Navigation Services Contribute to Improved Oncology Care at Reduced Cost

Orlando, FL—With advances in cancer treatment, patients face increasingly more complex treatment and follow-up decisions that require efficient coordination within the health care system to optimize outcomes. To facilitate this need, patient navigation services that include nurse navigators have recenlty emerged.  

Since the first patient navigation program was initiated at Harlem Hospital Cancer Center in New York City in 1990, several milestones have been reached, making these programs an essential part of the fabric of oncology care. Among them are the Patient Protection and Affordable Care Act, which contained provisions for a patient navigator program. This was followed by the American College of Surgeons issuing revised standards in 2012 that require a patient navigation process as part of its focus on patient-centered care.

To better understand the role and impact of these programs, a number of studies looked at clinical and economic outcomes. Sheryl Riley, RN, director, clinical services, SAI Systems, provided an overview of the role of navigators and the results of these studies during a session on the impact of nurse navigators on oncology outcomes at the NAMCP forum.

The role of nurse navigators is to provide support and guidance to those with an abnormal cancer screening or a new cancer diagnosis in accessing the cancer care system; overcoming barriers; and facilitating timely, quality care. Important to this role is targeting individuals who are at high risk for delays in care, including ethnic and racial minorities and low-income populations. 

Ms Riley described a number of studies examining the impact of nurse navigators on cancer care outcomes. One multicenter, 5-year study that included over 10,000 individuals from 9 community program sites across the United States who had an abnormal screening test for breast, cervical, colorectal, or prostate cancer, found that a patient navigation program provided a moderate benefit in improving timely cancer care. The study, conducted by the Patient Navigation Research Program and sponsored by the National Cancer Institute Center to Reduce Cancer Health Disparities, showed that most patients with a diagnosis of cancer or pre-cancer were from a racial or ethnic minority (73%) and received public insurance (40%) or were uninsured (31%). As such, the study suggested that patient navigation should be adopted in settings that serve populations at risk of being lost to follow-up.

Additional studies support the use of patient navigators, particularly in underserved populations. Although these studies have shown that patient navigation programs improve screening, timeliness to care, and treatment and follow-up, Ms Riley emphasized that these past studies failed to come up with a universal tool or process to prove the clinical value of nurse navigators or their cost because they use many different endpoints to measure success and, therefore, their validity is questionable.

Although cultural competence is a key feature of most current patient navigator programs that focus primarily on a racial or ethnic minority or low-income patients, Ms Riley stressed that “nurse navigation has many faces and is a valued service for all patients, not just those underinsured or of lower socioeconomic background.”

More recent studies, she said, are showing that the addition of coordination with navigation is the key to improved cost savings and clinical metrics. She
described gaps in care when coordination is lacking during complex phases of cancer care that leads to missed opportunities and creates serious consequences. For example, a lack of coordination in terms of diagnosis can create a gap in referrals not being made that can lead to patients seeking care elsewhere and delays in treatment. Gaps in treatment, including lack of patient compliance and missed accrual into clinical trials, can lead to patients missing neoadjuvant treatment opportunities and subsequent inferior outcomes. When nurse navigators help to coordinate services, including imaging, treatment, ancillary services, and supportive care, both physicians and patients benefit (Table).

Citing data from a study that looked at changes in health care services and cost in cancer disease management after 12 months of incorporating a program that included navigation and coordination, Ms Riley showed that hospital admissions due to pain decreased by 36%, readmissions decreased by 24%, and drug costs for supportive care decreased by 54%, while hospice use increased by 47%. The average annual cost per cancer patient was reduced by 34% due to decreased emergency room visits, reductions in inappropriate admissions and readmissions, use of standardized treatment protocols, effective therapy management, reduction in duplicate testing, and increased use of hospice care.

“By adding coordination of services, appointments, screening, labs, primary care, and follow-up, you are bringing together all the pieces of the puzzle and improving the experience for all stakeholders,” Ms Riley said. She also stated that navigation and education alone can only bring you so far.

The evidence to date shows that patient navigation reduces health care disparities for the underserved population, reduces the time from screening to diagnosis, and alters the economic cost of the natural history of disease process through early detection and timely treatment.

“The next step is to work to create a validated tool to measure the success of the [navigation] programs,” Ms Riley said. To date, she said that government and private funding have helped to add patient navigation services to hospitals around the country and that by 2015, cancer centers will be required to offer patient navigation services to meet accreditation requirements.—Mary Beth Nierengarten