Abstract The number of people in their last years of life with advanced chronic conditions, palliative care needs, and limited life prognosis due to different causes including multi-morbidity, organ ...failure, frailty, dementia, and cancer is rising. Such people represent more than 1% of the population. They are present in all care settings, cause around 75% of mortality, and may account for up to one-third of total national health system spend. The response to their needs is usually late and largely based around institutional palliative care focused on cancer. There is a great need to identify these patients and integrate an early palliative approach according to their individual needs in all settings, as suggested by the World Health Organization. Several tools have recently been developed in different European regions to identify patients with chronic conditions who might benefit from palliative care. Similarly, several models of integrated palliative care have been developed, some with a public health approach to promote access to all in need. We describe the characteristics of these initiatives and suggest how to develop a comprehensive and integrated palliative approach in primary and hospital care and to design public health and community-oriented practices to assess and respond to the needs in the whole population. Additionally, we report ethical challenges and prognostic issues raised and emphasize the need for research to test the various tools and models to generate evidence about the benefits of these approaches to patients, their families, and to the health system.
Background:
The Surprise Question (‘Would I be surprised if this patient died within 12 months?’) identifies patients in the last year of life. It is unclear if ‘surprised’ means the same for each ...clinician, and whether their responses are internally consistent.
Aim:
To determine the consistency with which the Surprise Question is used.
Design:
A cross-sectional online study of participants located in Belgium, Germany, Italy, The Netherlands, Switzerland and UK. Participants completed 20 hypothetical patient summaries (‘vignettes’). Primary outcome measure: continuous estimate of probability of death within 12 months (0% certain survival–100% certain death). A threshold (probability estimate above which Surprise Question responses were consistently ‘no’) and an inconsistency range (range of probability estimates where respondents vacillated between responses) were calculated. Univariable and multivariable linear regression explored differences in consistency. Trial registration: NCT03697213.
Setting/participants:
Registered General Practitioners (GPs). Of the 307 GPs who started the study, 250 completed 15 or more vignettes.
Results:
Participants had a consistency threshold of 49.8% (SD 22.7) and inconsistency range of 17% (SD 22.4). Italy had a significantly higher threshold than other countries (p = 0.002). There was also a difference in threshold levels depending on age of clinician, for every yearly increase, participants had a higher threshold. There was no difference in inconsistency between countries (p = 0.53).
Conclusions:
There is variation between clinicians regarding the use of the Surprise Question. Over half of GPs were not internally consistent in their responses to the Surprise Question. Future research with standardised terms and real patients is warranted.
For GPs to implement early palliative care, the first step is to identify patients with palliative care needs. The surprise question (SQ) is a screening tool that aims to aid this identification; for ...example, a response of 'no' to the SQ - 'Would you be surprised if this patient would die within a year?' - would suggest palliative care may be needed.
To describe setting-specific screening results of patients eligible for early palliative care in family practices, which is defined as patients aged
45 years with GPs' responses of 'no' to the SQ.
A secondary analysis was undertaken using a cross-sectional descriptive study in family practices in five areas in Belgium.
GPs were recruited by targeted sampling. As a first part of an implementation research project, participating GPs provided demographic information about themselves and also provided a response to the SQ for all patients who came to the practice in 10 consecutive office days. A summary table describing the sex, age, location of contact (GP surgeries, patients' homes, or nursing homes) of the patients was provided by each GP.
Fifty-six GPs provided complete data for the practice summary tables. In total, 9150 patients were described (all ages, all settings), of which 506 patients (6%) had a GP response of 'no' to the SQ. The distribution of SQ-no-as-answer patients per setting was: 152/7659 (2%) patients seen in family practice surgeries; 139/998 (14%) patients seen in their homes; and 215/493 (44%) patients seen in nursing homes.
There was a large number of patients with SQ-no-as-answer, with possible palliative care needs. To enhance implementation of early palliative care, future research should compare results of SQ and other screening tools with palliative care symptoms assessments.
To deliver optimal palliative care, a Care Pathway for Primary Palliative Care (CPPPC) was developed. This CPPPC was implemented by general practitioners (GPs) in territories of five Belgian ...palliative care networks (2014-2016). Belgian doctors have much therapeutic freedom, and do not commonly follow guidelines.
