Patient experience of primary care and advance care planning: a multicentre cross-sectional study in Japan

Implementing advance care planning in palliative and end of life care: a scoping review of community nursing perspectives

BACKGROUND

Advance care planninganning (ACP) is a priority within palliative care service provision. Nurses working in the community occupy an opportune role to engage with families and patients in ACP. Carers and family members of palliative patients often find ACP discussions difficult to initiate. However, community nurses caring for palliative patients can encourage these discussions, utilising the rapport and relationships they have already built with patients and families. Despite this potential, implementation barriers and facilitators continue to exist. To date, no research synthesis has captured the challenges community nurses face when implementing ACP, nor the facilitators of community nurse-led ACP. Considering this, the review question of: 'What factors contribute to or hinder ACP discussion for nurses when providing care to palliative patients?' was explored.

METHOD

To capture challenges and facilitators, a global qualitative scoping review was undertaken in June 2023. The Arksey and O'Malley framework for scoping reviews guided the review methodology. Six databases were searched identifying 333 records: CINAHL (16), MEDLINE (45), PUBMED (195), EMBASE (30), BJOCN (15), IJOPN (32). After de-duplication and title and abstract screening, 108 records remained. These were downloaded, hand searched (adding 5 articles) and subject to a full read. 98 were rejected, leaving a selected dataset of 15 articles. Data extracted into a data extraction chart were thematically analysed.

RESULTS

Three key themes were generated: 'Barriers to ACP', 'Facilitators of ACP' and 'Understanding of professional role and duty'. Key barriers were - lack of confidence, competence, role ambiguity and prognostic uncertainty. Key facilitators concerned the pertinence of the patient-practitioner relationship enabling ACP amongst nurses who had both competence and experience in ACP and/or palliative care (e.g., palliative care training). Lastly, nurses understood ACP to be part of their role, however, met challenges understanding the law surrounding this and its application processes.

CONCLUSIONS

This review suggests that community nurses' experience and competence are associated with the effective implementation of ACP with palliative patients. Future research is needed to develop interventions to promote ACP uptake in community settings, enable confidence building for community nurses and support higher standards of palliative care via the implementation of ACP.

Association between person-centred care quality and advance care planning participation in haemodialysis

OBJECTIVE

Person-centred care (PCC), which incorporates patients' preferences and values for medical care and their life, has been proposed in decision-making for promoting advance care planning (ACP) among patients with kidney failure. Therefore, we aimed to examine variations in PCC across facilities and the association between PCC and ACP participation.

METHODS

This multicentre cross-sectional study included Japanese adults undergoing outpatient haemodialysis at six dialysis centres. The main exposure was PCC, measured using the 13-item Japanese version of the Primary Care Assessment Tool-short form. The main outcome was ACP participation as defined by discussion with the attending physician or written documentation or notes regarding treatment preferences. A general linear model was used to examine the covariates of the quality of PCC. Modified Poisson regression models were used to examine the associations of ACP participation.

RESULTS

A total of 453 individuals were analysed; 26.3% of them participated in ACP. Higher PCC was associated with greater ACP participation in a dose-response manner (adjusted prevalence ratios for the first to fourth quartiles: 1.36, 2.31, 2.64 and 3.10, respectively) in respondents with usual source of care (USC) than in those without USC. Among the PCC subdomains, first contact, longitudinality, comprehensiveness (services provided) and community orientation were particularly associated with ACP participation. A maximum of 12.0 points of facility variation was noted in the quality of PCC.

CONCLUSIONS

High quality of PCC was associated with ACP participation. The substantial disparity in PCC between facilities provides an opportunity to revisit the quality improvement in PCC.

Public awareness of advance care planning and hospice palliative care: a nationwide cross-sectional study in Korea

CONTEXT

Advance care planning (ACP) and hospice palliative care (HPC) have potential benefits for individuals and health systems. Public awareness of them might increase their acceptance.

OBJECTIVES

To examine public awareness of ACP and HPC and related factors including individuals' experience of health care among Korean population.

METHODS

A cross-sectional study based on a nationally representative sample was conducted. Data from participants aged 15 years or older were examined. Socio-demographic characteristics, health-related factors, health care experience in the past year, and awareness of ACP and HPC were analyzed. Subgroup analysis was conducted to determine associations between specific experiences during outpatient visit and awareness of ACP and HPC.

RESULTS

Of a total of 13,546 subjects, 39.3% and 35.7% reported awareness of ACP and HPC, respectively. About half (48.6%) of participants reported that they were completely unaware of ACP or HPC. Recent outpatient visit was positively associated with HPC awareness. Participants were more likely to recognize ACP or HPC if they had experience in hospitalization and health checkup over the past year and had trust in the medical system. Conversely, participants who had inadequate health care access due to cost burden showed low awareness of ACP and HPC.

CONCLUSION

There was a lack of public awareness of ACP and HPC. There were significant differences depending on various factors, especially individual health care experiences. Appropriate interventions are needed to facilitate discussion of ACP and HPC, thereby increasing public awareness.

From difficulty to meaning - Experiences of patients with advanced cancer having advance care planning conversations and a palliative care plan

PURPOSE

This study aimed to explore the experiences of patients with advanced cancer with Advanced care planning (ACP) communication and drawing up a palliative plan in primary healthcare settings in Norway.

METHODS

In this exploratory qualitative study, data were collected using semi-structured interviews with five patients with cancer who had undergone ACP and had a palliative care plan.

