Defining the Complexity of Patients Through an Acuity Tool: A Scoping Review

Background: Tools that help to characterize patient acuity have been used in healthcare for decades and have proved successful as a means of determining staffing needs, improving patient care, and controlling costs. In fact, a wide array of navigation acuity tools used for a variety of different purposes exist, but there has been little nursing research into the validity and reliability of these tools. Currently, despite an acute need and the efforts of individual institutions, there is not a standardized, validated, evidence-based acuity tool available for oncology navigation programs.

Objectives: To investigate and analyze articles related to components of the oncology acuity tool, including age, race, ethnicity, diagnosis and stage, barriers, and treatment per National Comprehensive Cancer Network (NCCN) guidelines or other national standards published in English from January 1, 2018, to December 31, 2021. Please note, there were no studies included from 2021. These articles will be used to inform the development of 10 evidence-based case studies. These case studies will be used to test the navigation-specific acuity tool that is expected to help oncology navigators characterize the complexity of their patients, aid in the allocation of navigation resources, and measure the effectiveness of navigation on patient outcomes.

Methods: This scoping review considered all studies that addressed age, race, ethnicity, diagnosis and stage, barriers, and treatment per NCCN guidelines or other national standards. A 3-step search strategy was used: (1) initial limited search of PubMed; (2) extensive search using all keywords and index terms; and (3) hand search of the reference lists of included articles. Reviewers extracted data independently; disagreements that arose among the reviewers were resolved via discussion, or with a third reviewer.

Results: A total of 1764 articles were screened, 555 full-text publications were reviewed, and 49 relevant articles were identified. Most studies focused on physical well-being. Studies focused on age, race, ethnicity, diagnosis and stage, barriers, and treatment for the case studies used to support the creation of the acuity tool.

Conclusions: Inclusion of these case studies will be beneficial for developing an evidence-based navigation-specific acuity tool that is expected to help oncology navigators characterize the complexity of their patients, aid in the allocation of navigation resources, and measure the effectiveness of navigation on patient outcomes.

Tools that help to characterize patient acuity have been used in healthcare for decades and have proved successful as a means of determining staffing needs, improving patient care, and controlling costs. In fact, a wide array of acuity tools used for a variety of different purposes exist, but there has been little nursing research into the validity and reliability of navigation tools. One of the problems inherent to the study of acuity is that the term is often used without specifying an exact meaning or referencing which attribute of acuity is being examined.¹ In other words, an acuity attribute must be defined by how it is intended to be used or what it attempts to quantify. Brennan and Daly identified 4 acuity attributes: nonpatient-related, patient-related, provider-related, and system-related.¹ The authors further defined each attribute with specific characteristics. In their concept analysis, Brennan and Daly only describe acuity and acuity tools that relate to nursing care of patients on an inpatient unit.¹ One of the questions before us is whether inpatient acuity attributes and characteristics define navigation acuity as well.

Over the past decade, there has been enormous change within the oncology setting that has led to the need for navigation services. Navigators have become an integral part of the multidisciplinary team with a focus on guiding the patient through the cancer care continuum while identifying and addressing barriers to care and coordinating access to medical and psychosocial services. Commonly, navigators may be nurses, social workers, or other nonclinically trained individuals with a variety of experiences and education levels. They may be employed or volunteer and may work in various settings, including academic centers, community cancer centers, private practice, specialty centers, and inpatient or outpatient.

Navigation services are rarely reimbursable, so there has been debate about whether such services are fiscally prudent. There has been a call for a measurable way to validate the benefit of navigation services. Oncology administrators and leaders want to be able to measure the return on investment for navigation programs. The development of the 35 evidence-based navigation metrics allows all models of navigation programs to measure their success and sustainability.²

Although standardized metrics help us measure the outcomes of navigation, a gap exists for best practices to optimize the utilization of navigation resources. The diversity of practice settings and types of navigators, along with the need for a tool to be used across the cancer care continuum, present unique challenges. A number of practices and professionals have sought to develop navigation acuity tools to assist with allocation of resources, caseload management, and workflow. A review of these existing tools reveals that a navigation acuity tool, although similar in structure to nursing acuity tools, requires unique structure and measurements. There are reports that some institutions have abandoned their “home-grown” tools because they did not, in fact, measure patient acuity. Most tools were designed specifically for a particular practice or purpose. None of the existing tools have been validated, and most cannot easily be replicated in other facilities. To build sustainable navigation programs, we must develop a standardized acuity tool specifically for oncology navigation.

The validated and reliable acuity tool must provide navigators and administrators a way to characterize the complexity of the oncology patient, allocate resources, and measure the effectiveness of navigation on patient outcomes. The navigation acuity tool must also be able to be utilized by all models of navigation in every setting across the cancer continuum.

