Review question / Objective

What is the effectiveness of a patient navigator on patient satisfaction among adult patients 18 years and older in ambulatory care settings?

The purpose of this review is to synthesize the best available evidence on the effectiveness of a patient navigator on patient satisfaction among adult patients in ambulatory care settings.

Background

Ambulatory care service encompasses a variety of healthcare services provided to patients in a multitude of settings that can include primary care practitioner offices, urgent care centers, dialysis facilities, ambulatory surgical centers, comprehensive cancer centers, imaging centers, endoscopy clinics, public health clinics, and other types of outpatient clinics for non-hospitalized patients.1 In 2010, 1.2 billion ambulatory care visits were made to primary care provider offices, and hospital outpatient and emergency departments.2 Most acute and chronic illness, and oncology services are now provided in the ambulatory care setting.3,4 Ambulatory cancer clinic visits increased by more than 35% from 2003 to 2008.5 Over the next two decades the number of new cancer diagnoses is expected to rise by approximately 70%.3 Older adults will live longer than previous generations, and are at increased risk of developing multiple chronic diseases that can pose a significant economic burden worldwide.6 Worldwide projections indicate that by 2050, two billion people will be aged 60 years and over.6 The Centers for Disease Control and Prevention (CDC) estimates that by 2030, the number of adults aged 65 or older in the United States (US) will more than double, resulting in increased demands on ambulatory care services.4

This increase in demand for ambulatory care services is estimated to increase healthcare costs by 25% and account for 66% of the US healthcare budget.7 As of 2015, 75% of annual healthcare costs for chronic disease in the US is estimated to be $US 2.5 trillion dollars with 141 million Americans living with one or more chronic conditions causing major limitations in daily living.4 In a one-year period, a patient 65 years or over with one chronic illness will consult four different healthcare providers, while those with five or more chronic conditions will consult 14 different healthcare providers.8 Patients with chronic diseases have increased morbidity and utilize substantially more healthcare resources worldwide.4,6 This increased demand for ambulatory care services can create overcrowding and extended wait times for diagnosis and treatment.9

New treatment therapies and treatment modalities for acute and chronic illnesses will improve overall survival requiring long-term patient follow-up in the ambulatory setting.4 Most patients undergoing treatment for a wide range of diagnoses prefer to be managed as outpatients, and ambulatory management is more cost-effective than inpatient management.10 Disease prevention programs and greater use of primary care globally may reduce deaths, rates of illness and costs associated with chronic illness.6

Individuals with chronic diseases and other health problems may not have access to optimal health care and can encounter provider and healthcare system barriers to optimizing the necessary health care.11 Increased demand for ambulatory care services can lead to barriers that may affect wait times for diagnosis, and treatment, outcomes and satisfaction of care.12-16

Barriers to timely care can be multifactorial but certain individuals are at greater risk. Patient related barriers may be a lack of community base resources, financial constraints, work-home balance, and cultural challenges to adhering to the recommended treatment.11 Healthcare providers may not have the support needed for necessary treatment and care recommendations.12,13 Healthcare system related barriers may be the overall complexity of the ambulatory care setting and having poor access to specialty care services.11 Addressing the multitude of patient, provider, cultural and healthcare system barriers that patients with chronic diseases face will promote access to optimal care.11-13

Disparities in healthcare, particularly cancer care and chronic diseases, are often associated with socio-demographic factors, race, gender, sexual orientation, age and/or geographic location.13,14,17 These social determinants can impact on health outcomes.13 To mitigate the consequences which these social determinants may impose on health outcomes of adult patients, Harold P. Freeman, a surgical oncologist, developed the phenomenon of patient navigator in an attempt to reduce the barriers that hinder an early diagnosis of breast cancer.14 A patient navigator is defined as a trained person who helps patients in overcoming barriers to care and use the health care system effectively and efficiently.11 The patient navigator uses alternative approaches in addition to conventional information and support services for addressing patient specific needs.18 Patient navigators do not provide clinical care and may not be clinically oriented individuals.15 Patient navigators can be non-professionals such as lay persons or volunteers,16,19,20,21 health professionals such as nurses or nurse practitioners20-22 or social workers.22-24 Patient navigation became a promising strategy to address disparities in access to prompt diagnosis and treatment of cancer, particularly among the poor and uninsured as well as to improve overall patient satisfaction.17,24-28 More recently patient navigation has focused on addressing disparities associated with chronic diseases and mental illness.29-32

In 1990, the first patient navigator program was implemented at Harlem Hospital in New York City by Dr Harold Freeman.14 As a result of the patient navigator program, the five year survival rates at Harlem Hospital increased from 39% to 70% between 1995 and 2000.14 Freeman identified the barriers to healthcare as a lack of insurance, confusion about proper treatment, and distrust of the health system; navigators could lessen these barriers and guide the patient through the overwhelming process.14 Barriers to healthcare reach far beyond New York City to around the world.6 There is a need to ensure that all countries, particularly developing countries, have the ability to develop strong healthcare systems that support early detection, diagnosis and treatment of diseases.33 Breast cancer rates, in particular, are high in developing countries and the need for patients with breast cancer to understand how to navigate healthcare systems to receive the appropriate and necessary levels of care is crucial.33 Ethiopia, a country in Africa, has focused its attention on breast cancer expanding clinical and public health efforts aimed at diagnosing and treating breast cancer earlier and more efficiently through the integration of patient navigators.33

