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Kovacevic L, Naik R, Lugo-Palacios DG, Ashrafian H, Mossialos E, Darzi A. The impact of collaborative organisational models and general practice size on patient safety and quality of care in the English National Health Service: A systematic review. Health Policy 2023; 138:104940. [PMID: 37976620 DOI: 10.1016/j.healthpol.2023.104940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 10/31/2023] [Accepted: 11/03/2023] [Indexed: 11/19/2023]
Abstract
Collaborative primary care has become an increasingly popular strategy to manage existing pressures on general practice. In England, the recent changes taking place in the primary care sector have included the formation of collaborative organisational models and a steady increase in practice size. The aim of this review was to summarise the available evidence on the impact of collaborative models and general practice size on patient safety and quality of care in England. We searched for quantitative and qualitative studies on the topic published between January 2010 and July 2023. The quality of articles was assessed using the Newcastle-Ottawa Scale and the Critical Appraisal Skills Programme checklist. We screened 6533 abstracts, with full-text screening performed on 76 records. A total of 29 articles were included in the review. 19 met the inclusion criteria following full-text screening, with seven identified through reverse citation searching and three through expert consultation. All studies were found to be of moderate or high quality. A predominantly positive impact on service delivery measures and patient-level outcomes was identified. Meanwhile, the evidence on the effect on pay-for-performance outcomes and hospital admissions is mixed, with continuity of care and access identified as a concern. While this review is limited to evidence from England, the findings provide insights for all health systems undergoing a transition towards collaborative primary care.
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Affiliation(s)
- Lana Kovacevic
- NIHR Imperial Patient Safety Translational Research Centre, Institute of Global Health Innovation, Imperial College London, Queen Elizabeth Queen Mother Wing, St Mary's Hospital, South Wharf Road, W2 1NY, London, UK; Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, W2 1NY, London, UK.
| | - Ravi Naik
- Institute of Global Health Innovation, Imperial College London, Faculty Building, South Kensington Campus, Kensington, SW7 2AZ, London, UK; Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, W2 1NY, London, UK
| | - David G Lugo-Palacios
- Institute of Global Health Innovation, Imperial College London, Faculty Building, South Kensington Campus, Kensington, SW7 2AZ, London, UK; Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, WC1H 9SH, London, UK
| | - Hutan Ashrafian
- Institute of Global Health Innovation, Imperial College London, Faculty Building, South Kensington Campus, Kensington, SW7 2AZ, London, UK; Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, W2 1NY, London, UK
| | - Elias Mossialos
- Institute of Global Health Innovation, Imperial College London, Faculty Building, South Kensington Campus, Kensington, SW7 2AZ, London, UK; Department of Health Policy, London School of Economics and Political Science, Houghton Street, WC2A 2AE, London, UK
| | - Ara Darzi
- Institute of Global Health Innovation, Imperial College London, Faculty Building, South Kensington Campus, Kensington, SW7 2AZ, London, UK; Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, W2 1NY, London, UK
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Aboelkhir HAB, Elomri A, ElMekkawy TY, Kerbache L, Elakkad MS, Al-Ansari A, Aboumarzouk OM, El Omri A. A Bibliometric Analysis and Visualization of Decision Support Systems for Healthcare Referral Strategies. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16952. [PMID: 36554837 PMCID: PMC9778793 DOI: 10.3390/ijerph192416952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 10/24/2022] [Accepted: 11/14/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND The referral process is an important research focus because of the potential consequences of delays, especially for patients with serious medical conditions that need immediate care, such as those with metastatic cancer. Thus, a systematic literature review of recent and influential manuscripts is critical to understanding the current methods and future directions in order to improve the referral process. METHODS A hybrid bibliometric-structured review was conducted using both quantitative and qualitative methodologies. Searches were conducted of three databases, Web of Science, Scopus, and PubMed, in addition to the references from the eligible papers. The papers were considered to be eligible if they were relevant English articles or reviews that were published from January 2010 to June 2021. The searches were conducted using three groups of keywords, and bibliometric analysis was performed, followed by content analysis. RESULTS A total of 163 papers that were published in impactful journals between January 2010 and June 2021 were selected. These papers were then reviewed, analyzed, and categorized as follows: descriptive analysis (n = 77), cause and effect (n = 12), interventions (n = 50), and quality management (n = 24). Six future research directions were identified. CONCLUSIONS Minimal attention was given to the study of the primary referral of blood cancer cases versus those with solid cancer types, which is a gap that future studies should address. More research is needed in order to optimize the referral process, specifically for suspected hematological cancer patients.
