General practitioner attitudes to case conferences: how can we increase participation and effectiveness?

Understanding How to Improve the Use of Clinical Coordination Mechanisms between Primary and Secondary Care Doctors: Clues from Catalonia

Clinical coordination between primary (PC) and secondary care (SC) is a challenge for health systems, and clinical coordination mechanisms (CCM) play an important role in the interface between care levels. It is therefore essential to understand the elements that may hinder their use. This study aims to analyze the level of use of CCM, the difficulties and factors associated with their use, and suggestions for improving clinical coordination. A cross-sectional online survey-based study using the questionnaire COORDENA-CAT was conducted with 3308 PC and SC doctors in the Catalan national health system. Descriptive bivariate analysis and logistic regression models were used. Shared Electronic Medical Records were the most frequently used CCM, especially by PC doctors, and the one that presented most difficulties in use, mostly related to technical problems. Some factors positively associated with frequent use of various CCM were: working full-time in integrated areas, or with local hospitals. Interactional and organizational factors contributed to a greater extent among SC doctors. Suggestions for improving clinical coordination were similar between care levels and related mainly to the improvement of CCM. In an era where management tools are shifting towards technology-based CCM, this study can help to design strategies to improve their effectiveness.

Facilitators and barriers to general practitioner and general practice nurse participation in end-of-life care: systematic review

BACKGROUND

General practitioners (GPs) and general practice nurses (GPNs) face increasing demands to provide palliative care (PC) or end-of-life care (EoLC) as the population ages. To enhance primary EoLC, the facilitators and barriers to their provision need to be understood.

OBJECTIVE

To provide a comprehensive description of the facilitators and barriers to GP and GPN provision of PC or EoLC.

METHOD

Systematic literature review. Data included papers (2000 to 2017) sought from Medline, PsycInfo, Embase, Joanna Briggs Institute and Cochrane databases.

RESULTS

From 6209 journal articles, 62 reviewed papers reported the GP's and GPN's role in EoLC or PC practice. Six themes emerged: patient factors; personal GP factors; general practice factors; relational factors; co-ordination of care; availability of services. Four specific settings were identified: aged care facilities, out-of-hours care and resource-constrained settings (rural, and low-income and middle-income countries). Most GPs provide EoLC to some extent, with greater professional experience leading to increased comfort in performing this form of care. The organisation of primary care at practice, local and national level impose numerous structural barriers that impede more significant involvement. There are potential gaps in service provision where GPNs may provide significant input, but there is a paucity of studies describing GPN routine involvement in EoLC.

CONCLUSIONS

While primary care practitioners have a natural role to play in EoLC, significant barriers exist to improved GP and GPN involvement in PC. More work is required on the role of GPNs.

Fostering Local Health Department and Health System Collaboration Through Case Conferences for At-Risk and Vulnerable Populations

In case conferences, health care providers work together to identify and address patients' complex social and medical needs. Public health nurses from the local health department joined case conference teams at federally qualified health center primary care sites to foster cross-sector collaboration, integration, and mutual learning. Public health nurse participation resulted in frequent referrals to local health department services, greater awareness of public health capabilities, and potential policy interventions to address social determinants of health.

The Development of Practice Guidelines for a Palliative Care Multidisciplinary Case Conference

CONTEXT

In Ontario, we identified that few hospitals have developed multi-disciplinary case conferences or forums for discussion of patients with palliative care issues.

OBJECTIVE

We describe the process of creating a province-wide standards document for palliative care multidisciplinary case conferences (pMCCs).

METHODS

A provincial survey and a multidisciplinary cancer conference symposium identified pMCCs as a priority. A literature search focusing on pMCCs and their implementation was completed as well as a current state assessment (survey and interviews) to understand challenges with existing pMCCs in Ontario. A working group was then assembled to draft a recommendation report that was finalized by an expert panel.

