Effect of a Community Health Worker Intervention on Acute Care Use, Advance Care Planning, and Patient-Reported Outcomes Among Adults With Advanced Stages of Cancer

Abstract

IMPORTANCE Deficiencies in advance care planning and symptom management are associated with avoidable acute care use among patients with cancer. Community health worker (CHW)-led approaches may be an approach to reduce acute care use but remain untested in community settings.OBJECTIVE To determine whether a CHW-led advance care planning and symptom screening intervention can reduce acute care use more than usual care in a community setting.DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial was conducted among patients with newly diagnosed advanced-stage or recurrent solid and hematologic cancers from August 8, 2017, through November 30, 2021. Data analysis was performed November 30, 2021, through January 1, 2022, by intention to treat.INTERVENTIONS Participants were randomized 1:1 to usual care (control group) or usual care with the 6-month CHW-led intervention (intervention group). MAIN OUTCOMES AND MEASURESThe primary outcome was acute care use. Secondary outcomes included advance care planning documentation, supportive care use, patient-reported outcomes, survival, and end-of-life care use. RESULTS Among 128 participants, median (range) age was 67 (19-89) years; 61 (47.7%) were female; and 2 (1.6%) were American Indian or Alaska Native, 11 (8.6%) were Asian, 5 (3.9%) were Black, 23 (18.0%) were Hispanic or Latino, 2 (1.6%) were of mixed race, 2 (1.6%) were Native Hawaiian or other Pacific Islander, 86 (67.2%) were White, and 20 (15.6%) did not report race. Intervention participants had 62% lower risk of acute care use than the control (hazard ratio, 0.38; 95% CI, 0.19-0.76) within 6 months. At 12 months, intervention participants had 17% lower odds of acute care use (odds ratio [OR], 0.83; 95% CI, 0.69-0.98), 8 times the odds of advance care planning documentation (OR, 7.18; 95% CI, 2.85-18.13), 4 times the odds of palliative care (OR, 4.46; 95% CI,, nearly double the odds of hospice (OR, 1.83; 95% CI, 1.16-2.88), and nearly double the odds of improved mental and emotional health from enrollment to 6 and 12 months postenrollment (OR, 1.82; 95% CI, 1. and OR, 2.20; 95% CI,, respectively) than the control. There were no differences in the death (control, 26 [40.6%] vs intervention, 32 [50.0%]). Fewer intervention participants had acute care use (0 vs 6 [23.1%]) in the month before death than the control. CONCLUSIONS AND RELEVANCEIn this randomized clinical trial, integration of a CHW-led intervention into cancer care reduced acute care use and is one approach to improve cancer care delivery for patients with advanced stages of disease in community settings.

Community Health Worker–Led Intervention Improves Acute Care Use and Advance Care Planning for Patients With Cancer

“…Although the current study provides strong support for CHW-led interventions to improve advance care planning and symptom management and reduce unnecessary acute care use among patients with advanced cancer, it also raises additional questions regarding implementation of these interventions. The authors address the limitation of generalizability of their findings because their study was performed in a single community clinic setting.…”

“…The Centers for Medicare & Medicaid Services Oncology Care Model (OCM), an alternative payment model designed to improve the quality and coordination of cancer care, was not significantly associated with differences in hospitalizations, emergency department visits, or survival. The main difference between the OCM study and the current study is the intervention level: practice vs individual level, respectively. This may explain why the CHW-led intervention in the current study had a superior effect on outcomes.…”

“…In this issue of JAMA Oncology , Patel et al present the results of a prospective randomized clinical trial designed primarily to test the effect of a novel, combined community health worker (CHW)–led advance care planning and symptom management intervention on acute care use among patients with advanced cancer in a community cancer clinic. They found that among 128 participants, the 6-month CHW-led intervention reduced acute care use by 62% compared with usual care.…”

“…Following the intervention, symptom burden, psychological distress, and advance care planning improved significantly from baseline, and 77% of patients were referred to palliative care. The combined approach in the current study is innovative, as is the application of the intervention to improve health care use and patient-reported outcomes for patients with advanced cancer.…”

“…The authors describe their intervention as “high-touch, technology independent,” which raises another question of ideal intervention dose and frequency. Although the authors should be lauded for creating an intervention that does not depend on technology, enabling potential implementation within vulnerable populations that may lack technological resources or ability, the inclusion of technology may in fact improve intervention effectiveness.…”