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Health Navigation: A Review of the Evidence

Fall 2014

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Screening, Testing and Diagnosis

Testing, or screening, for any health condition is the first step in seeking a diagnosis. In HIV care, diagnosis is the first step in the treatment cascade. We know that we need to do a better job improving the number of people who are aware they have HIV. An estimated 25% of people living with HIV in Canada are unaware of their status.24 Testing is important because people who know they live with HIV can seek care and treatment and improve their health outcomes. Diagnosis also has a prevention benefit. Research shows that people who know they are HIV-positive take measures to reduce the risk of passing HIV to their partners.25

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There is strong evidence that navigation improves screening rates.15,16,26 There is also strong evidence that navigation improves confirmatory testing rates.16 There is limited evidence that navigation impacts rates of early diagnosis.4,27


Screening

In cancer care, screening is the periodic testing for cancer. Mammograms or Pap smears are two common types of screening tests. In the case of HIV, testing would include rapid or standard blood tests done at regular intervals.

There is strong evidence from two reviews in cancer care and one observational study that navigation improves screening rates.15,16,26 There is no evidence from HIV care or diabetes care that navigation has an impact on screening rates.

Based on a review of 45 articles from 2008 and a case control study published in 2012, the improvement in the rate of adherence to cancer screening ranged from 11%16 to 23%26 when clients who received navigation were compared to a control group. Another review of 33 articles concluded that navigation has a positive impact on cancer screening rates.15


Confirmatory Testing

In cancer care, when a screening test is abnormal, further confirmatory testing is required to determine if cancer is present. This is often called diagnostic follow-up. There is not always the same diagnostic follow-up in HIV care. It does occur when there is an inconclusive standard test result, or with rapid testing, however. When a rapid test is reactive (potential positive), clients are encouraged to get confirmatory testing. If a standard or rapid test is carried out in the window period, clients are also encouraged to retest.

There is strong evidence from a review of 45 published studies in cancer care that navigation improves diagnostic follow-up between 21% and 29%.16 There is no evidence from HIV care or diabetes care that navigation has an impact on diagnostic follow-up.


Earlier Diagnosis

Early diagnosis of any illness may lead to improved health outcomes through earlier access to care and treatment. Early diagnosis in people living with HIV is key for optimal health. In addition, research shows that early diagnosis can have implications for prevention as well. The risk of passing HIV on to others is substantially higher during the first few months of HIV infection. Some research suggests it can increase the risk of passing HIV by as much as 2500%.28-30

There is limited evidence from observational cancer care research that navigation leads to earlier diagnosis4,27 and no evidence from HIV care or diabetes care.

One case control study in cancer investigated navigation's impact on time to diagnosis. This study found that after starting a navigation program, 41% of women were diagnosed with early stage breast cancer compared to only 6% prior to the start of the program.4 Another case control study found that navigation increased early stage cancer diagnosis from 33% of all diagnoses before navigation to 53% after navigation was introduced.27


Care Outcomes

Once diagnosed, chronic illnesses such as HIV require access to care providers to monitor health and adjust treatment. The general consensus is that people living with HIV should see their HIV primary care physician every three to six months.31 Going to these appointments regularly, sometimes called client retention, is crucial to ensure optimal health outcomes.

There is limited evidence that navigation improves access to care32,33 and improves the timeliness of that access.11,27 There is also limited evidence that navigation improves client retention in care.1,34


Access to Care

Access to care is a critical component for improved health outcomes. When in care, people living with HIV have access to medical and other supports that may help them achieve the best health outcomes. There is limited evidence from observational research in HIV that navigation improves access to care32,33 and no evidence from cancer care or diabetes care.

One case control study found that the proportion of clients with no HIV care decreased from 12% to 5% six months after starting with a navigator.32 Another study reported that 95% of clients enrolled in their program had a visit with a medical provider after working with a navigator.33


More Timely Access to Care

More timely access to care, meaning shorter times between diagnosis and treatment, may contribute to improved health outcomes by providing quicker access to treatment and other supports.

There is limited evidence from observational research in cancer11,27,35 and no evidence from HIV care or diabetes care that providing navigation improves timely access to care for clients.

A quality assessment study and a case control study found a reduction of five to 10 days in the average time from diagnosis to cancer treatment after navigation services were introduced.11,35 In addition, a case control study in a veterans' hospital found that navigation reduced the number of days from suspicion of cancer to treatment by 65 days.27


Improved Retention in Care

Remaining in care, which is sometimes called client retention, is key for treatment success. When clients show up for appointments at appropriate intervals, clinicians can provide optimal care and support. Retention in care can be monitored through HIV care visits, or having CD4 count or viral load blood tests.9

There is limited evidence from observational research in HIV that navigation improves client retention.32,33,36-38 There is limited evidence from observational research in diabetes care that navigation improves client retention.34

In a case control study of four sites using navigators, the number of patients with two or more HIV care visits in the past 12 months increased from 64% before navigation was offered to 87% with a navigator.32

In a study that reviewed the findings from a navigation program in Louisiana, 67% of patients had at least two HIV primary care visits within a year of working with a navigator.33

A case control study from Washington, D.C. defined retention in care as a client having two viral load or CD4 tests within 12 months. This study showed that clinics that have navigators retain 76% of clients compared to only 60% of clients retained in clinics that do not have navigators.36 Navigation has also been shown to work among released prisoners,37,38 with one program demonstrating that 96% of clients in the program were still in care after 12 months.38

A case control study in diabetes care found that 59% of clients attended their medical appointments in the year before they were enrolled in the navigation program compared to 73% in the year after using a navigator.34


Treatment Outcomes

For health care to be effective, clients must take and respond to their treatment. When clients are ready to start HIV treatment, medicines must be taken daily for them to be effective. People living with HIV who start treatment soon after their diagnosis can expect to live almost as long as the general population.39 Viral suppression of HIV is also associated with reduced likelihood of passing HIV to others.40

There is limited evidence that navigation supports improved treatment outcomes.1,4,32,33


Clinical Outcomes

Successful HIV treatment is measured by two clinical outcomes: viral load and CD4 count.41 In cancer care, fewer treatment delays and survivorship are measures of successful treatment.

There is limited evidence from observational research in HIV that health navigation is associated with lower viral load and higher CD4 cell counts.32,33 There is also limited evidence from cancer care that navigation is associated with fewer treatment delays and increased rates of 5-year survival.1,4

A study of an HIV navigation program documented improvements in median viral load from 15,607 to 267 copies/ml and in median CD4 count from 297 to 367 (24% improvement) after enrollment in a health navigation program.33

In a case control study of four navigator programs in the United States, the proportion of clients who worked with a navigator and who had an undetectable viral load was 50% greater at 12 months than when they entered the program.32

In a case control study from cancer care that reported on treatment outcomes, on average, cancer patients who worked with a navigator had three fewer days of treatment delays than non-navigated patients,1 meaning they were treated more effectively than clients who did not work with a navigator.

Another case control study from cancer care shows that navigation improves 5-year survivorship for people diagnosed with and who have received treatment for cancer. In this study, the 5-year survival rate of clients at the hospital was 39% before navigation but increased to 70% after navigation was introduced.4

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This article was provided by Canadian AIDS Treatment Information Exchange. It is a part of the publication Prevention in Focus: Spotlight on Programming and Research. Visit CATIE's Web site to find out more about their activities, publications and services.
 

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