ACRIN Fall meeting 10-2009 Minority Recruitment in the NLST Catherine Duda, MPHIrene Mahon, RN, MPH...

ACRIN Fall meeting 10-2009

Minority Recruitment in the NLST

Catherine Duda, MPH Irene Mahon, RN, MPH

Mei Hsiu Chen, PhD Bradley Snyder, MS

Richard Barr, MD PhD Caroline Chiles, MD

Robert Falk, MD Elliott Fishman, MD

David Gemmel, PhD Jonathan G. Goldin, MD PhD

Reginald Munden, MD Kay Vydaryny, MD

Kathy Brown, MD Denise R. Aberle, MD



the problem

• Limited minority participation in prevention research• Impact:

– Generalizability | health care delivery– Equitably distribute risks and benefits of clinical trials

• Barriers– Lack of awareness of clinical trials– Lack of opportunity– Barriers of opportunity


NLST ACRIN objectives

• Measure effects of targeted strategies on accruing underrepresented groups

• Characterize participant characteristics as result of strategies

• Estimate the costs of targeted enrollment


methods

• Estimate proportions of racial/ethnic categories– Tobacco Use Supplement of the 1998-99 population survey– Proportions: 91.7% White, 6.3% African American,1.0% Asian,

1.0% American Indian/Alaskan native, 3.4% Hispanic


methods

• Estimate proportions of racial/ethnic categories– Tobacco Use Supplement of the 1998-99 population survey– Proportions: 91.7% White, 6.3% African American,1.0% Asian,

1.0% American Indian/Alaskan native, 3.4% Hispanic

• Site selection criteria– Situated in cultural diverse settings: UC Census Bureau– Target recruitment strategies already implemented– Proven success in accruing minority populations


methods - planning

• Strategic planning began March 2003 (month 7)

• Initial meeting: ACS, NCI, NCI OC, ACRIN leadership

• NLST ACRIN trial-wide conference calls– Introduce the minority recruitment plan– Review barriers | potential solutions

• Sites asked to submit recruitment plan with budget

• Supplemental funding was requested, not guaranteed

• 6 sites (1 site later participated)

Institution Location Population of Interest

Emory University Atlanta, GA African American

Jewish Heart and Lung Louisville, KY African American

Johns Hopkins University Baltimore, MD African American

M.D. Anderson Cancer Center Houston, TX Hispanic

St. Elizabeth’s Health System 1 Youngstown, OH African American

UCLA Jonsson Cancer Center Los Angeles, CA African American, Hispanic, Asian

Wake Forest University Winston-Salem, NC African American

1 St. Elizabeth’s Health System was not initially an accruing NLST-ACRIN institution, but later submitted a plan.

NLST-ACRIN minority institutions

Race | EthnicityMinority Sites

N (%)

Remaining Sites

N (%)

Total

N (%)

African American 895 (82%) 193 (18%) 1088 (100%)

Asian 81 (74%) 29 (26%) 110 (100%)

Hispanic / Latino 163 (67%) 82 (33%) 245 (100%)

> 1 race 70 (71%) 28 (29%) 98 (100%)

Total 1209 (78%) 332 (22%) 1541 (100%)

results: summary minority accrual

EmoryJewish

Heart and Lung

Johns Hopkins

MDASt

Elizabeth’s

UCLAWake Forest

All Minority Sites

All other Institutions

Total

Race N (%)

AA175

(14.3%)87

(4.4%)406

(24.3%)56

(7.1%)39

(3.7%)99

(6.3%)33

(3.0%)895

(9.5%)193

(2.0%)1088 (5.8%)

Asian1

(0.1%)5

(0.3%)5

(0.3%)4

(0.5%)5

(0.5%)57

(3.6%)4

(0.4%)81

(0.9%)29

(0.3%)110

(0.6%)

White1048

(85.3%)1876

(95.0%)1253

(74.9%)675

(86.0%)988

(94.5%)1349

(85.5%)1061

(95.8%)8250

(87.8%)9157

(96.9%)17407

(92.4%)

> 1 Race0

(0.0%)2

(0.1%)2

(0.1%)21

(2.7%)7

(0.7%)35

2.2%)3

(0.3%)70

(0.7%)28

(0.3%)98

(0.5%)

