Navigation/Care Coordination

Navigation/Care Coordination

PEP Topic 
Anxiety
Description 

Patient navigation in the cancer care setting is defined by ONS, the Association of Oncology Social Work, and the National Association of Social Workers as individualized assistance offered to patients, families, and caregivers to help overcome healthcare system barriers and facilitate timely access to quality health and psychosocial care from prediagnosis through all phases of the cancer experience.

Effectiveness Not Established

Research Evidence Summaries

Ferrante, J.M., Chen, P.H., & Kim, S. (2008). The effect of patient navigation on time to diagnosis, anxiety, and satisfaction in urban minority women with abnormal mammograms: A randomized controlled trial. Journal of Urban Health, 85, 114–124.

doi: 10.1007/s11524-007-9228-9
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Study Purpose:

To examine the effectiveness of a patient navigator after a suspicious mammogram in urban minority women in improving the time to diagnosis, decreasing anxiety, and increasing satisfaction

Intervention Characteristics/Basic Study Process:

Women with suspicious mammogram findings were identified from radiology logs and contacted to participate. Women were told that the hospital was conducting a study to better understand their experience, in order to blind participants. Patients were randomly assigned to control/usual care or usual care plus patient navigation (intervention group). The navigator provided patients with emotional and social support, helped make appointments and arrive for appointments, facilitated financial assistance applications, provided information on resources and support systems, and facilitated interaction with healthcare providers and staff. The navigator had a bachelor’s degree in social relations and previous experience in counseling and community outreach, and was previously a volunteer for a breast cancer support group. The navigator underwent additional training and had ongoing mentoring with an oncology social worker. Study instruments were administered at the time of study enrollment and one month after resolution—either determination of benign diagnosis or initiation of cancer treatment.

Sample Characteristics:

  • The study reported on a sample of 105 female patients: 55 in the intervention group and 50 in the control group.
  • Mean patient age was 50.1 years ± 11.6.
  • Patients had suspicious mammography findings: 15 in the intervention group and 11 in the control group were diagnosed with cancer.
  • Of the sample, 60% had no insurance, 59% were black, 28% were Hispanic, 32% were married, 76% had a high school education or less, 63% did not have a previous abnormal mammogram, 81% had no family history of breast cancer, and 52% had no regular source of primary care.

Setting:

  • Single site
  • Outpatient setting
  • Urban university hospital in Newark, NJ

Phase of Care and Clinical Applications:

Patients were undergoing the diagnostic phase of care.

Study Design:

A randomized, single-blind, controlled trial design was used.

Measurement Instruments/Methods:

  • Zung Anxiety Self-Assessment Scale
  • Satisfaction With Hospital Care Questionnaire

Results:

Women in the intervention group had a shorter time to diagnosis (p = 0.001). Women in the intervention group had significantly lower anxiety at follow-up (p < 0.001) and a significantly greater reduction in anxiety from baseline to follow-up (p < 0.001). Baseline anxiety scores were similar in both groups. While anxiety declined in the intervention group, in the control group, anxiety scores were increased at follow-up compared to baseline. Satisfaction scores were significantly higher in the intervention group (p < 0.001). There were no differences between groups in demographic findings, and results indicated that effectiveness of the intervention did not differ associated with demographic characteristics. The mean time to diagnosis was 14.3 days in the intervention group, compared to 33.9 days in the control group.

Conclusions:

The use of a patient navigator was effective to improve timeliness of diagnosis, reduce anxiety, and increase satisfaction in this group of patients.

Limitations:

  • The study excluded a high proportion of the potential study population who did not speak English, since the navigator did not speak a foreign language.
  • Subgroup analysis based on ethnicity and other factors may not have detected differences due to the small sample sizes in these subgroups.
  • There was an overall low enrollment rate (36%) of the eligible population; this suggests that findings may be biased by self-selection of the study participants.
  • There was no ability to compare study results to those in the general population who did not participate.

Nursing Implications:

Findings show that patient navigation is an effective strategy to improve timeliness of diagnosis, anxiety, and satisfaction in a group of poor urban minority patients. Findings also show that many of these types of patients refused to participate, suggesting predominance of issues such as mistrust in this population. This suggests that assistance to this group of patients remains a challenge. Future research in this area needs to incorporate mechanisms to study those patients who also do not speak English. Larger sample sizes in this area of research are needed to further examine differences in outcomes based on demographic characteristic of potential relevance.

