Effectiveness of the ACA (Availability, Current issues and Anticipation) training programme on GP-patient communication in palliative care; a controlled trial

Education modalities for serious illness communication training: A scoping review on the impact on clinician behavior and patient outcomes

BACKGROUND

Several clinician training interventions have been developed in the past decade to address serious illness communication. While numerous studies report on clinician attitudes and confidence, little is reported on individual education modalities and their impact on actual behavior change and patient outcomes.

AIM

To examine what is known about the education modalities used in serious illness communication training and their impact on clinician behaviors and patient outcomes.

DESIGN

A scoping review using the Joanna Briggs Methods Manual for Scoping Reviews was conducted to examine studies measuring clinician behaviors or patient outcomes.

DATA SOURCES

Ovid MEDLINE and EMBASE databases were searched for English-language studies published between January 2011 and March 2023.

RESULTS

The search identified 1317 articles: 76 met inclusion criteria describing 64 unique interventions. Common education modalities used were: single workshop (n = 29), multiple workshops (n = 11), single workshop with coaching (n = 7), and multiple workshops with coaching (n = 5); though they were inconsistently structured. Studies reporting improved clinician skills tended to be in simulation settings with neither clinical practice nor patient outcomes explored. While some studies reported behavior changes or improved patient outcomes, they did not necessarily confirm improvements in clinician skills. As multiple modalities were commonly used and often embedded within quality improvement initiatives, the impact of individual modalities could not be determined.

CONCLUSION

This scoping review of serious illness communication interventions found heterogeneity among education modalities used and limited evidence supporting their effectiveness in impacting patient-centered outcomes and long-term clinician skill acquisition. Well-defined educational modalities and consistent measures of behavior change and standard patient-centered outcomes are needed.

Effectiveness of Training Programs About a Palliative Care Approach: A Systematic Review of Intervention Trials for Health Care Professionals

Background: Palliative care (PC) training initiatives have proliferated to assist generalist health care providers (HCPs) develop skills for applying an early PC approach. To date, there is little synthesis of high-level evidence to review the content and effectiveness of these programs. To address this gap in knowledge, we conducted a systematic review of trials of training inventions to build PC competency in HCPs, according to PRISMA guidelines (PROSPERO registration no. 271741). Materials and Methods: We searched MEDLINE, Embase, PsycINFO, CINAHL, HealthSTAR, Web of Science, and the Cochrane Database of Systematic Reviews and Clinical Trials for studies published since 2000. Eligible studies were trials assessing PC training for HCPs. Interventions had to address at least two of six PC-related components, adapted from the National Consensus Project: identification or assessment; illness understanding; symptom management; decision making; coping; and referral. Two reviewers independently assessed articles for inclusion, using Rayyan, and extracted relevant data. Risk of bias was assessed using the Cochrane ROB2 or ROBINS-I tools. Results: Of 1209 articles reviewed, 22 studies met the inclusion criteria, with the majority being conducted in the United States (n = 9) or Europe (n = 8). Nearly all studies (n = 19) collected data through self-reported surveys; administrative (n = 4), clinical outcomes (n = 4), or interaction analysis (n = 6) data were also or solely used. Interventions featured didactic, skill-based training followed by role-play and/or individual coaching. Communication around illness understanding was the most taught PC component. Few interventions involved comprehensive PC training, with 12 studies representing 3 or less of the 6 framework components. Most studies (n = 16) reported a significant positive impact on at least one outcome, most often HCP self-reported outcomes. Conclusions: While many of these interventions demonstrated improved confidence among HCPs in the PC components taught, findings were mixed on more objective outcome measures. Further trial-based evidence is required on comprehensive PC training to help inform these interventions.

Continuing Professional Development for Primary Care Providers in Palliative and End-of-Life Care: A Systematic Review

Background and Objective: This review updates and expands on previous reviews of educational interventions for primary care providers (PCPs) involved in palliative and end-of-life care (PEoLC) and is the first to include early studies related to medical assistance in dying (MAiD). Methods: A comprehensive search strategy was conducted across five electronic databases to locate published interventional studies related to ongoing PEoLC and/or MAiD education for primary care professionals. A descriptive summary of results and a narrative discussion of common themes and comparisons are provided. Results: Thirty-seven studies met the inclusion criteria. The researchers found a myriad of interventions, including courses based, practical experience, mentoring, and workshops. The researchers categorized results by four domains: attitude, confidence, knowledge, and skills. Across domains, seven educational topics emerged: general care, interprofessional collaboration, nutrition, pain and symptom management, patient communication, and professional coping. Overall, studies employed various methodologies, but often relied on cross-sectionally measured self-assessment. Two articles were found that measured the impact of MAiD education. Conclusion: These findings suggest that PEoLC education can improve PCPs' perceived attitudes, confidence, knowledge, and skills across multiple areas of palliative care practice. While PCPs across studies valued educational interventions, the findings relating to the impact of PEoLC education on PCP's provision of effective PEoLC were unclear. However, most interventions resulted in enhanced confidence and knowledge. To date, there are only two studies that have examined MAiD educational programs. There is a need for studies of higher rigor with more emphasis on follow-up to clarify the impact training has on those involved in PEoLC and MAiD.

