Finlay, Ilora

Meyboom-de Jong, Betty

Otter, Renee

van Heest, Florien

English

This study describes a novel type of support for GPs caring for patients dying at home: the establishment and evaluation of a telephone advisory service for GPs, run by GPs with a special interest in palliative care (GPwSIs) in the Netherlands 2000-2003. A growing number of GPs called for advice, 10% during out of hours. Prognosis of the patients was generally short (days to weeks in 70% of cases). Most advice sought by GPs concerned symptom management and on evaluation, 85% of the GPs followed the advice.</p

Dissertations of the University of Groningen

   University of GroningenThe new millennium palliative care project (2000-2003)van Heest, Florien; Finlay, Ilora; Otter, Renee; Meyboom-de Jong, BettyPublished in:British Journal of General PracticeIMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite fromit. Please check the document version below.Document VersionPublisher's PDF, also known as Version of recordPublication date:2007Link to publication in University of Groningen/UMCG research databaseCitation for published version (APA):van Heest, F., Finlay, I., Otter, R., & Meyboom-de Jong, B. (2007). The new millennium palliative careproject (2000-2003): the impact of specialised GP advisors. British Journal of General Practice, 57(539),494-496.CopyrightOther than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of theauthor(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons).The publication may also be distributed here under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license.More information can be found on the University of Groningen website: https://www.rug.nl/library/open-access/self-archiving-pure/taverne-amendment.Take-down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons thenumber of authors shown on this cover page is limited to 10 maximum.Download date: 04-06-2022ABSTRACTThis study describes a novel type of support for GPscaring for patients dying at home: the establishmentand evaluation of a telephone advisory service for GPs,run by GPs with a special interest in palliative care(GPwSIs) in the Netherlands 2000–2003. A growingnumber of GPs called for advice, 10% during out ofhours. Prognosis of the patients was generally short(days to weeks in 70% of cases). Most advice soughtby GPs concerned symptom management and onevaluation, 85% of the GPs followed the advice.Keywordsadvisory services; family physicians; palliative care;quality of health care.INTRODUCTIONIn 1998 the Dutch government initiated a nationalprogramme to stimulate service development andimprovement in the quality of palliative care. Thedevelopment of consultative facilities forprofessional carers was part of this programme.The aim of this project was to organise rapidaccess to palliative care advice for all GPs caringfor patients dying at home in the region covered bythe Comprehensive Cancer Centre North-Netherlands (CCCN). This region is a predominantlyrural area with a population of 2.1 million, about1000 GPs, 17 hospitals (one university hospital) and5500 cancer deaths per year.1,2 Access to cancertherapy and disease-modifying therapy is wellorganised. Sixty-one per cent of all patient deathsin 1998–1999 occurred at home.3 In 2000, the areahad neither hospices nor nurses or doctors workingas specialists in palliative care.The research questions were to determine towhat extent the service was used, for whom and bywhom, what type of problems were discussed,whether the advice was followed by the GP, andwhether the advice made a difference to the qualityof care, according to the GP.METHODFour GPs with a special interest (GPwSIs) inpalliative care were appointed in the different sub-regions for 1 day per week in addition to theirnormal activities as a GP (September 1999). All fourobtained the Diploma in Palliative Medicine in 2001at Cardiff University UK; they acted as a team, metregularly and discussed problems openly.An educational programme in pain managementand the subcutaneous administration of drugs wasdeveloped to promote the advisory service, andoffered to every GP out-of-hours consortium in theregion covered by the CCCN. Within 2 years thisprogramme was presented to almost all GPs in thearea. The GPwSI advisors were available out ofhours. The use of telephone advice made theGPwSI rapidly accessible, and the process ofobtaining advice time efficient.All telephone advice calls from 2000–2003 wereFB van Heest, MSc, GPwSI adviser in palliative medicine forDrenthe, Comprehensive Cancer Centre North-Netherlands,Groningen, the Netherlands. B Meyboom-de Jong, MD, PhD,Professor of General Practice; IG Finlay, FRCP, FRCGP,professor the Baroness Finlay of Llandaff, Cardiff University,UK, and honorary professor in palliative medicine, UniversityMedical Centre of Groningen, the Netherlands. R Otter, MD,PhD, oncologist, University Medical Centre of Groningen,director of the Comprehensive Cancer Centre North-Netherlands, Groningen, the Netherlands.Address for correspondenceDr Florien van Heest, Zuidzijde, 1 7874 TD Odoornerveen,The Netherlands. E-mail: f.vanheest@ikn.nlSubmitted: 24 June 2006; Editor’s response: 22 August2006; final acceptance: 20 November 2006.