RESULTS

A total of 22 articles were identified and 10 were used by the working group to create a framework for the pMCC guideline. The current state assessment identified substantial variability in pMCC structure and function. The expert panel made recommendations about meeting format (multidisciplinary discussion encouraged), frequency (at least every two weeks), type of cases to present, attendees (palliative care, nursing, primary care, social work, and community nursing), provider roles and responsibilities, and institutional requirements (pMCC coordinator, meeting room and videoconference capability). All patients (not just those with cancer) with palliative care needs were to be discussed at the pMCC, and pMCCs should serve as a crucial link between the hospital and community.

CONCLUSION

We have described the process of creating the first pMCC guideline. A key component of this guideline is that pMCCs should serve as a link between the hospital and community.

A facilitated approach to family case conferencing for people with advanced dementia living in nursing homes: perceptions of palliative care planning coordinators and other health professionals in the IDEAL study

BACKGROUND

Palliative care for nursing home residents with advanced dementia is often sub-optimal due to poor communication and limited care planning. In a cluster randomized controlled trial, registered nurses (RNs) from 10 nursing homes were trained and funded to work as Palliative Care Planning Coordinators (PCPCs) to organize family case conferences and mentor staff. This qualitative sub-study aimed to explore PCPC and health professional perceptions of the benefits of facilitated case conferencing and identify factors influencing implementation.

METHOD

Semi-structured interviews were conducted with the RNs in the PCPC role, other members of nursing home staff, and physicians who participated in case conferences. Analysis was conducted by two researchers using a thematic framework approach.

RESULTS

Interviews were conducted with 11 PCPCs, 18 other nurses, eight allied health workers, and three physicians. Perceived benefits of facilitated case conferencing included better communication between staff and families, greater multi-disciplinary involvement in case conferences and care planning, and improved staff attitudes and capabilities for dementia palliative care. Key factors influencing implementation included: staffing levels and time; support from management, staff and physicians; and positive family feedback.

CONCLUSION

The facilitated approach explored in this study addressed known barriers to case conferencing. However, current business models in the sector make it difficult for case conferencing to receive the required levels of nursing qualification, training, and time. A collaborative nursing home culture and ongoing relationships with health professionals are also prerequisites for success. Further studies should document resident and family perceptions to harness consumer advocacy.

Effects of facilitated family case conferencing for advanced dementia: A cluster randomised clinical trial

Background

Palliative care planning for nursing home residents with advanced dementia is often suboptimal. This study compared effects of facilitated case conferencing (FCC) with usual care (UC) on end-of-life care.

Methods

A two arm parallel cluster randomised controlled trial was conducted. The sample included people with advanced dementia from 20 Australian nursing homes and their families and professional caregivers. In each intervention nursing home (n = 10), Palliative Care Planning Coordinators (PCPCs) facilitated family case conferences and trained staff in person-centred palliative care for 16 hours per week over 18 months. The primary outcome was family-rated quality of end-of-life care (End-of-Life Dementia [EOLD] Scales). Secondary outcomes included nurse-rated EOLD scales, resident quality of life (Quality of Life in Late-stage Dementia [QUALID]) and quality of care over the last month of life (pharmacological/non-pharmacological palliative strategies, hospitalization or inappropriate interventions).

Results

Two-hundred-eighty-six people with advanced dementia took part but only 131 died (64 in UC and 67 in FCC which was fewer than anticipated), rendering the primary analysis under-powered with no group effect seen in EOLD scales. Significant differences in pharmacological (P < 0.01) and non-pharmacological (P < 0.05) palliative management in last month of life were seen. Intercurrent illness was associated with lower family-rated EOLD Satisfaction with Care (coefficient 2.97, P < 0.05) and lower staff-rated EOLD Comfort Assessment with Dying (coefficient 4.37, P < 0.01). Per protocol analyses showed positive relationships between EOLD and staff hours to bed ratios, proportion of residents with dementia and staff attitudes.

Conclusion

FCC facilitates a palliative approach to care. Future trials of case conferencing should consider outcomes and processes regarding decision making and planning for anticipated events and acute illness.