Australian GPs' perceptions of barriers and enablers to best practice palliative care: a qualitative study

Background

General Practitioners (GPs) often play an important role in caring for people at the end of life. While some international studies suggest that GPs experience a number of barriers to providing palliative care, little is known about views and experiences of GPs in Australia. This study explored Australian GPs’ perceptions of barriers and enablers to the provision of palliative care and provides new insights into how to implement best practice care at the end of life.

Methods

This was a qualitative study using 25 semi-structured phone interviews conducted with GPs practising in metropolitan and non-metropolitan New South Wales, Australia. Data were analysed using qualitative content analysis.

Results

GPs reported difficulties with palliative care provision due to i) the complex and often emotional nature of doctor-family-interaction; ii) a lack of evidence to guide care; and iii) the need to negotiate roles and responsibilities within the healthcare team. GPs listed a number of strategies to help deal with their workload and to improve communication processes between healthcare providers. These included appropriate scheduling of appointments, locally tailored mentoring and further education, and palliative care guidelines which more clearly outline the roles and responsibilities within multidisciplinary teams. GPs also noted the importance of online platforms to facilitate their communication with patients, their families and other healthcare providers, and to provide centralised access to locally tailored information on palliative care services. GPs suggested that non-government organisations could play an important role by raising awareness of the key role of GPs in palliative care provision and implementing an “official visitor” program, i.e. supporting volunteers to provide peer support or respite to people with palliative care needs and their families.

Conclusions

This study offers new insights into strategies to overcome well documented barriers to palliative care provision in general practice and help implement optimal care at the end of life. The results suggest that researchers and policy makers should adopt a comprehensive approach to improving the provision of palliative care which tackles the array of barriers and enablers identified in this study.

Provider Tools for Advance Care Planning and Goals of Care Discussions: A Systematic Review

BACKGROUND

Advance care planning and goals of care discussions involve the exploration of what is most important to a person, including their values and beliefs in preparation for health-care decision-making. Advance care planning conversations focus on planning for future health care, ensuring that an incapable person's wishes are known and can guide the person's substitute decision maker for future decision-making. Goals of care discussions focus on preparing for current decision-making by ensuring the person's goals guide this process.

AIM

To provide evidence regarding tools and/or practices available for use by health-care providers to effectively facilitate advance care planning conversations and/or goals of care discussions.

DATA SOURCES

A systematic review was conducted focusing on guidelines, randomized trials, comparative studies, and noncomparative studies. Databases searched included MEDLINE, EMBASE, and the proceedings of the International Advance Care Planning Conference and the American Society of Clinical Oncology Palliative Care Symposium.

CONCLUSIONS

Although several studies report positive findings, there is a lack of consistent patient outcome evidence to support any one clinical tool for use in advance care planning or goals of care discussions. Effective advance care planning conversations at both the population and the individual level require provider education and communication skill development, standardized and accessible documentation, quality improvement initiatives, and system-wide coordination to impact the population level. There is a need for research focused on goals of care discussions, to clarify the purpose and expected outcomes of these discussions, and to clearly differentiate goals of care from advance care planning.

Primary care physicians' educational needs and learning preferences in end of life care: A focus group study in the UK

BACKGROUND

Primary care physicians (General Practitioners (GPs)) play a pivotal role in providing end of life care (EoLC). However, many lack confidence in this area, and the quality of EoLC by GPs can be problematic. Evidence regarding educational needs, learning preferences and the acceptability of evaluation methods is needed to inform the development and testing of EoLC education. This study therefore aimed to explore GPs' EoLC educational needs and preferences for learning and evaluation.

METHODS

A qualitative focus group study was conducted with qualified GPs and GP trainees in the UK. Audio recordings were transcribed and analysed thematically. Expert review of the coding frame and dual coding of transcripts maximised rigour.

RESULTS

Twenty-eight GPs (10 fully qualified, 18 trainees) participated in five focus groups. Four major themes emerged: (1) why education is needed, (2) perceived educational needs, (3) learning preferences, and (4) evaluation preferences. EoLC was perceived as emotionally and clinically challenging. Educational needs included: identifying patients for palliative care; responsibilities and teamwork; out-of-hours care; having difficult conversations; symptom management; non-malignant conditions; and paediatric palliative care. Participants preferred learning through experience, working alongside specialist palliative care staff, and discussion of real cases, to didactic methods and e-learning. 360° appraisals and behavioural assessment using videoing or simulated interactions were considered problematic. Self-assessment questionnaires and patient and family outcome measures were acceptable, if used and interpreted correctly.

CONCLUSIONS

GPs require education and support in EoLC, particularly the management of complex clinical care and counselling. GPs value mentoring, peer-support, and experiential learning alongside EoLC specialists over formal training.

