Cost-effectiveness analysis of community health worker interventions: A systematic review in the United States

Background: Health care costs in the United States remain elevated with significant gaps in health outcomes, especially in vulnerable populations. Objective: To systematically assess if utilizing CHWs can be shown to be a cost effective means of providing health care in the United States. Data Source: PubMed, MEDLINE, Cochrane (1980-October 2016) Study Eligibility Criteria: A strategy to identify relevant articles was developed. The data sources were searched using the following terms: community health worker, lay worker, promotora, link worker, peer based health worker, indigenous health worker, cost, cost analysis, cost allocation, cost benefit analysis, cost control, cost savings, cost of illness, cost sharing, health care costs, direct service costs, employer health costs, hospital costs, and health expenditures. Additionally, studies were selected by searching reference lists of identified articles. Studies were restricted to English and U.S. based studies only. Synthesis Methods: Abstracts and titles were initially screened by one reviewer and relevant abstracts then underwent full text review. Due to heterogeneous cost analyses and data, a meta-analysis was not conducted. Results: A total of 471 unique articles, of which 30 met inclusion criteria for full text review. All interventions presented cost data of the CHW intervention through cost-analysis, itemized costs of the intervention, and hourly wages. Some interventions included simulation models as well. The economic analyses varied in methodology, results, economic perspectives, and staffing. Conclusions: CHW interventions are cost effective when used for targeted outreach for vulnerable populations. This review showed CHW programs to have a positive financial effect on health outcomes and lower costs than usual care, even without taking the societal costs in consideration. Some positive returns on investment as well as savings for Medicaid were shown to be possible. A coherent approach to better define training, function, and title of CHWs nationally may help to enhance the positive economic aspects of these programs. This review is meant to inform key decision makers on the economic cost effectiveness of CHW interventions in the U.S. Continued research should be done to better understand the sustainability of the programs and universality of the certification of CHWs across states