Trial registration

Australian New Zealand Clinical Trial Registry ACTRN12612001164886

Case conferencing for palliative care patients – a survey of South Australian general practitioners

Benefits of case conferencing for people with palliative care needs between a general practitioner, the person and other key participants include improving communication, advance care planning, coordination of care, clarifying goals of care and support for patient, families and carers. Despite a growing evidence base for the benefits, the uptake of case conferencing has been limited in South Australia. The aim of this study is to explore the beliefs and practice of South Australian general practitioners towards case conferencing for people with palliative care needs. Using an online survey, participants were asked about demographics, attitudes towards case conferencing and details about their most recent case conference for a person with palliative care needs. Responses were received from 134 general practitioners (response rate 11%). In total, 80% valued case conferencing for people with palliative care needs; however, <25% had been involved in case conferencing in the previous 2years. The major barrier was time to organise and coordinate case conferences. Enablers included general practitioner willingness or interest, strong relationship with patient, specialist palliative care involvement and assistance with organisation. Despite GPs’ beliefs of the benefits of case conferencing, the barriers remain significant. Enabling case conferencing will require support for organisation of case conferences and review of Medicare Benefits Schedule criteria for reimbursement.

Pragmatic cluster randomised controlled trial of facilitated family case conferencing compared with usual care for improving end of life care and outcomes in nursing home residents with advanced dementia and their families: the IDEAL study protocol

BACKGROUND

Care for people with advanced dementia requires a palliative approach targeted to the illness trajectory and tailored to individual needs. However, care in nursing homes is often compromised by poor communication and limited staff expertise. This paper reports the protocol for the IDEAL Project, which aims to: 1) compare the efficacy of a facilitated approach to family case conferencing with usual care; 2) provide insights into nursing home- and staff-related processes influencing the implementation and sustainability of case conferencing; and 3) evaluate cost-effectiveness.

DESIGN/METHODS

A pragmatic parallel cluster randomised controlled trial design will be used. Twenty Australian nursing homes will be randomised to receive either facilitated family case conferencing or usual care. In the intervention arm, we will train registered nurses at each nursing home to work as Palliative Care Planning Coordinators (PCPCs) 16 h per week over 18 months. The PCPCs' role will be to: 1) use evidence-based 'triggers' to identify optimal time-points for case conferencing; 2) organise, facilitate and document case conferences with optimal involvement from family, multi-disciplinary nursing home staff and community health professionals; 3) develop and oversee implementation of palliative care plans; and 4) train other staff in person-centred palliative care. The primary endpoint will be symptom management, comfort and satisfaction with care at the end of life as rated by bereaved family members on the End of Life in Dementia (EOLD) Scales. Secondary outcomes will include resident quality of life (Quality of Life in Late-stage Dementia [QUALID]), whether a palliative approach is taken (e.g. hospitalisations, non-palliative medical treatments), staff attitudes and knowledge (Palliative Care for Advanced Dementia [qPAD]), and cost effectiveness. Processes and factors influencing implementation, outcomes and sustainability will be explored statistically via analysis of intervention 'dose' and qualitatively via semi-structured interviews. The pragmatic design and complex nature of the intervention will limit blinding and internal validity but support external validity.

DISCUSSION

The IDEAL Project will make an important contribution to the evidence base for dementia-specific case conferencing in nursing homes by considering processes and contextual factors as well as overall efficacy. Its strengths and weaknesses will both lie in its pragmatic design.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12612001164886. Registered 02/11/2012.

Interventions to improve continuity of care in the follow-up of patients with cancer

BACKGROUND

Care from the family physician is generally interrupted when patients with cancer come under the care of second-line and third-line healthcare professionals who may also manage the patient's comorbid conditions. This situation may lead to fragmented and uncoordinated care, and results in an increased likelihood of not receiving recommended preventive services or recommended care.

OBJECTIVES

To classify, describe and evaluate the effectiveness of interventions aiming to improve continuity of cancer care on patient, healthcare provider and process outcomes.

SEARCH METHODS

We searched the Cochrane Effective Practice and Organization of Care Group (EPOC) Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, EMBASE, CINAHL, and PsycINFO, using a strategy incorporating an EPOC Methodological filter. Reference lists of the included study reports and relevant reviews were also scanned, and ISI Web of Science and Google Scholar were used to identify relevant reports having cited the studies included in this review.

