Health care coach support to assist with advance care planning and symptom management -A randomized controlled trial

Interventions aiming to improve advance care planning uptake in oncology: a scoping review of recent randomized controlled trials

PURPOSE OF REVIEW

The evidence regarding the effectiveness of interventions aiming to improve ACP uptake appears mixed. The purpose of this scoping review is to summarize findings from recent RCTs assessing the efficacy of interventions designed to increase ACP uptake in cancer care.

RECENT FINDINGS

The PubMed database was searched for studies published between 2021 and 2023. Ten RCTs were identified that evaluated a wide range of interventions aimed at encouraging or facilitating ACP communication among patients with advanced cancer, caregivers, and HCPs. Three RCTs developed ACP facilitation tools for patients and sometimes caregivers. Six RCTs involved integrating trained ACP facilitators into patient care, and one RCT used nudges to encourage oncologists trained in ACP discussions to initiate discussions with patients at highest risk of short-term mortality. Most of the reviewed interventions were based on previously tested intervention approaches or tools.

SUMMARY

The key effects identified in this review are the facilitation of ACP discussions among patients, caregivers, and HCPs, and the documentation of patient preferences in the medical record. The direct involvement of facilitators in ACP document drafting and inclusion in patient files, as well as interventions prompting end-of-life discussions, contributed to this effect.

Coaches Activating, Reaching, and Engaging Patients to Engage in Advance Care Planning: A Randomized Clinical Trial

Importance

Advance care planning (ACP) remains low among patients with advanced cancer. Multilevel interventions compared with clinician-level interventions may be more effective in improving ACP.

Objective

To evaluate whether a multilevel intervention could improve clinician-documented ACP compared with a clinician-level intervention alone.

Design, Setting, and Participants

This randomized clinical trial, performed from September 12, 2019, through May 12, 2021, included adults with advanced genitourinary cancers at an academic, tertiary hospital. Data analysis was performed by intention to treat from May 1 to August 10, 2023.

Intervention

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 documentation template (intervention group) or to the clinician-level intervention alone (control group).

Main Outcome and Measures

The primary outcome was ACP documentation in the electronic health record by the oncology clinician within 12 months after randomization. Secondary, exploratory outcomes included shared decision-making, palliative care use, hospice use, emergency department visits, and hospitalizations within 12 months after randomization.

Results

Among 402 participants enrolled in the study, median age was 71 years (range, 21-102 years); 361 (89.8%) identified as male. More intervention group participants had oncology clinician-documented ACP than control group participants (82 [37.8%] vs 40 [21.6%]; odds ratio [OR], 2.29; 95% CI, 1.44-3.64). At 12-month follow-up, more intervention than control group participants had palliative care (72 [33.2%] vs 25 [13.5%]; OR, 3.18; 95% CI, 1.91-5.28) and hospice use (49 [22.6%] vs 19 [10.3%]; OR, 2.54; 95% CI, 1.44-4.51). There were no differences in the proportion of participants between groups with an emergency department visit (65 [30.0%] vs 61 [33.0%]; OR, 0.87; 95% CI, 0.57-1.33) or hospitalization (89 [41.0%] vs 85 [46.0%]; OR, 0.82; 95% CI, 0.55-1.22). Intervention group participants had fewer hospitalizations than control group participants (mean [SD] number of hospitalizations per year, 0.87 [1.60] vs 1.04 [1.77]) and a lower risk of hospitalization (incidence rate ratio, 0.80; 95% CI, 0.65-0.98).

Conclusions and Relevance

In this randomized clinical trial, a multilevel intervention improved oncology clinician-documented ACP compared with a clinician-level intervention alone for patients with genitourinary cancer. The intervention is one approach to effectively increase ACP among patients with cancer.

Trial Registration

ClinicalTrials.gov Identifier: NCT03856463.

Effects of remote dignity therapy on mental health among patients with hematologic neoplasms and their significant others: A randomized controlled trial

BACKGROUND

Families of patients with hematologic neoplasms involved in dignity therapy have exhibited a remarkable improvement in psychological well-being and family functioning. However, the applicability and generalizability of family participatory dignity therapy are limited as it is influenced by factors such as intervention time, place, and participants. Whether remote support from significant others is feasible and effective remains unknown.

OBJECTIVES

This study aimed to confirm the efficacy of significant others participating in remote dignity therapy (r-DT) on hope, dignity loss, meaning of life, and sense of stigma among patients with hematologic neoplasms as well as their significant others' depression and anxiety.