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Affiliation(s)
| | - Adel Elomri
- College of Science and Engineering, Hamad Bin Khalifa University, Doha 34110, Qatar
| | - Tarek Y. ElMekkawy
- Department of Mechanical and Industrial Engineering, College of Engineering, Qatar University, Doha 2713, Qatar
| | - Laoucine Kerbache
- College of Science and Engineering, Hamad Bin Khalifa University, Doha 34110, Qatar
| | - Mohamed S. Elakkad
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha 3050, Qatar
| | - Abdulla Al-Ansari
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha 3050, Qatar
| | - Omar M. Aboumarzouk
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha 3050, Qatar
- College of Medicine, QU-Health, Qatar University, Doha 2713, Qatar
- School of Medicine, Dentistry and Nursing, The University of Glasgow, Glasgow G12 8QQ, UK
| | - Abdelfatteh El Omri
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha 3050, Qatar
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Benitez Majano S, Lyratzopoulos G, de Wit NJ, White B, Rachet B, Helsper C, Usher-Smith J, Renzi C. Mental Health Morbidities and Time to Cancer Diagnosis Among Adults With Colon Cancer in England. JAMA Netw Open 2022; 5:e2238569. [PMID: 36315146 PMCID: PMC9623442 DOI: 10.1001/jamanetworkopen.2022.38569] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 08/29/2022] [Indexed: 11/29/2022] Open
Abstract
Importance Mental health morbidity (MHM) in patients presenting with possible cancer symptoms may be associated with prediagnostic care and time to cancer diagnosis. Objective To compare the length of intervals to cancer diagnosis by preexisting MHM status in patients who presented with symptoms of as-yet-undiagnosed colon cancer and evaluate their risk of emergency cancer diagnosis. Design, Setting, and Participants This cohort study was conducted using linked primary care data obtained from the population-based Clinical Practice Research Datalink, which includes primary care practices in England, linked to cancer registry and hospital data. Included participants were 3766 patients diagnosed with colon cancer between 2011 and 2015 presenting with cancer-relevant symptoms up to 24 months before their diagnosis. Data analysis was performed in January 2021 to April 2022. Exposures Mental health conditions recorded in primary care before cancer diagnosis, including anxiety, depression, schizophrenia, bipolar disorder, alcohol addiction, anorexia, and bulimia. Main Outcomes and Measures Fast-track (also termed 2-week wait) specialist referral for investigations, time to colonoscopy and cancer diagnosis, and risk of emergency cancer diagnosis. Results Among 3766 patients with colon cancer (median [IQR] age, 75 [65-82] years; 1911 [50.7%] women ), 623 patients [16.5%] had preexisting MHM recorded in primary care the year before cancer diagnosis, including 562 patients (14.9%) with preexisting anxiety or depression (accounting for 90.2% of patients with preexisting MHM) and 61 patients (1.6%) with other MHM; 3143 patients (83.5%) did not have MHM. Patients with MHM had records of red-flag symptoms or signs (ie, rectal bleeding, change in bowel habit, or anemia) in the 24 months before cancer diagnosis in a smaller proportion compared with patients without MHM (308 patients [49.4%] vs 1807 patients [57.5%]; P < .001). Even when red-flag symptoms were recorded, patients with MHM had lower odds of fast-track specialist referral (adjusted odds ratio [OR] = 0.72; 95% CI, 0.55-0.94; P = .01). Among 2115 patients with red-flag symptoms or signs, 308 patients with MHM experienced a more than 2-fold longer median (IQR) time to cancer diagnosis (326 [75-552] days vs 133 [47-422] days) and higher odds of emergency diagnosis (90 patients [29.2%] vs 327 patients [18.1%]; adjusted OR = 1.63; 95% CI, 1.23-2.24; P < .001) compared with 1807 patients without MHM. Conclusions and Relevance This study found that patients with MHM experienced large and prognostically consequential disparities in diagnostic care before a colon cancer diagnosis. These findings suggest that appropriate pathways and follow-up strategies after symptomatic presentation are needed for earlier cancer diagnoses and improved health outcomes in this large patient group.