RESULTS

The result shows three main themes with subthemes; (1) The difficult ACP conversation about cancer and death was tough, painful, and considered a "taboo." The patients wished they had been prepared for the conversation and had it in their own homes. (2) Interactions with the doctor/nurse about the palliative care plan helped the patients feel valued and involved and brought their wishes into focus. The next of kin was present but not involved in the process. (3) Having a palliative plan was meaningful for the patients; they felt safe, and it gave them a sense of security.

CONCLUSIONS

Patients with advanced cancer in a home setting in Norway experienced ACP for the preparation of a palliative plan as a process from difficulty to meaning. In this process, the context and interactions provided by the doctor/nurse and their competency in communicating with the patients and involving them as persons was important. The palliative plan gave the patients a sense of meaning, control, and safety connected to the time for the end of life.

Characteristics of international primary care practices and physicians related to advance care planning: a cross-sectional survey study

BACKGROUND

Primary care providers (PCPs) are well-situated to delivery primary palliative care such as advance care planning (ACP). The aim of this work is to identify practice characteristics, including features found in advanced primary care models (APCMs), that predict PCP engagement of patients in ACP.

METHODS

We analyzed characteristics of physician respondents and their practices associated with ACP conversations in older and sicker patients using data from 11 countries who participated in the 2015 Commonwealth Fund International Survey of Primary Care Physicians in 10 Nations. The primary outcome was how routinely these ACP conversations are reported. We used a validated measure to describe practice-level characteristics of advanced primary care models. We conducted bivariate and multivariable analyses to determine PCP and practice characteristics associated with routinely engaging patients in ACP and with documenting patient preferences in medical records.

RESULTS

Respondents (N = 12,049) predominantly were older than 45 and did not view their jobs as high stress. PCPs reported routinely engaging patients in ACP work in practices with more APCM features. They are more likely to view their jobs as high stress, to work more hours, to practice in rural areas, and to work in smaller practices. Multivariable analyses showed that older PCP age, higher perceived stress of the job, practice location in rural areas, and increased number of APCM features were associated with more ACP conversations. Increased number of APCM features was also associated with higher odds of routinely recording patient preferences in their medical records.

CONCLUSIONS

In this international survey, physician and practice characteristics, including having features associated with APCMs, were associated with whether physicians routinely discuss ACP with patients who are older and sicker. Many features of APCMs may facilitate ACP discussions between PCPs and patients.

Culturally Adapted Consensus Definition and Action Guideline: Japan's Advance Care Planning

CONTEXT

A conceptual framework for advance care planning is lacking in societies like Japan's valuing family-centered decision-making.

OBJECTIVES

A consensus definition of advance care planning with action guideline adapted to Japanese society.

METHODS

We conducted a multidisciplinary modified Delphi study 2020-2022. Thirty physicians, 10 healthcare and bioethics researchers, six nurses, three patient care managers, three medical social workers, three law experts, and a chaplain evaluated, in 7 rounds (including two web-based surveys where the consensus level was defined as ratings by ≥70% of panelists of 7-9 on a nine-point Likert scale), brief sentences delineating the definition, scope, subjects, and action guideline for advance care planning in Japan.

RESULTS

The resulting 29-item set attained the target consensus level, with 72%-96% of item ratings 7-9. Advance care planning was defined as "an individual's thinking about and discussing with their family and other people close to them, with the support as necessary of healthcare providers who have established a trusting relationship with them, preparations for the future, including the way of life and medical treatment and care that they wish to have in the future." This definition/action guideline specifically included support for individuals hesitant to express opinions to develop and express preparations for the future.

CONCLUSION

Adaptation of advance care planning to Japanese culture by consciously enhancing and supporting individuals' autonomous decision-making may facilitate its spread and establishment in Japan and other societies with family-centered decision-making cultures.

Relationship between patient-centred care and advance care planning among home medical care patients in Japan: the Zaitaku evaluative initiatives and outcome study

BACKGROUND

There is a growing need to realize high-quality end-of-life care at home that respects the patient's wishes.

OBJECTIVE

To examine the association between the quality of primary care and advance care planning (ACP) participation among patients receiving home-based medical care.

METHODS

In this multicentre, cross-sectional study, 29 home medical care clinics in Japan were included. Adult Japanese patients receiving home medical care were surveyed to assess their consideration of ACP. The quality of primary care, which reflects patient-centredness, was assessed with the Japanese version of the Primary Care Assessment Tool-Short Form (JPCAT-SF). Information on the clinical conditions that require home medical care was collected from physicians.

RESULTS

Of the 194 patients surveyed from 29 home medical services, 62 patients (32%) showed signs of ACP participation. Lack of opportunities was the most common reason for not participating in the ACP. In a multivariable-adjusted generalized estimating equation, primary care quality was associated with ACP participation (per 10-point increase, adjusted odds ratio: 1.96, 95% confidence interval: 1.51-2.56). In addition, all domains of the JPCAT-SF were associated with ACP participation.

CONCLUSIONS

Patient-centredness in home medical care facilitates the initiation of ACP participation.

Avaliação da integralidade na atenção primária à saúde através da Primary Care Assessment Tool: revisão sistemática

Objetivo.

Avaliar a integralidade na atenção primária à saúde (APS) em diferentes países.

Métodos.

Foi realizada uma revisão sistemática nas bases de dados PubMed, Biblioteca Virtual em Saúde e Scopus. Foram selecionados estudos observacionais publicados no período de 2017 a 2019, sem restrições de idioma ou país, que avaliaram a integralidade na APS através da Primary Care Assessment Tool (PCATool) versão adultos. A qualidade dos estudos foi avaliada por meio da escala de Newcastle-Ottawa (NOS).

Resultados.

