LAUSR

Patient navigation (PN) was formally defined by Freeman in 1990 in response to high breast cancer mortality rates observed among African American women in Harlem, New York.1 It is designed to help patients complete recommended tests , appointments, and treatments by identifying and resolving barriers to care.1 The single-site observational data by Freeman showed the influence of PN on breast cancer mortality rates1; however, randomized trials were needed to truly validate PN. The Patient Navigation Research Program (PNRP), funded by the National Cancer Institute and the American Cancer Society, did exactly this. Both the individual study site results2 and the combined analysis3 demonstrated that PN reduced delays in diagnostic resolution and start of treatment among patients, predominantly minority or underserved, for 4 types of cancer. Unfortunately, the cost analysis, which did not use the same primary outcome as the combined analysis, did not find any cost savings for PN.4 Nonetheless, the PNRP results were influential in the mention of PN in the Patient Protection and Affordable Care Act and the inclusion of PN in the American College of Surgeons Commission on Cancer accreditation process. However, PN is an unfunded mandate. What is needed is evidence on the cost-effectiveness of PN, as well as which model might work best in achieving better cost-benefit and health outcomes. The study by Rocque et al5 in this issue of JAMA Oncology provides some evidence to justify coverage of PN by major insurers and the Centers for Medicare & Medicaid Services, as well as clarity on models of PN. Within The University of Alabama at Birmingham Health System Cancer Community Network, a natural experiment provided the setting to evaluate a lay PN program in terms of health care spending and resource use in a Medicare population. Using propensity score–matched regression analyses to compare the period before PN with the period during PN, the team found that PN saved the health care system an estimated $19 million per year in inpatient, outpatient, emergency department, hospitalization, and intensive care unit costs. Lay navigators, a less costly and more voluminous workforce compared with nurse navigators, were assigned to patients with cancer throughout the cancer care continuum, from diagnosis to treatment and survivorship or end of life. The successful use of lay navigators in this study complements PNRP data showing that more clinically trained navigators (eg, nurses) tended to be pulled into nonnavigation clinical duties that took time away from PN duties,6 making them less efficient. What do patient navigators do that makes them so important? As described in the article by Rocque et al,5 navigators identify barriers to care that each patient has and help resolve those barriers so that patients can get the care they need on time and adhere to medication regimens to stay out of the emergency department and hospital. In the example of breast cancer, as described by Daly and Olopade,7 PN can address patterns of care, mainly access to timely, appropriate care that is essential to reducing cancer health disparities. In addition, and this point cannot be overemphasized, navigators often have more time to spend with patients than physicians, physician assistants, and nurse practitioners do and are trained in skills that these care professionals may not possess. Therefore, having navigators in the health care team can increase efficiency and address more broad causes for cancer health disparities. With the strong evidence from many well-designed studies of PN, the latest being this large study by Rocque et al,5 there is little doubt that PN is effective in terms of cost savings and health outcomes. Therefore, the Centers for Medicare & Medicaid Services and insurers should cover PN, as directed in the Patient Protection and Affordable Care Act, to help control health care costs and to reduce the burden of cancer, especially in underserved populations.