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Affiliation(s)
- Sara Benitez Majano
- Inequalities in Cancer Outcomes Network Group, Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare and Outcomes Research Group, Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London, London, United Kingdom
| | - Niek J. de Wit
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht University, Utrecht, the Netherlands
| | - Becky White
- Epidemiology of Cancer Healthcare and Outcomes Research Group, Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London, London, United Kingdom
| | - Bernard Rachet
- Inequalities in Cancer Outcomes Network Group, Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Charles Helsper
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht University, Utrecht, the Netherlands
| | - Juliet Usher-Smith
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Cristina Renzi
- Epidemiology of Cancer Healthcare and Outcomes Research Group, Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London, London, United Kingdom
- Faculty of Medicine, University Vita-Salute San Raffaele, Milan, Italy
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Martins T, Abel G, Ukoumunne OC, Mounce LTA, Price S, Lyratzopoulos G, Chinegwundoh F, Hamilton W. Ethnic inequalities in routes to diagnosis of cancer: a population-based UK cohort study. Br J Cancer 2022; 127:863-871. [PMID: 35661833 PMCID: PMC9427836 DOI: 10.1038/s41416-022-01847-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 04/08/2022] [Accepted: 05/06/2022] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND UK Asian and Black ethnic groups have poorer outcomes for some cancers and are less likely to report a positive care experience than their White counterparts. This study investigated ethnic differences in the route to diagnosis (RTD) to identify areas in patients' cancer journeys where inequalities lie, and targeted intervention might have optimum impact. METHODS We analysed data of 243,825 patients with 10 cancers (2006-2016) from the RTD project linked to primary care data. Crude and adjusted proportions of patients diagnosed via six routes (emergency, elective GP referral, two-week wait (2WW), screen-detected, hospital, and Other routes) were calculated by ethnicity. Adjusted odds ratios (including two-way interactions between cancer and age, sex, IMD, and ethnicity) determined cancer-specific differences in RTD by ethnicity. RESULTS Across the 10 cancers studied, most patients were diagnosed via 2WW (36.4%), elective GP referral (23.2%), emergency (18.2%), hospital routes (10.3%), and screening (8.61%). Patients of Other ethnic group had the highest proportion of diagnosis via the emergency route, followed by White patients. Asian and Black group were more likely to be GP-referred, with the Black and Mixed groups also more likely to follow the 2WW route. However, there were notable cancer-specific differences in the RTD by ethnicity. CONCLUSION Our findings suggest that, where inequalities exist, the adverse cancer outcomes among Asian and Black patients are unlikely to be arising solely from a poorer diagnostic process.
