Implementation of a palliative care intervention for patients with COPD – a mixed methods process evaluation of the COMPASSION study

Abstract

Objectives Little direction exists on how to effectively implement palliative care for patients with COPD. In the COMPASSION study, we developed, executed, and evaluated a multifaceted implementation strategy to improve the uptake of region-tailored palliative care intervention components into routine COPD care. We evaluated the implementation strategy and assessed the implementation process, barriers, and facilitators. Methods A mixed methods process evaluation was performed. Primary and secondary healthcare providers in four hospital regions in the Netherlands were trained. Patients identified during hospitalisation for an acute exacerbation received palliative care and were followed for a year. Various sources were used: process data, questionnaires including the End-of-life Professional Caregiver Survey (EPCS), medical records, monitoring meetings, and interviews. The Consolidated Framework of Implementation Research (CFIR) was used to categorize implementation determinants. Results The training sessions with roleplay were positively evaluated and increased professionals’ self-efficacy in providing palliative care statistically significantly. Of 98 patients identified, 44 (44.9%) received one or more palliative care conversations at the outpatient clinic. Having those conversations was highly valued by healthcare providers because it led to clarity and peace of mind for the patient and higher job satisfaction. Coordination and continuity remained suboptimal. Most important barriers to implementation were time constraints, the COVID-19 pandemic, and barriers related to transmural and interdisciplinary collaboration. Facilitators were the systematic screening of patients for palliative care needs, adapting to the patient’s readiness, conducting palliative care conversations with a pulmonologist and a COPD nurse together, and meeting regularly with a small team led by a dedicated implementation leader. Conclusions Providing integrated palliative care for patients with COPD is highly valued by healthcare providers but remains challenging. Our findings will guide future implementation efforts. Future research should focus on how to optimize transmural and interdisciplinary collaboration. Trial registration The COMPASSION study is registered in the Netherlands Trial Register (NTR): NL7644. Registration date: 07/04/2019.

The effect of an integrated palliative care intervention on quality of life and acute healthcare use in patients with COPD: Results of the COMPASSION cluster randomized controlled trial

“…The barriers and facilitators to successful implementation we encountered have been published in our process evaluation article separately. 19 Nevertheless, our rate of 37% is comparable to the average rate (33%) found across advance care planning intervention studies. 20 …”

“…The barriers and facilitators to successful implementation we encountered have been published in our process evaluation article separately. 19 Nevertheless, our rate of 37% is comparable to the average rate (33%) found across advance care planning intervention studies. 20 Effects at the provider's level tended to be more prominent in our study, probably because our implementation strategy was at healthcare provider level: they were trained and guided to implement palliative care components.…”

“…Also, we found that self-efficacy in palliative care provision increased in trained healthcare providers. 19 Thus, although no effects were found at patient level, our implementation strategy effectively changed providers’ behaviour.…”

“…According to them, patients expressed that knowing what would happen if the disease worsened and the care possibilities provided them clarity and peace of mind. 19 Feeling better equipped to cope with a severe chronic illness affects the patient’s quality of life but may not be reflected in an overall quality of life measure.…”

External Validation and User Experiences of the ProPal-COPD Tool to Identify the Palliative Phase in COPD

“…To evaluate the implementation process, four monitoring meetings per region were held by EV and JB over the course of the study, and interviews were held by JB at study completion. 25 In these meetings and interviews, providers were asked to reflect on their experiences with the ProPal-COPD tool using open questions about the practical use, appropriateness of the patient selection, and the perceived effects of its use. Experiences with both the original and the adapted cut-off value were inquired.…”