Patient navigators address the six aims identified by the Institute of Medicine (IOM) for improvement in health care quality: timely, safe, effective, efficient, patient-centered and equitable care.34 Patient navigators engage patients to make sure they receive the recommended therapy.11 Patient navigators assist with minimizing wait times and delays in services, promoting improved patient and family satisfaction, and ensuring individuals, regardless of race, age, gender, sexual orientation, income or geographic location, receive necessary recommended care.11,18,34 Services that can be provided by a patient navigator range from assisting with financial support, scheduling services, interpreter services, coordination of care, and helping patients with chronic diseases overcome access barriers often encountered during the care process.35 The focus of a patient navigator is on meeting the needs and preferences of patients by creating a more personalized experience that may foster open and honest conversations and patient empowerment.11

As many interventions aiming to improve healthcare continue to focus on the patient as the consumer, the need to improve patient satisfaction is as important as providing quality care. Satisfaction with interpersonal care is a key driver underlying overall patient satisfaction.5 Patient satisfaction is the quality of the patient's healthcare experience corresponding to the patient's expectations of care that is measured using valid and reliable instruments.5,26,36 Patient satisfaction is the extent to which the patient's general health care and specific condition needs are met.37 In 1985, the measurement of patient satisfaction through the development of a survey was introduced as a means to quantify and improve performance of health care institutions.38 Patient satisfaction can be measured in ambulatory settings by utilizing Press Ganey Satisfaction Surveys39 or Patient Satisfaction Questionnaires such as PSQ-1840 and the PSQIII.41 Press Ganey is an organization that captures the voice of the patients to better understand and improve performance and patient satisfaction in healthcare services in the ambulatory setting.39 The outcomes of the Press Ganey patient satisfaction surveys are utilized by participating institutions to drive quality improvement initiatives to improve patient satisfaction and overall quality of care.39

The Patient Satisfaction with Navigation (PSN-I) is a tool that assesses patient satisfaction with navigation services using a five-point Likert scale.16,42 This nine-item measure assesses key aspects of navigator performance including adequate time spent with patient, patient's level of comfort, perceived navigator's dependability, courtesy and respect, listening ability, ability to facilitate patient-navigator communication, perceived navigator's problem solving, and perception of a caring relationship and accessibility of the navigator.16,42 Higher scores on the tool indicate higher patient satisfaction that is often a significant driver underlying overall patient satisfaction across diverse clinical populations.16,42 The PSQ-1840 and the PSQIII41 are two other patient satisfaction tools; the long form (PSQ-III) and the short forms (PSQ-18) are from the RAND Health Corporation.43,44 The PSQ-III is a 50-item questionnaire that assesses patient satisfaction with healthcare, incorporating six aspects of care: technical quality, interpersonal manner, communication, financial aspects of care, time spent with healthcare provider, and accessibility of care.43 The PSQ-18 is a short form version that has many characteristics of its full-version form but takes approximately three to four minutes to complete.43 The Patients Intentions Questionnaire (PIQ) and the Expectations Met Questionnaire (EMQ) are primary care surveys used in London.44 A fundamental goal to improving patient satisfaction is to have the ability to identify ways that measure patient satisfaction effectively.45 The patient experience is shaped by how each an individual conceptualizes health and understands how healthcare interventions may promote or fail to recognize the patient's personal health goals.36

Patients are not satisfied when they have to wait for services, providers, diagnoses or treatments. Increased wait times are associated with emotional distress and reflect poorly organized processes.13 Wait times may trigger feelings of not being respected by patients which ultimately leads to dissatisfaction.46 Healthcare organizations are using quality improvement initiatives in ambulatory care settings to evaluate what processes need to be changed and what works well; patient satisfaction is a key indicator of quality of services provided.9 Patient navigation can be integrated into the Affordable Care Act Patient Centered Medical Home (PCMH) model which includes team-based and coordinated care, whole person orientation, emphasis on quality and safety, and enhanced access to care.47

The challenge that remains globally is the provision of optimal health care to patients in a timely and cost effective manner. High levels of patient satisfaction have been associated with the presence of a patient navigator, particularly across the continuum of cancer care.17,24-26,47 Positive patient experiences have been correlated with improved clinical outcomes through the use of preventative screenings, and early detection and treatment of chronic diseases which leads to a decreased financial burden on the healthcare system.48

In a randomized controlled trial (RCT) by Ferrante et al.,49 patient navigation is identified as an effective strategy for improving patient adherence to timely diagnostic services, decreasing patient anxiety and increasing patient satisfaction. A patient navigator can help alleviate patient distress by facilitating access to services and information.47-49 Through patient navigator advocacy, the patient can better utilize health care resources for early detection, hence negating costs to the patient and the need for ambulatory care services that may be escalated when the patient has a late stage diagnosis.49

A patient navigator is patient-centered, providing assistance to patients with the potential of creating a seamless flow through the fragmented and complex processes inherent in most health care systems. A patient navigator helps to eliminate barriers to timely care while maintaining cost effectiveness.48 The goal of navigation is to facilitate quality standard care in a culturally sensitive manner resulting in overall patient satisfaction.48 Institutions have implemented many computer-based systems to enhance patient satisfaction; however, patient navigation is a reminder of the importance of the human interactions that can be far more satisfying than what technological advancement can provide.

