Evaluating the Liverpool Care Pathway for care of the terminally ill in rural Australia.

PURPOSE: This study evaluates a pilot implementation of the Liverpool Care Pathway (LCP), a clinical tool used to guide the care of dying patients in the last days of life, on the end-of-life care for dying patients in three regions in rural Australia. METHODS: The LCP was implemented at 13 participating sites: nine hospitals (general wards), one community-based palliative care service, and three in-hospital palliative care units. To evaluate the implementation of the LCP, 415 eligible patient records were examined: 223 pre-implementation and 192 post-implementation (116 on the LCP and 76 receiving usual care). The primary analysis compared all patients pre-implementation of the LCP versus all patients post-implementation. RESULTS: Increases were found post-implementation for communication with other health professionals and with patients or family (pre-69 %, post-87 %; p ≤ 0.000), use of palliative medications (pre-87 %, post-98 %; p ≤ 0.000) and frequency of symptom assessments (pre-66 %, post-82 %; p ≤ 0.000). Fewer blood and radiological investigations were conducted and venous access devices used in the post-implementation groups than in the pre-implementation period. CONCLUSIONS: This study suggests that when rigorously implemented, the LCP improves important components of end-of-life care for dying patients and their families.

Deploying a clinical innovation in the context of actor-patient consultations in general practice: a prelude to a formal clinical trial.

BACKGROUND: Innovations to be deployed during consultations with patients may influence the clinical performance of the medical practitioner. This study examined the impact on General Practitioners' (GPs) consultation performance of novel computer software, designed for use while consulting the patient. METHODS: Six GPs were video recorded consulting six actor-patients in a simulated clinical environment. Two sessions were recorded with six consultations per GP. Five cases presented cancer symptoms which warranted a referral for specialist investigation. Practitioners were invited to use a novel software package to process referrals made during the consultations in the second session. Two assessors independently reviewed the consultation performance using the Leicester Assessment Package (LAP). Inter-rater agreement was assessed by a Bland-Altman plot of the difference in score against the average score. RESULTS: Sixty of the seventy two consultations were successfully recorded. Each video consultation was scored twice by two assessors leaving 120 LAP scores available for analysis. There was no evidence of a difference in the variance with increasing score (Pitmans test p = 0.09). There was also no difference in the mean differences between assessor scores whether using the software or not (T-test, P = 0.49) CONCLUSION: The actor-patient consultation can be used to test clinical innovations as a prelude to a formal clinical trial. However the logistics of the study may impact on the validity of the results and need careful planning. Ideally innovations should be tested within the context of a laboratory designed for the purpose, incorporating a pool of practitioners whose competencies have been established and assessors who can be blinded to the aims of the study.

Advice to consult a general medical practitioner in Western Australia: could it be cancer?

BACKGROUND: Many people will consult a medical practitioner about lower bowel symptoms, and the demand for access to general practitioners (GPs) is growing. We do not know if people recognise the symptoms of lower bowel cancer when advising others about the need to consult a doctor. A structured vignette survey was conducted in Western Australia. METHOD: Participants were recruited from the waiting rooms at five general practices. Respondents were invited to complete self-administered questionnaires containing nine vignettes chosen at random from a pool of 64 based on six clinical variables. Twenty-seven vignettes described high-risk bowel cancer scenarios. Respondents were asked if they would recommend a medical consultation for the case described and whether they believed the scenario was a cancer presentation. Logistic regression was used to estimate the independent effects of each variable on the respondent's judgement. Two-hundred and sixty-eight completed responses were collected over eight weeks. RESULTS: The majority (61%) of respondents were female, aged 40 years and older. A history of rectal bleeding, six weeks of symptoms, and weight loss independently increased the odds of recommending a consultation with a medical practitioner by a factor of 7.64, 4.11 and 1.86, respectively. Most cases that were identified as cancer (75.2%) would not be classified as such on current research evidence. Factors that predict recognition of cancer presentations include rectal bleeding, weight loss and diarrhoea. CONCLUSION: Within the limitation of this study, respondents recommended that most symptomatic people present to their GP. However, we report no evidence that they recognised a cancer presentation, and duration of symptoms was not a significant variable in this regard. Cases that were identified as 'cancer' could not be classified as high risk on the available evidence.

What is the importance of the referral letter in the patient journey? A pilot survey in Western Australia.

