Palliative care in general practice; a questionnaire study on the GPs role and guideline implementation in Norway.
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ABSTRACT: Background
Patients in need of palliative care often want to reside at home. Providing palliative care requires resources and a high level of competence in primary care. The Norwegian guideline for palliative care points to the central role of the regular general practitioner (RGP), specifying a high expected level of competence. Guideline implementation is known to be challenging in primary care. This study investigates adherence to the guideline, the RGPs experience with, and view of their role in palliative care.Methods
A questionnaire was distributed, by post, to all 246 RGPs in a Norwegian county. Themes of the questionnaire focused on experience with palliative and terminal care, the use of recommended work methods from the guideline, communication with partners, self-reported role in palliative care and confidence in providing palliative care. Data were analyzed descriptively, using SPSS.Results
Each RGP had few patients needing palliative care, and limited experience with terminal care at home. Limited experience challenged RGPs possibilities to maintain knowledge about palliative care. Their clinical approach was not in agreement with the guideline, but most of them saw themselves as central, and were confident in the provision of palliative care. Rural RGPs saw themselves as more central in this work than their urban colleagues.Conclusions
This study demonstrated low adherence of the RGPs, to the Norwegian guideline for palliative care. Guideline requirements may not correspond with the methods of general practice, making them difficult to adopt. The RGPs seemed to have too few clinical cases over time to maintain skills at a complex and specialized level. Yet, there seems to be a great potential for the RGP, with the inherent specialist skills of the general practitioner, to be a key worker in the palliative care trajectory.
SUBMITTER: Fasting A
PROVIDER: S-EPMC8028821 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:BackgroundDemographic changes, the evolvement of modern medicine and new treatments for severe diseases, increase the need for palliative care services. Palliative care includes all patients with life-limiting conditions, irrespective of diagnosis. In Norway, palliative care rests on a decentralised model where patient care can be delivered close to the patient's home, and the Norwegian guideline for palliative care describes a model of care resting on extensive collaboration. Previous research suggests that this guideline is not well implemented among general practitioners (GPs). In this study, we aim to investigate barriers to GPs' participation in palliative care and implementation of the guideline.MethodsWe interviewed 25 GPs in four focus groups guided by a semi-structured interview guide. The interviews were recorded and transcribed verbatim. Data were analysed qualitatively with reflexive thematic analysis.ResultsWe identified four main themes as barriers to GPs' participation in palliative care and to implementation of the guideline: (1) different established local cultures and practices of palliative care, (2) discontinuity of the GP-patient relationship, (3) unclear clinical handover and information gaps and (4) a mismatch between the guideline and everyday general practice.ConclusionSignificant structural and individual barriers to GPs' participation in palliative care exist, which hamper the implementation of the guideline. GPs should be involved as stakeholders when guidelines involving them are created. Introduction of new professionals in primary care needs to be actively managed to avoid inappropriate collaborative practices. Continuity of the GP-patient relationship must be maintained throughout severe illness and at end-of-life.
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Project description:BACKGROUND:PaTz (palliative care at home) is a method to improve palliative care in the primary care setting in the Netherlands. PaTz has three basic principles: (1) local GPs and DNs meet at least six times per year to identify and discuss their patients with a life-threatening illness; (2) these meetings are supervised by a specialist palliative care professional; (3) groups use a palliative care register on which all identified patients are listed. Since the start in 2010, the number of PaTz-groups in the Netherlands has been growing consistently. Although the theory of all PaTz-groups is the same, the practical functioning of PaTz-groups may vary substantially, which may complicate further implementation of PaTz as well as interpretation of effect studies. This study aims to describe the variation in practice of PaTz-groups in the Netherlands. METHOD:In this prospective observational study, ten PaTz-groups logged and described the activities in their meetings as well as the registered and discussed patients and topics of discussions in registration forms for a 1 year follow-up period. In addition, non-participatory observations were performed in all participating groups. Meeting and patient characteristics were analysed using descriptive statistics. Conventional content analysis was performed in the analysis of topic discussions. RESULTS:While the basic principles of PaTz are found in almost every PaTz-group, there is considerable variation in the practice and content of the meetings of different PaTz-groups. Most groups spend little time on other topics than their patients, although the number of patients discussed in a single meeting varies considerably, as well as the time spent on an individual patient. Most registered patients were diagnosed with cancer and patient discussions mainly concerned current affairs and rarely concerned future issues. CONCLUSION:The basic principles are the cornerstone of any PaTz-group. At the same time, the observed variation between PaTz-groups indicates that tailoring a PaTz-group to the needs of its participants is important and may enhance its sustainability. The flexibility of PaTz-groups may also provide opportunity to modify the content and tools used, and improve identification of palliative patients and advance care planning.