DESIGN

A randomized, single-blinded, two-arm, parallel-group controlled trial.

SETTING(S) AND PARTICIPANTS

Participants included patients with hematologic neoplasms and their significant others, who were recruited from Fujian Medical University Union Hospital from May 2021 to January 2022.

METHODS

A total of 72 eligible participants (patients and significant others) agreed to participate, and were randomly assigned to an intervention group (n = 35) or a control group (n = 37). Each pair of participants in the intervention group participated in two or three conversations based on the online video function of the WeChat platform, performed by one therapist in accordance with a specific communication outline. To evaluate the effects of the intervention, we assessed the patients' degree of dignity loss, hope level, meaning of life, and sense of stigma, as well as their significant others' depression, anxiety, and intimacy at baseline (T0), 15 days (T1), 30 days (T2), and 60 days (T3), and compared the scores between the two groups after the completion of the intervention. The Generalized Estimation Equation Model (GEE) was used to examine the effects of time, group, and their interaction.

RESULTS

The intervention group statistically significantly differed in lower dignity loss (t = 2.190, p = 0.032), higher hope level (t = -2.010, p = 0.049), and higher meaning of life (t = -2.066, p = 0.043) than the control group at T1. Regarding their significant others, the results of the comparison between the two groups showed that significant others in the intervention group had reduced levels of anxiety and depression at T1 and T2 (p < 0.05). The majority of patients (84.38 %) and significant others (75.00 %) provided positive evaluations of the program.

CONCLUSIONS

The r-DT showed a short-term positive effect on decreasing patients' dignity loss and promoting patients' hope and meaning of life; among their significant others, it decreased anxiety and depression.

TRIAL REGISTRATION

Registered in the China Clinical Trial Registry on 17 March 2021(ChiCTR2100044374).

TWEETABLE ABSTRACT

Remote dignity therapy decreased patients' dignity loss and promoted their hope and meaning of life; among their significant others, it decreased anxiety and depression.

The Impact of Palliative Care on Mitigating Pain and Its Associated Effects in Determining Quality of Life among Colon Cancer Outpatients

Pain continues to be a significant problem for cancer patients, and the impact of a population-based strategy on their experiences is not completely understood. Our study aimed to determine the impact of palliative care on mitigating pain and its associated effects in determining the quality of life (QoL) among colon cancer outpatients. Six collection databases were used to perform a structured systematic review of the available literature, considering all papers published between the year 2000 and February 2023. PRISMA guidelines were adopted in our study, and a total of 9792 papers were evaluated. However, only 126 articles met the inclusion criteria. A precise diagnosis of disruptive colorectal cancer (CRC) pain disorders among patients under palliative care is necessary to mitigate it and its associated effects, enhance health, promote life expectancy, increase therapeutic responsiveness, and decrease comorbidity complications. Physical activities, the use of validated pain assessment tools, remote outpatient education and monitoring, chemotherapeutic pain reduction strategies, music and massage therapies, and bridging social isolation gaps are essential in enhancing QoL. We recommend and place a strong emphasis on the adoption of online training/or coaching programs and the integration of formal and informal palliative care systems for maximum QoL benefits among CRC outpatients.

Association between advanced care planning and emergency department visits: A systematic review

BACKGROUND

Advance care planning can help provide optimal medical care according to a patient's wishes as a part of patient-centered discussions on end-of-life care. This can prevent undesired transfers to emergency departments. However, the effects of advance care planning on emergency department visits and ambulance calls in various settings or specific conditions remain unclear.

AIM

To evaluate whether advanced care planning affected the frequency of emergency department visits and ambulance calls.

DESIGN

Systematic review. This study was registered in PROSPERO (CRD42022340109). We assessed risk of bias using RoB 2.0, ROBINS-I, and ROBINS-E.

DATA SOURCES

We searched the PubMed, Cochrane CENTRAL, and EMBASE databases from their inception until September 22, 2022 for studies comparing patients with and without advanced care planning and reported the frequency of emergency department visits and ambulance calls as outcomes.

RESULTS

Eight studies were included. Regarding settings, two studies on patients in nursing homes showed that advanced care planning significantly reduced the frequency of emergency department visits and ambulance calls. However, two studies involving several medical care facilities reported inconclusive results. Regarding patient disease, a study on patients with depression or dementia showed that advanced care planning significantly reduced emergency department visits; in contrast, two studies on patients with severe respiratory diseases and serious illnesses showed no significant reduction. Seven studies showed a high risk of bias.

