Effects of a standardized community health worker intervention on hospitalization among disadvantaged patients with multiple chronic conditions: A pooled analysis of three clinical trials

Abstract

Objective: To analyze the effects of a standardized community health worker (CHW) intervention on hospitalization.

Data sources/study setting: Pooled data from three randomized clinical trials (n = 1340) conducted between 2011 and 2016.

Study design: The trials in this pooled analysis were conducted across diseases and settings, with a common study design, intervention, and outcome measures. Participants were patients living in high-poverty regions of Philadelphia and were predominantly Medicaid insured. They were randomly assigned to receive usual care versus IMPaCT, an intervention in which CHWs provide tailored social support, health behavior coaching, connection with resources, and health system navigation. Trial one (n = 446) tested two weeks of IMPaCT among hospitalized general medical patients. Trial two (n = 302) tested six months of IMPaCT among outpatients at two academic primary care clinics. Trial three (n = 592) tested six months of IMPaCT among outpatients at academic, Veterans Affairs (VA), and Federally Qualified Health Center primary care practices.

Data collection/extraction methods: The primary outcome for this study was all-cause hospitalization, as measured by total number of hospital days per patient. Hospitalization data were collected from statewide or VA databases at 30 days postenrollment in Trial 1, twelve months postenrollment in Trial 2, and nine months postenrollment in Trial 3.

Principal findings: Over 9398 observed patient months, the total number of hospital days per patient in the intervention group was 66 percent of the total in the control group (849 days for 674 intervention patients vs 1258 days for 660 control patients, incidence rate ratio (IRR) 0.66, P < .0001). This reduction was driven by fewer hospitalizations per patient (0.27 vs 0.34, P < .0001) and shorter mean length of stay (4.72 vs 5.57 days, P = .03). The intervention also decreased rates of hospitalization outside patients' primary health system (18.8 percent vs 34.8 percent, P = .0023).

Conclusions: Data from three randomized clinical trials across multiple settings show that a standardized CHW intervention reduced total hospital days and hospitalizations outside the primary health system. This is the largest analysis of randomized trials to demonstrate reductions in hospitalization with a health system-based social intervention.

Keywords: access/demand/utilization of services; determinants of health/population health/socioeconomic causes of health; internal medicine; social determinants of health.

FIGURE 1

Consort Diagram Note: Across all three trials included in this pooled analysis, 2588 individuals were screened for eligibility, 2504 were found to be eligible, and 1340 consented to be part of the intervention. Of these 1340 participants, 664 were allocated to usual care, and 676 to the CHW intervention. Hospitalization data were available for all but 2 of the intervention participants and all but 4 of the control participants.

FIGURE 2

Cumulative Hospitalizations Over 9 months Following Enrollment [Color figure can be viewed at wileyonlinelibrary.com] Notes: This graph shows the cumulative number of hospitalizations for patients in the intervention control groups in the nine months following enrollment, including the six‐month IMPaCT intervention period and a three‐month postintervention period. This graph uses only data from trials 2 and 3, for which longitudinal hospitalization data were available.