BACKGROUND: Access to specialists is mediated by general practitioners in many countries. In these settings, specialists rely on information in referral letters when deciding which cases to schedule for their clinics. METHOD: Two-hundred and seven consecutive referral letters to gastroenterologists were scored for the amount of information relayed to the specialist, using a published schedule. The 'quality' scores for these referral letters were compared for four groups of patients: patients diagnosed with histological lesion, those with no histological lesion, those who failed to attend clinic, or those who had a diagnosis unknown. Forty-two referral letters were generated with a range of quality scores. Four gastroenterologists were asked to identify which letters described patients 'likely' to have a significant or benign colorectal condition, and whether they could triage the cases for their clinic given only the information in the letters. RESULTS: It was not possible to differentiate which letters related to patients in each of the four categories (P = 0.6). Patients who failed to attend were more symptomatic than those with a histological lesion (35.4 versus 28.2, mean difference 7.14, 95% confidence interval (CI) 14.1 to 0.15, P = 0.045). Patients referred 'urgently' were not, on the basis of the referral letters, the most symptomatic group (29.7 versus 27, mean difference 2.7, 95% CI -3.4 to 8.8, P = 0.38). The specialists failed to agree on the proportion of cases that could be triaged for their clinics. The cases that could be triaged contained more information (mean 66.38 versus 49.86, mean difference 16, 95% CI 1.3-31.7, P < 0.001). CONCLUSION: There was no evidence for an association between the amount of information relayed and the diagnosis of a histological lesion. However, more information was helpful when deciding which patients to schedule first. By corollary, patients referred with lesser documentation of their clinical presentation may be denied 'urgent' access to the gastroenterology clinic.

Does smoking status affect the likelihood of consulting a doctor about respiratory symptoms? A pilot survey in Western Australia.

BACKGROUND: Smokers attribute respiratory symptoms, even when severe, to everyday causes and not as indicative of ill-health warranting medical attention. The aim of this pilot study was to conduct a structured vignette survey of people attending general practice to determine when they would advise a person with respiratory symptoms to consult a medical practitioner. Particular reference was made to smoking status and lung cancer. METHODS: Participants were recruited from two general practices in Western Australia. Respondents were invited to complete self-administered questionnaires containing nine vignettes chosen at random from a pool of sixty four vignettes, based on six clinical variables. Twenty eight vignettes described cases with at least 5% risk of cancer. For analysis these were dubbed 'cancer vignettes'. Respondents were asked if they would advise a significant other to consult a doctor with their respiratory symptoms. Logistic regression and non-parametric tests were used to analyse the data. RESULTS: Three hundred questionnaires were distributed and one hundred and forty completed responses were collected over six weeks. The majority (70.3%) of respondents were female aged forty and older. A history of six weeks' of symptoms, weight loss, cough and breathlessness independently increased the odds of recommending a consultation with a medical practitioner by a factor of 11.8, 2.11, 1.40 and 4.77 respectively. A history of smoking independently increased the odds of the person being thought 'likely' or 'very likely' to have cancer by a factor of 2.46. However only 32% of cancer vignettes with a history of cigarette smoking were recognised as presentations of possible cancer. CONCLUSION: Even though a history of cigarette smoking was more likely to lead to the suggestion that a symptomatic person may have cancer we did not confirm that smokers would be more likely to be advised to consult a doctor, even when presenting with common symptoms of lung cancer.

Investigating the impact of extraneous distractions on consultations in general practice: lessons learned.

BACKGROUND: Extraneous distractions may influence the flow of general practice consultations. This study piloted a methodology to examine the impact of interrupting general practitioners (GPs) while consulting actor-patients. METHODS: Six GPs were video recorded consulting six actor-patients each presenting a different clinical scenario in a simulated surgery. Five cases presented red flag cancer symptoms. Half the consultations were interrupted. Two independent assessors, blinded to the occurrence of interruptions, assessed consultation performance using the Leicester Assessment Package (LAP) for clinical competence. RESULTS: 24 of 36 consultations were video recorded with sufficient audio-visual clarity to allow scoring. The association between LAP score and three variables could be studied: a variety of interruptions, different GPs and various scenarios. Agreement between assessors on GP performance was poor and showed an increased bias with increasing LAP score. Despite this, the interruption did not significantly impact on assessor LAP scores (Mean difference: 0.22, P = 0.83) even after controlling for assessor, different GPs and scenarios. CONCLUSION: Extraneous distractions had no impact on GP performance in this underpowered pilot study, a conclusion which needs to be confirmed in a larger study. However several important lessons were learned. Recorded actor-patient clinical sessions are logistically challenging. GPs whose skills were not previously assessed were working in unfamiliar surroundings dealing with relatively straight forward diagnostic challenges and may have anticipated the interruptions. In a redesign of this experiment it may be possible to eliminate some of these limitations.