SELECTION CRITERIA

Randomised controlled trials (including cluster trials), controlled clinical trials, controlled before and after studies and interrupted time series evaluating interventions to improve continuity of cancer care were considered for inclusion. We included studies that involved a majority (> 50%) of adults with cancer or healthcare providers of adults with cancer. Primary outcomes considered for inclusion were the processes of healthcare services, objectively measured healthcare professional, informal carer and patient outcomes, and self-reported measures performed with scales deemed valid and reliable. Healthcare professional satisfaction was included as a secondary outcome.

DATA COLLECTION AND ANALYSIS

Two reviewers described the interventions, extracted data and assessed risk of bias. The authors contacted several investigators to obtain missing information. Interventions were regrouped by type of continuity targeted, model of care or interventional strategy and were compared to usual care. Given the expected clinical and methodological diversity, median changes in outcomes (and bootstrap confidence intervals) among groups of studies that shared specific features of interest were chosen to analyse the effectiveness of included interventions.

MAIN RESULTS

Fifty-one studies were included. They used three different models, namely case management, shared care, and interdisciplinary teams. Six additional interventional strategies were used besides these models: (1) patient-held record, (2) telephone follow-up, (3) communication and case discussion between distant healthcare professionals, (4) change in medical record system, (5) care protocols, directives and guidelines, and (6) coordination of assessments and treatment.Based on the median effect size estimates, no significant difference in patient health-related outcomes was found between patients assigned to interventions and those assigned to usual care. A limited number of studies reported psychological health, satisfaction of providers, or process of care measures. However, they could not be regrouped to calculate median effect size estimates because of a high heterogeneity among studies.

AUTHORS' CONCLUSIONS

Results from this Cochrane review do not allow us to conclude on the effectiveness of included interventions to improve continuity of care on patient, healthcare provider or process of care outcomes. Future research should evaluate interventions that target an improvement in continuity as their primary objective and describe these interventions with the categories proposed in this review. Also of importance, continuity measures should be validated with persons with cancer who have been followed in various settings.

The effectiveness and appropriateness of a palliative approach to care for people with advanced dementia: a systematic review

BACKGROUND

Dementia is a progressive and incurable disease which presents many challenges to care providers, particularly in terms of end-of-life care. A palliative approach; that is an approach to care which seeks to ease burdensome symptoms without attempting curative treatment, has been suggested as the most appropriate framework for addressing the needs of these people.

OBJECTIVES

The overall objective was to establish best practice in relation to palliative care for people with advanced dementia in terms of effectiveness and appropriateness.

SEARCH STRATEGY

The search strategy aimed to find both published and unpublished English language studies, published between 1997 and 2009. A three-step search strategy was utilised in each component of this review.

CRITICAL APPRAISAL

Quantitative, qualitative and discursive text articles were included in this review. Articles were assessed for congruence to the review criteria and then critically appraised for quality using the appropriate JBI tool.

DATA COLLECTION AND ANALYSIS

Data were extracted using the appropriate JBI data extraction tool for each methodology. No quantitative meta-analysis was possible due to clinical and statistical heterogeneity. Qualitative synthesis was performed with the JBI QARI tool. Discursive textual synthesis was performed with the JBI NOTARI tool.

RESULTS

Quantitative studies recommended the use of do not resuscitate, do not hospitalise orders and other forms of advance directives to prevent interventions unwanted by the patient and/or their family. Feeding tubes and the use of intravenous antibiotics were not found to be an effective intervention. Interventions designed to treat the burdensome symptoms of advanced dementia (such as pain and agitation) were found to be of the most benefit to patients.Qualitative analysis found it distressing for families to discuss or plan for, a poor quality of life for their loved one during the process of dying. Decisions concerned with palliative treatment for the person with advanced dementia were found to be complicated by knowledge differences, lack of understanding of the disease trajectory of dementia, the unpredictable nature of dementia itself and religious and socio-economical issues. Textual analysis found that a palliative approach to end of life care in advanced dementia is both appropriate and effective in terms of benefit to patients and their significant others.Despite the large volume of data retrieved and analysed for this review, no studies examining the role of case-conferencing for managing the introduction of palliative care or managing a palliative approach met the inclusion criteria for this systematic review.