No systematic reviews were found on the effectiveness of a patient navigator on patient satisfaction in adults 18 years and over in ambulatory care settings in a preliminary search of CINAHL, PubMed, The Cochrane Central Register of Controlled Trials (CENTRAL) and The JBI Database of Systematic Reviews and Implementation Reports. A systematic review would efficiently integrate existing evidence and provide data for supporting the role of a patient navigator in patient satisfaction, and clinical and patient-oriented outcomes in ambulatory care settings.

Inclusion criteria

Types of participants

This review will consider studies that include adult patients, 18 years and over, of any gender and ethnicity receiving outpatient ambulatory care, regardless of diagnoses, stage of illness, acute or chronic illnesses or previous treatment. Outpatient ambulatory care includes clinics, primary care practices, community health centers, hospital based outpatient clinics, and home based transferring to outpatient ambulatory care. Studies that include pediatric populations, 17 years and below, hospitalized inpatients and all patients receiving treatment in the emergency department will be excluded in this review.

Types of intervention

This review will consider studies that examine the patient navigator role.

A patient navigator is defined as a trained person who helps patients in overcoming barriers to care and use the health care system effectively and efficiently.8 The patient navigator uses alternative approaches in addition to conventional information and support service for addressing patient specific needs.13 Usual care is the comparator. For this review, usual care is defined as a process patients regularly follow to gain access to health care professionals, appointments and procedures without a patient navigator.

Types of outcome

The primary outcome is patient satisfaction. For the purpose of this review, patient satisfaction is defined as the quality of the patient's healthcare experience corresponding to the patient's expectations of care measured by using valid and reliable instruments.5,26,36 Patient satisfaction is the extent to which the patient's general health care and specific condition needs are met.26 Patient satisfaction measures that can be used are surveys that engage patients in addressing improved safety, increased efficiency and improved patient experience and outcomes such as the PSQ 18, PSQ-III Questionnaires and Press Ganey survey.39,40,41 These tools have undergone rigorous reliability and validity testing and can provide valuable information on the effect of patient navigator interventions on adult patient satisfaction in the ambulatory care setting.

Types of studies

This review will consider study designs including randomized controlled trials (RCTs). In the absence of RCTs, non-randomized controlled trials, quasi-experimental, before and after studies, comparative, prospective and retrospective cohort studies, case control studies and analytical cross sectional studies will be considered for inclusion.

Search strategy

The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of PubMed, CINAHL, and Embase will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Studies published in English will be considered for inclusion in this review. Studies published in 1990, from the inception of a patient navigator, to current date of review will be considered for inclusion.

The databases to be searched include:

Pub Med, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, PsycINFO, Health Source: Nursing/Academic Edition and ProQuest Nursing & Allied Health Source and Social Work Abstracts.

The search for unpublished studies/grey literature will include:

Google Scholar, Institute Of Medicine, Virginia Henderson, World Health Organization, ProQuest Dissertation and Thesis, Dissertations Abstract International, New York Academy of Medicine, any patient navigation relevant websites, as well as the National Institute of Health (NIH), Institute for Health Improvement (IHI), Patient Navigation in Cancer Care, American Society of Clinical Oncology (ASCO), Oncology Nursing Society (ONS), European Society for Medical Oncology (ESMO) and the National Cancer Institute (NCI).

Hand searching of reference lists and bibliographies of included studies and appropriate journals including Journal of Primary Care and Community Health, Journal of Urban Health, Social Work, Annuals of Oncology, Journal of Clinical Oncology and Clinical Journal of Oncology will be included.

Initial keywords to be used will be: adults, ambulatory care setting, outpatient setting, patient navigator, patient satisfaction, patient experience, patient navigation, patient perception of care.

Assessment of methodological quality

Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.

Data extraction

Data will be extracted from papers included in the review by two independent reviewers using the standardized data extraction tool from JBI-MAStARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. For studies where there is missing or unclear data, an attempt will be made to contact primary authors for information.

Data synthesis

Quantitative data will, where possible, be pooled in statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry. Effect sizes expressed as weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-square and also explored using subgroup analyses based on the different study designs included in this review. Where statistical pooling is not possible the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate.

Conflicts of interest

There are no conflicts of interest to declare.

Acknowledgements

This review will partially fulfill degree requirements for successful completion of the Doctor of Nursing Practice Program at Pace University, College of Health Professions, New York, NY for Coleen P Ranaghan, Kathleen Boyle, Maureen Meehan, Shadiatu Moustapha and Patrice Fraser.

References