Delivering Care by Taking a Step Back

Lay health worker GEE ZHU (center) and MANALI PATEL, MD (right) meet with patient DONALD FREDERICK

Can someone with no medical training improve the quality of life for a terminally ill cancer patient? And will that have any impact on health care costs?

That’s what Manali Patel, MD, an assistant professor of oncology, wanted to find out.

During her undergraduate and medical school studies Patel spent time in rural areas overseas where medical technology is scarce, and she noticed how community members without formal medical skills can be effective health workers.

She wondered if it were possible to counteract the U.S. tendency to over-depend on technology by using lay health workers (nonclinical, nonprofessional personnel with no prior experience in the medical field who are trained in specific skills to help deliver various services, including end-of-life care).

That led her to design a randomized clinical trial of 213 patients with late-stage or recurrent cancer at Palo Alto Veterans Affairs.

The primary objective was to see if lay health worker intervention encouraged patients to discuss their personal goals of care with their medical professionals.

Patel split the patients into two groups. While both groups received the standard of care for their disease, one group (the intervention arm) was also paired with lay health workers who were trained to assist patients with establishing end-of-life care preferences.

Patients in the intervention arm could talk about their worries and concerns with their assigned lay health worker on a regular basis and especially during “trigger points” (for example, after receiving results from a medical exam or imaging test that might cause unease). The workers also encouraged their patients to share with their medical professional or team what they were discussing with the worker.

Patel’s study, “Effect of a Lay Health Worker Intervention on Goals-of-Care Documentation and on Health Care Use, Costs, and Satisfaction Among Patients With Cancer,” was published in the July 26, 2018 issue of JAMA Oncology.

The study’s results exceeded Patel’s expectations. More than 90 percent of the patients who were assigned a lay health worker had the types of discussions described above, while less than 25 percent of the patients without lay health workers had them. The discussions also made patients feel more satisfied with their medical decision making and oncology care.

A startling result of the study was how the lay health worker involvement affected health care costs and use.

“In the last month of life we saw a 95 percent reduction in patients’ health care spending, which was largely because patients did not use the emergency department or the hospital,” Patel notes.

The drop in spending is consistent with patients feeling more empowered to decline those interventions after clarifying their wishes with their lay health worker.

“In my own practice I can get tunnel vision and focus solely on wanting to eradicate or decrease the size of the cancer in hopes that I can make my patients experience less suffering. But sometimes the treatments may make the patient feel worse, and I need a reminder from the patient that the therapies themselves may not necessarily be achieving the gain,” Patel admits.

“The big takeaway from this study is that lay health workers can serve as support for patients to formulate their care preferences and feel encouraged to openly communicate with physicians like myself. Especially when our focus may narrow, our patients allow us to take a step back and think about the big picture,” she adds.