Strategies to implement evidence into practice to improve palliative care: recommendations of a nominal group approach with expert opinion leaders

Advance Care Planning Billing Codes Associated With Decreased Healthcare Utilization in Neurological Disease

GOALS

Advance care planning (ACP) procedure codes have been established to reimburse meaningful care goal discussions; however, the utilization frequency of these codes in neurological disease is unknown. The objective of this study is to identify the association between ACP codes and healthcare utilization in chronic neurodegenerative diseases.

METHODS

This is a multicenter cohort study using real-world electronic health data. Using the TriNetX database, we collected electronic health data from 92 institutions in the United States. We included patients aged 65 and older who had been diagnosed with one of four neurological diseases: Alzheimer's disease, Parkinson's disease, multiple sclerosis, or amyotrophic lateral sclerosis (ALS). Patients with congestive heart failure were included as a reference. From the 64,683,009 total patients in the database, 877,138 had Alzheimer's disease, 544,610 had Parkinson's disease, 208,341 had multiple sclerosis, 9,944 had amyotrophic lateral sclerosis, and 1,500,186 had congestive heart failure. For each disease, we compared hospitalizations and emergency department (ED) visits over a two-year period between patients with and without ACP codes documented. Then, in patients with ACP, we investigated the rates of hospitalizations and ED visits over the two years before ACP and two years after ACP to understand the impact of ACP on the healthcare utilization trend. All patients had records for at least two years after index.

PRINCIPAL FINDINGS

The rate of ACP code documentation ranged from 1.8% of multiple sclerosis patients to 3.6% of Alzheimer's disease patients. After matching for demographic and health variables, usage of ACP codes was associated with significantly fewer hospitalizations for Alzheimer's disease patients. Across all diseases, there was a 20% to 30% decrease in ED visits, which was significant. Furthermore, there was a significant change in the trend of hospitalizations and ED visits for patients after ACP documentation. Patients went from increasing utilization before ACP documentation to decreasing utilization after documentation.

PRACTICAL APPLICATIONS

ACP billing codes are used infrequently in neurological disease, which may indicate that reimbursement alone is not sufficient to drive code usage. Usage of ACP billing codes was associated with decreased healthcare utilization, particularly in terms of ED visits. Beyond the primary objective of providing goal-concordant care, ACP may impact the economic burden of chronic neurodegenerative disease, which has high costs of care in our aging society. There may be particular benefits with Alzheimer's disease, which had an impact on both hospitalizations and ED visits and is the most prevalent neurodegenerative disease. Future work is needed to better understand the best implementation strategy for ACP in a multifaceted approach that emphasizes patient care preferences for their illness.

Needs Analysis for The Development of a Manual in Palliative Care for Malaysia: An Islamic Psychospiritual Approach

This study explicates an Islamic approach to palliative care based on the results of a needs analysis regarding the development of an Islamic psychospiritual manual of palliative care alongside related elements. This article represents the first phase of a three-phase study using the design and development research (DDR) approach developed by Richey and Klein to study for design and development of manual either needed or otherwise. This project is a quantitative study that uses purposive sampling through a questionnaire instrument to investigate 210 participants from the general population in Malaysia that have experience in taking care of terminally ill patients. The findings of the study indicated that the majority of participants agreed with the development of an Islamic psychospiritual manual with mean values (x̅) of 4.57 and 4.66. Concurrently, the findings showed that the hierarchy of emphasis in terms of the elements to be included in the manual starts with emotional support, which exhibited the highest mean rate (x̅), followed by faith in God, spiritual and religious support, self and physical management, trauma management and social support. The correlations indicated that all the elements to be included in the manual were significant.