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Affiliation(s)
- Tanimola Martins
- College of Medicine and Health, University of Exeter, College House, St Luke's Campus, Magdalen Road, Exeter, EX1 2LU, UK.
| | - Gary Abel
- College of Medicine and Health, University of Exeter, College House, St Luke's Campus, Magdalen Road, Exeter, EX1 2LU, UK
| | - Obioha C Ukoumunne
- National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) South West Peninsula (PenARC), University of Exeter, Exeter, UK
| | - Luke T A Mounce
- College of Medicine and Health, University of Exeter, College House, St Luke's Campus, Magdalen Road, Exeter, EX1 2LU, UK
| | - Sarah Price
- College of Medicine and Health, University of Exeter, College House, St Luke's Campus, Magdalen Road, Exeter, EX1 2LU, UK
| | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare & Outcomes (ECHO) Group, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
| | - Frank Chinegwundoh
- Barts Health NHS Trust & Department of Health Sciences, University of London, London, UK
| | - William Hamilton
- College of Medicine and Health, University of Exeter, College House, St Luke's Campus, Magdalen Road, Exeter, EX1 2LU, UK
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Martins T, Abel G, Ukoumunne OC, Price S, Lyratzopoulos G, Chinegwundoh F, Hamilton W. Assessing Ethnic Inequalities in Diagnostic Interval of Common Cancers: A Population-Based UK Cohort Study. Cancers (Basel) 2022; 14:3085. [PMID: 35804858 PMCID: PMC9264889 DOI: 10.3390/cancers14133085] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 06/17/2022] [Accepted: 06/20/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND This study investigated ethnic differences in diagnostic interval (DI)-the period between initial primary care presentation and diagnosis. METHODS We analysed the primary care-linked data of patients who reported features of seven cancers (breast, lung, prostate, colorectal, oesophagogastric, myeloma, and ovarian) one year before diagnosis. Accelerated failure time (AFT) models investigated the association between DI and ethnicity, adjusting for age, sex, deprivation, and morbidity. RESULTS Of 126,627 eligible participants, 92.1% were White, 1.99% Black, 1.71% Asian, 1.83% Mixed, and 2.36% were of Other ethnic backgrounds. Considering all cancer sites combined, the median (interquartile range) DI was 55 (20-175) days, longest in lung [127, (42-265) days], and shortest in breast cancer [13 (13, 8-18) days]. DI for the Black and Asian groups was 10% (AFT ratio, 95%CI 1.10, 1.05-1.14) and 16% (1.16, 1.10-1.22), respectively, longer than for the White group. Site-specific analyses revealed evidence of longer DI in Asian and Black patients with prostate, colorectal, and oesophagogastric cancer, plus Black patients with breast cancer and myeloma, and the Mixed group with lung cancer compared with White patients. DI was shorter for the Other group with lung, prostate, myeloma, and oesophagogastric cancer than the White group. CONCLUSION We found limited and inconsistent evidence of ethnic differences in DI among patients who reported cancer features in primary care before diagnosis. Our findings suggest that inequalities in diagnostic intervals, where present, are unlikely to be the sole explanation for ethnic variations in cancer outcomes.
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Affiliation(s)
- Tanimola Martins
- College House St Luke’s Campus, College of Medicine and Health, University of Exeter, Magdalen Road, Exeter EX1 2LU, UK; (S.P.); (W.H.)
| | - Gary Abel
- National Institute for Health and Care Research (NIHR), Applied Research Collaboration (ARC) South West Peninsula (PenARC), University of Exeter, Exeter EX1 2LU, UK; (G.A.); (O.C.U.)
| | - Obioha C. Ukoumunne
- National Institute for Health and Care Research (NIHR), Applied Research Collaboration (ARC) South West Peninsula (PenARC), University of Exeter, Exeter EX1 2LU, UK; (G.A.); (O.C.U.)
| | - Sarah Price
- College House St Luke’s Campus, College of Medicine and Health, University of Exeter, Magdalen Road, Exeter EX1 2LU, UK; (S.P.); (W.H.)
| | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare & Outcomes (ECHO) Group, University College London, 1–19 Torrington Place, London WC1E 7HB, UK;
| | - Frank Chinegwundoh
- Barts Health NHS Trust & Department of Health Sciences, University of London, London WC1E 7HB, UK;
| | - William Hamilton
- College House St Luke’s Campus, College of Medicine and Health, University of Exeter, Magdalen Road, Exeter EX1 2LU, UK; (S.P.); (W.H.)