IMPLICATIONS FOR PRACTICE

IMPLICATIONS FOR FUTURE RESEARCH: There is a need for further studies in the area of palliation and advanced dementia, particularly high quality studies investigating palliative care case conferencing and other methods of arranging and planning end of life care for people with dementia.

CONCLUSION

There is some evidence to suggest that a palliative approach is both effective and appropriate for use with people who have advanced dementia. There is no evidence for or against the use of case-conferencing as a method of arranging care for people with advanced dementia.

Utilisation of podiatry services in Australia under the Medicare Enhanced Primary Care program, 2004-2008

Background

In 2004, as an extension of the Enhanced Primary Care (EPC) program, the Australian Government introduced a policy of providing Medicare rebates for allied health services provided to patients with chronic or complex health conditions. The objective of this study was to evaluate the utilisation of podiatry services provided under this scheme between 2004 and 2008.

Methods

Data pertaining to the Medicare item 10962 for the calendar years 2004-2008 were extracted from the Australian Medicare Benefits Schedule (MBS) database and cross-tabulated by sex and age. Descriptive analyses were undertaken to assess sex and age differences in the number of consultations provided and to assess for temporal trends over the five-year assessment period. The total cost to Medicare over this period was also determined.

Results

During the 2004-2008 period, a total of 1,338,044 EPC consultations were provided by podiatrists in Australia. Females exhibited higher utilisation than males (63 versus 37%), and those aged over 65 years accounted for 75% of consultations. There was a marked increase in the number of consultations provided from 2004 to 2008, and the total cost of providing EPC podiatry services during this period was $62.9 M.

Conclusion

Podiatry services have been extensively utilised under the EPC program by primary care patients, particularly older women, and the number of services provided has increased dramatically between 2004 and 2008. Further research is required to determine whether the EPC program enhances clinical outcomes compared to standard practice.

Feasibility and sustainability of a model of multidisciplinary case conferencing in residential aged care

This paper reports a pilot study examining the feasibility, acceptability and sustainability of a multidisciplinary case conferencing model in residential aged care. The model was developed through a consultation process and then implemented in 31 case conferences over a 6-month period between May and October 2008. This paper explores the feasibility and acceptability of model implementation, the experience of the facility staff, general practitioners and residents/family carers and the perceived sustainability of the model in clinical practice. It shows that although there was a degree of confusion around the concept of multidisciplinary case conferencing, implementation of this partnership model significantly improved communication between health workers, facilitated interaction between staff and family carers, and provided a focus for reflecting on individual residents’ health needs.

Do case conferences between general practitioners and specialist palliative care services improve quality of life? A randomised controlled trial (ISRCTN 52269003)

Australian palliative care is delivered by general practitioners (GPs) and specialist palliative care teams. Patient outcomes should improve if they work in formal partnership. We conducted a multi-centred randomised controlled trial of specialist- GP case conferences, with the GP participating by teleconference, or usual care and communication methods. Primary outcome measure was global Quality of Life (QoL) scores at 3 weeks from intervention. Secondary measures included subscale QoL scores and carer burden. Two a priori intention-to-treat analyses were conducted using recruitment, and time of death, as fixed time points. There was no difference between groups in the magnitude of change in global QoL measures from baseline to any time point up to 9 weeks post-case conference, or at any time before death. The case conference group showed better maintenance of some physical and mental health measures of QoL in the 35 days before death. Case conferences may improve clinical relationships and care plans at referral, which are not implemented until severe symptoms develop. Case conferences between GPs and specialist palliative care services may be warranted for palliative care patients.

Mental health case conferences in primary care: Content and treatment decision making

BACKGROUND

Case conferences are multidisciplinary meetings of health professionals to plan treatment for specific people with chronic and complex care needs. The value of multidisciplinary teamwork in mental health care is well recognized.

OBJECTIVE

This study aimed to explore the process of decision making in mental health case conferences involving community pharmacists and primary care physicians.