The use and application of Lean Management methods to research processes-a scoping review protocol

INTRODUCTION

Waste in medical research is a relatively well-known issue. However, only a few initiatives exist to address this issue. Lean Management methods (Lean) were developed in industrial manufacturing and later applied within healthcare improvement. Overall, the results from studies of the application of Lean to healthcare appear to be positive in terms of greater efficiency regarding treatment outcomes and patient care. Nevertheless, the application of Lean to improve research processes is not well studied and, given that research alongside clinical practice and experiential knowledge provides the foundation for the treatment and care of patients, it is paramount to identify approaches and review the degree to which they increase efficiency within research procedures. Therefore, this review will scope the landscape of studies that investigated Lean and how to implement Lean in research processes, particularly regarding healthcare research.

METHODS AND ANALYSIS

Our approach follows the methodological framework of Arksey and O'Malley for conducting scoping reviews (PRISMA-ScR). The search strategy for this scoping review was developed using the PCC model. We will identify the relevant literature by searching four search databases: Scopus, Web of Science, Academic Search Premier and Business Source Complete. Next, we will use citation pearl growing to identify all relevant published literature. The data charting process will follow the PRISMA-ScR checklist and will be organised using NVivo. We will generate qualitative and quantitative assessments of the extracted data by using NVivo, RStudio and Excel. We will follow the PRISMA-ScR guideline when reporting the results.

ETHICS AND DISSEMINATION

The review will comprise existing published studies and no primary data will be collected. Our findings will be shared through open access peer-reviewed journals, national and international conferences and emails to all relevant collaborative relationships. We plan to disseminate our findings via academic social media platforms, newspaper articles and blogposts.

Co-designing person-centred quality indicator implementation for primary care in Alberta: a consensus study

BACKGROUND

We aimed to contribute to developing practical guidance for implementing person-centred quality indicators (PC-QIs) for primary care in Alberta, Canada. As a first step in this process, we conducted stakeholder-guided prioritization of PC-QIs and implementation strategies. Stakeholder engagement is necessary to ensure PC-QI implementation is adapted to the context and local needs.

METHODS

We used an adapted nominal group technique (NGT) consensus process. Panelists were presented with 26 PC-QIs, and implementation strategies. Both PC-QIs and strategies were identified from our extensive previous engagement of patients, caregivers, healthcare providers, and quality improvement leaders. The NGT objectives were to: 1. Prioritize PC-QIs and implementation strategies; and 2. Facilitate the participation of diverse primary care stakeholders in Alberta, including patients, healthcare providers, and quality improvement staff. Panelists participated in three rounds of activities. In the first, panelists individually ranked and commented on the PC-QIs and strategies. The summarized results were discussed in the second-round face-to-face group meeting. For the last round, panelists provided their final individual rankings, informed by the group discussion. Finally, we conducted an evaluation of the consensus process from the panelists' perspectives.

RESULTS

Eleven primary care providers, patient partners, and quality improvement staff from across Alberta participated. The panelists prioritized the following PC-QIs: 'Patient and caregiver involvement in decisions about their care and treatment'; 'Trusting relationship with healthcare provider'; 'Health information technology to support person-centred care'; 'Co-designing care in partnership with communities'; and 'Overall experience'. Implementation strategies prioritized included: 'Develop partnerships'; 'Obtain quality improvement resources'; 'Needs assessment (stakeholders are engaged about their needs/priorities for person-centred measurement)'; 'Align measurement efforts'; and 'Engage champions'. Our evaluation suggests that panelists felt that the process was valuable for planning the implementation and obtaining feedback, that their input was valued, and that most would continue to collaborate with other stakeholders to implement the PC-QIs.

CONCLUSIONS

Our study demonstrates the value of co-design and participatory approaches for engaging stakeholders in adapting PC-QI implementation for the primary care context in Alberta, Canada. Collaboration with stakeholders can promote buy-in for ongoing engagement and ensure implementation will lead to meaningful improvements that matter to patients and providers.