©British Journal of General Practice 2007; 57: 494–496.British Journal of General Practice, June 2007F van Heest, I Finlay, R Otter, et al494The New Millennium Palliative CareProject (2000–2003):the impact of specialised GP advisorsFlorien van Heest, Ilora Finlay, Renée Otter and Betty Meyboom-de JongBritish Journal of General Practice, June 2007documented (data on the GP and the patientincluding Eastern Cooperative Oncology Group[ECOG] performance status, the type of problemand the advice given). The impact of the advice wasevaluated by standard questionnaire to the GP after2–6 weeks.RESULTSThe number of calls for advice increased each yearstarting with about 100 calls in the first year (Figure1). Calls lasted 15 minutes (mean) and soughtadvice on patients of all age groups (mean age62 years, range 0–100 years), usually in the lastphase of illness. Over 10% of the calls soughtadvice out of hours. Twenty-four per cent ofpatients had lung cancer. The involvement of formalnursing care increased from 76% in 2000 to 81% in2003. The ECOG performance status, as assessedby the person seeking advice, was 4 (= completelybedridden and dependent) in 48% of the patients.GPs presented a mean number of 1.3 problemsper patient (median = 1), but after discussion amean of 1.9 problems (median = 2) was revealed;70% of the presenting problems concernedsymptom control (pain 38%, nausea and vomiting20%, and delirium 10%), and 13% concerned drugmanagement (Table 1). Further symptom controland other problems became evident duringdiscussion.The use of subcutaneous infusions at homeincreased with time from 111 in 2000 to 418 (threeregions) in 2003 (data were incomplete data for thefourth region).The response rate for the evaluationquestionnaires was 68% (947 of 1389). Responderswere representative of GPs in the area; 60% wereborn between 1951 and 1966 (26% born before1950), 68% were male, 63% worked full-time; 47%worked in the city and 53% in a rural area. They hadworked as GP for <1–35 years (mean 12.9 years).In 85% of the cases the advice was followed, andin 11% it was followed in part; 4% did not follow theadvice. Eighty-six per cent of those seeking adviceHow this fits inMany patients with a progressive life-threateningdisease wish to die at home; for different reasonsthis is often not achieved. In this descriptive studythe GP is supported in delivering palliative care byGPwSIs round-the-clock. Advice to GPs in thepresent study was followed (85%) and evaluated asuseful (86%).Brief Reports495Subject Presenting problems Revealed problemsPain 509 501Other symptoms 794 859Pharmacotherapeutics 238 476Psychological problems 68 116Existential problems 20 40Social problems 25 56Technical medical problems 70 160Organisational problems 25 87Communication problems 23 78Problems with planning 30 103Need for confirmation 31 142Problem of the doctor 22 65Table 1. Type of problems discussed during the advice calls.Yeartotal number   to GPs                    to others unknown/missing01002003004005006007002003200220012000NumberofadvicecallsFigure 1. number ofadvice calls given byGPwSI 2000–2003.thought that the advice was useful; 84% ofresponders felt that the advice had improved thequality of palliative care.DISCUSSIONThe increasing number of calls for advice suggeststhat the advisory service fulfils a need of GPs. Mostsought advice on symptom management, butdiscussion revealed additional problems in over halfof the calls, suggesting the importance of anexchange of thoughts in discussion. The advicegiven by the GPwSI adviser was evaluated aspositively contributing to care.As this service responded to the needs of the GP,outcome at patient level could not be reliablymeasured.4F van Heest, I Finlay, R Otter, et alBritish Journal of General Practice, June 2007496When this advisory service was instigated, nostudy had compared different team models inpalliative care.5 The assumption was made that tosupport GPs in palliative home care theappointment of GPwSIs would be moreappropriate. This would result in more deaths athome than with the establishment of a hospital-based multidisciplinary team. Kuin et al6 found thatadvice from 19 hospital-based teams was soughtfor patients with a longer prognosis than thepatients in the present study,6 and Klinkenberg et al7reported that almost half (49%; n = 84) of terminallyill Dutch patients were moved to hospital to die,with 39% of admissions less than a week beforedeath. The round-the-clock support of the GPs inthe present study may be key in supporting patientsdying at home, but further study is needed toevaluate this.Funding bodyThis project and study was funded by grants from theDutch Ministry of HealthEthics committeeNot applicableCompeting interestsThe authors have stated that there are noneAcknowledgementsThe fellow workers of the department of Palliative Care,especially the other GPwSI advisers (Paul Cost Budde,Christa Rolf and Karel Schuit) of the CCCN and the GPs inthe area are acknowledged for the registration andevaluation of the consultations.REFERENCES1. Centraal Bureau voor de Statistiek (Statistics Netherlands)http://statline.cbs.nl/StatWeb/table.asp?D5=7&LA=en&DM=SLNL&PA=70065ned&D1=0-91&D2=0&D3=0&D4=0 (accessed 8May 2007).2. Dutch institute for research in healthcare. (NIVEL)http://www.nivel.nl/beroepenindezorg/ (accessed 8 May 2007).3. Oppewal F, Meyboom-de Jong B. Mortality in general practice.An analysis of 841 deaths during a two-year period in 17 Dutchpractices. Europ J Gen Pract 2004; 10: 13–17.4. Black N. Why we need observational studies to evaluate theeffectiveness of health care. BMJ 1996; 312: 1215–1218.5. Higginson IJ, Finlay IG, Goodwin DM, Hood K. Is there evidencethat palliative care teams alter end-of-life experiences of patientsand their caregivers? J Pain Symptom Manage 2003; 25: 150–168.6. Kuin A, Courtens AM, Deliens L, et al. Palliative careconsultation in the Netherlands: a nationwide evaluation study. JPain Symptom Manage 2004; 27: 53–60.7. Klinkenberg M, Visser G, Groenou van MI, et al. The last 3months of life: care, transitions and the place of death of olderpeople. Health Soc Care Community 2005; 13: 420–430.

The new millennium palliative care project (2000-2003):the impact of specialised GP advisors

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The new millennium palliative care project (2000-2003):the impact of specialised GP advisors

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