Training general practitioners in early identification and anticipatory palliative care planning: a randomized controlled trial

BACKGROUND

Most patients with advanced cancer, debilitating COPD or chronic heart failure (CHF) live at home. General practitioners (GPs) asked for guidance in how to recognize patients in need of palliative care in a timely way and to structure anticipatory care. For that reason, we developed a training for GPs in identifying patients in need of palliative care and in structuring anticipatory palliative care planning and studied its effect on out-of-hours contacts, contacts with their own GP, hospitalizations and place of death.

METHODS

We performed a cluster randomised controlled trial. GPs in the intervention group were trained in identifying patients in need of palliative care and anticipatory care planning. Next, for each identified patient, they were offered a coaching session with a specialist in palliative care to fine-tune a structured care plan. The GPs in the control group did not receive training or coaching, and were asked to provide care as usual. After one year, characteristics of patients deceased of cancer, COPD or CHF in both study groups were compared with mixed effects models for out-of-hours contacts (primary outcome), contacts with their own GP, place of death and hospitalizations in the last months of their life (secondary outcomes). As a post-hoc analysis, of identified patients (of the intervention GPs) these figures were compared to all other deceased patients, who had not been identified as in need of palliative care.

RESULTS

We did not find any differences between the intervention and control group. Yet, only half of the trained GPs (28) identified patients (52), which was only 24% of the deceased patients. Those identified patients had significantly more contacts with their own GP (B 4.5218; p <0.0006), were less often hospitalized (OR 0.485; p 0.0437) more often died at home (OR 2.126; p 0.0572) and less often died in the hospital (OR 0.380; p 0.0449).

CONCLUSIONS

Although we did not find differences between the intervention and control group, we found in a post-hoc analysis that those patients that had been identified as in need of palliative care had more contacts with their GP, less hospitalizations, and more often died at home. We recommend future controlled studies that try to further increase identification of patients eligible for anticipatory palliative care. The Netherlands National Trial Register: NTR2815 date 07-04-2010.

Effectiveness of the palliative care 'Availability, Current issues and Anticipation' (ACA) communication training programme for general practitioners on patient outcomes: a controlled trial

BACKGROUND

Although communicating effectively with patients receiving palliative care can be difficult, it may contribute to maintaining or enhancing patients' quality of life. Little is known about the effect of training general practitioners in palliative care-specific communication. We hypothesized that palliative care patients of general practitioners exposed to the 'Availability, Current issues and Anticipation' communication training programme would report better outcomes than patients of control general practitioners.

AIM

To evaluate the effectiveness of the Availability, Current issues and Anticipation training programme for general practitioners on patient-reported outcomes.

DESIGN

In a controlled trial, general practitioners followed the Availability, Current issues and Anticipation programme or were part of the control group. Patients receiving palliative care of participating general practitioners completed the Palliative Care Outcome Scale, the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 15 Palliative, the Rest & Peace Scale, the Patient Satisfaction Questionnaire-III and the Availability, Current issues and Anticipation Scale, at baseline and 12 months follow-up. We analysed differences between groups using linear mixed models.

TRIAL REGISTRATION

ISRCTN56722368.

SETTING/PARTICIPANTS

General practitioners who attended a 2-year Palliative Care Training Course in the Netherlands.

RESULTS

Questionnaire data were available for 145 patients (89 in intervention and 56 in control group). We found no significant differences over time between the intervention and control groups in any of the five outcome measures. Ceiling effects were observed for the Rest & Peace Scale, Patient Satisfaction Questionnaire-III and Availability, Current issues and Anticipation Scale.

CONCLUSION

General practitioner participation in the Availability, Current issues and Anticipation training programme did not have a measurable effect on any of the outcomes investigated. Patients reported high levels of satisfaction with general practitioner care, regardless of group assignment. Future research might focus on general practitioners without special interest in palliative care.

Effectiveness of the 'availability, current issues and anticipation' (ACA) training programme for general practice trainees on communication with palliative care patients: a controlled trial

OBJECTIVE

This study aimed to evaluate the effectiveness of a new palliative care 'availability, current issues and anticipation' (ACA) training programme to improve communication skills of general practice trainees (GPTs).

METHODS

In a controlled trial among third-year GPTs, we videotaped one 20-min consultation between each GPT and a simulated palliative care patient at baseline and at six months follow-up. We measured the number of issues discussed and the quality of communication skills and analysed between-group differences using linear mixed models and logistic regression.

RESULTS

Fifty-four GPTs were assigned to the intervention and 64 to the control group. We found no effect of the programme on the number of issues discussed or on the quality of GPT communicative behaviour. GPTs infrequently addressed 'spiritual/existential issues' and 'unfinished business'. In a selection of the consultations, simulated patients brought up more issues than the GPTs did.

CONCLUSION

The ACA training programme was not effective in the way it was carried out and evaluated in this trial.

PRACTICE IMPLICATIONS

The ACA programme should focus on the issues that scored low in this trial. Future research on GPT-patient communication in palliative care should consider using real patients in a series of consultations to evaluate effectiveness.