Navigation/Care Coordination

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

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.

• 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.

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

Patients were undergoing the diagnostic phase of care.

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

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

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.

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

• 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.

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.

To evaluate how nurse navigation affected care satisfaction and distress among women who were undergoing breast biopsy. Specifically, were there significant differences in women undergoing breast biopsy with and without nurse navigators?

• N = 137  
• AGE: Range = 18-89 years. Thirty-two percent were aged 50 years or younger; 68% older than age 50
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: Non-pregnant women aged 18 years or older undergoing core needle breast biopsy procedure

• SITE: Multi-site    
• SETTING TYPE: Outpatient    
• LOCATION: Northern Appalachia

• PHASE OF CARE: Diagnostic

• Descriptive, cross-sectional survey

• Demographics were collected via a questionnaire.
• Distress was measured with the Hospital Anxiety and Depression Scale (HADS-A, HADS-D) and the State Trait Anxiety Inventory, State (STAI-S) scale.
• Satisfaction was recorded with the Patient Satisfaction Questionnaire (PSQ-18).

No significant between-group differences were noted in depression. Lower scores were shown for anxiety (significance p < 0.05) among patients who had navigation. There was no difference in overall satisfaction with care though there was an association between satisfaction and distress: that is, women with more satisfaction reported less distress. The population with nurse navigators shows stronger relationship-based characteristics. Significant differences were shown in five categories (accessibility, communication, finances, interpersonal manner, and time) for the navigated population and in two categories (accessibility, general satisfaction) for the non-navigated or usual care population.

Nurse navigation increased satisfaction with care. General satisfaction measured significantly higher in the non-navigated sample when compared to the navigated group. Distress screening followed by interventions of emotional support, education, and facilitating communication between and among providers are roles nurses can fulfill to improve satisfaction outcomes and lower distress levels.

Train nurse navigators in addressing key areas of patient-center interface: accessibility to care, communication among providers, financial support, interpersonal manner, time with care provider, and technical quality. Nurse navigators have knowledge and skill to manage care of women undergoing needle biopsy and, thereby, improve general satisfaction in specific areas.

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

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.

• 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.

• Outpatient setting
• Canada

Patients were undergoing the active treatment phase of care.

A randomized controlled trial design was used.

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

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).

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.

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.

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.

To evaluate feasibility and effectiveness of a brief psychosocial intervention delivered by front-line health professionals as part of a planned stepped integrated care model

Clinical sites were randomized to the intervention or control condition. Those randomized to the intervention received a training manual and had a one-day skill development program focusing on supportive-expressive, CNT, and dignity-conserving strategies. At intervention sites, the level of intervention was determined based on distress thermometer (DT) scores and assigned to trained healthcare providers. Patients with HADS scores of 8-21 received the health provider intervention described, and those with HADS scores of 22 or higher were referred for specialist treatment. Patients were contacted and offered up to four individual sessions by telephone or face to face. Weekly supervision was provided by a psychiatrist in a group setting. Patients completed baseline measurements in clinic visits and follow-up measures were provided via reply paid envelope. A phone reminder was done to encourage completion of follow-up measures. Health professionals who delivered the intervention included oncology nurses, physiotherapists, cancer care coordinators, radiation therapists, and an occupational therapist.

• N = 358   
• AGE: Mean = 58.9 years
• MALES: 29.9%  
• FEMALES: 69.1%
• KEY DISEASE CHARACTERISTICS: Varied tumor types–breast and gynecologic were most prevalent. Seventy-six percent had disease progression.  
• OTHER KEY SAMPLE CHARACTERISTICS: Most were married and not working. Formal education level ranged from less than high school to university education. Patients taking antidepressants were excluded.

• SITE: Multi-site   
• SETTING TYPE: Outpatient    
• LOCATION: Australia

Cluster, randomized, crossover, multi-site design

• Hospital Anxiety and Depression Scale (HADS)
• FACT-General for quality of life
• EQ 5D-5L
• Demoralization scale
• Unmet needs

There were no significant differences in outcome measures between those patients in the intervention or control conditions. In the intervention condition, 112 were allocated to written resources, 115 to the brief intervention, and 18 were allocated to specialist treatment. There were no differences in outcomes in any of these groups. Providers involved in delivering the intervention reported that it was difficult to provide this along with the other demands in daily practice.

The brief intervention delivered by various front-line healthcare professionals was insufficient to effectively manage depression or anxiety. The amount of skill development provided to the mix of providers involved may have been insufficient.

• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)
• Key sample group differences that could influence results
• Measurement/methods not well described
• Intervention expensive, impractical, or training needs
• Subject withdrawals ≥ 10%
• Other limitations/explanation: The timing of follow-up measurement is unclear. The differences in effectiveness according to the provider used for the intervention may be a question. Some of these disciplines have no basic education in psychosocial intervention as part of professional education. Significant education and training for skill development and ongoing clinical supervision are required.

This study did not demonstrate effectiveness of this stepped program and brief intervention by varied healthcare professionals. Other research has shown that nurse-delivered programs can be effective. Many other disciplines do not have the depth of initial education in psychosocial care and may require much more education and training to develop sufficient skill to provide an effective intervention for anxiety and depression.