METHODS

Case conferences were conducted for 44 people receiving one or more medicines for a mental illness. Before participating in the case conferences, pharmacists conducted home visits and produced written reports that detailed Home Medicines Review findings and recommendations. The case conferences were audio taped and transcribed verbatim. A framework, based on the 3 components of decision making (derived from the Model of Shared Decision Making), was used to code statements made at the case conferences. These components were (1) information exchange, (2) deliberation, and (3) decision making.

RESULTS

Pharmacists and physicians exchanged personal and medical information. Pharmacists presented their treatment findings and recommendations, and generally a brief discussion about treatment options followed (deliberation). The responsibility for deciding which treatments to implement (decision) typically remained with the physicians.

CONCLUSIONS

The case conferences provided an opportunity for pharmacists and physicians to share information and discuss treatment options. Responsibility for deciding which treatment to implement generally remained with the primary care physicians.

The impact of conducting a regional palliative care clinical study

End-of-life care must be informed by methodologically rigorous, high-quality research, but well-documented barriers make the conduct of palliative care clinical trials difficult. With careful consideration to study design and procedures, these barriers are surmountable. This paper discusses the approach used in a large scale, randomised, controlled trial of service-based interventions in a regional palliative care service in South Australia, and the impact of this trial on palliative care research more broadly, the changes to the service in which it was conducted, and on health policy beyond palliative care. The Palliative Care Trial evaluated three interventions in a 2 x 2 x 2 factorial cluster randomised design: case conferences, general practitioner education, and patient education. Main outcomes were performance status, pain intensity, and resource utilisation. A total of 461 patients were enrolled in the study. Pre-study planning and piloting is crucial, and accurately estimated withdrawal and death rates in the study. Other study design elements that facilitated this research included assessment of three interventions at one time, a dedicated recruitment role, a single clinical triage point, embedding data collection into routine clinical assessments, and meaningful outcome measures. Recruitment and retention of participants is possible if barriers are systematically identified and addressed. This study challenged and developed the research culture within our clinical team and subsequently translated into further research.

Residential aged care: the last frontier for palliative care

AIM

This paper is a report of an explorative study describing the perceptions and beliefs about palliative care among nurses and care assistants working in residential aged care facilities in Australia.

BACKGROUND

Internationally, the number of people dying in residential aged care facilities is growing. In Australia, aged care providers are being encouraged and supported by a positive policy platform to deliver a palliative approach to care, which has generated significant interest from clinicians, academics and researchers. However, a little is known about the ability and capacity of residential aged care services to adopt and provide a palliative approach to care.

METHODS

Focus groups were used to investigate the collective perceptions and beliefs about palliative care in a convenience sample of nurses and care assistants working in residential aged care facilities in Australia. Thematic content analysis was used to analyse the data, which were collected during 2004.

RESULTS

Four major themes emerged: (1) being like family; (2) advocacy as a key role; (3) challenges in communicating with other healthcare providers; (4) battling and striving to succeed against the odds. Although participants described involvement and commitment to quality palliative care, they also expressed a need for additional education and support about symptom control, language and access to specialist services and resources.

CONCLUSION

The residential aged care sector is in need of support for providing palliative care, yet there are significant professional and system barriers to care delivery. The provision of enhanced palliative care educational and networking opportunities for nurses and care assistants in residential aged care, augmented by a supportive organizational culture, would assist in the adoption of a palliative approach to service delivery and requires systematic investigation.

Educational and health service needs of Australian general practitioners in managing hepatitis C

BACKGROUND

There has been interest in recent years in the role of primary care practitioners in managing hepatitis C, but there has been minimal research to identify educational and health service needs. A national survey of Australian general practitioners (GPs) was therefore conducted to assess their needs and identify areas for service development.

METHODS

A self-administered questionnaire was developed that included questions to assess caseload, confidence in patient management, educational needs and approaches to management and prevention. Questionnaires were sent to a random sample of Australian GPs. Returned questionnaires were coded, frequencies tabulated and significant associations identified.