Dos 124 artigos inicialmente selecionados, 13 foram incluídos neste estudo: quatro da China, dois do Japão e quatro do Vietnã; em relação ao continente americano, todos os quatro estudos incluídos foram realizados no Brasil. Apenas um estudo da África, realizado no Malawi, foi incluído. A qualidade dos estudos conforme a NOS foi satisfatória. A avaliação da integralidade quanto à disponibilidade dos serviços classificou oito locais como tendo baixo grau de orientação à APS, enquanto cinco apresentaram alto grau de orientação. Já para os serviços prestados, nove locais foram classificados como de baixo grau de orientação, e apenas quatro apresentaram alto grau de orientação à APS.

Conclusão.

O baixo grau de orientação à APS quanto à integralidade dos serviços disponíveis e prestados pode ser interpretado como a não compreensão das reais demandas dos usuários, exigindo uma ação concreta para fortalecimento da APS como base dos sistemas de saúde.

Associations of primary care structures with polypharmacy and patient-reported indicators in patients with complex multimorbidity: a multicentre cross-sectional study in Japan

OBJECTIVES

Evidence supporting the effects of primary care structures on the quality of care for patients with complex multimorbidity, which is one of the most important challenges facing primary care, is scarce internationally. This study aimed to examine the associations of the types of primary care facilities with polypharmacy and patient-reported indicators in patients with complex multimorbidity, with a focus on differences between community clinics and hospitals.

DESIGN

Multicentre cross-sectional study.

SETTING

A total of 25 primary care facilities (19 community clinics and 6 small- and medium-sized hospitals).

PARTICIPANTS

Adult outpatients with complex multimorbidity, which was defined as the co-occurrence of three or more chronic conditions affecting three or more different body systems within one person.

PRIMARY OUTCOME MEASURE

Polypharmacy, the Patient-Reported Experience Measure using the Japanese version of Primary Care Assessment Tool Short Form (JPCAT-SF) and the Patient-Reported Outcome Measure using self-rated health status (SRH).

RESULTS

Data were analysed for 492 patients with complex multimorbidity. After adjustment for possible confounders and clustering within facilities, clinic-based primary care practices were significantly associated with a lower prevalence of polypharmacy, higher JPCAT-SF scores in coordination and community orientation, and a lower prevalence of poor or fair SRH compared with hospital-based primary care practices. In contrast, the JPCAT-SF score in first contact was significantly lower in clinic-based practices. The associations between the types of primary care facilities and JPCAT-SF scores in longitudinality and comprehensiveness were not statistically significant.

CONCLUSIONS

Clinic-based primary care practices were associated with a lower prevalence of polypharmacy, better patient experience of coordination and community orientation, and better SRH in patients with complex multimorbidity compared with hospital-based primary care practices. In the primary care setting, small and tight teams may improve the quality of care for patients with complex multimorbidity.

Practices and perspectives of primary care physicians in Japan and the United States about diagnosing dementia: a qualitative study

BACKGROUND

While dementia is a common problem in Japan and the US, primary care physicians' practices and perspectives about diagnosing dementia in these different healthcare systems are unknown.

METHODS

Qualitative research was conducted in an ethnographic tradition using semi-structured interviews and thematic analysis in primary care settings across Japan and in the Midwest State of Michigan, US. Participants were a total of 48 primary care physicians, 24 each from Japan and the US participated. Both groups contained a mixture of geographic areas (rural/urban), gender, age, and years of experience as primary care physicians.

RESULTS

Participants in Japan and the US voiced similar practices for making the diagnosis of dementia and held similar views about the desired benefits of diagnosing dementia. Differences were found in attitudes about the appropriate timing of formally diagnosing dementia. Japanese physicians tended to make a formal diagnosis when problems that would benefit from long-term care services emerged for family members. US physicians were more proactive in diagnosing dementia in the early stages by screening for dementia in health check-ups and promoting advance directives when the patients were still capable of decision-making. Views about appropriate timing of diagnostic testing for dementia in the two systems reflect what medical or nursing care services physicians can use to support dementia patients and caregivers.

CONCLUSIONS

Benefits of making the diagnosis included the need to activate the long-term care services in Japan and for early intervention and authoring advance directives in the US. Testing to establish an early diagnosis of dementia by primary care physicians only partly relates to testing and treatment options available. Benefits of making the diagnosis included the need to activate the long-term care services in Japan and for early intervention and authoring advance directives in the US.

A scoping review of nurse-led advance care planning

BACKGROUND

Advance care planning (ACP) supports persons at any age or health status to determine their values, goals, and preferences regarding future medical care. The American Nurses Association endorses nurses to facilitate ACP to promote patient- and family-centered care.

PURPOSE

This project reviewed and synthesized literature on nurse-led ACP training models.

METHODS

A scoping review used the Arksey and O'Malley Framework to identify: (a) ACP training model type, (b) nurse-led ACP recipients, (c) ACP in special populations, (d) ACP outcomes.

FINDINGS

Of 33 articles reviewed, 19 included 11 established models; however, the primary finding was lack of a clearly identified evidence-based nurse-led ACP training model.

DISCUSSION

Nurses are integral team members, well positioned to be a bridge of communication between patients and care providers. This is a call to action for nurse leaders, researchers, educators to collaborate to identify and implement an evidence-based, effective nurse-led ACP training model.

Healthcare Providers' Perceptions on the Timing of Initial Advance Care Planning Discussions in Japan: a Mixed-Methods Study

BACKGROUND

Most adult patients are willing to discuss advance care planning before the onset of any illness. There might be differences in preferences for timing when it comes to initiating advance care planning discussions by healthcare providers with patients.

OBJECTIVE

To identify healthcare providers' willingness to initiate advance care planning discussions in Japan.

DESIGN

A mixed-methods questionnaire comprising three case scenarios based on three different illness trajectories.