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Project description:BackgroundThe postpartum period is a time of increased morbidity for mothers and infants under 12 months, yet is an under-researched area of primary care. Despite a relatively clear framework for involving general practitioners (GPs) in antenatal care, the structure of maternity service provision in some Australian jurisdictions has resulted in highly variable roles of general practice in routine postpartum care. This study aimed to investigate the views and experiences of mothers and GPs about postpartum care in general practice.MethodsThis was a qualitative study of mothers and GPs in rural, regional and metropolitan areas of Queensland, Australia. Semi-structured interviews were conducted with 88 mothers and six general practitioners between September 2010 and February 2012. Interviews were recorded and transcribed verbatim. Data were analysed thematically and compared across groups.ResultsThree main themes emerged: The relationship between the mother and GP; practice management; and GP visits. This paper focuses on the theme GP visits and its subthemes: recommendations for GP visits; scope of practice; and content of a routine visit. Recommendations about GP visits given to mothers varied by birthing sector, obstetric provider and model of maternity care resulting in confusion amongst mothers about the timing and role of GPs in routine postpartum care. Similarly, GPs voiced concerns about a lack of consistent guidelines for their involvement in routine postpartum care. Although ideally placed to provide primary care to mothers and their infants in the postpartum period, the lack of consistent guidelines for the role of GPs is of concern to both the GPs and early parenting women.ConclusionGeneral practice is an important source of postpartum care for mothers and provides a basis for ongoing support for the family. More consistent guidelines and better coordination with other care providers would benefit both mothers and GPs.
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Project description:BackgroundUsing delirium clinical guidelines may align interprofessional clinical practice and improve the care of delirious patients and their families. The aim of this project was to adapt, implement and evaluate an interprofessional modular delirium clinical practice guideline for an inpatient palliative care unit.MethodsThe setting was a 31-bed adult inpatient palliative care unit within a university-affiliated teaching hospital. Participants for the evaluation were interprofessional team members. Using integration of guideline adaptation and an education initiative, an interprofessional guideline adaptation group developed a face-to-face 'starter kit' module and four online self-learning modules. The mixed methods evaluation comprised pre-and post-implementation review of electronic patient records, an online survey, and analysis of focus groups/ interviews using an iterative, inductive thematic analysis approach.ResultsGuideline implementation took 12 months. All palliative care unit staff attended a 'starter kit' session. Overall completion rate of the four e-Learning modules was 80.4%. After guideline implementation, nursing documentation of non-pharmacological interventions occurring before medication administration was observed. There was 60% less scheduled antipsychotic use and an increase in 'as needed' midazolam use. The online survey response rate was 32% (25/77). Most participants viewed the guideline's implementation favourably. Six key themes emerged from the qualitative analysis of interviews and focus groups with ten participants: prior delirium knowledge or experiences, challenges of facilitating change, impacts on practice, collaborative effort of change, importance of standardized guidelines, and utility of guideline elements.ConclusionsGuideline implementation warrants concerted effort, time, and management support. Interprofessional team support facilitates the modular approach of guideline adaptation and implementation, leading to a change in clinical practice.
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Project description:BackgroundThe Department of Veterans Affairs (VA) mandated the system-wide implementation of clinical practice guidelines (CPGs) in the mid-1990s, arming all facilities with basic resources to facilitate implementation; despite this resource allocation, significant variability still exists across VA facilities in implementation success.ObjectiveThis study compares CPG implementation strategy patterns used by high and low performing primary care clinics in the VA.Research designDescriptive, cross-sectional study of a purposeful sample of six Veterans Affairs Medical Centers (VAMCs) with high and low performance on six CPGs.SubjectsOne hundred and two employees (management, quality improvement, clinic personnel) involved with guideline implementation at each VAMC primary care clinic. MEASURES; Participants reported specific strategies used by their facility to implement guidelines in 1-hour semi-structured interviews. Facilities were classified as high or low performers based on their guideline adherence scores calculated through independently conducted chart reviews.FindingsHigh performing facilities (HPFs) (a) invested significantly in the implementation of the electronic medical record and locally adapting it to provider needs, (b) invested dedicated resources to guideline-related initiatives, and (c) exhibited a clear direction in their strategy choices. Low performing facilities exhibited (a) earlier stages of development for their electronic medical record, (b) reliance on preexisting resources for guideline implementation, with little local adaptation, and (c) no clear direction in their strategy choices.ConclusionA multifaceted, yet targeted, strategic approach to guideline implementation emphasizing dedicated resources and local adaptation may result in more successful implementation and higher guideline adherence than relying on standardized resources and taxing preexisting channels.