To assess how palliative care was provided by GPs before the CPPPC and its implementation project were presented publicly.
Between 2013 and 2015, seven focus groups with GPs were conducted. Participants included 15 GPs in three French-speaking focus groups and 26 GPs in four Dutch-speaking focus groups, with diversity for age, gender, palliative care experience and practice context. Some GPs implemented the CPPPC later.
GPs considered each palliative care case unique and disliked strict protocols. However, they expressed a need for peer review and reflective frameworks. GPs felt it is important to identify palliative care patients 'timely', but found this difficult. Screening methods help, but are not widely used. GPs struggled most with identifying palliative care needs in non-oncological patients. Bad news breaking was considered difficult. Continuity of care was considered very important. However, advance care planning seemed more widely practised by Dutch-speaking GPs than by French-speaking GPs. The taboo of palliative care provoked emotional discussions.
Palliative care frameworks which help GPs to deliver 'tailor-made' care have more chance to be adopted than strict protocols. GPs should be given education for bad news breaking. Palliative care and advance care planning practices differ locally: guideline dissemination plans should respect these local differences.
The Surprise Question (SQ) "would I be surprised if this patient were to die in the next 12 months?" has been suggested to help clinicians, and especially General Practitioners (GPs), identify people ...who might benefit from palliative care. The prognostic accuracy of this approach is unclear and little is known about how GPs use this tool in practice. Are GPs consistent, individually and as a group? Are there international differences in the use of the tool? Does including the alternative Surprise Question ("Would I be surprised if the patient were still alive after 12 months?") alter the response? What is the impact on the treatment plan in response to the SQ? This study aims to address these questions.
An online study will be completed by 600 (100 per country) registered GPs. They will be asked to review 20 hypothetical patient vignettes. For each vignette they will be asked to provide a response to the following four questions: (1) the SQ Yes/No; (2) the alternative SQ Yes/No; (3) the percentage probability of dying 0% no chance - 100% certain death; and (4) the proposed treatment plan multiple choice. A "surprise threshold" for each participant will be calculated by comparing the responses to the SQ with the probability estimates of death. We will use linear regression to explore any differences in thresholds between countries and other clinician-related factors, such as years of experience. We will describe the actions taken by the clinicians and explore the differences between groups. We will also investigate the relationship between the alternative SQ and the other responses. Participants will receive a certificate of completion and the option to receive feedback on their performance.
This study explores the extent to which the SQ is consistently used at an individual, group, and national level. The findings of this study will help to understand the clinical value of using the SQ in routine practice.
Clinicaltrials.gov NCT03697213 (05/10/2018). Prospectively registered.
In recent research, Google Trends data has been identified as a potentially useful data source to complement or even replace otherwise traditional data for predicting migration flows. However, the ...research on this is in its infancy, and as of yet suffers from a distinctive Western bias both in the topics covered as in the applicability of the methods. To examine its wider utility, this paper evaluates the predictive potential of Google Trends data, which captures Google search frequencies, but applies it to the case of Japanese migration flows to Europe. By doing so, we focus on some of the specific challenging aspects of the Japanese language, such as its various writing systems, and of its migration flows, characterized by its relative stability and sometimes limit size. In addition, this research investigates to what extent Google Trends data can be used to empirically test theory in the form of the aspirations and (cap)ability approach. The results show that after careful consideration, this method has the potential to reach satisfactory predictions, but that there are many obstacles to overcome. As such, sufficient care and prior investigation are paramount when attempting this method for less straightforward cases, and additional studies need to address some of the key limitations more in detail to validate or annul some of the findings presented here.
