Wednesday, September 5, 2018

Lay Health Workers Increase Documentation of Care Preferences

by Ben Skoch (@skochb)

Review of Effect of a Lay Health Worker Intervention on Goals-of-Care Documentation and on Health Care Use, Costs, and Satisfaction Among Patients with Cancer. A Randomized Clinical Trial. Patel MI, Sundaram V, Desai M, et al. JAMA Oncology July 2018. doi:10.1001/jamaoncol.2018.2446

I’m sure many, if not most health professionals who have spent time around an oncology unit have encountered patients receiving care in the late stages of their disease and had the thought, “Is this really helping?” Or possibly, “Has anyone asked this patient how they feel about this treatment?” As a palliative medicine physician, it feels like having these conversations have become a cornerstone to the type of care I provide. Knowing palliative care is a relatively young field, the number of cancer patients is increasing, and that those patients on the whole are living longer with their diseases, it becomes clear palliative care clinicians will need help in having these conversations. Furthermore, a dedicated effort to document these conversations will be imperative to communicate those wishes to all of the patient’s healthcare providers.

This quality improvement study indicates help might not be as far away as it might seem. What the study calls a “lay health worker” (LHW) was one individual with a BA degree currently doing a part time health education program. That person received additional training in the form of online training modules, as well as shadowing the institution’s palliative care team. Once trained, the LHW performed five tasks under the supervision of a registered nurse. The LHW provided the intervention group of patients with education on goals-of-care principles, establishing care preferences, identifying a surrogate decision maker, filing an advance directive, and encouraging patients to discuss care preferences with providers.

A part-time, blinded study was conducted at a single center, a VA medical system in California. Patients had either newly diagnosed stage III or IV solid tumors, or recurrent disease. The two groups were divided into an intervention arm (where they worked with their oncology team in addition to the LHW) and a usual care arm (oncology team alone), with over 100 patients in each arm. It is important to note 99% of the patients in this study were men, 77% of whom were Caucasian.

The primary objective was simply to see if the system could increase documentation of patient wishes and goals of care in late stage cancer. The usual care group had 17.6% and 24.1% goals of care documentation at 6 and 15 months post-randomization, while the intervention group had 92.4% and 93.3% at the same checkpoints. An advance directive was documented 25.9% and 33.3% of the time for usual care, and 67.6% and 74.3% in the intervention group. Secondary outcomes showed higher patient satisfaction, low emergency department utilization within 30 days of death, lower hospitalization rates within 30 days of death, higher hospice utilizations within 30 days of death, and decreased overall healthcare costs within 30 days of death in the intervention arm. And all of them were statistically significant. The authors point out cost savings did not translate to the groups when examined at 15 months post-randomization.

Interestingly, mortality rates among the two groups were nearly identical (57.1% for intervention and 55.5% for control). Some might expect the control group who utilized hospice at a higher rate within the last thirty days of life would have a significantly higher mortality rate, but this was not the case.

The knee-jerk reaction to this study is, “Let’s get a lay health worker trained!” It’s especially appealing when it was described that implementation costs (about $20,000) paled in comparison to rough estimates of net savings for the health care system (about $3 MILLION). It seems to me that this would be a legitimate feeling, especially considering that palliative care usage did not differ among the two groups. In other words, this LHW was able to locate people who did not need specialized palliative care to have these conversations, they simply needed someone to have them with. So often it is cited clinicians don’t have enough time during a regular patient visit, or think they have more time in the future to address these issues. That is, until often it becomes too late for a person to make their wishes known. Maybe this intervention really could be a game changer moving into the future of health care.

But before you go singing this from the mountain tops, I’d caution you to practice a healthy sense of skepticism. As was stated, the study population was fairly uniform (mostly white men in the VA system in California). A repeat of this study across hospital systems in other geographic locations would be extremely helpful to see if the results are reproducible and generalizable. But at the very least, I hope this helps spread the message that people might be more ready than physicians think to have goals of care and advance care planning conversations. Perhaps we just need to ask more.

Ben Skoch, DO, MBA, a Hospice and Palliative Medicine physician at the University of Kansas Medical Center. Outside of Family Medicine and Palliative Medicine, he enjoys most sports, black coffee, and most especially spending time with his wife and two adorable children.

More posts from Ben Skoch here. More Pallimed posts about advance care planning can be found here

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