Characteristics of the reviews included
A total of nine systematic reviews describing 223 individual studies on patient navigation roles met the inclusion criteria and were included (see Tables 1-3). The included reviews covered three areas of care: four systematic reviews analysed patient navigator roles for patients with various types of cancer (‘cancer care’ including diagnosis and treatment), three reviews focused on screenings for the prevention and early identification of diseases and two reviews covered transitional care interventions for patients with various chronic conditions. The analysis of the results is structured along these three areas of care. Patient navigators performed tasks such as providing education and counselling (addressing the language needs of the target groups), translations, home visits, outreach, scheduling of appointments and follow-ups.
Seven of the nine reviews covered interventions targeted primarily or exclusively at vulnerable population groups such as ethnic minorities, non-native speakers or medically underserved populations (19; 26; 27; 11; 15; 28; 29). Most individual studies were conducted in the U.S. and Canada, followed by studies from European countries (e.g. Austria, Italy, UK) and Asia (e.g. Bangladesh, Korea, Japan). Randomized Controlled Trials (RCTs) made up a majority of studies included in the systematic reviews. Two out of the nine systematic reviews performed meta analyses (15; 30).
All systematic reviews reported on the professional background of the patient navigator (e.g. nurses, physicians, lay health worker). Three systematic reviews provided information on the length or contents of their patient navigation training (28; 29; 19). The reporting of education and training in the three reviews was often limited to individual studies and not consistent. Reporting on the details of the interventions and outcome measures was available for all systematic reviews.
The quality of the systematic reviews included in the overview of reviews varied. Two were assessed as moderate quality (30; 19) and seven systematic reviews were of low quality (28; 15; 29; 26; 31; 27; 11).
Patient navigation interventions with a focus on diagnosis and treatment of cancer
Four systematic reviews focused on patient navigation for cancer care covering interventions to improve cancer diagnosis and treatment (Table 1: (19; 26; 27; 11)). Two reviews also included interventions for diagnosis and screening (27; 11). Out of the four reviews, one targeted ethnic minorities (27) and three covered all cancer patients, of which the majority were ethnic minorities in two reviews (19; 11). One review covered medically underserved patients including uninsured persons and patients from rural and urban areas in the US (26). The main interventions undertaken by patient navigators were education on the disease, its treatment and self-care scheduling appointments and assistance with appointments in the included systematic reviews. Other roles included facilitating communication between providers (11; 19; 27; 26).
Patient navigator roles were undertaken by individuals with diverse backgrounds, ranging from health professionals to lay persons (19; 26; 27; 11) and patients (19) such as breast cancer survivors (11). Among health professionals, nurses were the most common profession to take on the role of patient navigation. The reporting of details of the training and education of the patient navigators was limited among the four reviews. Only Ranaghan et al. (19) reported on patient navigator training. In the review, one out of four studies provided details on education, with patient navigators trained in breast health education, public speaking and observing mammograms undertaken in mobile breast cancer screening units by radiologists, breast surgeons and oncologists.
Patient navigation showed improved outcomes in all four systematic reviews focusing on facilitating access to health services. Two systematic reviews demonstrated improvements in access and timeliness of treatment and care for vulnerable patients or ethnic minority patients, for example by reducing waiting times and improving appointment scheduling with specialists (11; 26). Earlier treatment and treatment initiation were demonstrated by one systematic review (26). One review showed improved adherence to follow-up for medically underserved patients (26). Ranaghan et al. (19) reported a shorter time to diagnosis and appointments and indicated improved patient satisfaction and coordination of care. However, the authors report that the effect was not statistically significant, which was largely attributed to small sample sizes for sub groups analyses in the evaluated studies.
Patient navigation interventions with a focus on screening of diseases
Five systematic reviews analysed patient navigator roles to increase screening uptake (see table 2: (29; 15; 28; 27; 11)). Except for Al-Faisal et al. (15), all other focussed on cancer. Two reviews focused on diagnosis and treatment in addition to screening and have therefore also been covered in the previous sub-section (27; 11). One review focused on vulnerable patients such as medically underserved groups (28), while another provided evidence on patient navigation interventions for non-English proficient persons (29). Interventions covered various components such as education, reminders, assistance in setting up appointments, language support and the identification and removal of barriers.
Health professionals (15) or trained lay persons (29; 15; 28) undertook patient navigator roles. In the review by Roland et al. (28), lay patient navigators received general training in information related to cancer and health, cancer screening and guidelines. Moreover, they were trained in providing patient support and care. Skill-based training was provided on topics such as motivational interviewing and communication. In the review by Genoff et al. (29), five out of fifteen studies reported on the length of training of patient navigators, which ranged from six hours training to two days workshops and additional follow-ups one year later.
Patient navigation improved screening rates for population groups in all five systematic reviews, with the majority of patient groups being from ethnic minorities (15; 28; 29; 27; 11).
The results of the meta-analysis by Al-Faisal et al. (15) showed a significant increase in screenings rates with patient navigation (OR: 2.48, 95 % CI, 1.93 to 3.18, p<0.001). Three other systematic reviews also found improved screening rates (28; 29; 27). Glick et al. (27) showed improved adherence to screening for ethnic minority cancer patients. Another systematic review demonstrated improved adherence to breast cancer screening and diagnostic follow up for breast cancer patients, of which the majority were ethnic minority women (11).
Patient navigation also significantly improved the probability of attending recommended care events (OR 2.48, 95% CI, 1.27 to 5.10, p= 0.008) (15). Improved completion of diagnostic (28) and screening (27) was also shown. Improved referrals and shorter time to diagnosis for patients with abnormal screening results were reported in one systematic review (28).
Patient navigator interventions in transitional care
Transitional care interventions from hospital to ambulatory care or home involving patient navigator roles were the focus of two systematic reviews. The patient navigation interventions were targeted at older patients with at least one chronic condition (see table 3: (31; 30)).
Although a wide range of different interventions were covered, patient navigator tasks mostly included coordination, discharge planning and follow up in addition to education and multiprofessional collaboration among health professionals. Nurses (e.g. advanced practice nurses), physicians, pharmacists and social workers performed patient navigation interventions, among other professions.
Patient navigation in transitional care focusing on older patients with chronic diseases demonstrated a significant reduction in mortality rates (Risk Difference (RD) -0.02, 95% CI: -0.05-0.00) (30), improvements for depression symptoms and disease management (31) and a positive effect on activities of daily living (ADL), communication with patients, caregivers, education for caregivers, self-management and knowledge of patient medication (31). Mixed results on quality of life were reported in the two reviews, with no difference in quality of life between intervention and non-intervention groups reported in Le Berre et al. (30), but improved quality of life reported for the intervention group in Manderson et al. (31).
Improved referrals were reported by Manderson et al. (31). Le Berre et al (30) showed that introducing patient navigation in transitional care results in significantly fewer Emergency Department visits at 3 months post-discharge (Risk Difference (RD) -0.08, -0.15, -0.01), yet, showed no effect at six or twelve months (30). However, the review reported significantly lower hospital readmissions at 6 months (RD -0.05, -0.09, -0.00), 12 months (RD -0.11, -0.17, -0.05), and at 24 months (MD -1.03, -1.81, -0.24) and no effect one month (30). Mandersen et al. (31) reported lower readmissions, shorter time to readmission and less hospital days. This review reported an inconclusive effect on costs related to the use of emergency departments.