Case conferences between general practitioners and specialist teams to plan end of life care of people with end stage heart failure and lung disease: an exploratory pilot study

Abstract

BackgroundMost people die of non-malignant disease, but most patients of specialist palliative care services have cancer. Adequate end of life care for people with non-malignant disease requires acknowledgement of their limited prognosis and appropriate care planning. Case conferences between specialist palliative care services and GPs improve outcomes in cancer-based populations. We report a pilot study of case conferences between the patient’s GP and specialist staff to facilitate care planning for people with end stage heart failure or non-malignant lung disease in a regional health service in Queensland Australia.MethodsSingle face to face case conferences about patients with a primary diagnosis of advanced heart failure or respiratory failure from non-malignant disease were conducted between a palliative care consultant, a case management nurse and the patient’s GP. Annualised rates of service utilisation (emergency department [ED] presentations, ED discharges back to home, hospital admissions, and admission length of stay) before and after case conference were calculated. Content and counts of case conference recommendations, and the rate of adherence to recommendations were also assessed. A process evaluation of case conferences was undertaken.ResultsTwenty-three case conferences involving 21 GPs were conducted between November 2011 and November 2012. One GP refused to participate. Ten patients died, three at home. Of 82 management recommendations made, 55 (67%) were enacted. ED admissions fell from 13.9 per annum (pa) to 2.1 (difference 11.8, 95% CI 2.2-21.3, p = 0.001); ED admissions leading to discharge home from 3.9 to 0.4 pa (difference 3.5, 95% CI -0.4-7.5, p = 0.05); hospital admissions from 11.4 to 3.5 pa (difference 7.9, 95% CI 2.2-13.7, p = 0.002); and length of stay from 7.0 to 3.7 days (difference 3.4, 95% CI 0.9-5.8, p = 0.007). Participating health professionals were enthusiastic about the process.ConclusionsThis pilot is the initial step in the development and testing of a complex intervention based on a model of integrated care. A single case conference involving the patient’s heart or lung failure team is associated with significant reductions in service utilization, apparently by improving case coordination, enhancing symptom management and assessing and managing carer needs. A randomized controlled trial is being developed.Trial registrationAustralian and New Zealand Controlled Trials Register ACTRN12613001377729: Registered 16/12/2013.

The “surprise question” for predicting death in seriously ill patients: a systematic review and meta-analysis

“…Of these studies, 7 did not include outcomes data for patients who were SQ- [14][15][16][17][18][19]36 that were confirmed in the publication [15][16][17][18]36 or after contact with study authors. 14,19 In 3 studies, the SQ was used only to predict 7-and/or 30-day mortality.…”

“…Of these studies, 7 did not include outcomes data for patients who were SQ- [14][15][16][17][18][19]36 that were confirmed in the publication [15][16][17][18]36 or after contact with study authors. 14,19 In 3 studies, the SQ was used only to predict 7-and/or 30-day mortality. 29,37,38 Sixteen remaining studies of SQ to predict death met inclusion criteria 1,[20][21][22][23][24][25][26][27][28][30][31][32][33][34][35] (Table 1) and were included in the meta-analysis.…”

Systematic review of the effectiveness, barriers and facilitators to general practitioner engagement with specialist secondary services in integrated palliative care

“…Although little quantitative work has been completed in GP engagement in the integration of primary and secondary services in the provision of palliative care, studies showed a significant decrease in number of hospital admissions (p=0.0069; p=0.001) 2 22 23. Case conferences and shared care were both effective in reducing hospitalisations and in significantly (p<0.05) reducing the length of hospital stay 22 23.…”

“…Although little quantitative work has been completed in GP engagement in the integration of primary and secondary services in the provision of palliative care, studies showed a significant decrease in number of hospital admissions (p=0.0069; p=0.001) 2 22 23. Case conferences and shared care were both effective in reducing hospitalisations and in significantly (p<0.05) reducing the length of hospital stay 22 23. There was some evidence that patient functional status as measured by the Australian-modified Karnofsky Performance Scale (AKPS) was better maintained by patients receiving integrated care when performance status had already declined below a score of 70 (p=0.0425) 2.…”

“…Funding for extra staff may solve this issue. Savings found in reduced admissions to hospital and reduced length of admission to hospital by providing integrated palliative care2 22 23 could offset these financial challenges. It may be that more resources directed to this sort of care may generate more demand.…”