Patient Navigators Enhance Colonoscopy Screening Rates and Save Money in the Long Run
Orlando, FL—The use of patient navigators can reduce racial disparities in colorectal cancer (CRC) screening and can potentially reduce the mortality rates—and do both cost-effectively, according to studies presented at Digestive Disease Week 2013.
Through a 1-to-1 relationship, patient navigators bridge disparities by assisting with scheduling appointments; educating patients about bowel preparation; and by addressing cultural, linguistic, and financial obstacles. The value of patient navigators was documented in a study by Delia Calo, MD, Memorial Sloan-Kettering Cancer Center, New York.
To improve adherence to colonoscopy screening, in 2003 the New York City Department of Health and Mental Hygiene implemented the Colonoscopy Patient Navigator Program at 22 sites. Dr Calo reported on a total of 37,077 scheduled screening colonoscopies and 2198 surveillance colonoscopies (ie, follow-up after a positive finding). With the assistance of patient navigators, 31,215 individuals had screening colonoscopy, for an adherence rate of 84.2%, and 2062 had surveillance colonoscopy, for an adherence rate of 93.8%. No racial discrepancies were documented, Dr Calo said.
Patient Navigation Is Cost-Effective
Patient navigation not only enhances colonoscopy rates, but it is also cost-effective, according to a modeling study that evaluated navigation over a long-term horizon.
“We found that patient navigation for one-time screening colonoscopy appears to increase life expectancy while saving costs,” reported Uri Ladabaum, MD, MS, Interim Chief, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, CA. “This reflects a favorable balance between the increase in screening uptake achieved by navigation, and the costs of providing navigation,” he said.
The investigators examined one-time colonoscopy in a cohort reflecting a population at a major New York City hospital. The study compared the costs for patient navigation versus no navigation and no screening, with a time horizon through age 100 years or death. Outputs were mean discounted quality-adjusted life-years (QALYs) and costs per person. The base-case inputs were based on navigation studies and 2012 Medicare payments.
The costs of patient navigation were added to the costs of screening. Base-case inputs assumed screening uptake rates of 40% without navigation and of 65% with navigation. The cost of a diagnostic colonoscopy was $661, and a colonoscopy with intervention was $939. Navigation costs were figured at $29 per colonoscopy completer, $21 per noncompleter, and $3 per incomplete navigation.
The model determined that CRC would be diagnosed in 551 per 10,000 persons without screening, 453 who had colonoscopy without navigation, and 392 for colonoscopy with navigation. CRC deaths per 10,000 persons would number 216, 174, and 148, respectively.
“We found that navigation improved life expectancy and was cost-saving,” Dr Ladabaum reported. “With navigation, for all ages and ethnicities, patients could anticipate a life expectancy of 15.458 QALYs, and without navigation, a lower number, 15.444 QALYs, so there were better clinical outcomes with navigation. The cost per person was $2422 with navigation and $2558 without, so navigation was more effective and less costly, making it the dominant strategy.”
Navigation improved life expectancy and decreased costs for all subgroups (Table), he said.
The clinical and economic benefits were greatest for patients aged 50 to 69 years. Gains in life expectancy were highest in whites, then blacks, and third Hispanics; however, cost-savings were greatest in blacks.
“These results reflect the interplay between subgroup-specific colorectal cancer incidence and age-specific all-cause mortality,” Dr Ladabaum noted.
In the sensitivity analysis, navigation became cost neutral when the navigation cost per colonoscopy completer rose to $199, and it cost $25,000 per QALY gained when the navigation cost per colonoscopy completer was as high as $622. With base-case navigation costs, navigation became cost neutral at a modest increase in uptake of only 3% with navigation, and it cost $25,000 per QALY gained at an increase in uptake of 1% with navigation, he added.
“In emerging healthcare models that reward outcomes, payers should strongly consider covering the costs of patient navigation for colorectal cancer screening,” Dr Ladabaum concluded.
Should You Hire a Patient Navigator?
Based on these results, David Lieberman, MD, Chief, Division of Gastroenterology, Oregon Health and Science University School of Medicine, Portland, asked, “So, if I’m the CEO of a coordinated care organization, I should rush out to hire patient navigators?”
Dr Ladabaum responded, “Assuming you believe the findings, I think the answer is yes.”
Steven H. Itzkowitz, MD, Associate Director, the Dr Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mt Sinai, New York, said that his patient navigation program “turns a profit for the institution, mainly by increasing the volume of colonoscopies. We are getting more patients in for colonoscopies, our bowel preps are better, and our completion rates are higher. That’s how the hospital makes money: more colonoscopies, higher quality.”
Dr Itzkowitz noted that the navigation of 1000 patients costs 0.43 full-time equivalent health educators at a salary of approximately $40,000 annually. “So, for $20,000 a year you can navigate 1000 patients,” he suggested. “If you really want to be cost-effective, you can train volunteers from the community. This is almost a no-brainer at this point.”