Results Summary
What was the project about?
Palliative care focuses on improving quality of life by preventing and treating suffering. Patients may find it hard to travel to a clinic for palliative care. In home-based palliative care, or HBPC, healthcare teams visit patients at home. Another way to provide HBPC is through telehealth. Telehealth provides care to patients remotely using phone, video, or other devices that can help manage care.
In this study, the research team first wanted to compare video visits and home visits for HBPC. But in this study, few patients and clinicians, such as doctors and nurses, used video visits for HBPC. The team then focused on learning about barriers to using video visits for HBPC.
What did the research team do?
The research team surveyed and interviewed 66 patients and 32 caregivers by phone one to two months after they signed up for the original study and again six months later. Eight months after the initial study started, the team surveyed 84 HBPC clinicians and interviewed 14 of these clinicians to get feedback about video visits. All surveys and interviews took place in the year before January 2020.
To collect more information about video visits, the research team looked at health records and held weekly meetings with patients, doctors, nurses, and health system senior staff. The team observed video visits and took notes. They also visited clinics.
The study took place at 14 Kaiser Permanente clinics in Southern California, Oregon, and Washington State.
Patients, caregivers, clinicians, and clinic staff helped design the study.
What were the results?
Of the patients and caregivers who took surveys about their care, 49 percent of patients and 38 percent of caregivers were very satisfied with video visits. Patients and caregivers stated that video visits offered an easy way to talk with doctors more frequently.
Patients preferred to first have an in-person visit with doctors. Having the first visit with their doctors in person made patients feel better about later video visits.
Barriers to using video visits included the following:
- Patients with limited hearing or vision who used video visits couldn't see the screen or hear the doctor well.
- The video didn't always work, which made meeting urgent, complex, or sensitive HBPC needs hard.
- Aligning nurses' and doctors' schedules to have video visits was hard.
What were the limits of the project?
The study took place in one health system. Results may differ in other health systems.
Future research could look for ways to address the barriers described in this study.
How can people use the results?
Researchers and hospitals can use these results when considering ways to use video visits for HBPC.
| How this project fits under PCORI’s Research Priorities PCORI identified planning and delivery of care for patients with advanced illness and their caregivers as an important research topic. Patients, clinicians, and others wanted to know: How can we identify care needs and address them effectively in real-life community settings? To address this issue, PCORI launched an initiative in 2016 on Community-Based Palliative Care Delivery for Adult Patients with Advanced Illnesses and their Caregivers. The initiative funded this research project and others. |
Professional Abstract
Background
The research team originally planned a cluster randomized controlled non-inferiority trial to compare the effectiveness of early remote access to a clinician via video-supported home-based palliative care (HBPC) with standard HBPC care on improving patient and caregiver outcomes. As part of this trial, the team conducted surveys and interviews with patients, caregivers, and clinicians to obtain ongoing feedback about implementation. After the first year of participant enrollment and based on the results of the surveys and interviews, the team decided to terminate the original trial due to challenges, including low uptake of video visits due to shortages of healthcare staff and unreliable technology, as well as anticipated telehealth payment policy changes. The team then focused on studying barriers to implementing video-supported HBPC.
Objective
To identify lessons learned and challenges to implementing video-supported interventions for patients receiving HBPC
Study Design
| Design Element | Description |
|---|---|
| Design | Mixed-methods study with qualitative interviews, surveys, record review, and field observation |
| Data Sources and Data Sets |
Data from surveys and interviews with 66 patients and 32 caregivers who had video visits; surveys with 84 HBPC clinicians; interviews with 14 clinicians; electronic medical records; field observations by research staff; weekly meetings with key stakeholders, including patients, clinicians, and health system administrators |
| Analytic Approach | Descriptive and thematic analysis using quantitative and qualitative data |
| Outcomes | Lessons learned and barriers to implementation of video-supported visits for HBPC to support palliative care practice and policy |
Methods
This study examined barriers to implementing video-supported HBPC at 14 Kaiser Permanente clinics in Southern California, Oregon, and Washington State in the year prior to January 2020.
One to two months after enrollment in the original trial and again six months later, 66 patients and 32 caregivers who had video visits completed surveys and telephone interviews to offer feedback about video-supported HBPC.
In addition, eight months after the original trial started, the research team surveyed 84 HBPC clinicians and conducted semistructured interviews with a subset of 14 clinicians about their attitudes toward telehealth.
To supplement insights from surveys and interviews about barriers to video-supported HBPC, the research team conducted field and in-office observations; reviewed electronic medical record data; conducted site visits with clinics; and held weekly meetings with patients, clinicians, and health system administrators.
Patients, caregivers, clinicians, and health system administrators helped plan the study.
Results
Of the patients and caregivers who completed surveys, 49% of patients and 38% of caregivers were very satisfied with video visits. These patients and caregivers stated that video visits offered convenient and frequent communication with physicians.
Patients preferred that their initial visit with a physician be an in-person visit. Having previous in-person encounters with their physicians made patients feel more comfortable with subsequent video visits.
Barriers to video-supported HBPC included the following:
- Patients with hearing or vision impairments who received HBPC had difficulty interacting with physicians during video visits.
- Unreliable technology and poor connectivity made addressing urgent, complex, or sensitive issues during the initial HBPC visit difficult.
- Coordinating schedules between nurses and physicians to complete video visits was difficult.
Limitations
The study took place in one health system. Results may not be generalizable to patient and caregiver experiences in other health systems.
Conclusions and Relevance
In this study, the research team identified barriers to using video-supported HBPC. A multilevel approach to addressing these barriers could promote access to video-supported palliative care for patients with serious chronic conditions.
Future Research Needs
Future research could examine ways to address barriers to using video-supported HBPC.
| How this project fits under PCORI’s Research Priorities PCORI identified planning and delivery of care for patients with advanced illness and their caregivers as an important research topic. Patients, clinicians, and others wanted to know: How can we identify care needs and address them effectively in real-life community settings? To address this issue, PCORI launched an initiative in 2016 on Community-Based Palliative Care Delivery for Adult Patients with Advanced Illnesses and their Caregivers. The initiative funded this research project and others. |
Final Research Report
View this project's final research report.
Journal Citations
Related Journal Citations
Peer-Review Summary
Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.
The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.
Peer reviewers commented and the researchers made changes or provided responses. Those comments and responses included the following:
- The reviewers were impressed with the researchers’ transparency regarding the problems they faced implementing this study and their willingness to discuss the lessons learned.
- One reviewer questioned the impetus for this research, questioning the need to conduct a large randomized controlled trial comparing physician palliative care home visits to physicians meeting with patients using telehealth with registered nurses conducting home visits. The researchers acknowledged that in the postpandemic environment it may not seem as necessary to test whether patient outcomes are the same with in-person and telehealth care, but when the study was initially devised and conducted this was the major question in the field.
- The reviewers suggested that many of the problems the researchers faced could have been uncovered using a different study design instead of implementing a full-scale randomized controlled trial. The researchers agreed that in hindsight, a stepped wedge research design could have given them more warning about some of the obstacles they would face in implementing the study. However, the researchers noted that such a design would be less appropriate to evaluate comparative effectiveness and more appropriate to evaluate how the telehealth intervention could be integrated in a palliative care practice. The stepped wedge design would also not have solved some of the challenges they faced with this study, including technological challenges and workforce shortages.