PARTICIPANTS

The study participants were physicians and nurses employed in four community hospitals in Japan.

MAIN MEASURES

Percentages of physicians' and nurses' willingness to initiate advance care planning discussions at four stages of patients' illness trajectory were quantitatively determined, and perceptions on preferred timing were qualitatively identified.

KEY RESULTS

From 108 physician and 123 nurse respondents (response rate: 99%), 291 physician and 362 nurse responses about three case scenarios were obtained. Overall, 51.2% of physicians and 65.5% of nurses (p < 0.001) accepted discussion before illness. Less than one-third of physicians considered advance care planning a "wise precaution," while about two-thirds of nurses did. Additionally, more than half of both physicians and nurses preferred to postpone advance care planning until the patient's imminent death.

CONCLUSIONS

Physicians are less willing than nurses to begin advance care planning discussions before patients' health has deteriorated though most prefer to wait until the patients are close to death. Healthcare providers' attitudes toward advance care planning will need to be addressed to improve rates of completion in Japan.

Physicians' Perceptions and Suggestions for the Adaptation of a US-Based Serious Illness Communication Training in a Non-US Culture: A Qualitative Study

CONTEXT

US-based serious illness communication training pedagogy has not been well studied outside of the United States.

OBJECTIVES

To explore the perception of a US-based, serious illness communication training pedagogy in a non-US culture and to identify aspects requiring cultural adaptations.

METHODS

In September 2019, we conducted a qualitative study using convenient sampling at two urban, academic medical centers in Tokyo, Japan. Semistructured interviews were conducted to Japanese physicians who participated in the four-hour VitalTalk training in Japanese. We explored six majored themes: 1) global impression of the training; 2) main goals from participation; 3) appropriateness of didactics; 4) role play experiences; 5) take away points from the training; and 6) changes in their own communication practice after the training. Interviews were transcribed, coded, and analyzed using phenomenological approach.

RESULTS

All 24 participants found the VitalTalk pedagogy novel and beneficial, stressing the importance of demonstrating empathy, reflecting on own skills, and recognizing the importance of feedback that emphasizes the use of specific words. Participants also pointed out that Japanese patients generally do not express their strong emotions explicitly.

CONCLUSION

Our study found empirical evidence that the VitalTalk pedagogy is perceived to be novel and beneficial in a non-US cultural setting. Cultural adaptations in expression and response to emotion may be required to maximize its efficacy in Japan. To meet the needs of clinical practice in Japan, further studies are needed to empirically test the suggested refinements for the VitalTalk pedagogy.

Development and psychometric properties of the Japanese Consumer Assessment of Healthcare Providers and Systems Clinician & Group Survey (CG-CAHPS)

The Consumer Assessment of Healthcare Providers and Systems Clinician & Group Survey (CG-CAHPS) is one of the most widely studied and endorsed patient experience measures for ambulatory care. This study aimed to develop a Japanese CG-CAHPS and examine its psychometric properties. We evaluated the structural validity, criterion-related validity, internal consistency reliability, and site-level reliability of the scale. Data were analyzed for 674 outpatients aged 18 years or older in 11 internal medicine clinics. The confirmatory factor analysis supported the scale’s structural validity and the same composites (Access, Provider Communication, Care Coordination, and Office Staff) as that of the original CG-CAHPS. All site-level Pearson correlation coefficients between the Japanese CG-CAHPS composites and overall provider rating exceeded the criteria. Results of item-total correlations and Cronbach’s alpha indicated adequate internal consistency reliability. We developed the Japanese CG-CAHPS and examined its validity and reliability to measure the quality of ambulatory care based on patient experience. The results of the Japanese CG-CAHPS survey will provide useful information to providers, organizations, and policy makers for achieving a patient-centered healthcare system in Japan.

[The role of advance care planning and palliative care in new york city during COVID-19 pandemic]

New York City faced an explosive spread of Coronavirus disease 2019 (COVID-19), causing the city's death toll to spike owing to the high virulence of COVID-19. The health care system was on the verge of collapse. Advance care planning (ACP), informed assent, and palliative care played significant roles in supporting patient self-determination and dignity, facilitating decision making, and promoting better care. The importance of these strategies was revisited. Learning from the COVID-19 pandemic in New York City, it is anticipated that several approaches such as ACP and palliative intervention may attract more attention and become increasingly essential to the healthcare system in Japan.

Better Patient Experience is Associated with Better Vaccine Uptake in Older Adults: Multicentered Cross-sectional Study

BACKGROUND

Older adults' uptake of influenza and pneumococcus vaccines is insufficient worldwide. Although patient experience of primary care is associated with vaccine uptake in children, this relationship remains unclear for older adults.

OBJECTIVE

This study examined the association between patient experience of primary care and influenza/pneumococcal vaccine uptake in older adults.

DESIGN AND METHODS

We conducted a multicentered cross-sectional survey involving 25 primary care institutions in urban and rural areas in Japan. Participants were outpatients aged ≥ 65 years who visited one of the participating institutions within the 1-week study period. We assessed patient experience of primary care using the Japanese version of the Primary Care Assessment Tool (JPCAT), which includes six domains: first contact (accessibility), longitudinality (continuity of care), coordination, comprehensiveness (services available), comprehensiveness (services provided), and community orientation. We used a generalized linear mixed-effects model to adjust for clustering within institutions and individual covariates.

KEY RESULTS

One thousand participants were included in the analysis. After adjusting for clustering within institutions and other possible confounders, influenza and pneumococcal vaccine uptake was positively associated with JPCAT total scores (odds ratio per 1 standard deviation increase: 1.19, 95% confidence interval: 1.01-1.40 and odds ratio: 1.26, 95% confidence interval: 1.08-1.46, respectively). Of the JPCAT domains, coordination and community orientation were associated with influenza vaccine uptake and longitudinality, coordination, and comprehensiveness were associated with pneumococcal vaccine uptake.