Ethnicity 1 N (%)

Hispanic11

(0.9%)10

(0.5%)8

(0.5%)40

(5.1%)22

(2.1%)67

(4.2%)5

(0.5%)163

(1.7%)82

(0.9%)245

(1.3%)

Non Hispanic

1216 (99.0%)

1960 (99.3%)

1665 (99.5%)

744 (94.8%)

1022 (97.7%)

1483 (94.0%)

1102 (99.5%)

9192 (97.9%)

9357 (99.0%)

18549 (98.4%)

Total1228

(100%)1974

(100%)1673

(100%)785

(100%)1046

(100%)1578

(100%)1108

(100%)9392

(100%)9450

(100%)18842 (100%)

results: site-specific accruals

EmoryJewish

Heart and Lung

Johns Hopkins

MDASt

Elizabeth’s

UCLAWake Forest

All Minority Sites

All other Institutions

Total

Race N (%)

AA175

(14.3%)87

(4.4%)406

(24.3%)56

(7.1%)39

(3.7%)99

(6.3%)33

(3.0%)895

(9.5%)193

(2.0%)1088 (5.8%)

Asian1

(0.1%)5

(0.3%)5

(0.3%)4

(0.5%)5

(0.5%)57

(3.6%)4

(0.4%)81

(0.9%)29

(0.3%)110

(0.6%)

White1048

(85.3%)1876

(95.0%)1253

(74.9%)675

(86.0%)988

(94.5%)1349

(85.5%)1061

(95.8%)8250

(87.8%)9157

(96.9%)17407

(92.4%)

> 1 Race0

(0.0%)2

(0.1%)2

(0.1%)21

(2.7%)7

(0.7%)35

2.2%)3

(0.3%)70

(0.7%)28

(0.3%)98

(0.5%)

Ethnicity 1 N (%)

Hispanic11

(0.9%)10

(0.5%)8

(0.5%)40

(5.1%)22

(2.1%)67

(4.2%)5

(0.5%)163

(1.7%)82

(0.9%)245

(1.3%)

Non Hispanic

1216 (99.0%)

1960 (99.3%)

1665 (99.5%)

744 (94.8%)

1022 (97.7%)

1483 (94.0%)

1102 (99.5%)

9192 (97.9%)

9357 (99.0%)

18549 (98.4%)

Total1228

(100%)1974

(100%)1673

(100%)785

(100%)1046

(100%)1578

(100%)1108

(100%)9392

(100%)9450

(100%)18842 (100%)

results: racial | ethnic characteristics

FeatureMinority

InstitutionNon-Minority

InstitutionTotal

Age at study consent

Median 61 61 61

Range 1 (55 - 74) (55 - 74) (55 - 74)

Smoking Status

Current smokers (%) 5052 (53.8%) 4463 (47.2%) 9515 (50.5%)

Former smokers (%) 4340 (46.2%) 4987 (52.8%) 9327 (49.5%)

Sex

Female 4020 (42.8%) 4417 (46.7%) 8437 (44.8%)

Male 5372 (57.2%) 5033 (53.3%) 1 10405 (55.2%)1 P < 0.001

results: age, smoking characteristics, sex

Minority Sites (N = 7) Other Sites (N = 16)

MinorityWhite Non-Hispanic 1 Total Minority

White Non-Hispanic 1 Total

Education N (%)Less than high school 217 (17.8%) 567 (6.9%) 784 (8.3%) 42 (11.9%) 423 (4.7%) 465 (4.9%)

High school graduate or GED 313 (25.6%) 1855 (22.7%) 2169 (23.1%) 71 (20.1%) 2106 (23.2%) 2178 (23.0%)

Post-high school:technology school, associate degree, some college

389 (31.8%) 2804 (34.4%) 3194 (34.0%) 121 (34.2%) 3141 (34.5%) 3264 (34.5%)

Bachelor’s degree 136 (11.1%) 1446 (17.7%) 1584 (16.9%) 43 (12.1%) 1565 (17.2%) 1608 (17.0%)

