Engagement of Patients with Advanced Cancer (EPAC) randomized clinical trial: Long-term effects on survival and healthcare use.

Abstract

1513 Background: The Engagement of Patients with Advanced Cancer (EPAC) randomized Veterans with newly diagnosed stage 3 or 4 cancer or recurrent disease to usual care (control) or usual care with 6-month community health worker (CHW) support (intervention) to engage Veterans in end-of-life (EOL) goals and care preference discussions. At 6- and 15-months follow-up, the intervention tripled goals of care documentation (primary outcome), doubled hospice (secondary outcome), and reduced end-of-life (EOL) acute care use (secondary outcome). This post-hoc analysis after 10 years from study initiation evaluates effects on overall survival (OS) and EOL healthcare use. Methods: We abstracted dates of death, emergency department (ED), hospitalization, palliative care (PC), and hospice use within and outside Veterans Affairs (VA) using electronic health record and claims before data cut-off on February 1, 2023 for all EPAC participants. We compared OS using Kaplan Meier and log-rank, risk of death using Cox-proportional hazard models, ED, hospitalization, PC, and hospice use in the last 30 days of life using Logistic Regression, and incidence rate ratios of ED and hospitalizations using Poisson regression. Results: Among 213 participants, there were no imbalances in demographic or clinical characteristics. 165 (77.4%) were White, 211 (99%) males, 80 (37.6%) had lung cancer, and 118 (55.3%) had stage 4 disease. Median follow-up was 298 days (range 12-3438). Intervention group participants had greater OS (log rank p=0.04), 25% reduction in risk of death, lower acute care use, and greater PC and hospice use than control group participants. Conclusions: The CHW-led intervention significantly improved OS and maintained robust effects on EOL healthcare use. The intervention may have had unintended, unmeasured effects on other aspects of care, such as treatment and follow-up adherence, and/or hospice acceptance, which require investigation. Nonetheless, results support integration of community health workers into cancer care to improve clinical outcomes. Clinical trial information: NCT02966509 .[Table: see text]