Community Health Worker Interventions May Improve Outcomes in Advanced Stages of Cancer

Among adults with advanced stages of cancer, community health worker (CHW)–led advance care planning (ACP) and symptom screening resulted in a substantially decreased risk of acute care use compared with usual cancer care alone, according to results from a randomized clinical trial (NCT03154190) published in JAMA Oncology.

CHW-led intervention 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 vs the control group. The intervention group was also found to have an 8-fold odds of advance care planning documentation (OR, 7.18; 95% CI, 2.85-18.13), 4 times odds of palliative care (OR, 4.46; 95% CI, 1.88-10.55), and nearly doubled odds of hospice (OR, 1.83; 95% CI, 1.16-2.88) and improved mental and emotional health from baseline to 6 and 12 months following enrollment (OR, 1.82; 95% CI, 1.03-3.28; and OR, 2.20; 95% CI, 1.04-4.65, respectively) vs control. Intervention participants were also 23.1% less likely to have acute care use in the month before death vs those receiving usual care alone.

“In this study, we developed and implemented a high-touch, low-cost, technology-independent intervention that integrates CHWs into cancer care soon after an initial or recurrent cancer diagnosis. The intervention was informed by patient, clinician, and payer stakeholders as a potentially more acceptable and effective approach to overcome our previously identified structural barriers in the delivery of these important services,” the investigators wrote.

The randomized trial was conducted at the Virginia K. Crosson Cancer Center in Fullerton, California, and examined the activity of 2 part-time (20 hours/week) CHWs for the intervention group. Of the 128 patients included in the analysis, randomization occurred in a 1:1 fashion to either the intervention or usual care groups (n = 64 each). The median patient age was 67 years (range, 19-89), with most patients being White (67.2%) and privately insured (60.9%). Most patients had at least some college education or a 2-year degree (32.8%), a 4-year college degree (14.8%), or more than 4 years of college (15.6%). Cancer upon presentation was most frequently at 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 gynecologic organs (8.6%).

The 2 CHWs, a White retired nurse and a bilingual Latinx woman, were hired based on their interpersonal skills and were trained for their roles using curricula developed by the lead investigator. Each delivered structured programs to their assigned participants twice monthly over 6 months. Open-ended discussions also occurred 1:1 between CHWs and participants.

Within the primary 6-month period, in addition to the reductions in acute care use and other factors, participants in the intervention group also had lower Emergency Department (ED) use risk (15.6% vs 31.3%) and 70% fewer mean ED visits (RR, 0.30; 95% CI, 0.20-0.47) than the control. Notably, there was not a statistically significant difference between odds of ED use (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 investigators did report fewer mean events in both categories for those receiving CHW-led intervention vs standard care (RR, 0.45; 95% CI, 0.33-0.62; and RR, 0.50; 95%CI, 0.36-0.70, respectively).

Some of the benefits of CHW-led intervention persisted even after the conclusion of the study. “In this study…acute care use reductions were sustained after the intervention, suggesting a potential enduring effect. As expected, at 12-month follow-up, more participants had either an ED visit or a hospitalization, and the between-group differences were smaller. Yet the intervention sustained reductions in the numbers of visits to these services, with 55% reductions in ED visits and 50% reductions in hospitalizations 6 months after the intervention ended,” the investigators wrote.

According to investigators, future research may include examinations of larger and more diverse participant groups with longer follow-up periods. This trial was conducted in only 1 community clinic and had a low number of Black participants, thereby limiting generalizability. Nonetheless, the results indicated the potentially robust benefits of CHW-led interventions for adults with advanced stages of cancer.

Reference

Patel MI, Kapphahn 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 stages of cancer: a randomized clinical trial. JAMA Oncol. 2022;8(8):1139-1148. doi:10.1001/jamaoncol.2022.1997