CONCLUSIONS

Influenza and pneumococcal vaccine uptake were positively associated with patient experience of primary care in older adults. Consideration of patient experience, particularly longitudinality, coordination, comprehensiveness, and community orientation, could improve vaccine uptake.

Translation, adaptation and validation of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) for use in Japan: a multicentre cross-sectional study

OBJECTIVES

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a well-established and internationally recognised scale for measuring patients' experience with hospital inpatient care. This study aimed to develop a Japanese version of the HCAHPS and to examine its structural validity, criterion-related validity and internal consistency reliability.

DESIGN

Multicentere cross-sectional study.

SETTING

A total of 48 hospitals in Japan.

PARTICIPANTS

6522 patients aged ≥16 years who were discharged from the participating hospitals.

RESULTS

Confirmatory factor analysis showed excellent goodness of fit of the same factor structure as that of the original HCAHPS, with the following composites: communication with nurses, communication with doctors, responsiveness of hospital staff, hospital environment, communication about medicines and discharge information. All hospital-level Pearson correlation coefficients between the Japanese HCAHPS composites and overall hospital rating exceeded the criteria. Results of inter-item correlations indicated adequate internal consistency reliability.

CONCLUSIONS

The Japanese HCAHPS has acceptable psychometric properties for assessing patients' experience with hospital inpatient care. This scale could be used for quality improvement based on the assessment of patients' experience with hospital care and for health services research in Japan.

Development of a Japanese version of the Advance Care Planning Engagement Survey: Examination of its reliability and validity

OBJECTIVES

The importance of supporting advance care planning (ACP) by healthcare professionals is recognized worldwide, and assessing the outcomes, such as people's understanding and readiness for ACP, using an appropriate instrument is essential. We, therefore, developed a Japanese version of the Advance Care Planning Engagement Survey (ACP Engagement Survey; 15 items, 9 items, and 4 items), an international scale for assessing the progress of the ACP, and examined its validity and reliability.

METHODS

The ACP Engagement Survey was translated into Japanese, back-translated, and culturally adapted, and the final version was reviewed by the author of the original version. Data on basic demographic information and ACP-related experiences were simultaneously collected as external criteria in an online survey of older adults with chronic diseases. The Cronbach's alpha was calculated to assess its internal consistency, and a retest was performed three days later to calculate the intra-class correlation coefficients (ICCs).

RESULTS

A total of 200 respondents (mean age 70; 9.5% female) were included in the analysis. None of the items showed a ceiling effect, but several items did exhibit a floor effect. The factor structure was the same 2-factor structure as the original version, and both factors exhibited a high cumulative contribution rate. The Cronbach's alphas were 0.94 (15-item version), 0.91 (9-item version), and 0.95 (4-item version), and ICCs were of 0.88 (15-item version), 0.9 (9-item version), and 0.84 (4-item version).

SIGNIFICANCE OF RESULTS

The Japanese version of the ACP Engagement Survey was confirmed to have very good reliability regarding both internal consistency and test-retest reliability. Together with the result of the item analysis, we can conclude that the Japanese version of the ACP Engagement Survey is sufficiently reliable to be utilized in interventional studies, and it has acceptable content validity, construct validity, and criterion-related validity.

Effects of Brief Nurse Advance Care Planning Intervention with Visual Materials on Goal-of-Care Preference of Japanese Elderly Patients with Chronic Disease: A Pilot Randomized-Controlled Trial

Purpose: Advance care planning is an important component of quality palliative care. In Asian countries, few randomized clinical trials have been reported. This pilot randomized-controlled trial examined the effects of brief nurse intervention with visual materials on the goal-of-care preference, cardiopulmonary resuscitation (CPR) preference, and designation of a health care proxy. Methods: This randomized clinical trial was performed from January to February 2018 on elderly Japanese patients with chronic disease. The patients were randomly assigned to a control group (brief nurse intervention using verbal descriptions) or intervention group (using visual materials). The primary endpoint was goal-of-care preference, and secondary outcomes included the following: (1) CPR preference, (2) presence of a designated health care proxy, (3) knowledge of CPR, and (4) readiness for advance care planning. Outcome measures were obtained at baseline and just after completion of the intervention. Results: A total of 220 patients were enrolled (117 in the intervention group and 103 in the control group). All patients completed post-intervention measurement. There was no significant difference between the groups in any of the outcome measures, while <5% of the participants wanted life-prolonging care as the goal of care at the baseline. Before/after comparisons indicated that, in both groups, the number of participants who designated a health care proxy significantly increased (29% to 65% vs. 22% to 52%, respectively; p < 0.001 each); and the knowledge and readiness scores significantly increased. Moreover, there was a significant increase in the number of patients who did not want CPR (55% to 67% with a terminal condition, p = 0.003; 67% to 80% with a bedridden condition, p < 0.001) in the intervention group. Conclusions: Brief nurse intervention increased documentation of a patient-designated health care proxy and improved the knowledge of CPR and patient readiness. Visual materials might help patients to imagine the actual situation regarding CPR.

Frequency of discussing and documenting advance care planning in primary care: secondary analysis of a multicenter cross-sectional observational study

BACKGROUND

To improve the quality of advance care planning (ACP) in primary care, it is important to understand the frequency of and topics involved in the ACP discussion between patients and their family physicians (FPs).