Skrutkowski, M., Saucier, A., Eades, M., Swidzinski, M., Ritchie, J., Marchionni, C., & Ladouceur, M. (2008). Impact of a pivot nurse in oncology on patients with lung or breast cancer: Symptom distress, fatigue, quality of life, and use of healthcare resources. Oncology Nursing Forum, 35, 948–954.

doi: 10.1188/08.ONF.948-954
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Study Purpose:

To determine whether patients followed by a pivot nurse/nurse coordinator would have less symptom distress and less healthcare resource utilization as evidenced by fewer unscheduled clinic visits, fewer emergency room visits, and hospitalizations than a control group

Intervention Characteristics/Basic Study Process:

Patients were randomly assigned to a pivot nurse in addition to usual care (experimental group) or usual care only. The pivot nurse (PNO) was a baccalaureate-prepared palliative care nurse with experience and additional training in cancer symptom management. The PNO met with patients and caregivers in the ambulatory setting to review understanding of the diagnosis, expected side effects of treatment, and resources available to the patient. Patients were taught ways to identify and cope with systems and offered education and support as needed. The PNO advocated for patients in interdisciplinary rounds, developed care plans and referrals, and provided support, information, coaching, etc., via follow-up telephone calls. Usual care included symptom assessment and teaching for management, but not in a formally coordinated manner. With usual care, patients did not necessarily see the same nurse at each appointment, and telephone follow-up was usually patient initiated. The study was conducted over a six-month period. Data were collected at each clinic visit, about every three weeks, for a maximum of eight measurements.

Sample Characteristics:

  • The study reported on a total sample of 113 patients.
  • Mean patient age in the control group was 60.5 years ± 11.1; mean patient age in the experimental group was 59.3 years ± 10.7.
  • Patients were diagnosed with breast or lung cancer.
  • The sample was 67%–71% female and 29%–33% male.
  • Of the total sample, 67%–72% were married; 36% in the control group and 51% in the experimental group had stage III or IV cancer, and 19% in the control group and 23% in the experimental group had metastatic disease; 75%–83% were deemed as having adequate financial resources; and more than 70% in both groups had sufficient help at home.

Setting:

  • Outpatient setting
  • Canada

Phase of Care and Clinical Applications:

Patients were undergoing the active treatment phase of care.

Study Design:

A randomized controlled trial design was used.

Measurement Instruments/Methods:

  • McCorkle Symptom Distress Scale (SDS)
  • Functional Assessment of Cancer Therapy Scale–General (FACT-G), version 4
  • Brief Fatigue Inventory (BFI)
  • Hospital records

Results:

There were no differences in SDS scores over time between groups. Over time, patients in the lung cancer groups had more distress than patients with breast cancer (p = 0.023). There were no significant differences between groups for BFI findings. Patients with lung cancer reported more fatigue (p = 0.002). There were no differences between groups in FACT scores. Significantly lower quality-of-life score were reported by patients with lung cancer (p = 0.0024). There were no differences between groups in healthcare resource utilization data included in this study. Over time, patients with breast cancer were less likely to have hospitalizations shorter than 72 hours than those with lung cancer (p = 0.001).

Conclusions:

Care provided by a PNO did not result in any difference in symptom distress or healthcare resource utilization. Patients with lung cancer had higher symptom distress, had more fatigue, and used more healthcare resources, which is in concert with differences in the disease trajectories between lung and breast cancer.

Limitations:

A higher proportion of patients in the intervention group had presence of metastases, and a slightly higher proportion had disease recurrence. It was not stated whether these differences were statistically significant, and these differences could have influenced results in terms of symptoms and resource usage needs. No information was provided in terms of any other chronic healthcare conditions that may have also influenced the results. Authors reported overall SDS results but did not identify actual symptoms experienced or differences at that level between groups. Clinically, different symptoms can be expected to yield different degrees of distress and needs for medical intervention and associated healthcare use. The authors reported a final sample of 113 and results in these, but provided baseline characteristics in 190 patients. One cannot evaluate actual final differences between groups in these characteristics. No power analysis was provided in order to determine if the sample size had sufficient power to detect differences. The study assumes that all practitioners in a given role should be expected to achieve standard results, while this may not be the case. The PNO in this study was not an advanced practice nurse, with associated advanced education. Nurses in the usual care group were highly experienced, and more than 75% were oncology certified. This factor may have caused there to be no substantial clinical difference in the actual nursing care provided for symptom management. The study only lasted six months—effect of better care coordination and symptom management may be more effective over a longer term. No information was provided regarding the time since diagnosis or the phase of care for patients studied, factors that could be expected to influence these aspects of care and patient needs.

Nursing Implications:

This study did not provide any supportive findings for the role of a PNO as implemented in the study. Further research in this area needs to provide the ability to directly contrast this type of intervention with the nursing care provided in usual care. Research in the impact of various roles such as this, navigators, clinical nurse specialists, etc., need to provide better structure, consistency, and definition of these responsibilities and patient interactions. Inclusion of findings related to patient satisfaction with care in this type of research may be helpful.


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