Integrating primary healthcare into cancer aftercare for older patients post discharge – a pragmatic non-randomized controlled trial

Background

The increasing incidence and survival rates of cancers, driven by an ageing population, present a significant challenge to China’s healthcare system. Patients with cancer are managed and followed-up almost exclusively within tertiary care with resulting overburdened services. Recent policy directives recommend that primary healthcare adopt an expanded role in cancer care, especially in follow-up and aftercare. Advantages include easier access and lower out-of-pocket costs compared to tertiary hospitals, but effective coordination between tertiary hospitals and primary healthcare centres (PHCs) for post-discharge cancer care remains limited. We conducted a pragmatic trial integrating PHCs into aftercare of older cancer patients.

Methods

This pragmatic controlled trial was centred at a tertiary oncology hospital in Nantong, Jiangsu province, China, which treats over 80% of local cancer patients, and involved six PHCs —one urban PHC and five township hospitals—serving as step-down facilities. Patients aged 60 and older with lung, breast, colorectal, or prostate cancer were identified by tertiary physicians after hospitalization for surgery, chemotherapy, or radiotherapy. Participants were assigned according to their preference, to either the usual care group, with aftercare from the tertiary hospital, or the intervention group, where the follow-up and aftercare plan was developed and monitored by tertiary physicians, but delivered by PHC doctors. Outcomes measured were hospital admissions within three months, length of hospital stay, and the mean difference in health-related quality of life (HRQoL) at one - and three - months. Subgroup analyses investigated differential effects by treatment types. This trial was registered (ChiCTR2300073108).

Findings

Of the 1,722 individuals screened, 755 patients (mean age 70.2years, SD 6.40, 276 females [37%] and 479 males [63%]) were enrolled between May 2023 and April 2024. Ninety participants were assigned to the intervention group and 665 to the usual care group. Patients in the intervention group had significantly lower household incomes. Intervention group patients had 43% fewer admissions to tertiary hospital at one-month (IRR = 0.57, 95% CI: 0.41–0.81, p = 0.001), with no significant difference at three months (IRR = 0.96, 95% CI: 0.78–1.18, p = 0.705). Patients who underwent surgery in the intervention group, had an 83% reduction in hospitalizations at one-month (IRR = 0.17, 95% CI: 0.04–0.76, p = 0.020) and a 61% reduction at three months (IRR = 0.39, 95% CI: 0.18–0.82, p = 0.014), compared to control patients who received surgery. Patients in the intervention group had 4.68 fewer admission days within one-month (95% CI: -7.92 to -1.44, p = 0.005) and 4.26 fewer days within three months (95% CI: -8.47 to -0.06, p = 0.047) compared to the control group. Intervention group patients showed better HRQoL, at one month and three months, with a significantly higher adjusted HRQoL at three months (mean difference = 0.05, 95% CI: 0.01 to 0.08).

Interpretation

The model integrating PHCs into post-discharge cancer care significantly reduced overall hospitalizations while improving quality of life and reduced inappropriate use of tertiary care. Randomized controlled trials are needed to further explore benefits of PHCs integration into cancer care.