While working toward her master's degree in public health, Manali Patel, MD, observed firsthand the benefits of including nonclinical workers in health care. She saw them conduct cervical cancer screenings in Honduras, and help native populations understand how to manage their diabetes in Australia.
Still, Patel was surprised when U.S. patients she surveyed said they would prefer a lay worker to a doctor for discussing one of the most sensitive topics in health: their goals for care -- and the rest of their lives -- after a diagnosis of advanced cancer.
"What we heard from patients was they have better conversations with friends and peers about what their goals are than they do with medical providers," Patel, an assistant professor of medicine at Stanford, told me recently.
Patel took these words to heart. As an oncologist and a fellow with Stanford's Clinical Excellence Research Center, she was looking for new ways the U.S. health system can improve care while reducing spending, particularly for high-cost conditions. She designed a study in which a trained lay health worker conducted ongoing conversations with advanced cancer patients about their personal desires for their care.
"Though all CERC fellows learn the discipline of care innovation design, Dr. Patel is the very first to demonstrate extraordinary impact," said Arnold Milstein, MD, the center's director.
The results of a pilot study of 213 patients at the Veterans Administration Palo Alto Health Care System were published in JAMA Oncology. In sum, as I wrote in the news release:
Patients with advanced cancer who spoke with a trained nonclinical worker about personal goals for care were more likely to talk with doctors about their preferences, report higher satisfaction with their care and incur lower health costs in their final month of life.
Though more research is needed, the findings are promising on several fronts, Patel said.
Discussing bucket list-type questions with someone outside the examination room -- and receiving encouragement to broach the subject with their clinician -- seemed to pave the way for an important conversation that often neither patient nor provider knows how to start.
Opening the line of communication corresponded with more satisfied patients, with those who spoke to the lay health worker giving higher average scores for their oncology care then the control group and reporting higher satisfaction with their decision-making. And ultimately, among patients who died, those in the intervention group were more likely to use hospice services and significantly less likely to visit the emergency department or be hospitalized in their final month. As the release reports, "their median health care cost within 30 days of death was $1,048, compared with $23,482 for the control group."
Patel said these findings track with other studies that connect communication to patient satisfaction, and that indicate patients who understand they have an incurable illness tend to choose less aggressive health care.
The results also illustrate the value of exploring suggestions from patients, even when their ideas seem unconventional. As Patel said in the release:
Communication and listening to patients seem to be the common theme because when providers listen to patients and they're receiving care that's concordant with their goals, they seem to have better outcomes, especially at the end of life.
Photo by Joshua Ness