Interventions by community health workers can improve outcomes in advanced stages of cancer

Interventions led by community health workers appeared to improve outcomes among patients with newly diagnosed recurrent or advanced stage hematological and solid tumors.

According to the results of a randomized clinical trial, among adults with advanced stages of cancer, advance care planning (ACP) and community health worker-guided symptom screening (CHW) and symptom screening posed a risk substantially reduced use of acute care compared to usual cancer care (NCT03154190) published in JAMA Oncology.

The intervention conducted by CHW resulted in a 62% lower risk of acute care use (HR, 0.38; 95% CI, 0.19-0.76) within 6 months and a 17% lower risk (odds ratio [OR], 0.83; 95% CI, 0.69-0.98) within 12 months compared with the control group. It was also found that the intervention group was 8 times more likely to have early care planning documentation (OR, 7.18; 95% CI, 2.85-18.13), 4 times likelihood of palliative care (OR , 4.46; 95% CI, 1.88-10.55), and the odds of having a hospice nearly doubled (OR, 1.83; 95% CI, 1.16-2.88) and improved mental and emotional health from baseline to 6 and 12 months after enrollment (OR, 1.82; 95% CI, 1.03-3.28; and OR, 2.20; 95% CI, 1.04-4 , 65, respectively) with respect to control. Participants in the intervention were also 23.1 percent less likely to seek acute care in the month prior to death than those receiving usual care alone.

“In this study, we developed and implemented a high-level, low-cost, technology-independent intervention that integrates CHWs into cancer treatment soon after an initial or recurrent cancer diagnosis. The intervention was informed by the stakeholders of patients, doctors and payers as a potentially more acceptable and effective approach to overcome our previously identified structural barriers in the provision of these important services, “the researchers wrote.

The randomized study was conducted at the Virginia K. Crosson Cancer Center in Fullerton, California, and examined the activity of 2 part-time CHWs (20 hours / week) for the intervention group. Of the 128 patients included in the analysis, randomization was 1: 1 in the intervention or usual care groups (n = 64 each). The median age of the patients was 67 years (range, 19-89), with the majority of patients being white (67.2%) and privately insured (60.9%). Most patients had at least some undergraduate education or a 2-year college degree (32.8%), a 4-year degree (14.8%), or more than 4 years of college (15.6%). Presenting cancer was most frequently stage IV (75.8%) and many (40.6%) had recurrent disease. The most common sites of malignancy were the gastrointestinal tract (38.2%), thoracic structures (18.8%) or gynecological organs (8.6%).

The 2 CHWs, a retired white nurse and a bilingual Latinx woman, were hired based on their interpersonal skills and trained for their roles using programs developed by the lead researcher. Each delivered structured programs to assigned participants twice a month for 6 months. There were also 1: 1 open discussions between CHW and attendees.

In the primary 6-month period, in addition to the reduction in acute care use and other factors, participants in the intervention group also had a lower risk of emergency room use (ED) (15.6% vs 31.3% ) and 70% fewer mean emergency room visits (RR, 0.30; 95% CI, 0.20-0.47) compared to the control. Notably, there was no statistically significant difference between the odds of using ED (OR, 0.84; 95% CI, 0.70-1.00) or hospitalization (OR, 0.85; 95% CI, 0.71-1.02) between groups at 12 months, but the researchers reported fewer mean events in both categories for those who received CHW-guided intervention compared to standard care (RR, 0.45; CI 95%, 0.33-0.62; and RR, 0.50; 95% CI, 0.36-0.70, respectively).

Some of the benefits of the CHW-led intervention persisted even after the study ended. “In this study … reductions in acute care use were sustained after surgery, suggesting a potential lasting effect. As expected, at the 12-month follow-up, more participants had an emergency room visit or a hospitalization and the differences between groups were smaller. However, the intervention supported a reduction in the number of visits to these services, with a 55% reduction in emergency room visits and 50% hospitalizations 6 months after end of the intervention, “the investigators wrote.

According to the researchers, future research could include examinations of larger and more diverse groups of participants with longer follow-up periods. This study was conducted in a single community clinic and had a low number of black participants, thus limiting generalizability. However, the results indicated potentially robust benefits of CHW-led interventions for adults with advanced stages of cancer.

Reference

Patel MI, Kaphahn K, Dewland M, et al. Effect of a community health worker intervention on acute care use, advance care planning, and patient-reported outcomes among adults with advanced cancer: a randomized clinical trial. JAMA Oncol. 2022; 8 (8): 1139-1148. doi: 10.1001 / jamaoncol.2022.1997

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