Therefore, the objective of this scoping review was to investigate and analyze articles related to components of the oncology acuity tool, including age, race, ethnicity, diagnosis and stage, barriers, and treatment per NCCN guidelines or other national standards published in the past 3 years. These articles will be used to provide an evidence-based navigation-specific acuity tool that is expected to help oncology navigators characterize the complexity of the oncology patient, aid in the allocation of navigation resources, and measure the effectiveness of navigation on patient outcomes. A preliminary search for existing relevant scoping reviews was conducted using PubMed and Cochrane Database of Systematic Reviews; no previous scoping review on this topic was identified.

Methods

Inclusion Criteria

This scoping review considered all studies and interventions, including quantitative studies, qualitative studies, and systematic reviews, implemented and evaluated in the context of age, race, ethnicity, diagnosis and stage, barriers, and treatment per NCCN guidelines or other national standards related to the components of the oncology acuity tool.

Search Strategy

A 3-step search strategy was undertaken: (1) an initial limited search of PubMed; (2) an extensive search using all identified keywords and index terms; and (3) a hand search of the reference lists of included articles. This review was limited to studies published in English from 2018 to 2021. The search was conducted in the PubMed database. Keywords used in the search are shown in Table 1.

Identified articles were assessed for relevance to the current review based on information provided in the title and abstract by 2 independent reviewers. If the reviewers doubted the relevance of a study from the abstract, the full-text article was retrieved. Full-text articles were retrieved for all studies that met the inclusion criteria.

Two reviewers independently examined the full-text articles to determine whether they met inclusion criteria. Disagreements that arose among reviewers were resolved through discussion or input from a third reviewer. Studies identified from reference lists were assessed for relevance based on titles and abstracts. Data were extracted independently by 2 reviewers; any disagreements that arose were resolved through discussion or input from a third reviewer.

Results

After removing duplicates, 1789 articles were screened for inclusion. A total of 555 articles met the inclusion criteria based on titles and abstracts, and full-text publications were then reviewed. After review of full-text publications, 49 relevant articles were identified. The Figure shows the study selection process.

Research Design

A total of 2 studies used a quantitative design, 38 a qualitative design, and 9 used review or systematic review methodology. Table 2 shows the studies included in this scoping review by study design.

Contexts and Populations of Studies

The majority of the analyzed studies were implemented in oncology settings or from population- or registry-based samples. Literature identified for each case study are summarized below and in Table 3.

59-year-old with squamous-cell right base of tongue, stage IVA HPV (head and neck cancer)

We identified 13 articles related to this case.^3-15 These articles discussed clinical presentation and treatment outcomes; patterns of distant metastasis; epidemiologic and clinical characteristics of patients; the impact of time to treatment initiation on outcomes; treatment-related priorities, concerns, and regret among patients; risk factors for refusal of recommended surgery; the impact of travel time on stage at diagnosis; the role of surgery; incidence and survival; multidisciplinary care; the impact of age on disease-specific survival; comorbidity prevalence; and the association between nonsurgical treatment choice and patient disparities.

56-year-old with adenocarcinoma non–small-cell (L-Rad 4B, N2)

We identified 1 article related to this case.¹⁶ This article discussed evidence related to the utilization of multimodality therapy.

32-year-old with invasive ductal carcinoma of the breast stage II (T2N1M0)

We identified 4 articles related to this case.^17-20 These articles discussed incidence, management, presentation, and surveillance; factors predictive of invasion; clinicopathologic and radiologic features; and diagnostic rates, treatments, and outcomes.

55-year-old with infiltrating adenocarcinoma colon cancer stage I (T1N0M0)

We identified 5 articles related to this case.^21-25 These articles discussed sociodemographic predictors of surgery refusal; factors associated with KRAS-mutated cancers; differences in right- and left-sided disease; patterns of presentation, treatment, and survival; and clinicopathologic features and prognosis.

45-year-old with non-Hispanic male diagnosed with AML. Patient will be getting high-dose chemotherapy and stem cell transplant

We identified 4 articles related to this case.^26-29 These articles discussed prognostic markers in patients treated with autologous stem cell transplant after intensive induction chemotherapy; workup and risk stratification of acute myeloid leukemia (AML) based on guidelines, quality of life, and mood of patients receiving chemotherapy; and the impact of remission status on patients’ experiences.

70-year-old Hispanic female with refractory AML

We identified 1 article related to this case.³⁰ This article discussed challenges and supports following intensive chemotherapy.

71-year-old Caucasian male diagnosed with urothelial carcinoma, high grade, stage II

We identified 6 articles related to this case. These articles discussed clinical characteristics and prognostic implications; staging and treatment trends; risks from delayed treatment; clinicopathologic parameters; impact of surgical waiting time on survival; and impact of age on cancer-specific mortality.

47-year-old African American male diagnosed with high-grade prostate cancer, Gleason score 9, 8 of 12 core biopsies are positive

We identified 3 articles related to this case.^37-39 These articles discussed the association between vascularity and histopathology; combination therapy; and patterns of care and outcomes.