RESULTS

A 70% response rate was achieved from 658 eligible GPs. A total of 76% of respondents had managed one patient in the previous year with hepatitis C. While 69% reported feeling more confident about their management of hepatitis C than 5 years previously, 55% identified a high level of need for hospital-based clinics. Financial benefits for case conferences and chronic case management were not considered useful by most GPs. Topics identified for further skills development included therapeutics and diagnostic testing. Only 39% were highly likely to discuss psychosocial issues as part of initial patient management and 37% reported finding it difficult to play a central role in the medical and psychosocial care of patients with hepatitis C.

CONCLUSION

These results have significant implications for policy and service development, as well as identifying areas where GPs need support. The findings invite further discussion between health authorities about the source and magnitude of funding for hospital-based services and further consideration of how to provide services to address patients' psychosocial needs.

A pragmatic 2×2×2 factorial cluster randomized controlled trial of educational outreach visiting and case conferencing in palliative care—methodology of the Palliative Care Trial [ISRCTN 81117481]

The demand for palliative care is increasing, yet there are few data on the best models of care nor well-validated interventions that translate current evidence into clinical practice. Supporting multidisciplinary patient-centered palliative care while successfully conducting a large clinical trial is a challenge. The Palliative Care Trial (PCT) is a pragmatic 2 x 2 x 2 factorial cluster randomized controlled trial that tests the ability of educational outreach visiting and case conferencing to improve patient-based outcomes such as performance status and pain intensity. Four hundred sixty-one consenting patients and their general practitioners (GPs) were randomized to the following: (1) GP educational outreach visiting versus usual care, (2) Structured patient and caregiver educational outreach visiting versus usual care and (3) A coordinated palliative care model of case conferencing versus the standard model of palliative care in Adelaide, South Australia (3:1 randomization). Main outcome measures included patient functional status over time, pain intensity, and resource utilization. Participants were followed longitudinally until death or November 30, 2004. The interventions are aimed at translating current evidence into clinical practice and there was particular attention in the trial's design to addressing common pitfalls for clinical studies in palliative care. Given the need for evidence about optimal interventions and service delivery models that improve the care of people with life-limiting illness, the results of this rigorous, high quality clinical trial will inform practice. Initial results are expected in mid 2005.

Remunerating private psychiatrists for participating in case conferences

Background

On 1 November 2000, a series of new item numbers was added to the Medicare Benefits Schedule, which allowed for case conferences between physicians (including psychiatrists) and other multidisciplinary providers. On 1 November 2002, an additional set of numbers was added, designed especially for use by psychiatrists. This paper reports the findings of an evaluation of these item numbers.

Results

The uptake of the item numbers in the three years post their introduction was low to moderate at best. Eighty nine psychiatrists rendered 479 case conferences at a cost to the Health Insurance Commission of $70,584. Psychiatrists who have used the item numbers are generally positive about them, as are consumers. Psychiatrists who have not used them have generally not done so because of a lack of knowledge, rather than direct opposition. The use of the item numbers is increasing over time, perhaps as psychiatrists become more aware of their existence and of their utility in maximising quality of care.

Conclusion

The case conferencing item numbers have potential, but as yet this potential is not being realised. Some small changes to the conditions associated with the use of the item numbers could assist their uptake.

A Comparison of Methodologies from Two Longitudinal Community-Based Randomized Controlled Trials of Similar Interventions in Palliative Care: What Worked and What Did Not?

BACKGROUND

Methodological challenges such as recruitment problems and participant burden make clinical trials in palliative care difficult. In 2001-2004, two community-based randomized controlled trials (RCTs) of case conferences in palliative care settings were independently conducted in Australia--the Queensland Case Conferences trial (QCC) and the Palliative Care Trial (PCT).

DESIGN

A structured comparative study of the QCC and PCT was conducted, organized by known practical and organizational barriers to clinical trials in palliative care.

RESULTS

Differences in funding dictated study designs and recruitment success; PCT had 6 times the budget of QCC. Sample size attainment. Only PCT achieved the sample size goal. QCC focused on reducing attrition through gate-keeping while PCT maximized participation through detailed recruitment strategies and planned for significant attrition. Testing sustainable interventions. QCC achieved a higher percentage of planned case conferences; the QCC strategy required minimal extra work for clinicians while PCT superimposed conferences on normal work schedules. Minimizing participant burden. Differing strategies of data collection were implemented to reduce participant burden. QCC had short survey instruments. PCT incorporated all data collection into normal clinical nursing encounters. Other. Both studies had acceptable withdrawal rates. Intention-to-treat analyses are planned. Both studies included sub-studies to validate new outcome measures.

