Effect of a Lay Health Worker Intervention on Goals-of-Care Documentation and on Health Care Use, Costs, and Satisfaction Among Patients With Cancer: A Randomized Clinical Trial.

Journal Article (Journal Article)


Although lay health workers (LHWs) improve cancer screening and treatment adherence, evidence on whether they can enhance other aspects of care is limited.


To determine whether an LHW program can increase documentation of patients' care preferences after cancer diagnosis.

Design, setting, and participants

Randomized clinical trial conducted from August 13, 2013, through February 2, 2015, among 213 patients with stage 3 or 4 or recurrent cancer at the Veterans Affairs Palo Alto Health Care System. Data analysis was by intention to treat and performed from January 15 to August 18, 2017.


Six-month program with an LHW trained to assist patients with establishing end-of-life care preferences vs usual care.

Main outcomes and measures

The primary outcome was documentation of goals of care. Secondary outcomes were patient satisfaction on the Consumer Assessment of Health Care Providers and Systems "satisfaction with provider" item (on a scale of 0 [worst] to 10 [best possible]), health care use, and costs.


Among the 213 participants randomized and included in the intention-to-treat analysis, the mean (SD) age was 69.3 (9.1) years, 211 (99.1%) were male, and 165 (77.5%) were of non-Hispanic white race/ethnicity. Within 6 months of enrollment, patients randomized to the intervention had greater documentation of goals of care than the control group (97 [92.4%] vs 19 [17.5%.]; P < .001) and larger increases in satisfaction with care on the Consumer Assessment of Health Care Providers and Systems "satisfaction with provider" item (difference-in-difference, 1.53; 95% CI, 0.67-2.41; P < .001). The number of patients who died within 15 months of enrollment did not differ between groups (intervention, 60 of 105 [57.1%] vs control, 60 of 108 [55.6%]; P = .68). In the 30 days before death, patients in the intervention group had greater hospice use (46 [76.7%] vs 29 [48.3%]; P = .002), fewer emergency department visits (mean [SD], 0.05 [0.22] vs 0.60 [0.76]; P < .001), fewer hospitalizations (mean [SD], 0.05 [0.22] vs 0.50 [0.62]; P < .001), and lower costs (median [interquartile range], $1048 [$331-$8522] vs $23 482 [$9708-$55 648]; P < .001) than patients in the control group.

Conclusions and relevance

Incorporating an LHW into cancer care increases goals-of-care documentation and patient satisfaction and reduces health care use and costs at the end of life.

Trial registration

ClinicalTrials.gov Identifier: NCT02966509.

Full Text

Duke Authors

Cited Authors

  • Patel, MI; Sundaram, V; Desai, M; Periyakoil, VS; Kahn, JS; Bhattacharya, J; Asch, SM; Milstein, A; Bundorf, MK

Published Date

  • October 2018

Published In

Volume / Issue

  • 4 / 10

Start / End Page

  • 1359 - 1366

PubMed ID

  • 30054634

Pubmed Central ID

  • PMC6233780

Electronic International Standard Serial Number (EISSN)

  • 2374-2445

International Standard Serial Number (ISSN)

  • 2374-2437

Digital Object Identifier (DOI)

  • 10.1001/jamaoncol.2018.2446


  • eng