image: Dr. Wagner, leader of the nurse navigator trial, is director emeritus of the MacColl Center for Health Care Innovation at Group Health Research Institute (GHRI) -- and a senior investigator at GHRI -- in Seattle. view more
Credit: Group Health Research Institute
SEATTLE—When Group Health patients received support from a nurse navigator, or advocate, soon after a cancer diagnosis, they had better experiences and fewer problems with their care—particularly in health information, care coordination, and psychological and social care—according to a randomized controlled trial in the Journal of Clinical Oncology.
Patients with a nurse navigator reported feeling better supported emotionally and more involved in their care. They also said they were better informed and more prepared for the future. And they tended to feel that the health care team had gone out of their way to make them feel better emotionally.
"Hearing that you have cancer is so difficult," said lead author Ed Wagner, MD, MPH, a senior investigator at Group Health Research Institute and director emeritus of the Institute's MacColl Center for Health Care Innovation. Right after a cancer diagnosis, patients and their families often need extra help: with information, translating medical jargon, psychological and social support, and coordinating care from various health providers. That's what Dr. Wagner learned earlier from studying the perspectives of patients, families, providers, and experts around the country.
"It makes sense that patients would benefit from having a single point person devoted to providing support and coordination of services," said Dr. Wagner's coauthor Ruth McCorkle, PhD, RN, the Florence Schorske Wald professor of nursing at Yale School of Nursing and a professor of epidemiology at Yale School of Public Health. "Oncology nurse navigator programs are proliferating across the country, but they are highly variable because there hasn't been much rigorous evidence."
In this randomized controlled trial, half of the 251 adult patients newly diagnosed with cancer were assigned to an oncology nurse navigator to help them for four months. Starting two weeks after the diagnosis, the nurse navigator initiated weekly phone calls and contacted each patient an average of 18 times, including meeting in person at least once with each patient: for instance, accompanying them to a doctor's appointment.
The other group of the patients received "enhanced usual care" consisting of educational material designed by a patient advisory committee. Most (190) of the patients had breast cancer, but 30 had lung and 31 had colon or rectal cancer. Patient-reported outcomes were measured at baseline, four months, and one year.
Some of the differences between the groups persisted for eight months after patients' last contact with a nurse navigator. "That suggests that the nurse navigators helped patients to develop the confidence and skills to manage their illness and treatment more effectively," Dr. Wagner said. "This is important because it's crucial for patients to be involved in their care and self-care."
Overall costs of health care, including the costs of the intervention, didn't rise at all with the nurse navigator intervention—and in lung cancer patients, they might have actually declined. No overall changes were detected in patients' quality of life or depression. "That might have been because our patients had high quality of life to start with," Dr. Wagner said, "and our way of measuring that might not have been sensitive enough."
The oncology nurse navigators had experience with cancer patients, received special training to deal with psychosocial distress, and were familiar with the Group Health system. "Our system tends to be better coordinated than average in the United States," Dr. Wagner said. "Further research is needed to see how well nurse navigation works in more fragmented care systems—and whether it can reduce the costs of cancer care."
Group Health was so impressed with this work that it has already incorporated an oncology nurse navigator into usual care for women newly diagnosed with breast cancer at its Capitol Hill campus—even before the research was published.
Also, the Group Health Foundation has awarded a Partnership for Innovation grant to Drs. Wagner and McCorkle's coauthor Evette J. Ludman, PhD, a senior research associate at Group Health Research Institute, to implement and evaluate a peer support program for women with breast cancer.
This work was supported by the National Cancer Institute (NCI)-funded Cancer Communication Research Center, affiliated with the HMORN Cancer Research Network (CRN), an NCI-funded consortium of 14 research centers based in integrated care delivery systems: grant P20CA137219, clinical trial NCT00921713.
Drs. Wagner, McCorkle, and Ludman's co-authors were Erin J. Aiello Bowles, MPH, a research associate; Robert Penfold, PhD, an assistant investigator, Jessica Chubak, PhD, an associate investigator, and Carolyn M. Rutter, PhD, and Robert J. Reid, MD, PhD, senior investigators, all at Group Health Research Institute.
Dr. Wagner is also a professor of health services at the University of Washington (UW) School of Public Health. Dr. Ludman is also an affiliate investigator at the Fred Hutchinson Cancer Research Center and an affiliate associate professor of psychiatry and behavioral sciences at the UW School of Medicine. Dr. Penfold is also an affiliate assistant professor of health services at the UW School of Public Health. Dr. Chubak is also an affiliate assistant professor of epidemiology at the UW School of Public Health. Dr. Rutter is also an affiliate professor of biostatistics and health services at the UW School of Public Health. And Dr. Reid is also a Group Health physician and Group Health's associate medical director for research translation.
HMORN Cancer Research Network
The HMORN Cancer Research Network (CRN) is a National Cancer Institute-funded initiative to support and facilitate cancer research based in 14 non-profit integrated health care delivery settings that belong to the HMO Research Network. The CRN welcomes collaborations that result in research projects that improve knowledge about cancer etiology, prevention, early detection, treatment and prognosis, and that decreases the burden of cancer across the cancer care spectrum. The integrated health care settings provide unique advantages for conducting population sciences research.
HMO Research Network
The HMO Research Network includes 18 research centers, each associated with a health care delivery system. Researchers at the centers collaborate on multi-site studies in real-world health care settings across the United States and in Israel. With access to information on more than 15 million ethnically and geographically diverse patients, these researchers are finding solutions for common and rare health problems. Since 1994, the Network has been answering pressing questions about keeping people healthy and delivering effective care.
Group Health Research Institute
Group Health Research Institute does practical research that helps people like you and your family stay healthy. The Institute is the research arm of Seattle-based Group Health Cooperative, a consumer-governed, nonprofit health care system. Founded in 1947, Group Health Cooperative coordinates health care and coverage. Group Health Research Institute changed its name from Group Health Center for Health Studies in 2009. Now celebrating its 30th anniversary year, the Institute has conducted nonproprietary public-interest research on preventing, diagnosing, and treating major health problems since 1983. Government and private research grants provide its main funding.
Journal
Journal of Clinical Oncology