Nurse Navigators Improve Patient-Reported Quality of Care in Early Cancer Care
In a study reported in the Journal of Clinical Oncology, Wagner et al assessed whether a nurse navigator intervention improved quality of life or patient experience with care in patients who recently received a diagnosis of breast, colorectal, or lung cancer. Although no differences in reported quality of life were observed between the nurse navigator intervention and enhanced usual care, patients receiving nurse navigator support reported significantly greater quality of care and significantly fewer problems with care.
Study Details
The trial was conducted in the Seattle and Bellevue service areas of Group Health, an integrated, nonprofit delivery system in Washington and Northern Idaho. In the study, 251 patients with recently diagnosed primary breast, colorectal, or lung cancer received either enhanced usual care (n = 118) or nurse navigator support for 4 months (n = 133), with primary care physicians as the units of randomization. The nurse navigator intervention was intended to create a trusting relationship between the patient and nurse, who served as patient advocate and source of support.
Three registered nurses devoted 20% of their time to the intervention and managed an average of eight patients at a time. Nurses initially contacted patients within 24 hours of their enrollment, usually within 2 weeks of diagnosis. They identified problems and monitored patient progress in weekly nurse-initiated telephone calls, collaborated with distressed patients to develop goals and action plans, and attempted to meet each patient at least once. Patients had an average of 18 interactions with the nurse navigator during the study. The nurses generally discharged patients at the end of 16 weeks, when most patients were involved in active cancer treatment. Enhanced usual care included more-tailored patient education.
Patient-reported measures included the Functional Assessment of Cancer Therapy-General (FACT-G) scale and Patient Health Questionnaire-9 (PHQ-9) survey to measure quality of life and depressive symptoms and three subscales of the Patient Assessment of Chronic Illness Care (PACIC) and selected subscales from a cancer adaptation of the Picker Institute’s patient experience survey to measure quality of care and problems in care. Patient reports were collected at baseline, 4 months, and 12 months.
For the nurse intervention and control groups, mean age was 64 and 60 years, 86% and 91% were female, 85% and 80% were white, 74% and 77% had a diagnosis of breast cancer, 69% in both were married or living with partner, and 19% and 22% were living alone. The nurse navigator group had significantly higher education attainment (42% vs 20% college graduates, 20.5% vs 23.7% with postgraduate degree; P = .003 for trend), and patients in the control group had borderline significantly worse Charlson comorbidity scores (2 in 8% vs 13%, ≥ 3 in 2.5% vs 8%; P = .06 for trend).
Outcomes
FACT-G total and subscale scores increased from baseline at 4 months and 12 months in both groups, with no significant differences between groups being observed. No differences between groups were observed in changes in PHQ-9 scores.
The summary PACIC score and all subscale scores were higher in the nurse navigator group at 4 months and 12 months, with differences in the summary scores (adjusted β = 0.3, 95% confidence interval [CI] = 0.02–0.6, at 4 months; β = 0.3, 95% CI = 0.01–0.5, at 12 months) and problem-solving/contextual subscale scores (β = 0.4, 95% CI = 0.04–0.7, at 4 months; β = 0.3, 95% CI = 0.03–0.6, at 12 months) being significant at both time points.
Picker survey coordination of care, confidence in providers, treatment information, health information, access to cancer care, and psychosocial care subscales were assessed at 4 months, and the coordination of care, confidence in providers, and psychosocial care subscales were assessed at 12 months. Patients in the nurse navigator group were significantly less likely to report problems with coordination of care (β = −7.0, 95% CI = −13.0 to −1.0), health information (β = −11.7, 95% CI = −20.2 to −3.1), and psychosocial care (β = −10.0, 95% CI = −16.8 to −3.2) at 4 months and psychosocial care (β = −9.2, 95% CI = −15.9 to −2.5) at 12 months.
Cumulative costs after diagnosis did not differ significantly between groups. Lung cancer costs were $6,852 less in the nurse navigator group.
The investigators noted that nurse navigator support “improved patient experience and reduced problems related to psychosocial support, care coordination, and obtaining information.” In addition, “patients reported feeling better supported emotionally, more involved in their care, better able to plan ahead, and better informed.” These positive effects were evident at 4 months and again at 12 months and continued for 8 months after the last contact, suggesting that nurse navigator involvement has a long-lasting effect.
“[Nurse navigator support] appeared to help patients develop the confidence and skills to more effectively manage their illness and its treatment. Further research will be needed to clarify how well nurse navigation works in more typical, fragmented care systems, and whether it can reduce the costs of cancer care,” they wrote.
The investigators concluded, “Compared with enhanced usual care, nurse navigator support for patients with cancer early in their course improves patient experience and reduces problems in care, but did not differentially affect quality of life.”
Edward H. Wagner, MD, MPH, Group Health Research Institute in Seattle, is the corresponding author for the Journal of Clinical Oncology article.
The study was supported by a grant from the National Cancer Institute. Study author Robert J. Reid, MD, PhD, reported an employment or leadership position and stock ownership with Group Health Physicians.
The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.