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Majano SB, Lyratzopoulos G, Rachet B, de Wit NJ, Renzi C. Do presenting symptoms, use of pre-diagnostic endoscopy and risk of emergency cancer diagnosis vary by comorbidity burden and type in patients with colorectal cancer? Br J Cancer 2022; 126:652-663. [PMID: 34741134 PMCID: PMC8569047 DOI: 10.1038/s41416-021-01603-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 09/06/2021] [Accepted: 10/13/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Cancer patients often have pre-existing comorbidities, which can influence timeliness of cancer diagnosis. We examined symptoms, investigations and emergency presentation (EP) risk among colorectal cancer (CRC) patients by comorbidity status. METHODS Using linked cancer registration, primary care and hospital records of 4836 CRC patients (2011-2015), and multivariate quantile and logistic regression, we examined variations in specialist investigations, diagnostic intervals and EP risk. RESULTS Among colon cancer patients, 46% had at least one pre-existing hospital-recorded comorbidity, most frequently cardiovascular disease (CVD, 18%). Comorbid versus non-comorbid cancer patients more frequently had records of anaemia (43% vs 38%), less frequently rectal bleeding/change in bowel habit (20% vs 27%), and longer intervals from symptom-to-first relevant test (median 136 vs 74 days). Comorbid patients were less likely investigated with colonoscopy/sigmoidoscopy, independently of symptoms (adjusted OR = 0.7[0.6, 0.9] for Charlson comorbidity score 1-2 and OR = 0.5 [0.4-0.7] for score 3+ versus 0. EP risk increased with comorbidity score 0, 1, 2, 3+: 23%, 35%, 33%, 47%; adjusted OR = 1.8 [1.4, 2.2]; 1.7 [1.3, 2.3]; 3.0 [2.3, 4.0]) and for patients with CVD (adjusted OR = 2.0 [1.5, 2.5]). CONCLUSIONS Comorbid individuals with as-yet-undiagnosed CRC often present with general rather than localising symptoms and are less likely promptly investigated with colonoscopy/sigmoidoscopy. Comorbidity is a risk factor for diagnostic delay and has potential, additionally to symptoms, as risk-stratifier for prioritising patients needing prompt assessment to reduce EP.
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Affiliation(s)
- Sara Benitez Majano
- Inequalities in Cancer Outcomes Network (ICON) Group, Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London, WC1E 7HT, UK
| | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare & Outcomes (ECHO) Research Group, Department of Behavioural Science and Health, Institute of Epidemiology & Health Care, University College London, London, WC1E 7HB, UK
| | - Bernard Rachet
- Inequalities in Cancer Outcomes Network (ICON) Group, Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London, WC1E 7HT, UK
| | - Niek J de Wit
- University Medical Center, Utrecht University, Julius Center for Health Sciences and Primary Care, PO Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Cristina Renzi
- Epidemiology of Cancer Healthcare & Outcomes (ECHO) Research Group, Department of Behavioural Science and Health, Institute of Epidemiology & Health Care, University College London, London, WC1E 7HB, UK.
