Highlights
- A randomized clinical trial involving 416 Medicare Advantage beneficiaries aged 75+ found that lay health worker-led symptom assessments reduced the odds of emergency department (ED) use by 53%.
- Hospitalization rates were significantly lower in the intervention group, with 68% lower odds compared to usual care.
- The intervention resulted in a mean total cost savings of $12,000 per participant over 12 months.
- End-of-life care was improved, with deceased participants in the intervention group showing 75% lower odds of acute care facility death.
The Unmet Need in Geriatric Oncology
Older adults representing the fastest-growing segment of the cancer population often face a disproportionate burden of symptoms that go undertreated. For patients aged 75 and older, the intersection of malignancy, comorbidities, and age-related physiological decline creates a high-risk profile for acute care utilization. While early symptom identification is a cornerstone of high-quality oncology care, traditional clinical models often rely on patient-initiated reporting, which can be delayed by cognitive barriers, limited health literacy, or the stoicism often seen in the geriatric population. Consequently, many symptoms escalate into crises requiring emergency department (ED) visits and hospitalizations, which are not only costly but also detrimental to the quality of life and functional independence of older patients.
Study Design and Methodology
To address this gap, researchers conducted a multisite randomized clinical trial across 43 oncology clinics in California and Arizona between November 2020 and October 2023. The study, published in JAMA, enrolled 416 Medicare Advantage beneficiaries aged 75 years or older with newly diagnosed, recurrent, or progressive cancer. The median age of participants was 82 years, and over 40% had stage 4 disease, representing a clinically complex and vulnerable cohort.
The Intervention: A Tiered Support Model
Participants were randomized 1:1 into two groups:
- Symptom Assessment Group (n = 200): Received usual care plus lay health worker-led, telephone-based symptom assessments for 12 months. Using the Edmonton Symptom Assessment System (ESAS), lay health workers screened for symptoms such as pain, tiredness, nausea, depression, and anxiety. If a symptom was rated 4 or greater (on a 0-10 scale) or increased by 2 points or more, the lay health worker reviewed the case with an advanced practice practitioner (APP), who then conducted targeted clinical interventions.
- Control Group (n = 216): Received usual care alone.
The primary outcomes were ED use and hospitalizations. Secondary outcomes included total healthcare costs, hospice enrollment, and acute care metrics within 30 days of death for those who passed away during the study period.
Key Findings: Impact on Acute Care and Costs
The results demonstrated a profound reduction in healthcare utilization among those receiving the lay health worker intervention. In the symptom assessment group, only 30.5% of patients had at least one ED visit, compared to 47.7% in the control group (adjusted odds ratio [OR], 0.47; 95% CI, 0.32-0.71). Even more striking was the impact on hospitalizations: 18.5% in the intervention group versus 39.8% in the control group (OR, 0.32; 95% CI, 0.20-0.51).
Economic Efficiency
From a health policy and system perspective, the economic data were particularly compelling. The intervention was associated with lower mean total costs of approximately $12,000 per participant (P = .01). By shifting the focus from reactive acute care to proactive symptom management, the model proved that high-touch support for older adults does not necessarily increase the total cost of care—it optimizes it.
End-of-Life Quality
Among the 142 participants who died during the follow-up period, those in the intervention group experienced significantly better end-of-life care quality. They had 68% lower odds of ED use within 30 days of death and 75% lower odds of dying in an acute care facility. These findings suggest that proactive symptom monitoring facilitates smoother transitions to palliative and hospice care, aligning medical intervention with patient preferences for home-based end-of-life care.
Expert Commentary and Clinical Implications
The success of this trial highlights the potential of “task-shifting” in oncology. By utilizing lay health workers—individuals who do not necessarily have formal clinical degrees but are trained in standardized assessment tools—oncology practices can extend their reach without overextending highly trained nursing or medical staff. This scalable approach addresses the workforce shortages currently facing the oncology and geriatric sectors.
Scalability and Implementation
The use of the Edmonton Symptom Assessment System (ESAS) provided a validated, structured language for symptoms that allowed lay health workers to effectively triage concerns. The critical component of this model, however, was the rapid escalation path to advanced practice practitioners. This ensures that while the screening is low-cost and broad-reaching, the clinical response remains sophisticated and evidence-based.
Methodological Considerations
While the results are robust, it is important to note the specific population studied: Medicare Advantage beneficiaries. The incentives within the Medicare Advantage framework may align more closely with cost-saving interventions than traditional fee-for-service models. Furthermore, the multisite nature of the trial across California and Arizona suggests good generalizability, but further studies in diverse geographic and socioeconomic settings would be beneficial.
Conclusion
The study by Patel et al. provides high-level evidence that a lay health worker-led symptom intervention is a potent tool for reducing acute care use and total costs in older adults with cancer. By identifying symptoms early and providing a structured pathway for intervention, clinicians can prevent the clinical crises that frequently lead to hospitalizations in this vulnerable demographic. This model serves as a blueprint for future geriatric oncology care, emphasizing that proactive, patient-centered monitoring is both clinically effective and economically sustainable.
Funding and ClinicalTrials.gov
This study was supported by various health research initiatives and conducted across oncology clinics within major healthcare networks. ClinicalTrials.gov Identifier: NCT04463992.
References
Patel MI, Voskanyan M, Agajanian H, Agajanian R, Podnos Y, Milstein A. A Lay Health Worker-Led Symptom Intervention and Acute Care Use in Older Adults With Cancer: A Randomized Clinical Trial. JAMA. 2025 Dec 30. doi: 10.1001/jama.2025.23403. Epub ahead of print. PMID: 41468027.