METHODS

A secondary analysis of a previous multicenter cross-sectional observational study was performed. The primary outcome of this analysis was the frequency of and topics involved in the ACP discussion between outpatients and FPs. In March 2017, 22 family physicians at 17 clinics scheduled a day to assess outpatients and enrolled patients older than 65 years who were recognized by FPs as having regular visits. We defined three ACP discussion topics: 1) future decline in activities of daily living (ADL), 2) future inability to eat, and 3) surrogate decision makers. FPs assessed whether they had ever discussed any ACP topics with each patient and their family members, and if they had documented the results of these discussions in medical records before patients were enrolled in the present study. We defined patients as being at risk of deteriorating and dying if they had at least 2 positive general indicators or at least 1 positive disease-specific indicator in the Japanese version of the Supportive and Palliative Care Indicators Tool.

RESULTS

In total, 382 patients with a mean age of 77.4 ± 7.9 years were enrolled, and 63.1% were female. Seventy-nine patients (20.7%) had discussed at least one ACP topic with their FPs. However, only 23 patients (6.0%) had discussed an ACP topic with family members and their FPs, with the results being documented in their medical records. The topic of future ADL decline was discussed and documented more often than the other two topics. Patients at risk of deteriorating and dying discussed ACP topics significantly more often than those not at risk of deteriorating and dying (39.4% vs. 16.8%, p < 0.001).

CONCLUSION

FPs may discuss ACP with some of their patients, but may not often document the results of this discussion in medical records. FPs need to be encouraged to discuss ACP with patients and family members and describe the decisions reached in medical records.

Comparison of Primary Care Experience in Hospital-Based Practices and Community-Based Office Practices in Japan

PURPOSE

The quality of health care, including primary care, is influenced by the context in which care is delivered. We investigated the association between primary care practice location and patient experience with a focus on differences between hospital-based practices and community-based office practices.

METHODS

We conducted a cross-sectional study in a primary care practice-based research network in Japan among 25 participating facilities: 6 small and medium-sized hospitals and 19 community-based offices. We assessed patient experience of primary care using a Japanese version of Primary Care Assessment Tool (JPCAT), which comprises 6 domains: first contact, longitudinality, coordination, comprehensiveness with respect to services available, comprehensiveness with respect to services provided, and community orientation.

RESULTS

Analyses were based on 1,725 primary care patients. After adjustment for possible confounders and clustering within facilities, compared with community-based office practices, hospital-based practices were associated with poorer patient experience of community orientation (adjusted mean difference = -5.76; 95% CI, -10.35 to -1.17). In contrast, hospital-based practices were associated with comparatively better patient experience of first contact (adjusted mean difference = 15.43; 95% CI, 5.13 to 25.72).

CONCLUSIONS

Our study elucidates differences in the strengths and challenges of primary care between hospital-based practices and community-based office practices, with a focus on patient centeredness. Improving community orientation in hospital-based practices and improving accessibility, including out-of-hours care, in community-based office practices may enhance the quality of primary care and promote standardization of care across settings.

Admissions for ambulatory care sensitive conditions on rural islands and their association with patient experience: a multicentred prospective cohort study

OBJECTIVES

The rate of admissions for ambulatory care sensitive conditions (ACSCs) is a key outcome indicator for primary care, and patient experience (PX) is a crucial process indicator. Studies have reported higher rates of admission for ACSCs in rural areas than in urban areas. Whether there is an association between admissions for ACSCs and PX in rural areas has not been examined. This study aimed to document admissions for ACSCs on Japanese rural islands, and assess whether there was an association between the rate of admissions for ACSCs and PX.

DESIGN

Multicentred, prospective, cohort study SETTING: This study was conducted on five rural islands in Okinawa, Japan.

PARTICIPANTS

The study participants were all island inhabitants aged 65 years or older.

PRIMARY OUTCOME MEASURES

This study examined the association between ACSCs and PX assessed by a questionnaire, the Japanese Version of Primary Care Assessment Tool. ACSCs were classified using the International Classification of Diseases, Tenth Revision, and the rate of admissions for ACSCs in 1 year.

RESULTS

Of 1258 residents, 740 completed the questionnaire. This study documented 38 admissions for ACSCs (29 patients, males/females: 15/14, median age 81.9) that included congestive heart failure (11), pneumonia (7) and influenza (5). After adjusting for covariates and geographical clustering, admissions for ACSCs had a significant positive association with each patient's PX scores (OR per 1 SD increase=1.62, 95% CI 1.02-2.61).

CONCLUSIONS

Physicians serving rural areas need to stress the importance of preventive interventions for heart failure, pneumonia and influenza to reduce the number of admissions for ACSCs. Contrary to previous studies, our findings might be explained by close patient-doctor relationships on the rural islands.

Barriers, enablers and initiatives for uptake of advance care planning in general practice: a systematic review and critical interpretive synthesis

OBJECTIVES

How advance care planning (ACP) is conceptualised in Australia including when, where and how ACP is best initiated, is unclear. It has been suggested that healthcare delivered in general practice provides an optimal setting for initiation of ACP discussions but uptake remains low. This systematic review and critical interpretive synthesis sought to answer two questions: (1) What are the barriers and enablers to uptake of ACP in general practice? (2) What initiatives have been used to increase uptake of ACP in general practice?

DESIGN

A systematic review and critical interpretive synthesis of the peer-reviewed literature was undertaken. A socioecological framework was used to interpret and map the literature across four contextual levels of influence including individual, interpersonal, provider and system levels within a general practice setting.

SETTING

Primary care general practice settings DATA SOURCES: Searches were undertaken from inception to July 2019 across Ovid Medline, Cumulative Index to Nursing and Allied Health Literature, Scopus, ProQuest and Cochrane Library of systematic reviews.

