1. Nalley, Catlin

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New research supports the integration of community-based interventions into cancer care for low-income and minority populations as a potentially more effective and sustainable approach that could ensure equitable care, according to a presentation at the 2021 ASCO Quality Care Symposium (Abstract 1).

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"People from low-income households and racial ethnic minorities with cancer-as compared to people from more affluent households and who self-identify as White, non-Latinx-have, for decades, experienced worse cancer outcomes overall, including significantly lower health-related quality of life (HrQOL)," said study author Manali I. Patel, MD, MPH, MS, Assistant Professor in the Division of Oncology at Stanford University. She also noted that they also experience significantly lower patient activation, or a willingness and ability to take independent actions to manage their health and their care.


This results in worse quality of care throughout the continuum of the disease that then leads to worse overall survival, according to Patel. Recognizing the need for community-based interventions to improve patient experiences and quality of care among these populations, Patel and colleagues built on their other work.


They aimed to refine a previously tested intervention called LEAPS, which "uses community health workers trained to activate patients to discuss advance care planning and their symptom burden with cancer clinicians and to connect patients with culturally relevant community resources to overcome complications from social determinants of health."


Patel and colleagues conducted a randomized controlled trial of LEAPS in collaboration with an employer-union health fund.


"In this study, a large labor union health plan approached us to assist with several barriers that they were facing with cancer care delivery amongst their members," explained Patel. "Specifically, the members of this health plan were experiencing very poor quality of cancer care and the costs were exorbitant, so very low-value cancer care delivery."


The health plan was primarily comprised of low-income, minority, hourly-wage workers, who worked in industries such as casinos, restaurants, and hotels. Patel noted these individuals would not have otherwise had health benefits if not for the union plan.


"We used community-based, participatory research methods," she said, creating a community advisory board with the health plan to better understand the unmet needs of its members, their stakeholders, and the community and then developed a multilevel intervention.


"We first started by creating novel payment models for all members of the health plan who were diagnosed with cancer," Patel outlined. "At the time that we were starting this intervention, MD Anderson Cancer Center had just opened up a clinic in Atlantic City. And so, we partnered with this clinic and created benefits, such as waiving copays so that employees would be incentivized to use this clinic.


"We also provided financial assistance programs to individuals, regardless of which program they chose," she continued. "For all participants that were randomized into the intervention group, they also received the same usual care, but they were also assigned to a bilingual care advocate who assisted patients with goals-of-care conversations, [and] proactively managed symptoms."


They also screened for complications for social determinants of health and connected participants to community resources, such as food banks, if food insecurity was an identified need.


Members of the employer-union health fund newly diagnosed with hematologic and solid tumor cancers were randomized to the 6-month intervention or to usual care. The primary objective was to determine if the intervention improved HrQOL. Secondary objectives included goals of care/advance directive documentation, patient activation, health care use, total health care costs, patient-reported satisfaction with cancer care, and end-of-life health care use and health care costs.


Researchers conducted patient interviews to assess HrQOL, as well as patient activation, and obtained claims data for health care use.


"We used regression models to evaluate differences in HrQOL (validated Functional Assessment of Cancer Therapy-General) scores and patient activation (validated Patient Activation Measure) scores between groups over time and exact Poisson regression adjusted for length of follow-up to compare emergency department and hospitalization utilization," according to the study authors.


A total of 160 patients were randomized; 80 were assigned to the intervention arm, and 80 were assigned to usual care. All were included in the intent-to-treat analysis, noted Patel. The researchers observed no differences in demographic or clinical factors across groups.


"Females represented the majority of the patient population across both the control and intervention group," said Patel. "The ages were a mean of 57 years, and we had the highest proportion of individuals self-identify as White, Latino, followed by Black or African American with one-quarter of individuals who identified as White, non-Latino."


In terms of clinical characteristics, the most common diagnoses were breast and gastrointestinal cancer, and the majority were diagnosed with Stage IV disease.


At 4 months, the researchers reported the intervention group had greater improvements in health-related quality of life compared to the control group. They also noted a greater change in patient activation among the intervention group, as well as lower acute care and emergency department use.


During her presentation, Patel acknowledged the limitations of the study, which included the following: single-site study, health care use and total health care costs pending, limited collection of process metrics, and lack of adjustment for multiple comparisons.


She also highlighted the strengths of this research; the most significant being that it was led by the community. "It was formed by a partnership that was a true partnership," Patel said, while noting that this not only included the labor union health plan, but also the clinic in Atlantic City.


"We also had community-based organizations that were represented in our community advisory board," she added. "And it showed how a collaboration with a diverse community and listening to community needs can really lead to a sustainable approach. In fact, the intervention is currently ongoing in Atlantic City as part of usual care for all members and the hope is that we'll see similar benefits and dissemination across multiple sites.


"The takeaways are that it improved HrQOL, improved patient activation, and reduced acute-care use," she concluded. "Hopefully this is a sustainable approach and may be disseminated across other community practices."


Catlin Nalley is a contributing writer.