72-year-old Caucasian male with metastatic adenocarcinoma of the gastroesophageal junction

We identified 5 articles related to this case.^40-44 These articles discussed first-line palliative treatment; diagnostic tests for preoperative staging; optimal management; and factors associated with second-line treatment.

56-year-old Caucasian female diagnosed with pancreatic ductal carcinoma cT2cN1cM0 (stage IIB)

We identified 7 articles related to this case.^45-51 These articles discussed epidemiology, clinical characteristics, and outcomes; early- versus later-onset disease; risk factors; treatment inequity and ancestry; diagnosis and management; health disparities and treatment adherence; and guidelines.

Case Studies Created to Test the Acuity Tool

A critical phase of the evidence-based navigation acuity tool is testing the tool; 10 case studies were created. The case studies included the following cancers: breast, colon, AML, refractory AML, prostate, lung, gastroesophageal junction, pancreatic, head and neck, and bladder. The case studies included the entire continuum of care from screening/diagnosis to treatment and concluded with the end-of-life or survivorship phase of care.

There are vital outcomes that need to be verified, such as:

• Does the acuity tool score reflect the case study acuity consistently among all the navigators testing the tool?
• Do the weights of the barriers seem appropriate?
• Are there key barriers missing from the acuity tool?

The next step was to set up virtual focus groups for testing the navigation acuity tool with navigators from all different models and settings.

Discussion

The purpose of this scoping review was to investigate and analyze articles related to components of the oncology acuity tool, including age, race, ethnicity, diagnosis and stage, barriers, and treatment per NCCN guidelines or other national standards, published in the past 3 years to provide support for an evidence-based navigation-specific acuity tool. To this end, 49 studies, including 9 reviews, were included. Most studies were published in 2019.

Today’s healthcare is driven by the delivery of value, quality, and outcomes. For cancer programs to receive full reimbursement from payers, they must not only demonstrate that patients receive high-value, high-quality care, they must also show improved patient outcomes. This, in and of itself, is a challenging endeavor. Adding to the challenge are healthcare workforce shortages, diminishing financial resources, and an aging patient population. It has been shown in the literature that navigation services are an essential component of quality oncology services that can address many of the challenges in providing patient-centered, value-based healthcare.^52,53 The Commission on Cancer,⁵⁴ the National Accreditation Program for Breast Centers,⁵⁵ and the Oncology Care Model⁵⁶ are some of the governing bodies that have mandated that navigation processes must be in place to achieve accreditation. The expectation of these agencies is that effective navigation services will impact clinical outcomes, patient experience, and return on investment. Yet, significant programmatic challenges exist for organizations trying to adequately staff navigation programs and provide services to all cancer patients throughout the continuum of care. As navigation programs are developed, administrators struggle to answer questions such as: Which patients need to be navigated and for how long? How do we know if the navigation process has been effective? What is a manageable workload? How can we measure patient outcomes related to navigation? Is navigation cost-effective?

Brennan and Daly identified the acuity attributes, including nonpatient-related, patient-related, provider-related, and system-related, that are related to nursing care of patients on an inpatient unit.¹ In the navigation setting, the diversity of practice settings and types of navigators, along with the need for a tool to be used across the cancer care continuum, present unique challenges. A review of existing navigation tools reveals that a navigation acuity tool, although similar in structure to nursing acuity tools, requires unique structure and measurements. Therefore, to build sustainable navigation programs, we must develop a standardized acuity tool specifically for oncology navigation.

A gap exists in the availability of a standardized and validated evidence-based acuity tool in oncology patient navigation to aid in the optimal allotment of navigation services and resources. An acuity tool can be incorporated into oncology patient navigation programs to support and enhance the effectiveness of navigators through patient-centric evidence-based methods that may have the potential to decrease the overall cost of care.

Limitations of the Scoping Review

This scoping review was limited based on the exclusion of studies published in languages other than English. Another limitation is that only studies published in the past 3 years were included. Older studies may have provided additional relevant information for this review. Lastly, there are navigation standards and national organization core competencies and knowledge domains; some AONN+ members are from other countries and have different standards.

Conclusions

This scoping review was designed to evaluate studies related to components of the oncology acuity tool, including age, race, ethnicity, diagnosis and stage, barriers, and treatment per NCCN guidelines or other national standards, published in the past 3 years to provide an evidence base for the development of 10 disease-specific acuity studies.

A total of 49 relevant studies were identified. The studies were implemented mostly in oncology and population- and registry-based sample settings. The articles provided support and details for each of the 10 case studies. Together, these findings provide an evidence base for the development of an evidence-based navigation-specific acuity tool that is expected to help oncology navigators identify the complexity of the oncology patient, aid in the allocation of navigation resources, and measure the effectiveness of navigation on patient outcomes.

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This Acuity Scoping Review as part of the National Acuity Initiative was sponsored by Astellas Pharma.