houston, Texas. The major focus of his research is the economic evaluation of preventive services and programs. He is currently directing the economic evaluation components of National Cancer Institute and CDC funded randomized trials of behavioral interventions to increase compliance with mammography, colorectal cancer, and cervical
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David R. Lairson, PhD, is a health economist and co-director of the Center for Health Services Research at the University of Texas School of Public Health in Houston, Texas. The major focus of his research is the economic evaluation of preventive services and programs. He is currently directing the economic evaluation components of National Cancer Institute and CDC funded randomized trials of behavioral interventions to increase compliance with mammography, colorectal cancer, and cervical cancer screening guidelines. He is co-author of Evaluating the healthcare system: Effectiveness, efficiency, and equity, 4th edition, Health Administration Press, 2013.
Jinhai Huo, MD, MPH, is a PhD candidate in the Division of Management, Policy and Community Health at the University of Texas School of Public Health in Houston, Texas. His research interests are in comparative effectiveness, cost-effectiveness and health disparities in cancer prevention and treatment. He has provided research support to projects that employed randomized trial designs to determine the cost-effectiveness of programs promoting prevention of breast, cervical, and colorectal cancers. His dissertation focuses on the clinical and economic evaluation of end-of-life care for patients with metastatic cancer.
Katharine A. Ball Ricks, PhD, is a project manager at the University of Texas School of Public Health in Houston, Texas. The major focus of her work has been with low-income and rural families, nutrition, smoking cessation and cancer prevention.
Lara Savas, PhD, is an assistant professor of Health Promotion and Behavioral Sciences at the University of Texas School of Public Health in Houston, Texas. Her area of expertise is in epidemiology and cancer prevention and control, and intervention research. Dr. Savas's primary interests include health and healthcare disparities in racial and ethnic minorities and economically disadvantaged populations.
María E. Fernández, PhD, is an associate professor of Health Promotion and Behavioral Sciences at the University of Texas School of Public Health in Houston, Texas. The major focus of her research is on cancer prevention and control among low-income and minority populations, the application of advanced health communication technology to health promotion, and dissemination and implementation research. She has extensive experience developing, implementing and evaluating cancer control interventions for Hispanic populations including farm workers and other Texas Mexico Border Hispanics. She has worked extensively with community and state partners to increase use of evidence-based cancer control programs through training and technical assistance.