Timely cancer diagnosis and management as a chronic condition: opportunities for primary care.

One in three men and one in four women in Australia will be diagnosed with cancer in the first 75 years of life. The majority will survive the cancer and ultimately die from unrelated causes. Many cancer patients and their families will experience some physical, social, economic and psychological sequelae, regardless of the prognosis. A recurring theme is that patients are disadvantaged by the lack of coordination of care and their needs are not being adequately met. We argue that greater integration of care through a multidisciplinary team of professionals, peer support groups and primary health practitioners functioning within a care hub could offer better practical and psychosocial supportive care for patients and their families.

Referring patients to specialists: a structured vignette survey of Australian and British GPs.

BACKGROUND: In Australia and in the United Kingdom (UK) access to specialists is sanctioned by General Practitioners (GPs). It is important to understand how practitioners determine which patients warrant referral. METHODS: A self-administered structured vignette postal survey of General Practitioners in Western Australia and the United Kingdom. Sixty-four vignettes describing patients with colorectal symptoms were constructed encompassing six clinical details. Nine vignettes, chosen at random, were presented to each individual. Respondents were asked if they would refer the patient to a specialist and how urgently. Logistic regression and parametric tests were used to analyse the data RESULTS: We received 260 completed questionnaires. 58% of 'cancer vignettes' were selected for 'urgent' referral. 1632/2367 or 69% of all vignettes were selected for referral. After adjusting for clustering the model suggests that 38.4% of the variability is explained by all the clinical variables as well as the age and experience of the respondents. 1012 or 42.8 % of vignettes were referred 'urgently'. After adjusting for clustering the data suggests that 31.3 % of the variability is explained by the model. The age of the respondents, the location of the practice and all the clinical variables were significant in the decision to refer urgently. CONCLUSION: GPs' referral decisions for patients with lower bowel symptoms are similar in the two countries. We question the wisdom of streaming referrals from primary care without a strong evidence base and an effective intervention for implementing guidelines. We conclude that implementation must take into account the profile of patients but also the characteristics of GPs and referral policies.

Factors influencing the speed of cancer diagnosis in rural Western Australia: a General Practice perspective.

INTRODUCTION: The speed of diagnosis impacts on prognosis and survival in all types of cancer. In most cases survival and prognosis are significantly worse in rural and remote Australian populations who have less access to diagnostic and therapeutic services than metropolitan communities in this country. Research suggests that in general delays in diagnosis were a factor of misdiagnosis, the confounding effect of existing conditions and delayed or misleading investigation of symptoms. The aim of this study is to further explore the factors that impact on the speed of diagnosis in rural Western Australia with direct reference to General Practitioners (GPs) working in this setting. METHODS: The methodology consisted of a structured discussion of specific cases. GPs based in two rural locations in Western Australia were asked to identify up to eight clinical cases for discussion. A diversity of cases was requested encompassing those with timely and delayed diagnosis of cancer. Focus groups were held with the practitioners to identify which factors under six headings delayed or facilitated the diagnosis in each case. A structured summary of the discussion was relayed to a wider group of GPs to seek additional views or comments on specific factors that impact on the speed of cancer diagnosis in rural and remote locations in Australia. RESULTS: A number of factors affecting the speed of diagnosis were identified: the demographic shift towards a frailer and older population, presenting with multiple and complex diseases, increases the challenge to identify early cancer symptoms; seasonal and demanding work patterns leading to procrastination in presenting for medical care; unhelpful scheduling of specialist appointments; and the varying impact of informal networks and social relationships. CONCLUSION: Within the limitations of this study we have generated a number of hypotheses that require formal evaluation: (1) GPs working within informal professional and social networks are better informed about their patients' health needs and have an advantage in making early diagnosis; (2) Despite the other differences in the population characteristics decentralising services would improve the prospect for timely diagnosis; and (3) Careful coordination of specialist appointments would improve the speed of diagnosis for rural patients.