Pilot Study to Develop and Test Palliative Care Quality Indicators for Nursing Homes

An increasingly frail population in nursing homes accentuates the need for high quality care at the end of life and better access to palliative care in this context. Implementation of palliative care and its outcomes can be monitored by using quality indicators. Therefore, we developed a quality indicator set for palliative care in nursing homes and a tailored measurement procedure while using a mixed-methods design. We developed the instrument in three phases: (1) literature search, (2) interviews with experts, and (3) indicator and measurement selection by expert consensus (RAND/UCLA). Second, we pilot tested and evaluated the instrument in nine nursing homes in Flanders, Belgium. After identifying 26 indicators in the literature and expert interviews, 19 of them were selected through expert consensus. Setting-specific themes were advance care planning, autonomy, and communication with family. The quantitative and qualitative analyses showed that the indicators were measurable, had good preliminary face validity and discriminative power, and were considered to be useful in terms of quality monitoring according to the caregivers. The quality indicators can be used in a large implementation study and process evaluation in order to achieve continuous monitoring of the access to palliative care for all of the residents in nursing homes.

Supporting GPs around euthanasia requests from people with dementia: a qualitative analysis of Dutch nominal group meetings

BACKGROUND

Euthanasia has been regulated by law under strict conditions in the Netherlands since 2002. Since then the number of euthanasia cases has constantly increased, and increased exponentially for patients with dementia (PWD). The number of euthanasia requests by such patients is even higher. Recently, an interview study showed that physicians who are confronted with a PWD's euthanasia request experience problems with communication, pressure from relatives, patients, and society, workload, interpretation of the law, and ethical considerations. Moreover, if honoured, the physician and patient may interpret the right moment for euthanasia differently.

AIM

To identify ways of supporting GPs confronted with a PWD's euthanasia request.

DESIGN AND SETTING

Two expert nominal group meetings were organised with Dutch care physicians for older people, GPs, legal experts, a healthcare chaplain, a palliative care consultant, and a psychologist.

METHOD

A total of 15 experts participated in the meetings. Both meetings were audio-recorded, transcribed verbatim, and analysed using thematic analysis.

RESULTS

Four themes emerged from the meetings: support provided by healthcare professionals, influencing public opinion, educational activities, and managing time and work pressure. The need for support was considered highest for GPs for all of these themes.

CONCLUSION

Consensus was reached with the help of experts on support needs for GPs confronted with euthanasia requests from PWD. A concise and clear explanation of the law is strongly desired. Changing public opinion seems the most challenging and a long-term aim. Communication training for finding the right balance between the physician's professional responsibility and the patient's autonomy should be made available, as a short-term aim.

[HeiMeKOM (Heidelberg Milestones Communication): development of an interprofessional intervention for improvement of communication in patients with limited prognosis]

BACKGROUND

The care for patients with advanced disease and limited prognosis and their relatives is complex and characterized by insufficient communication and lack of coordination and continuity.

AIM

Development of an interprofessional, practice-guided concept of longitudinally structured communication with the goal of fostering communication, improving quality of life and facilitating early integration of palliative care.

METHODS

Multi-level process starting from a draft with discussion and approval within the multiprofessional team and correlation with interviews with patients and relatives. Preparation of a comprehensive concept with review of the literature, problem analysis, theoretical foundation, goal setting and intervention components. Discussion of suitability for daily use, adaptation and further development of the concept.

RESULTS AND CONCLUSIONS

Concept with the following components: interprofessional communication training, structured conversations at defined moments in a tandem of physician and nurse with patient and relative, follow-up conversations conducted by the nurse, and respective instruments (conversation protocol, question prompt list, memory cards). Only iterative discussion with and the approval of patients, relatives and the multiprofessional team and their approval will put the concept into practice.

The Effect of Impactful Articles on Clinical Practice in the United States: Corticosteroid Injection for Patients with Lateral Epicondylitis

BACKGROUND

Following publication of high-level evidence demonstrating that it is not an effective treatment for lateral epicondylitis, a reduction in the corticosteroid injection rate would be expected. The authors aimed to clarify current clinical practice pattern for lateral epicondylitis and identify factors that influence the introduction of evidence into clinical practice.