RESULTS

The search yielded 4883 non-duplicate studies which were reduced to 54 studies for synthesis. Year of publication ranged from 1991 to 2019 and represented research from nine countries. Review findings identified a diverse and disaggregated body of ACP literature describing barriers and enablers to ACP in general practice, and interventions testing single or multiple mechanisms to improve ACP generally without explicit consideration for level of influence. There was a lack of cohesive guidance in shaping effective ACP interventions and some early indications of structured approaches emerging.

CONCLUSION

Findings from this review present an opportunity to strategically apply the ACP research evidence across targeted levels of influence, and with an understanding of mediators and moderators to inform the design of new and enhanced ACP models of care in general practice.

PROSPERO REGISTRATION NUMBER

CRD42018088838.

Building primary care in Japan: Literature review

Japan's health system is well known for achieving one of the world's highest life expectancy with universal health coverage. However, the country now faces challenges of a rapidly aging population and changes in patterns and burden of disease. Primary care is an important component of a well-functioning health system. In Japan, primary care services are provided in both the community and hospital settings. The distinction between primary and secondary care may not always be clear. This review is based on the framework from the 2015 WHO publication on primary care systems in Europe. Our aim is to describe the journey of primary care in Japan, with its past, present, and future as a valuable addition to the academic English literature. We also hope that this article would inspire readers outside of Japan who might face similar issues in their respective countries.

Associations of Patient Experience in Primary Care With Hospitalizations and Emergency Department Visits on Isolated Islands: A Prospective Cohort Study

PURPOSE

In rural areas, the management of hospitalizations and emergency department (ED) visits is an important issue, and it is compounded by factors such as the long distance to secondary care facilities, funding difficulties in many rural medical institutions, and shortage of medical staff. While better patient experience (PX) has been shown to reduce hospitalizations and ED visits, previous studies have not considered the differences between urban and rural areas. In addressing this gap, this study examines the association between PX and hospitalizations/ED visits on isolated islands.

METHODS

This prospective cohort study was conducted on 5 isolated islands in Okinawa, Japan. We assessed the PX of primary care using the Japanese version of the Primary Care Assessment Tool (JPCAT), which comprises 6 domains: first contact, longitudinality, coordination, comprehensiveness (services available), comprehensiveness (services provided), and community orientation. The primary outcome was hospitalizations and ED visits in a year. We used a mixed effect model to adjust clustering within islands and individual covariates.

FINDINGS

Of 1,258 residents, 740 responded to a questionnaire for PX measurement. There were 73 hospitalizations and 62 ED visits. Adjusting for confounding and geographical clustering, hospitalizations had significant positive association with the PX score of each patient. ED visits were not associated with the total score of the JPCAT.

CONCLUSION

On the isolated islands, PX in primary care had positive correlation with hospitalizations. The contrast of our findings to those of previous studies may be due to the close patient-doctor relationship on isolated islands.

Involvement of Japanese Care Managers and Social Workers in Advance Care Planning

Successful advance care planning relies heavily on effective communication between the elderly and their families, care managers, and social workers. However, care managers and social workers are often not adequately prepared to conduct such discussion. The aim of the present study was to identify the specific challenges facing Japanese care managers and social workers when involvement in advance care planning. Two focus group discussions were held between August and November 2017, involving eleven care managers and three social workers employed at two long-term care facilities actively pursuing advance care planning initiatives. Four main themes were identified, through content analysis, as barriers and facilitators: client readiness, communication, variation-rich client individuality, and difficult-to-explain end-of-life options. This study revealed the importance of building rapport with the residents and their families in order to assess their readiness to discuss care options and preferences. Obstacles included lack of medical knowledge of care managers and social workers. Study findings suggested that a multi-disciplinary team, facilitated by care managers and social workers, was fundamental to achieving the goals of advance care planning.

Social Isolation and Patient Experience in Older Adults

PURPOSE

Social isolation has been identified as a major health problem, particularly in the elderly. In the present study, we examine the association between social isolation and patient experience in elderly primary care patients.

METHODS

This cross-sectional study was conducted in a primary care practice-based research network (28 clinics) in Japan. We assessed social isolation using an abbreviated Lubben Social Network Scale and patient experience of primary care using a Japanese version of the Primary Care Assessment Tool (JPCAT), which comprises 6 domains: first contact, longitudinality, coordination, comprehensiveness (services available), comprehensiveness (services provided), and community orientation. We used a linear mixed effects model to adjust clustering within clinics and individual covariates.

RESULTS

Data were analyzed for 465 elderly primary care patients aged ≥65 years. After adjustment for possible confounders and clustering within clinics, social isolation was negatively associated with the JPCAT total score, (mean difference = -3.67; 95% CI, -7.00 to -0.38). Among the JPCAT domain scores, social isolation was significantly associated with longitudinality, comprehensiveness (service provided), and community orientation scores.

CONCLUSIONS

Social isolation was associated with negative patient experience in elderly primary care patients. Raising awareness regarding patient social networks among primary care providers and targeted interventions for socially isolated elderly patients aimed at improving the experience of primary care, especially regarding longitudinality, comprehensiveness, and community orientation, may be warranted.

Impact of advance care planning on end-of-life management

PURPOSE OF REVIEW

The aim of this review is to critically appraise the recent evidence on different aspects of impact of advance care planning (ACP) in palliative care and to reflect on further implications on practice and research in the future.

