|Patient navigation: state of the art or is it science?
|Wells K J, Battaglia T A, Dudley D J, Garcia R, Greene A, Calhoun E, Mandelblatt J S, Paskett E D, Raich P C
This review concluded that patient navigation may be associated with improvements in accessing cancer services, but that it was not possible to draw overall conclusions. These conclusions should be interpreted with caution due to the limited literature search, lack of detail on review methods and failure to consider study quality appropriately.
To determine the efficacy of patient navigation in cancer.
MEDLINE via PubMed was searched to October 2007. The review was limited to published or in press English-language studies. Search terms were reported. Reference lists of retrieved articles, and articles published in the same journal issues as the retrieved articles, were screened. Study authors were contacted.
Studies that provided a description of a patient navigator programme related to cancer treatment, diagnosis or screening and that reported outcomes of patient navigator interventions were eligible for inclusion.
Most studies focused on the receipt of cancer diagnostic care and treatment services. Cancer services targeted were breast, cervical, colorectal and prostate cancer. Studies assessed cancer screening and cancer care after the detection of abnormalities. All studies were conducted in the United States or Canada. Study designs included randomised controlled trials (RCTs), prospective comparative studies and prospective and retrospective comparisons of patients before and after the intervention. Interventions included patient navigation with or without co-interventions including health education, counselling, gastrointestinal suite improvement intervention and free cancer screening. Comparison groups included historical controls, non-enrollees, usual care, general health education, traditional cancer education and peer-educator. A wide range of outcomes were reported.
The authors stated neither how the papers were selected for the review nor how many reviewers performed the selection.
Assessment of study quality
The authors did not state that they assessed validity.
The authors stated neither how the data were extracted for the review nor how many reviewers performed the data extraction.
Methods of synthesis
A narrative synthesis was presented.
Results of the review
Sixteen studies (n=19,786, range 29 to 12,804) were included in the review, including seven RCTs.
Improving screening rates (seven studies, five RCTs): The improvement in adherence to screening ranged from 10.8% to 17.1% compared to control groups.
Cancer care after abnormality (10 studies, two RCTs): Patient navigation improved adherence to follow-up visits after the detection of an abnormality compared with control groups (improvements ranged from 21% to 29.2%) and in the timeliness of obtaining care (number of studies unclear).
One study that evaluated patient navigation combined with free cancer screening and culturally sensitive health education reported reduced late-stage cancer diagnosis. Two studies assessed improvements in cancer treatment. One study reported no effect of patient navigation and counselling compared to control in the timeliness of initiating breast cancer treatment. A second study reported that patient navigation and counselling lead to faster initiation of breast cancer treatment than patients randomised to usual care.
Patient navigation may be associated with improvements in screening and diagnostic resolution after screening in certain populations. It was not possible to draw generalisable conclusions regarding the efficacy of patient navigation.
The review addressed a very broad question supported by broadly defined inclusion criteria. The literature search was limited to one electronic database and the review was restricted to published English-language studies. The review may, therefore, have been subject to language and publication biases. Details on the review process were not reported, so it was not possible to determine whether appropriate steps were taken to minimise bias and errors. Study quality was not formally assessed. A narrative synthesis appeared appropriate given the differences between studies in terms of objectives and reported outcomes. However, the synthesis suffered from a number of limitations. Some study details were summarised in the tables, but there was a lack of numerical data on study outcomes that made it difficult to interpret the findings. There were some discrepancies between the text and tables; two studies were included in the tables, but not referred to in the text. More than half the included studies were RCTs, and so less prone to bias and confounding than studies of other designs, but the results from the RCTs were not considered separately. The authors' cautious conclusions appear to be supported by the data presented, but should be interpreted with caution due to the limited literature search, lack of detail on review methods and failure to appropriately consider study quality.
Implications of the review for practice and research
Practice and Research: The authors discussed an ongoing study, the Patient Navigation Research Programme (PNRP), that aims to provide data regarding the efficacy and cost-effectiveness of patient navigation. They stated that a thorough evaluation of thye PNRP study and other scientifically rigorous future programmes was required before continued dissemination of such programmes.
National Cancer Institute, Department of Health and Human Services (U01 CA 117281-01 and R25 CA 090314) and American Cancer Society (SIRSG-05-253-01).
Wells K J, Battaglia T A, Dudley D J, Garcia R, Greene A, Calhoun E, Mandelblatt J S, Paskett E D, Raich P C. Patient navigation: state of the art or is it science? Cancer 2008; 113(8): 1999-2010
Subject indexing assigned by NLM
Delivery of Health Care, Integrated /trends; Health Services Accessibility /trends; Humans; Medically Underserved Area; Neoplasms /diagnosis /therapy
Database entry date
This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.