医院初级保健团队中临床医生自我认知的姑息治疗障碍、教育需求及转诊模式：来自单中心调查和队列研究的经验教训

The self-perceived palliative care barriers and educational needs of clinicians working in hospital primary care teams and referral patterns: lessons learned from a single-center survey and cohort study.

作者信息

van der Stap Lotte, de Nijs Ellen J M, Oomes Marleen, Juffermans Carla C M, Ravensbergen Willeke M, Luelmo Saskia A C, Horeweg Nanda, van der Linden Yvette M

机构信息

Center of Expertise in Palliative Care, Leiden University Medical Center, Leiden, the Netherlands.

Center of Expertise in Palliative Care, Leiden University Medical Center, Leiden, the Netherlands; Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands.

出版信息

Ann Palliat Med. 2021 Mar;10(3):2620-2637. doi: 10.21037/apm-20-1706. Epub 2021 Jan 14.

DOI:10.21037/apm-20-1706

PMID:33474950

Abstract

BACKGROUND

Within the generalist-plus-specialist palliative care model, palliative care is mainly provided by nurses and physicians of hospital primary care teams. Palliative care consultation teams (PCCTs) support these clinicians in adequately caring for patients with advanced illnesses. Our team started in 2012. The aim of this study was to assess the self-perceived barriers, educational needs and awareness of available palliative care support options among our hospital primary care teams. In addition, palliative care referral patterns were evaluated.

METHODS

Single-center mixed methods study. Outcomes of two surveys of primary care team clinicians (2012 and 2016) on barriers to palliative care, educational needs and awareness of palliative care support options were compared (chi-square, Mann-Whitney U tests, qualitative analysis). Palliative care referral characteristics were evaluated (2012-2017), including referral timing (survival since referral) (descriptive statistics, Kaplan-Meier methodology). Predictions of survival at referral were analyzed (weighted Kappa).

RESULTS

In 2012 and 2016, the most frequently reported barrier was the late initiation of the palliative care approach. Clinicians reported a need for education on physical symptom management and basic palliative care principles. Awareness of support options increased from 2012 to 2016, including improved familiarity with the PCCT (56% vs. 85%, P<0.001) and positive appraisal of the team (8% vs. 40% gave an 'excellent' rating, P<0.001). The use of national symptom management guidelines also improved (23% vs. 53%, P<0.001). Of 1,404 referrals, 86% were for cancer patients. Referrals increased by 28% (mean) per year. Medical oncology clinicians referred most frequently (27%) and increasingly early in the disease trajectory (survival ≥3 months after referral) (P=0.016). Median survival after referral was 0.9 (range, 0-83.3) months. Referring physicians overestimated survival in 44% of patients (kappa 0.36, 95% CI: 0.30-0.42).

CONCLUSIONS

Primary care team clinicians persistently reported needing support with basic palliative care skills. PCCTs should continuously focus on educating primary care teams and promoting the use of guidelines. Because physicians tend to overestimate survival and usually referred patients late for specialist palliative care, consultation teams should support primary care teams to identify, treat and refer patients with palliative care needs in a timely manner.

摘要

背景

在通科医生加专科医生的姑息治疗模式中，姑息治疗主要由医院基层医疗团队的护士和医生提供。姑息治疗咨询团队（PCCTs）为这些临床医生充分护理晚期疾病患者提供支持。我们的团队始于2012年。本研究的目的是评估我院基层医疗团队对姑息治疗支持选项的自我感知障碍、教育需求和认知度。此外，还对姑息治疗转诊模式进行了评估。

方法

单中心混合方法研究。比较了基层医疗团队临床医生两次调查（2012年和2016年）关于姑息治疗障碍、教育需求和姑息治疗支持选项认知度的结果（卡方检验、曼-惠特尼U检验、定性分析）。评估了姑息治疗转诊特征（2012 - 2017年），包括转诊时机（转诊后的生存时间）（描述性统计、卡普兰-迈耶方法）。分析了转诊时生存的预测情况（加权卡帕）。

结果

在2012年和2016年，最常报告的障碍是姑息治疗方法启动较晚。临床医生报告需要接受有关身体症状管理和基本姑息治疗原则的教育。从2012年到2016年，对支持选项的认知度有所提高，包括对PCCT的熟悉程度提高（56%对85%，P<0.001）以及对该团队的积极评价增加（8%对40%给予“优秀”评级，P<0.001）。国家症状管理指南的使用也有所改善（23%对53%，P<0.001）。在1404例转诊中，86%是癌症患者。转诊每年平均增加28%。肿瘤内科临床医生转诊最为频繁（27%），且在疾病进程中越来越早（转诊后生存≥3个月）（P = 0.016）。转诊后的中位生存时间为0.9（范围，0 - 83.3）个月。转诊医生在44%的患者中高估了生存时间（卡帕0.36，95%置信区间：0.30 - 0.42）。