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Design and Participants: For patients with advanced genitourinary cancers, this trial (2019-2021, at an academic, tertiary hospital) evaluated whether a multilevel intervention (clinician-level and patient-level) could improve clinician-documented ACP vs a clinician-level intervention alone. Participants were randomized 1:1 to a 6-month patient-level lay health worker–structured ACP education along with a clinician-level intervention composed of 3-hour ACP training and integration of a structured electronic health record (EHR) documentation template (intervention) or to the clinician-level intervention alone (control). The primary outcome was ACP EHR documentation by the oncology clinician within 12 months post randomization. Secondary outcomes included shared decision-making, palliative care use, hospice use, emergency department visits, and hospitalizations within 12 months. Analyses (intention to treat) used logistic regression and generalized estimating equations log-Poisson models.
Results: Participants (N=402) were aged median 71 years (range=21-102); 90% male; and 13% Asian, 11% Hispanic/Latino, 7.0% Pacific Islander, 5.2% non-Hispanic Black, 62% non-Hispanic White, and 1.0% multiracial. More intervention participants had clinician-documented ACP than control (38% vs 22%; odds ratio [OR]=2.3; 95% CI=1.4-3.6). At 12-month follow-up, more intervention than control participants had palliative care (33% vs 14%; OR=3.2; 1.9-5.3) and hospice use (23% vs 10%; OR=2.5; 1.4-4.5). There were no between-group differences in the proportion of participants with emergency department visits (30% vs 33%; OR=0.87; 0.57-1.3) or hospitalization (41% vs 46%; OR=0.82; 0.55-1.2). Intervention had fewer hospitalizations than control (hospitalizations/yr, mean=0.87 [SD=1.6] vs. 1.0 [1.8]) and a lower risk of hospitalization (incidence rate ratio=0.80; 0.65-0.98).
Commentary: Highlighting that ACP is a process rather than a singular event, this study utilized trained lay health workers to engage in 6 months of discussion with patients while partnering with their oncology team. It’s no surprise that patients who had access to this resource were more likely to engage in palliative care and hospice. With better understanding and improved ability to plan while experiencing advanced cancer, these patients—despite similar emergency department use—had lower risk and frequency of hospitalization. This model showcases how collaboration between trained lay health workers and medical experts can leverage each specialty’s strengths and addresses common barriers to ACP including limited clinician time and patient hesitancy, and it could be adaptable across various settings.
Bottom Line: Integrating trained lay health workers into longitudinal ACP can improve patients’ knowledge and improve access to palliative care and hospice, empowering patients to request and receive care aligned with values and goals.
Reviewer: Amy Klein, MD FAAHPM, University of Arizona, Tucson, AZ
References:
1. Tang ST, Liu TW, Liu LN, Chiu CF, Hsieh RK, Tsai CM. Physician-patient end-of-life care discussions: correlates and associations with end-of-life care preferences of cancer patients—a cross-sectional survey study. Palliat Med. 2014;28(10):1222-1230. doi:10.1177/0269216314540974.
2. Waller A, Turon H, Bryant J, Zucca A, Evans TJ, Sanson-Fisher R. Medical oncology outpatients’ preferences and experiences with advanced care planning: a cross-sectional study. BMC Cancer. 2019;19(1):63. doi:10.1186/s12885-019-5272-6.
3. Bernard C, Tan A, Slaven M, Elston D, Heyland DK, Howard M. Exploring patient-reported barriers to advance care planning in family practice. BMC Fam Pract. 2020;21(1):94. doi:10.1186/s12875-020-01167-0.
Source: Rodriguez GM, Parikh DA, Kapphahn K, et al. Coaches activating, reaching, and engaging patients to engage in advance care planning: a randomized clinical trial. JAMA Oncol. 2024;10(7):949-953. doi:10.1001/jamaoncol.2024.1242.
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