| S-EPMC1955743 | biostudies-literature
Project description:BackgroundMental health problems are one of the leading causes of disease burden worldwide, and are mainly diagnosed and treated in general practice. It is unclear however, how general practitioners (GPs) identify mental health problems in their patients. The aim of this study was to explore how patients' self-reported levels of mental distress correspond with psychological diagnoses made by their GPs, and associations with sex, age, number of consultations, and somatic symptom diagnoses.MethodsA questionnaire study coupled with retrospective and prospective cohort data from 553 patients aged 16-65 years in six GP offices in Oslo, Norway during 21 months in 2014-2016.ResultsWe found that 73.3% of patients with self-reported high levels of mental distress versus only 13.3% of the patients with low levels of mental distress had received a psychological diagnosis (p < 0.01). We found an increase in number of consultations for the group with high levels of mental distress regardless of having received a psychological diagnosis (p < 0.01). There was also an increase in number of somatic symptoms (p = 0.04) and higher number of females (0.04) in this group. 35% of patients had received one or more psychological diagnosis by their GP. Mean CORE-10 score, being female and a high number of consultations was associated with having received a psychological diagnosis. In the adjusted analyses high CORE-10 score and a high number of consultations still predicted a psychological diagnosis.ConclusionsWe found a clear association between self-reported mental distress and having received a psychological diagnosis amongst the participants, and the probability for being identified increased with increasing levels of mental distress, and increasing number of visits to their doctor. This suggests that GPs can identify patients with high levels of mental distress in general practice in an adequate way, even though this can sometimes be a complex issue.Trial registrationTrial registration The main study was retrospectively registered in ClinicalTrials.gov on August 10 2019 with identification number NCT03624829.
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Project description:BackgroundHealthcare accreditation is a widely implemented tool used to enhance the quality of care and underpin quality control. However, research is sparse on the accreditation process in general practice. The aim of this study was to explore how team-based implementation activities preceding accreditation were associated with self-perceived improvements in emergency preparedness (preparedness for urgent disease and cardiac arrest) and handling of prescription renewals in Danish general practice.MethodsGPs (general practitioners) completed a questionnaire exploring practice-team activities conducted to implement two specific accreditation standards and the related improvements as perceived by the GPs. The following implementation activities were selected, inspired by Normalization Process Theory: Common understanding (obtaining a common understanding of the purpose of implementing changes according to the accreditation standard), key person (assigning a key person responsible for working with the standard), and easy integration (finding it easy to integrate changes into existing working procedures). Data were analysed with logistic regression, and adjusted analyses included practice type, number of GP partners, number of staff, training site for junior GPs and administrative region.ResultsThe total response rate was 74% (n = 920). Around 80% of the clinics reported having conducted team-based implementation activities. Almost half of the clinics (48%) reported perceived improvements in the emergency preparedness, and 30% reported perceived improvements in the handling of prescription renewals. Obtaining a common understanding was found to have a strong, significant association with perceived improvements in the emergency preparedness (OR = 5.07 (3.06-8.40)) and handling of prescription renewals (OR = 3.66 (2.07-6.46)). Easy integration of changes was also significantly associated with improvements in both emergency preparedness (OR = 1.88 (1.24-2.85)) and handling of prescription renewals (OR = 2.34 (1.44-3.79)), whereas assigning a key person was only significantly associated with improved emergency preparedness (OR = 1.95 (1.19-3.19)).ConclusionClinical quality initiatives that involve collaboration within a practice team are more likely to cause improvements if specific team-based implementation activities are conducted. It is particularly important to facilitate a common understanding of the purpose of the initiative. Therefore, external support for quality initiatives aiming at the practice level in general practice should facilitate such team-based activities.