Graduate or professional school

133 (10.9%) 1277 (15.6%) 1412 (15.0%) 66 (18.6%) 1601 (17.6%) 1667 (17.6%)

Household income N (%)< $15,000 363 (29.7%) 776 (9.5%) 1139 (12.1%) 59 (16.7%) 621 (6.8%) 680 (7.2%)

$15,000 – $34,999 293 (24.0%) 1768 (21.7%) 2062 (22.0%) 84 (23.7%) 1917 (21.1%) 2001 (21.2%)

$35,000 - $64,999 223 (18.2%) 2268 (27.8%) 2492 (26.5%) 89 (25.1%) 2737 (30.1%) 2828 (29.9%)

$65,000 - $100,000 122 (10.0%) 1396 (17.1%) 1518 (16.2%) 42 (11.9%) 1700 (18.7%) 1742 (18.4%)

> $100,000 64 (5.2%) 892 (10.9%) 958 (10.2%) 28 (7.9%) 1001 (11.0%) 1029 (10.9%)

results: education | income







389 (31.8%) 2804 (34.4%) 3194 (34.0%) 121 (34.2%) 3141 (34.5%) 3264 (34.5%)



133 (10.9%) 1277 (15.6%) 1412 (15.0%) 66 (18.6%) 1601 (17.6%) 1667 (17.6%)


$15,000 – $34,999 293 (24.0%) 1768 (21.7%) 2062 (22.0%) 84 (23.7%) 1917 (21.1%) 2001 (21.2%)

$35,000 - $64,999 223 (18.2%) 2268 (27.8%) 2492 (26.5%) 89 (25.1%) 2737 (30.1%) 2828 (29.9%)

$65,000 - $100,000 122 (10.0%) 1396 (17.1%) 1518 (16.2%) 42 (11.9%) 1700 (18.7%) 1742 (18.4%)

> $100,000 64 (5.2%) 892 (10.9%) 958 (10.2%) 28 (7.9%) 1001 (11.0%) 1029 (10.9%)








389 (31.8%) 2804 (34.4%) 3194 (34.0%) 121 (34.2%) 3141 (34.5%) 3264 (34.5%)



133 (10.9%) 1277 (15.6%) 1412 (15.0%) 66 (18.6%) 1601 (17.6%) 1667 (17.6%)


$15,000 – $34,999 293 (24.0%) 1768 (21.7%) 2062 (22.0%) 84 (23.7%) 1917 (21.1%) 2001 (21.2%)

$35,000 - $64,999 223 (18.2%) 2268 (27.8%) 2492 (26.5%) 89 (25.1%) 2737 (30.1%) 2828 (29.9%)

$65,000 - $100,000 122 (10.0%) 1396 (17.1%) 1518 (16.2%) 42 (11.9%) 1700 (18.7%) 1742 (18.4%)

> $100,000 64 (5.2%) 892 (10.9%) 958 (10.2%) 28 (7.9%) 1001 (11.0%) 1029 (10.9%)








389 (31.8%) 2804 (34.4%) 3194 (34.0%) 121 (34.2%) 3141 (34.5%) 3264 (34.5%)



133 (10.9%) 1277 (15.6%) 1412 (15.0%) 66 (18.6%) 1601 (17.6%) 1667 (17.6%)


$15,000 – $34,999 293 (24.0%) 1768 (21.7%) 2062 (22.0%) 84 (23.7%) 1917 (21.1%) 2001 (21.2%)

$35,000 - $64,999 223 (18.2%) 2268 (27.8%) 2492 (26.5%) 89 (25.1%) 2737 (30.1%) 2828 (29.9%)

$65,000 - $100,000 122 (10.0%) 1396 (17.1%) 1518 (16.2%) 42 (11.9%) 1700 (18.7%) 1742 (18.4%)

> $100,000 64 (5.2%) 892 (10.9%) 958 (10.2%) 28 (7.9%) 1001 (11.0%) 1029 (10.9%)








389 (31.8%) 2804 (34.4%) 3194 (34.0%) 121 (34.2%) 3141 (34.5%) 3264 (34.5%)



133 (10.9%) 1277 (15.6%) 1412 (15.0%) 66 (18.6%) 1601 (17.6%) 1667 (17.6%)