METHODS

In this administrative claims analysis, the authors used 2009 to 2015 Truven MarketScan data to extract claims for corticosteroid injection, physical therapy, platelet-rich plasma injection, and surgery for lateral epicondylitis. The authors performed multivariable analysis using a generalized estimating equation model to identify the variables that potentially affect the odds of receiving a given treatment.

RESULTS

Among 711,726 claims, the authors found that the odds of receiving a corticosteroid injection increased slightly after publication of contradictory evidence (OR, 1.7; 95 percent CI, 1.04 to 1.11 in 2015). Being male (OR, 1.21; 95 percent CI, 1.19 to 1.23), older (OR, 1.16; 95 percent CI, 1.13 to 1.19), and having managed care insurance (OR, 1.15; 95 percent CI, 1.13 to 1.18) significantly contributed to increased odds of receiving corticosteroid injections. Patients seen at facilities in the South (OR, 1.33; 95 percent CI, 1.30 to 1.36 compared with the Northeast) and by plastic/orthopedic surgeons (OR, 2.48; 95 percent CI, 2.43 to 2.52) also had increased odds of receiving corticosteroid injection.

CONCLUSIONS

Corticosteroid injection use did not decrease after publication of impactful articles, regardless of provider specialty or other patient-related factors. This finding emphasizes that there are various barriers for even high-level evidence to overcome the inertia of current practice.

Optimizing cancer pain management in resource-limited settings

Purpose

Adequate cancer pain management (CPM) is challenging in resource-limited settings, where current international guideline recommendations are difficult to implement owing to constraints such as inadequate availability and accessibility of opioids, limited awareness of appropriate opioid use among patients and clinicians, and lack of guidance on how to translate the best evidence into clinical practice. The multinational and multidisciplinary CAncer Pain managEment in Resource-limited settings (CAPER) Working Group proposes a two-step initiative to bridge clinical practice gaps in CPM in resource-limited settings.

Methods

A thorough review of the literature, a steering committee meeting in February 2017, and post-meeting teleconference discussions contributed to the development of this initiative. As a first step, we developed practical evidence-based CPM algorithms to support healthcare providers (HCPs) in tailoring treatment according to availability of and access to resources. The second part of the initiative proposes a framework to support an effective implementation of the CPM algorithms that includes an educational program, a pilot implementation, and an advocacy plan.

Results

We developed CPM algorithms for first-line use, breakthrough cancer pain, opioid rotation, and refractory cancer pain based on the National Comprehensive Cancer Network guidelines and expert consensus. Our proposed educational program emphasizes the practical elements and illustrates how HCPs can provide optimal CPM according to evidence-based guidelines despite varied resource limitations. Pilot studies are proposed to demonstrate the effectiveness of the algorithms and the educational program, as well as for providing evidence to support a draft advocacy document, to lobby policymakers to improve availability and accessibility of analgesics in resource-limited settings.

Conclusions

These practical evidence-informed algorithms and the implementation framework represent the first multinational step towards achieving optimal CPM in resource-limited settings.

Electronic supplementary material

The online version of this article (10.1007/s00520-018-4471-z) contains supplementary material, which is available to authorized users.

Translating Pressure Ulcer Prevention Into Intensive Care Nursing Practice: Overlaying a Care Bundle Approach With a Model for Research Implementation

This article reports on the development and implementation process used to integrate a care bundle approach (a pressure ulcer [PU] prevention bundle to improve patients' skin integrity in intensive care) and the Ottawa Model of Research Use (OMRU). The PU prevention care bundle demonstrated significant reduction in PU incidence, with the OMRU model providing a consolidated framework for the implementation of bundled evidence in an effective and consistent manner into daily clinical nursing practice.