The number of people in their last years of life with advanced chronic conditions, palliative care needs, and limited life prognosis due to different causes including multi-morbidity, organ failure, ...frailty, dementia, and cancer is rising. Such people represent more than 1% of the population. They are present in all care settings, cause around 75% of mortality, and may account for up to one-third of total national health system spend. The response to their needs is usually late and largely based around institutional palliative care focused on cancer. There is a great need to identify these patients and integrate an early palliative approach according to their individual needs in all settings, as suggested by the World Health Organization. Several tools have recently been developed in different European regions to identify patients with chronic conditions who might benefit from palliative care. Similarly, several models of integrated palliative care have been developed, some with a public health approach to promote access to all in need. We describe the characteristics of these initiatives and suggest how to develop a comprehensive and integrated palliative approach in primary and hospital care and to design public health and community-oriented practices to assess and respond to the needs in the whole population. Additionally, we report ethical challenges and prognostic issues raised and emphasize the need for research to test the various tools and models to generate evidence about the benefits of these approaches to patients, their families, and to the health system. (C) 2016 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
The aim of this exploratory survey was to provide an overview of physiotherapeutic and occupational therapeutic techniques and outcome measures applied in practice within palliative care. An ...anonymous web-based questionnaire was distributed to physiotherapists and occupational therapists in Flanders, Belgium between December 2017 and February 2018. A total of 91 respondents were included. Frequently applied interventions were: massage (51%), mobilization (49%), exercise therapy (46%), manual lymphatic drainage (42%), walking rehabilitation (40%) and breathing therapy (32%). Additional therapeutic aspects such as 'comfort care' and 'creating a therapeutic alliance' were mentioned by 34% of all therapists and cannot be ignored as an important part of treatment. Outcome measures were not always used to evaluate treatment because of time constraints and because progress was considered difficult to conceptualize in a palliative care context. The most frequently used outcome measures were a visual analogue scale (VAS) and the 6-minute walk test. In this study, the most frequently applied physiotherapeutic and occupational therapeutic interventions within palliative care were massage, mobilization and exercise therapy. However, therapists stress that these techniques are not mandatory, since care is always informed by the individual comfort and daily functioning of patients. Other than a VAS, outcome measures were used minimally.
Introduction: One of the main current challenges for the Belgian primary health care system is the integration of primary mental health care.
Belgium is known to have a shortage of mental health ...professionals. Public mental health services are understaffed, resulting in long waiting lists. Private mental health professionals are too expensive for many people in psychological distress.
Since 2019, a limited number of primary mental health consultations is reimbursed, to lower the financial threshold to access the private mental health sector. Since 2021, the primary mental health convention changed, towards higher renumeration for psychologists working in the convention, and starting more from a public mental health vision.
This is a Belgian federal action. In Pallieterland and four other primary care zones, this action is coordinated by two mental health networks: Emergo (for adults) and PANNG 0-18 (for minors).
In this article the focus is on the change management on the meso-level: how did and still does primary care zone Pallieterland help to implement this policy change?
What we did: The first step was to have a representative of the mental health sector in the board of the primary care zone, a necessary navigator and go-between, facilitating communication efforts of the primary care zone towards the mental health sector.
The second step was to help founding a local psychologists’ association. After some previous attempts, the start of the new convention showed to be a good momentum for the start of the local psychologists’ association. Their founders are good communicators, representing the local primary mental health professionals in the boards of both the primary care zone, and of the local implementation group of the new primary mental health care convention.
The third step is to keep monitoring the implementation progress, making sure that all localities in the primary care zone are well served with reimbursed primary health care consultations.
The primary care zone facilitated and still facilitates these processes, by using a diversity of communication platforms:
- A monthly electronic newsletter, reaching local healthcare and social care professionals;
- Siilo Connect, a “medical Whatsapp” respecting GDPR legislation and able to send messages both to the whole contact list and to specific professional groups. Sometimes we sent a targeted request to fill a survey related to this topic, whenever we needed input for local policy decisions;
- Six-monthly platform meetings on relevant interdisciplinary topics, reaching local healthcare and social care professionals: we both gave dedicated time for this project on one platform meeting and gave short follow-up notices on other platform meetings;
- Six-weekly board meetings and annual general meeting: short notices on the progress of implementation, allowing questions from diverse stakeholders.
Conclusion: Summarizing the efforts of primary care zone Pallieterland towards the implementation of the new primary mental health convention through the lens of Donabedian’s theory (Structure – Process – Outcome), we found that we spent most energy and time in modelling the structures, and monitoring processes of communication/collaboration. At the moment, primary care zones don’t have access to any outcome indicator.
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