What are the facilitators of, and barriers to, the communication of poor prognosis between secondary and primary care? A systematic review with narrative synthesis
Problem
The communication of poor prognosis between secondary care and primary care is important to ensure that patients with life-limiting illness receive appropriate and coordinated care. It allows GPs to prepare for the changing needs of the patient and provides an opportunity for advance care planning. We aimed to synthesise the evidence regarding the communication of poor prognosis between secondary and primary care to inform clinical practice. The following questions were addressed:How is poor prognosis communicated?What are the facilitators of, and barriers to, this communication? How acceptable and useful is this communication to patients, family/carers and clinicians?What is the impact of this communication on patient care?
Approach
Design: Systematic review with narrative synthesis. Four electronic databases were searched from 1st January 2000 to 17th May 2021 (re-run on 24th August 2022), supplemented by hand-searching five key journals. Any study reporting, in English, empirical data was included. Searches were developed to identify studies reporting any type of communication or intervention that facilitates the sharing of poor prognosis from secondary care to primary care, including the views and experiences of primary or secondary care clinicians and patients with incurable, advanced disease, or their (current or bereaved) carers. A quarter of titles and abstracts were independently screened by a second reviewer. Two reviewers independently undertook data extraction and quality appraisal using the Mixed-Methods Appraisal Tool. Data were synthesised into a narrative providing a critical overview and reported following PRISMA guidance.
Findings
Searches identified 23,853 unique records, 30 of which met the inclusion criteria. Few studies had a primary focus on the review questions and the quality of studies was highly variable, with only 18 meeting all possible appraisal criteria. Information about prognosis was not commonly communicated between secondary and primary care, but was more likely to occur if death was imminent. Challenges in the identification of patients with a poor prognosis by secondary care teams were a barrier to this communication. Facilitators included shared electronic records and direct clinician-clinician contact. GPs welcomed receiving prognostic information from secondary care colleagues and considered it vital for continuity of care.
Consequences
Although the communication of poor prognosis from secondary to primary care is highly valued, it happens rarely due to organisational or interpersonal challenges. Further research is necessary to understand the process of identification of poor prognosis and how good communication at the primary / secondary care interface can facilitate shared decision-making and continuity of care.