RECENT FINDINGS

Evidence about various ACP impacts is rapidly growing and most common outcome measures are still advance directive completion, change in hospital admission rate and patients' and families' views and experiences with ACP. Mainly descriptive studies bring new information of ACP impact for specific groups of patients, their families, settings, countries, contexts, staff and healthcare system as such. It is not yet clear who and when would best conduct ACP, from general practitioners (GPs) to specialists in the hospitals and even lay-navigators for cancer patients; from early ACP conversations to critical ACP in acute events at the end-of-life. The need for ACP impacts high-quality evidence is becoming more urgent because latest future projections are showing higher palliative care needs than previously expected.

SUMMARY

Recent studies on various ACP impacts reveal variety of outcomes for different patient groups and settings, and are contributing to a wider picture of ACP situation around the world. However, high-quality evidence on ACP impact is still urgently expected in times of growing need for system-level changes for effective ACP implementation.

Effect of Patient Experience on Bypassing a Primary Care Gatekeeper: a Multicenter Prospective Cohort Study in Japan

BACKGROUND

To discuss how best to implement the gatekeeping functionality of primary care; identifying the factors that cause patients to bypass their primary care gatekeepers when seeking care should be beneficial.

OBJECTIVE

To examine the association between patient experience with their primary care physicians and bypassing them to directly obtain care from higher-level healthcare facilities.

DESIGN AND METHODS

This prospective cohort study was conducted in 13 primary care clinics in Japan. We assessed patient experience of primary care using the Japanese version of Primary Care Assessment Tool (JPCAT), which comprises six domains: first contact, longitudinality, coordination, comprehensiveness (services available), comprehensiveness (services provided), and community orientation. The primary outcome was the patient bypassing their usual primary care physician to seek care at a hospital, with this occurring at least once in a year. We used a Bayesian hierarchical model to adjust clustering within clinics and individual covariates.

KEY RESULTS

Data were analyzed from 205 patients for whom a physician at a clinic served as their usual primary care physician. The patient follow-up rate was 80.1%. After adjustment for patients' sociodemographic and health status characteristics, the JPCAT total score was found to be inversely associated with patient bypass behavior (odds ratio per 1 SD increase, 0.44; 95% credible interval, 0.21-0.88). The results of various sensitivity analyses were consistent with those of the primary analysis.

CONCLUSIONS

We found that patient experience of primary care in Japan was inversely associated with bypassing a primary care gatekeeper to seek care at higher-level healthcare facilities, such as hospitals. Our findings suggest that primary care providers' efforts to improve patient experience should help to ensure appropriate use of healthcare services under loosely regulated gatekeeping systems; further studies are warranted.

A new model of exercise referral scheme in primary care: is the effect on adherence to physical activity sustainable in the long term? A 15-month randomised controlled trial

INTRODUCTION

Studies had not yet overcome the most relevant barriers to physical activity (PA) adherence. An exercise referral scheme (ERS) with mechanisms to promote social support might enhance adherence to PA in the long term.

SETTING

A randomised controlled trial in 10 primary care centres in Spain.

OBJECTIVE

To assess the effectiveness of a primary care-based ERS linked to municipal resources and enhancing social support and social participation in establishing adherence to PA among adults over a 15-month period.

PARTICIPANTS

422 insufficiently active participants suffering from at least one chronic condition were included. 220 patients (69.5 (8.4) years; 136 women) were randomly allocated to the intervention group (IG) and 202 (68.2 (8.9) years; 121 women) to the control group (CG).

INTERVENTIONS

The IG went through a 12-week standardised ERS linked to community resources and with inclusion of mechanisms to enhance social support. The CG received usual care from their primary care practice.

OUTCOMES

The main outcome measure was self-report PA with the International Physical Activity Questionnaire and secondary outcomes included stages of change and social support to PA practice.

DATA COLLECTION

Participant-level data were collected via questionnaires at baseline, and at months 3, 9 and 15.

BLINDING

The study statistician and research assessors were blinded to group allocation.

RESULTS

Compared with usual care, follow-up data at month 15 for the ERS group showed a significant increase of self-reported PA (IG: 1373±1845 metabolic equivalents (MET) min/week, n=195; CG: 919±1454 MET min/week, n=144; P=0.009). Higher adherence (in terms of a more active stage of change) was associated with higher PA level at baseline and with social support.

CONCLUSIONS

Prescription from ordinary primary care centres staff yielded adherence to PA practice in the long term. An innovative ERS linked to community resources and enhancing social support had shown to be sustainable in the long term.

TRIAL REGISTRATION NUMBER

NCT00714831; Results.

Implementation of an advance directive focus in a Chronic Multi-Organ Rare Disease Clinic

BACKGROUND

Education about an advance directive is frequently not addressed in the outpatient, ambulatory care setting. The objective of this study was to identify patients that do not have an advance directive in a Chronic Multi-Organ Rare Disease Clinic model, and define the role of a social worker in providing advance care planning (ACP).

METHODS

The Chronic Multi-Organ Rare Disease Clinic in-corporates a multi-disciplinary team to provide outpatient care to over 600 patients. A review of advance directives filed in the electronic health record (EHR) prior to hiring a clinic social worker was examined in this high risk population.

RESULTS

A total of 15 patients (2%) of this patient population were identified as having a completed, active advance directive filed with their EHR prior to hiring a clinic social worker. The clinic social worker began ACP discussions and inquiries about the status of patient advance directives with a total of 162 patients during September 2016-April 2017. Of these 162 patients, 14 patients (8.6%) submitted their completed advance directives for filing with their EHR after advanced care discussions were initiated by the clinic social worker. Two patients who completed an advance directive, died during this 7-month time period. Only three patients declined to complete advance directives during this same time period.

CONCLUSIONS

Patient-centered care must incorporate ACP. A clinic social worker is an effective member of a multi-disciplinary team and can incorporate education about advance directives in order to improve health care quality.