Table 3

Effectiveness of GP engagement with specialist secondary services in integration of palliative care

AuthorOutcome measuresLength of follow-upResults
RCTs
Abernethy et al 2 Primary: AKPS
Secondary: pain intensity, Brief Pain Inventory, QOL, symptoms and hospital usage
60 days after randomisation until study exit, mean time from case conference to death or end of study was 152 daysIntervention patients had a significantly reduced number of hospitalisations (1.26 vs 1.7) p=0.0069 compared with controls and maintained performance status—mean daily AKPS 57.3* vs 51.7 control, p=0.0368
Intervention patients were better able to maintain their performance status over time when performance status had already declined below 70% on referral (p=0.0425). Benefit was not seen when AKPS was above 70% on study entry. No significant impact on symptom burden, pain or QOL.
Doughty et al 22 QOL
Time to death or readmission
Hospital readmission
Hospital bed days
Hospital readmission specific to heart failure worsening
12 monthsThere was no difference between groups for time to death or readmission. The intervention group had significantly fewer admissions each (p=0.015) and fewer bed days per year (p=0.0001). QOL measures showed a significant improvement in physical functioning from baseline to 12 months for the intervention group (p=0.015), however no difference in emotional scores between groups.
Mitchell et al 24 Patient QOL—3 measures (AQEL, McGill Quality of Life Questionnaire, Subjective Wellbeing Scale
Carer burden—Caregiver Reaction Assessment)
1, 3, 5, 7, and 9 weeks postintervention and then monthly until death, withdrawal or cessation of projectSubstantial patient attrition with time.
Two a priori analyses:
(A) Date of case conference as reference point: QOL was not influenced by the intervention. The intervention group showed a significantly lower carer burden in week 5.
(B) Time of death as reference point. 1–14 days prior to death and 15–35 days prior to death: there were significant results favouring the intervention group for some physical and mental well-being items. However for more than 35 days prior to death the results favoured the control group.
Cohort studies
Mitchell et al 23 Service usage—ED presentations
ED discharged to home
Hospital admissions
Admission length of stay
Count of case conference recommendations and rate of adherence to recommendations
Up to 12 months after the case conferenceED admissions fell from 13.9 per annum to 2.1 (difference 11.8, 95% CI 2.2 to 21.3, p=0.001)
ED admission leading to discharge home from 3.9 to 0.4 per annum (difference 3.5, 95% CI 0.4 to 7.5, p=0.05
Hospital admissions 11.4 to 3.5 per annum (difference 7.9, 95% CI 2.2 to 13.7, p=0.002)
Length of stay 7.0 to 3.7 days (difference 3.4, 95% CI 0.9 to 5.8, p=0.0007).
67% of recommendations made were enacted.
Participating health professionals were enthusiastic about the process
Surveys
Goldschmidt et al 25 Follow-up at 1 month after home conference, which is held at the start of home careMore than half had learnt aspects of palliative care from the home conference. 90% were satisfied with home conference. At 1 month 91% reported improvement in care and treatment of patient because of home care team, more than half learnt aspects of palliative care and 89% were satisfies with level of cooperation.
Benefits included improvement in security for patient and relative, pain control, input from specialist in palliative care and improvements in general symptomatology and nursing care.
Training benefits were symptom control, patient-centred care.
Groot et al 35 Communication
Organisation
Knowledge and expertise
Integrated care
Time for relatives
No follow-upResponse rate to survey of 62.3%
GPs that participated in multidisciplinary case discussions reported fewer perceived obstacles to the delivery of primary palliative care.
Narrative
Stewart et al 26 Participation
Communication
Professional development
Hospice impact
Patient impact
Linkages
14 months73% of practices, 62% of GPs and 67% of practice nurses participated. Communication: communication between services is effective, with participants indicating a sense of partnership
Professional development: training has been extremely useful, with enhanced knowledge, increased confidence and familiarity with hospice staff
Hospice impact: referrals have decreased however complexity has increased
Patient impact: ∼60% of deaths occurred in community with <5% within the hospital setting. No comparison is provided to general NZ data.
Linkages: a strengthening of service relationships has been claimed, with the role of Patient Care Coordinator being responsible for this. No data were provided to support this.
Qualitative
Mitchell et al 27 Advantages of case conferences—time effective and efficient; building relationships with specialist teams
Potentially useful exchanges of information
Discharge planning easier and allowed role delineation
Increased specialist team appreciation of patient–GP relationship
GPs willingness to provide after-hours care and house calls
Negotiated management plans
Walshe et al 28 GSF has improved interprofessional communication, a positive impact on previously difficult communication
GSF provides structure, authority and permission to arrange formal meetings and informal communications
Impact of GSF on provision of anticipatory drugs is positive
GSF has adverse effect on workloads.
GSF lead by specialist palliative care practitioners
GSF is adapted over time to suit the professionals involved,
  • *SE 1.5 vs 2.3.

  • AKPS, Australian-modified Karnofsky Performance Scale; AQEL, Assessment of Quality of life at End of Life; ED, emergency department; GP, general practitioner; GSF, Gold Standard Framework; NZ, New Zealand; QOL, quality of life; RCT,randomised controlled trial.