CONCLUSIONS

Advanced care planning may lead to reduced emergency department visits and ambulance calls among nursing home residents and patients with depression or dementia. Further research is warranted to identify the effectiveness of advanced care planning in specific settings and diseases.

Health Care Professionals' Perspectives on Implementation, Adoption, and Maintenance of a Community Health Worker-Led Advance Care Planning and Cancer Symptom Screening Intervention: A Qualitative Study

PURPOSE

Advance care planning (ACP) and symptom screening are nationally recommended for all patients with advanced stages of cancer. Yet, routine delivery of such care remains challenging because of multilevel barriers. We hired and trained community health workers (CHWs) to assist with delivery of these services across the United States. The aim of this study was to explore health care professionals' perspectives on barriers and facilitators to these team-based approaches.

METHODS

We conducted semistructured interviews with 44 health care professionals in 21 cancer clinics in seven US cities using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. We recorded, transcribed, and analyzed interviews using the framework analysis approach.

RESULTS

Participants noted barriers and facilitators to implementation, adoption, and maintenance of CHW-led ACP and symptom management approaches. Participants were initially skeptical; however, they noted a positive shift in their views over time because of personal experiences and effectiveness in their clinics. There was significant variation in adoption with some using a prescriptive top-down approach and others a bottom-up approach. Most agreed that the combination of top-down and bottom-up approaches would be most efficient and effective for promoting team-based care. All participants discussed implementation and provided suggestions for maintenance including organizational support, leadership, and CHW retention.

CONCLUSION

CHW-led ACP and proactive symptom management interventions are effective and accepted by cancer care professionals at scale. Tailoring on the basis of organization and local contexts is required to ensure successful adoption, implementation, and maintenance of these effective team-based care delivery approaches.

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

Importance

Deficiencies in advance care planning and symptom management are associated with avoidable acute care use among patients with cancer. Community health worker (CHW)-led approaches may be an approach to reduce acute care use but remain untested in community settings.

Objective

To determine whether a CHW-led advance care planning and symptom screening intervention can reduce acute care use more than usual care in a community setting.

Design, Setting, and Participants

This randomized clinical trial was conducted among patients with newly diagnosed advanced-stage or recurrent solid and hematologic cancers from August 8, 2017, through November 30, 2021. Data analysis was performed November 30, 2021, through January 1, 2022, by intention to treat.

Interventions

Participants were randomized 1:1 to usual care (control group) or usual care with the 6-month CHW-led intervention (intervention group).

Main Outcomes and Measures

The primary outcome was acute care use. Secondary outcomes included advance care planning documentation, supportive care use, patient-reported outcomes, survival, and end-of-life care use.

Results

Among 128 participants, median (range) age was 67 (19-89) years; 61 (47.7%) were female; and 2 (1.6%) were American Indian or Alaska Native, 11 (8.6%) were Asian, 5 (3.9%) were Black, 23 (18.0%) were Hispanic or Latino, 2 (1.6%) were of mixed race, 2 (1.6%) were Native Hawaiian or other Pacific Islander, 86 (67.2%) were White, and 20 (15.6%) did not report race. Intervention participants had 62% lower risk of acute care use than the control (hazard ratio, 0.38; 95% CI, 0.19-0.76) within 6 months. At 12 months, intervention participants had 17% lower odds of acute care use (odds ratio [OR], 0.83; 95% CI, 0.69-0.98), 8 times the odds of advance care planning documentation (OR, 7.18; 95% CI, 2.85-18.13), 4 times the odds of palliative care (OR, 4.46; 95% CI, 1.88-10.55), nearly double the odds of hospice (OR, 1.83; 95% CI, 1.16-2.88), and nearly double the odds of improved mental and emotional health from enrollment to 6 and 12 months postenrollment (OR, 1.82; 95% CI, 1.03-3.28; and OR, 2.20; 95% CI, 1.04-4.65, respectively) than the control. There were no differences in the death (control, 26 [40.6%] vs intervention, 32 [50.0%]). Fewer intervention participants had acute care use (0 vs 6 [23.1%]) in the month before death than the control.

Conclusions and Relevance

In this randomized clinical trial, integration of a CHW-led intervention into cancer care reduced acute care use and is one approach to improve cancer care delivery for patients with advanced stages of disease in community settings.

Trial Registration

ClinicalTrials.gov Identifier: NCT03154190.