Community palliative care development: evaluating the role and impact of a general practitioner with a special interest in palliative medicine

How We Should Assess the Delivery of End-Of-Life Care in General Practice? A Systematic Review

BACKGROUND

The majority of end-of-life (EOL) care occurs in general practice. However, we still have little knowledge about how this care is delivered or how it can be assessed and supported.

AIM

(i) To review the existing evaluation tools used for assessment of the delivery of EOL care from the perspective of general practice; (ii) To describe how EOL care is provided in general practice; (iii) To identify major areas of concern in providing EOL care in this context.

DESIGN

A systematic review.

DATA SOURCES

Systematic searches of major electronic databases (Medline, EMBASE, PsycINFO, and CINAHL) from inception to 2017 were used to identify evaluation tools focusing on organizational structures/systems and process of end-of-life care from a general practice perspective.

RESULTS

A total of 43 studies representing nine evaluation tools were included. A relatively restricted focus and lack of validation were common limitations. Key general practitioner (GP) activities assessed by the evaluation tools were summarized and the main issues in current GP EOL care practice were identified.

CONCLUSIONS

The review of evaluation tools revealed that GPs are highly involved in management of patients at the EOL, but there are a range of issues relating to the delivery of care. An EOL care registration system integrated with electronic health records could provide an optimal approach to address the concerns about recall bias and time demands in retrospective analyses. Such a system should ideally capture the core GP activities and any major issues in care provision on a case-by-case basis.

Palliative care consultations in primary care: a cross-sectional survey among Dutch general practitioners

BACKGROUND

Expert consultation supports general practitioners (GPs) in delivering adequate palliative homecare. Insight into consultation practices from a GP's perspective is needed in order to shape consultation services to their wishes and needs.

AIM

To explore palliative care consultation practices from a GP's perspective.

DESIGN AND SETTING

Cross-sectional web-based survey among all GPs (n=235) in the region of Nijmegen, the Netherlands.

METHODS

Our questionnaire contained questions about the delivery of palliative care by GPs, their consultation practices and satisfaction with current services. Questions consisted mainly of 5-point Likert scales. We transformed these scales into numerical values to calculate mean scores. Linear mixed models for repeated measurements were used to study differences in scores.

RESULTS

GPs most often consulted informal caregivers (mean score 3.6) or fellow GPs (mean score 3.3). Physical problems were discussed the most (mean score 3.5), while social and existential issues were discussed least (mean score 1.9 for both). In their choice of a particular consultation service, GPs considered the quality of the provided advice to be the most important factor. GPs were satisfied with current consultation services, with fellow GPs receiving the highest satisfaction scores (mean score 4.6). Finally, when recalling their last palliative patient, most GPs started requesting consultation during this patient's last month of life.

CONCLUSIONS

Next to informal caregivers, GPs preferably seek advice from fellow GPs. Physical issues receive much attention during consultations; however, other vital aspects of palliative care seem to remain relatively neglected, such as social and existential issues and a proactive care approach.

Demand management for planned care: a realist synthesis

Background

The task of matching fluctuating demand with available capacity is one of the basic challenges in all large-scale service industries. It is a particularly pressing concern in modern health-care systems, as increasing demand (ageing populations, availability of new treatments, increased patient knowledge, etc.) meets stagnating supply (capacity and funding restrictions on staff and services, etc.). As a consequence, a very large portfolio of demand management strategies has developed based on quite different assumptions about the source of the problem and about the means of its resolution.

