Improving cancer care for older adults: Updated results from a randomized clinical trial.

3 Background: Undertreated cancer symptoms are common among older adults, yet effective early intervention remains limited. In prior work, our team developed a proactive symptom assessment approach to reduce unwanted hospital use among older adults with cancer. In a cohort study, we demonstrated the intervention association on reductions in acute care use and total costs of care. The effect at scale remains unknown. Methods: We conducted this multi-site randomized trial across 43 community-based oncology clinics in California and Arizona between November 2020 through October 2023 with 12 months follow-up. Medicare Advantage beneficiaries ages 75 years or older with newly diagnosed cancer who were planning to receive care at any of the clinics were eligible. Participants were consented and randomized 1:1 into a control group (usual care alone) or intervention group (usual care with LHW-led proactive, telephone-based weekly symptom assessments for 12 months using the Edmonton Symptom Assessment System) with planned enrollment of 200 in both groups. The LHW reviewed assessments with an advanced practice practitioner who conducted any necessary intervention for symptoms that changed by 2 points or were rated 4 or greater. Outcomes were determined a priori. The primary outcome was emergency department (ED) use and hospitalizations. Secondary outcomes included total costs, hospice, and, among decedents, acute care use within 30 days of death and facility deaths. Semi-structured 30 minute interviews were conducted with patients, caregivers, clinicians, and payer representatives to inform future adoption. Results: Among 416 patients (216 control; 200 intervention) median age was 82 years (range 75-99); 205 (49.3%) were Hispanic or Latino, 10 (2.4%) African American or Black, 3 (0.7%) American Indian or Alaska Native, 12 (2.9%) Asian, 4 (0.9%) Native Hawaiian, 2 (0.5%) Pacific Islander, 180 (43.3%) Non-Hispanic White, 20 (4.9%) with multiple races; 219 (52.6%) were male; 171 (41.1%) had stage 4 disease. Intervention group participants had 53% lower odds of ED use (OR: 0.47, 95% CI 0.37-0.62), 68% lower odds of hospital use (OR: 0.32, 95% CI 0.20-0.51), and lower mean total costs of care by $12,000 USD per participant (p = 0.01) than control group participants. Among 142 deceased (71 in each group) the intervention group had 68% lower odds of acute care (OR: 0.32, 95% CI 0.12-0.88) and 75% lower odds of a facility death (OR 0.25; 95% CI 0.08-0.77). Patients noted positive experiences with the intervention, caregivers noted lower caregiver-burden, clinicians noted efficiency in care due to the between-clinic intervention aspects, and payers noted return on investment. Conclusions: This intervention may be a scalable, value-based approach to reduce acute care use for older adults with cancer. Clinical trial information: NCT04463992 .