$15,000 – $34,999 293 (24.0%) 1768 (21.7%) 2062 (22.0%) 84 (23.7%) 1917 (21.1%) 2001 (21.2%)

$35,000 - $64,999 223 (18.2%) 2268 (27.8%) 2492 (26.5%) 89 (25.1%) 2737 (30.1%) 2828 (29.9%)

$65,000 - $100,000 122 (10.0%) 1396 (17.1%) 1518 (16.2%) 42 (11.9%) 1700 (18.7%) 1742 (18.4%)

> $100,000 64 (5.2%) 892 (10.9%) 958 (10.2%) 28 (7.9%) 1001 (11.0%) 1029 (10.9%)



Minority Participants

White | Non-Hispanic 1 Total

Minority Participants

White | Non-Hispanic 1 Total

Insurance Status N (%)

Private insurance and/or Medicare

859 (70.3%)7158

(87.7%)8024

(85.4%)278 (78.5%)

8218 (90.4%)

8499 (89.9%)

Medicaid 38 (3.1%) 42 (0.5%) 80 (0.9%) 10 (2.8%) 77 (0.8%) 87 (0.9%)

Medicaid and Medicare

35 (2.9%) 54 (0.7%) 89 (0.9%) 13 (3.7%) 83 (0.9%) 96 (1.0%)

Military or Veteran’s Administration

68 (5.6%) 278 (3.4%) 346 (3.7%) 17 (4.8%) 227 (2.5%) 244 (2.6%)

No insurance 191 (15.6%) 514 (6.3%) 706 (7.5%) 26 (7.3%) 341 (3.8%) 367 (3.9%)

Total 1222 (100%) 8162 (100%) 9392 (100%) 354 (100%) 9092 (100%) 9450 (100%)

results: medical insurance

results: enrollment pre- & post implementation

Type of Institution Time Period 1

Minority participant

N (%)

White/Non-Hispanic

N (%)Total

Institutions with Targeted Recruitment Strategies

Pre-Implementation 322 (9.3%) 3153 (90.6%) 3479

Post-Implementation 900 (15.2%) 5009 (84.7%) 5913

Other InstitutionsPre-Implementation 113 (3.6%) 3058 (96.3%) 3174


Total 1576 (8.4%) 17254 (91.6%) 18842

1 Pre-implementation refers to the period on or prior to 5/31/2003


Type of Institution Time Period 1 Minority participant

White/Non-Hispanic

participant 2

Total






Total 1576 (8.4%) 17254 (91.6%) 18842



Type of Institution Time Period 1 Minority participant

White/Non-Hispanic

participant 2

Total






Total 1576 (8.4%) 17254 (91.6%) 18842


results: minority recruitment strategies by site









• A priori accrual goals based on racial/ethnic proportions

• Minority enrollment a factor in site selection

• Recruitment planning well in advance

• Flexibility in eligibility1

• Endorsement by prominent representatives of the racial groups of interest1

1: SELECT: Phase III chemoprevention trial for prostate cancer: N = 35,53422% minorities: 15% AA | 6% Hispanic | 1% Asian

discussion: strategic approaches


































• Awareness– Grass roots education: Churches, clinics/providers, trial champions– Targeted advertising & mailing

• Opportunity– Access: Site hours | transportation | reimburse time & travel– Insurance status: site diagnostic testing | clinic referrals– Trial requirements and duration

• Individual beliefs: barriers of perspective



limitations

• No standard documentation of reasons for non-participation

• Incomplete description of recruitment methods– “Other” and “word of mouth” incorporates

• Grass roots efforts• Dedicated minority staff• Media ads: newspaper ads

• Site experience and organizational structure


conclusions

• Targeted strategies increase racial/ethnic representation

• Sites with targeted strategies accounted for 80% of all minorities enrolled

– Dominated minority accrual pre-implementation– 60% increase in minority accrual post-implementation

• No single strategy effective across all sites

• Costs associated with targeted accrual | highly variable

Date post:	11-Jan-2016
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ACRIN Fall meeting 10-2009 Minority Recruitment in the NLST Catherine Duda, MPHIrene Mahon, RN, MPH...

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