CONCLUSIONS

Health service interventions in palliative care can be studied using RCTs. Detailed comparative information of strategies, successes and challenges can inform the design of future trials. Key lessons include adequate funding, recruitment focus, sustainable interventions, and mechanisms to minimize participant burden.

Managing adverse drug reactions: time to get serious

Identifying these reactions is a good start, now we must focus on managing and preventing them.

Defining chronic conditions for primary care with ICPC-2

BACKGROUND

With the increasing prevalence of chronic conditions, there is need for a standardized definition of chronicity for use in research, to evaluate the population prevalence and general practice management of chronic conditions.

OBJECTIVES

Our aims were to determine the characteristics required to define chronicity, apply them to a primary care classification and provide a defined codeset of chronic conditions.

METHODS

A literature review evaluated characteristics used to define chronic conditions. The final set of characteristics was applied to the International Classification of Primary Care-Version 2 (ICPC-2) through more specific terms available in ICPC-2 PLUS, an extended terminology classified to ICPC-2. A set of ICPC-2 rubrics was delineated as representing chronic conditions.

RESULTS

Factors found to be relevant to a definition of chronic conditions for research were: duration; prognosis; pattern; and sequelae. Within ICPC-2, 129 rubrics were described as 'chronic', and another 20 rubrics had elements of chronicity. Duration was the criterion most frequently satisfied (98.4% of chronic rubrics), while 88.2% of rubrics met at least three of the four criteria.

CONCLUSION

Monitoring the prevalence and management of chronic conditions is of increasing importance. This study provided evidence for multifaceted definitions of chronicity. While all characteristics examined could be used by those interested in chronicity, the list has been designed to identify chronic conditions managed in Australian general practice, and is therefore not a nomenclature of all chronic conditions. Subsequent analysis of chronic conditions using pre-existing data sets will provide a baseline measure of chronic condition prevalence and management in general practice.

Palliative care at home: general practitioners working with palliative care teams

Home care is the preferred option for most people with a terminal illness. Providing home care relies on good community-based services, and a general practice workforce competent in palliative care practice and willing to accommodate patients' needs. Structured palliative care training of general practitioners is needed at undergraduate and postgraduate level, with attention to barriers to teamwork and communication. Good palliative care can be delivered to patients at home by GPs (supported by specialist palliative care teams) and community nurses, with access to an inpatient facility when required. To optimise patient care, careful planning and good communication between all members of the healthcare team is crucial.

Providing healthcare for people with chronic illness: the views of Australian GPs

OBJECTIVES

To explore general practitioners' views on chronic-disease care: the difficulties and rewards, the needs of patients, the impact of government incentive payments, and the changes needed to improve chronic-disease management.

DESIGN

Qualitative study, involving semi-structured questions administered to 10 focus groups of GPs, conducted from April to October 2002.

PARTICIPANTS AND SETTING

54 GPs from both urban and rural practices in New South Wales and South Australia.

RESULTS

Consistent themes emerged about the complex nature of chronic-disease management, the tension between patients' and GPs' goals for care, the time-consuming aspects of care (exacerbated by federal government requirements), and the conflicting pressures that prevent GPs engaging in structured multidisciplinary care (ie, team-based care involving systems for patient monitoring, recall, and care planning).

CONCLUSIONS

Structured multidisciplinary care for people with chronic conditions can be difficult to provide. Barriers include the lack of fit between systems oriented towards acute care and the requirements of chronic-disease care, and between bureaucratic, inflexible structures and the complex, dynamic nature of GP-patient relationships. These problems are exacerbated by administrative pressures associated with federal government initiatives to improve chronic-illness management. Changes are needed in both policies and attitudes to enable GPs to move from episodic care to providing structured long-term care as part of a multidisciplinary team.