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Project description:BACKGROUND:Because of practice variation and new developments in palliative pediatric care, the Dutch Association of Pediatrics decided to develop the clinical practice guideline (CPG) palliative care for children. With this guideline, the association also wanted to precipitate an attitude shift towards shared decision-making (SDM) and therefore integrated SDM in the CPG Palliative care for children. The aim was to gain insight if integrating SDM in CPGs can potentially encourage pediatricians to practice SDM. Its objectives were to explore pediatricians' attitudes and thoughts regarding (1) recommendations on SDM in CPGs in general and the guideline Palliative care for children specifically; (2) other SDM enhancing strategies or tools linked to CPGs. METHODS:Semi-structured face-to-face interviews. Pediatricians (15) were recruited through purposive sampling in three university-based pediatric centers in the Netherlands. The interviews were audio-recorded and transcribed verbatim, coded by at least two authors and analyzed with NVivo. RESULTS:Some pediatricians considered SDM a skill or attitude that cannot be addressed by clinical practice guidelines. According to others, however, clinical practice guidelines could enhance SDM. In case of the guideline Palliative care for children, the recommendations needed to focus more on how to practice SDM, and offer more detailed recommendations, preferring a recommendation stating multiple options. Most interviewed pediatricians felt that patient decisions aids were beneficial to patients, and could ensure that all topics relevant to the patient are covered, even topics the pediatrician might not consider him or herself, or deems less important. Regardless of the perceived benefit, some pediatricians preferred providing the information themselves instead of using a patient decision aid. CONCLUSIONS:For clinical practice guidelines to potentially enhance SDM, guideline developers should avoid blanket recommendations in the case of preference sensitive choices, and SDM should not be limited to recommendations on non-treatment decisions. Furthermore, preference sensitive recommendations are preferably linked with patient decision aids.
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Project description:BackgroundIt is unclear whether it is feasible to involve residents in guideline development or adaptation. We designed a multifaceted training program that combines training sessions, a handbook and a documentation tool to assist general practice (GP)-trainees in the adaptation of clinical practice guidelines (CPGs). The aim of this study is to adapt a database of CPGs by involving GP-trainees and to build evidence-based practice (EBP) learning capacity.MethodsWe assessed each adaptation process and surveyed all GP-trainees who enrolled in our training program on their views on the program. They were asked to formulate an overall rating for the training and were asked to rate individual aspects of the training program (the training sessions, the handbook and the documentation tool).ResultsTo date, 122 GP-trainees followed the training and have adapted 60 different CPGs. Overall quality of their work was good. Based on an assessment of the content of the documentation tool, 24 (40%) adapted CPGs rated as good quality and 30 (50%) rated as moderate quality. Only 3 adapted CPGs (5%) were evaluated as being of poor quality. 51 (42%) GP-trainees completed the survey on user satisfaction. 98% (50) of the GP-trainees found the training to be of good overall quality. 86% of the GP-trainees were satisfied with the handbook but satisfaction was lowest for the documentation tool (47% satisfied).ConclusionIt is possible to engage GP-trainees in CPG adaptation using a formal process when provided with training, feedback and documentation tools.
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Project description:INTRODUCTION: The development and publication of clinical practice guidelines for acute low-back pain has resulted in evidence-based recommendations that have the potential to improve the quality and safety of care for acute low-back pain. Development and dissemination of guidelines may not, however, be sufficient to produce improvements in clinical practice; further investment in active implementation of guideline recommendations may be required. Further research is required to quantify the trade-off between the additional upfront cost of active implementation of guideline recommendations for low-back pain and any resulting improvements in clinical practice. METHODS: Cost-effectiveness analysis alongside the IMPLEMENT trial from a health sector perspective to compare active implementation of guideline recommendations via the IMPLEMENT intervention (plus standard dissemination) against standard dissemination alone. RESULTS: The base-case analysis suggests that delivery of the IMPLEMENT intervention dominates standard dissemination (less costly and more effective), yielding savings of $135 per x-ray referral avoided (-$462.93/3.43). However, confidence intervals around point estimates for the primary outcome suggest that--irrespective of willingness to pay (WTP)--we cannot be at least 95% confident that the IMPLEMENT intervention differs in value from standard dissemination. CONCLUSIONS: Our findings demonstrate that moving beyond development and dissemination to active implementation entails a significant additional upfront investment that may not be offset by health gains and/or reductions in health service utilization of sufficient magnitude to render active implementation cost-effective.
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