Multilevel intervention increases advance care planning for people with advanced cancer
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A multilevel care intervention increase advanced care planning versus clinician-level intervention alone for patients with genitourinary cancer, according to study results.
The randomized clinical trial included 402 adults (median age, 71 years; range, 21-102) treated for advanced genitourinary cancers at Stanford Cancer Institute.
Researchers randomly assigned 217 participants to 6-month patient-level lay health worker-provided advanced care planning (ACP) education, plus a clinician-level intervention consisting of 3-hour ACP training and integration of a structured electronic health record documentation template. The other 185 participants received the clinician-level intervention only.
A higher percentage of patients assigned the multilevel intervention had clinician-documented ACP (37.8% vs. 21.6%; OR = 2.29; 95% CI, 1.44-3.64).
A higher percentage of those assigned the multilevel intervention received palliative care (33.2% vs. 13.5%; OR = 3.18; 95% CI, 1.91-5.28) and used hospice services (22.6% vs. 10.3%; OR = 2.54; 95% CI, 1.44-4.51) by 12-month follow-up.
Results also showed a lower risk for hospitalization in the intervention group (incidence rate ratio = 0.8; 95% CI, 0.65-0.98).
“We saw improvements with this intervention, but we would always like to see more improvements,” Gladys M. Rodriguez, MD, MS, assistant professor of medicine in the division of hematology and oncology at Northwestern Feinberg School of Medicine, told Healio. “My hope with this study is that we can encourage other multilevel interventions that can build on this study to further improve advanced care planning.”
Healio spoke with Rodriguez about the importance of ACP for patients with advanced cancer, the historically low use of ACP in this population and the potential impact of this study.
Healio: How important is ACP for people with cancer?
Rodriguez: ACP is a discussion between the patient and clinicians regarding patients’ goals, values and preferences at the end of life. ACP is fundamental, especially for patients who have advanced cancer. Our hope is always that we can honor the patient’s wishes, but data also has shown that patients who engage in ACP have less acute care use. They have increased use of palliative care, and overall improved quality of life and satisfaction.
Healio: Why do you think ACP use has historically been low?
Rodriguez: The reasons are multifactorial. One reason is a lack of time. There’s not a great deal of capacity during appointments for physicians to discuss these frequently sensitive issues with patients. Also, there’s not much training for clinicians about how to discuss ACP, even though there has been some push to increase it.
For some minority populations, this topic is very taboo and there may be a lack of cultural awareness, so this has been another barrier.
Healio: Why did you conduct this study?
Rodriguez: Increasing ACP is one of the main areas of research for the principal investigator of this study, Manali Patel, MD, MPH Dr. Patel works with community health workers and lay health workers on this. The idea was to combine two interventions we know work individually to see if that could improve ACP rates among patients with advanced cancer.
Healio: What did the multilevel intervention entail?
Rodriguez: All patients in the study received usual care. Those in the intervention arm received additional structured education about ACP via hour-long, twice-monthly sessions delivered by a trained lay health worker. The lay worker wrote structured accounts in the medical record of their conversations with the patient and sent it to the physician or oncologist to fill in their part.
Our primary outcome was whether the intervention increased the amount of advanced care planning compared with usual care. Secondary outcomes included whether the intervention increased palliative care use, increased hospice care or affected hospitalization.
Healio: What did you find?
Rodriguez: It did increase the odds of ACP documented by oncology clinicians in the medical records — more than a twofold increase over the control arm, which was significant. Patients in the intervention arm had greater odds of being enrolled in palliative care and getting hospice referrals. The intervention also reduced hospitalizations. Although we didn’t find was much difference in odds of hospitalization, the number of times patients were hospitalized was decreased.
Healio: What are the next steps in research?
Rodriguez: This study was done in a population of patients with genitourinary cancers. My hope is that we can broaden it to other populations with advanced cancers and also to a more diverse population. I do think these findings are applicable to any patient with advanced cancer.
Reference:
For more information:
Gladys M. Rodriguez, MD, MS, can be reached at gladys.m.rodriguez@nm.org.
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