Methods

This report presents a substantial review of the effectiveness of main strategies designed to alleviate demand pressures in the area of planned care. The study commences with an overview of the key ideas about the genesis of demand and capacity problems for health services. Many different diagnoses were uncovered: fluctuating demand meeting stationary capacity; turf protection between different providers; social rather than clinical pressures on referral decisions; self-propelling diagnostic cascades; supplier-induced demand; demographic pressures on treatment; and the informed patient and demand inflation. We then conducted a review of the key ideas (programme theories) underlying interventions designed to address demand imbalance. We discovered that there was no close alignment between purported problems and advocated solutions. Demand management interventions take their starting point in seeking reforms at the levels of strategic decision-making, organisational re-engineering, procedural modifications and behavioural change. In mapping the ideas for reform, we also noted a tendency for programme theories to become ‘whole-system’ models; over time policy-makers have advocated the need for concerted action on all of these fronts.

Findings

The remainder and core of the report contains a realist synthesis of the empirical evidence on the effectiveness on a spanning subset of four major demand management interventions: referral management centres (RMCs); using general practitioners with special interests (GPwSIs) at the interface between primary and secondary care; general practitioner (GP) direct access to clinical tests; and referral guidelines. In all cases we encountered a chequered pattern of success and failure. The primary literature is replete with accounts of unanticipated problems and unintended effects. These programmes ‘work’ only in highly circumscribed conditions. To give brief examples, we found that the success of RMCs depends crucially on the balance of control in their governance structures; GPwSIs influence demand only after close negotiations on an agreed and intermediate case mix; significant efficiencies are created by direct GP access to tests mainly when there is low diagnostic yield and high ‘rule-out’ rates; and referral guidelines are more likely to work when implemented by staff with responsibility for their creation.

Conclusions

The report concludes that there is no ‘preferred intervention’ that has the capacity to outperform all others. Instead, the review found many, diverse, hard-won, local and adaptive solutions. Whatever the starting point, success in demand management depends on synchronising a complex array of strategic, organisational, procedural and motivational changes. The final chapter offers practitioners some guidance on how they might ‘think through’ all of the interdependencies, which bring demand and capacity into equilibrium. A close analysis of the implementation of different configurations of demand management interventions in different local contexts using mixed methods would be valuable to understand the processes through which such interventions are tailored to local circumstances. There is also scope for further evidence synthesis. The substitution theory is ubiquitous in health and social care and a realist synthesis to compare the fortunes of different practitioners placed at different professional boundaries (e.g. nurses/doctors, dentists/dental care practitioners, radiologists/radiographers and so on) would be valuable to identify the contexts and mechanisms through which substitution, support or short-circuit occurs.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Survey of Italian general practitioners: knowledge, opinions, and activities of palliative care

CONTEXT

General practitioners (GPs) play a key role in the end-of-life care of patients; however, currently in Italy, there are no national population-based studies available of the knowledge and activities of GPs in palliative care.

OBJECTIVES

This survey aimed to investigate the knowledge, opinions, and activities of Italian GPs regarding palliative care.

METHODS

A telephone survey of 1690 GPs was performed. Information was gathered through an ad hoc questionnaire.

RESULTS

Valid interviews were obtained for 88% of the sampled GPs (n=1489). Regarding knowledge, 25% of GPs recognized a correct definition of palliative care, 41% the objectives of palliative care, 66% that palliative care should be provided by a multiprofessional team including GPs, and 60% that in-home care for patients at the end of life requires an individual plan care. Furthermore, 92% of them reported that "there is no maximum daily morphine dose for the management of pain." Regarding opinions, most of the GPs strongly agreed that for patients at the end of life, the GPs' duties included availability during working hours to break bad news to patients and families and to collaborate with the multiprofessional team in establishing an individual care plan. Finally, regarding activities, most GPs reported that, in their daily practice with patients at the end of life, they discontinue the drugs that are not beneficial to symptom management and seek advice from palliative care physicians when symptom management is ineffective.

CONCLUSION

This survey reveals the uncertainty of GPs regarding many theoretical issues but a strong willingness to integrate with the multiprofessional palliative care team. To further enhance the skills of GPs and facilitate the collaboration with palliative care services, it might be useful to realize ad hoc training schemes tailored to the different organizational procedures of in-home palliative care services.