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Hardy V, Yue A, Archer S, Merriel SWD, Thompson M, Emery J, Usher-Smith J, Walter FM. Role of primary care physician factors on diagnostic testing and referral decisions for symptoms of possible cancer: a systematic review. BMJ Open 2022; 12:e053732. [PMID: 35074817 PMCID: PMC8788239 DOI: 10.1136/bmjopen-2021-053732] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 12/23/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Missed opportunities for diagnosing cancer cause patients harm and have been attributed to suboptimal use of tests and referral pathways in primary care. Primary care physician (PCP) factors have been suggested to affect decisions to investigate cancer, but their influence is poorly understood. OBJECTIVE To synthesise evidence evaluating the influence of PCP factors on decisions to investigate symptoms of possible cancer. METHODS We searched MEDLINE, Embase, Scopus, CINAHL and PsycINFO between January 1990 and March 2021 for relevant citations. Studies examining the effect or perceptions and experiences of PCP factors on use of tests and referrals for symptomatic patients with any cancer were included. PCP factors comprised personal characteristics and attributes of physicians in clinical practice. DATA EXTRACTION AND SYNTHESIS Critical appraisal and data extraction were undertaken independently by two authors. Due to study heterogeneity, data could not be statistically pooled. We, therefore, performed a narrative synthesis. RESULTS 29 studies were included. Most studies were conducted in European countries. A total of 11 PCP factors were identified comprising modifiable and non-modifiable factors. Clinical judgement of symptoms as suspicious or 'alarm' prompted more investigations than non-alarm symptoms. 'Gut feeling' predicted a subsequent cancer diagnosis and was perceived to facilitate decisions to investigate non-specific symptoms as PCP experience increased. Female PCPs investigated cancer more than male PCPs. The effect of PCP age and years of experience on testing and referral decisions was inconclusive. CONCLUSIONS PCP interpretation of symptoms as higher risk facilitated testing and referral decisions for possible cancer. However, in the absence of 'alarm' symptoms or 'gut feeling', PCPs may not investigate cancer. PCPs require strategies for identifying patients with non-alarm and non-specific symptoms who need testing or referral. PROSPERO REGISTRATION NUMBER CRD420191560515.
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Affiliation(s)
- Victoria Hardy
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Adelaide Yue
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Stephanie Archer
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | | | - Matthew Thompson
- Department of Family Medicine, University of Washington, Seattle, Washington, USA
| | - Jon Emery
- Centre for Cancer Research and Department of General Practice, University of Melbourne VCCC, Parkville, Victoria, Australia
| | - Juliet Usher-Smith
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Fiona M Walter
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Associations between general practice characteristics and chest X-ray rate: an observational study. Br J Gen Pract 2021; 72:e34-e42. [PMID: 34903518 PMCID: PMC8714512 DOI: 10.3399/bjgp.2021.0232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 08/10/2021] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Chest X-ray (CXR) is the first-line test for lung cancer in many settings. Previous research has suggested that higher utilisation of CXR is associated with improved outcomes. AIM To explore the associations between characteristics of general practices and frequency of investigation with CXR. DESIGN AND SETTING Retrospective observational study of English general practices. METHOD A database was constructed of English general practices containing number of CXRs requested and data on practices for 2018, including patient and staff demographics, smoking prevalence, deprivation, and patient satisfaction indicators. Mixed-effects Poisson modelling was used to account for variation because of chance and to estimate the amount of remaining variation that could be attributed to practice and population characteristics. RESULTS There was substantial variation in GP CXR rates (median 34 per 1000 patients, interquartile range 26-43). Only 18% of between-practice variance in CXR rate was accounted for by recorded characteristics. Higher practice scores for continuity and communication skills, and higher proportions of smokers, Asian and mixed ethnic groups, and patients aged >65 years were associated with increased CXR rates. Higher patient satisfaction scores for access and greater proportions of male patients and patients of Black ethnicity were associated with lower CXR rates. CONCLUSION Substantial variation was found in CXR rates beyond that expected by chance, which could not be accounted for by practices' recorded characteristics. As other research has indicated that increasing CXR rates can lead to earlier detection, supporting practices that currently investigate infrequently could be an effective strategy to improve lung cancer outcomes.
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Joyce K, Zermanos T, Badrinath P. Factors associated with variation in emergency diagnoses of cancer at general practice level in England. J Public Health (Oxf) 2021; 43:e593-e600. [PMID: 32888030 DOI: 10.1093/pubmed/fdaa142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 07/03/2020] [Accepted: 07/30/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Cancer patients diagnosed following an emergency presentation have poorer outcomes. We explore whether practice characteristics are associated with differences in the proportion of emergency presentations. METHODS Univariable and multivariable logistic regression models were fitted to investigate the relationships between 2017-18 emergency cancer presentations at practice level in England and access and continuity in primary care, trust in healthcare professionals, 2-week-wait (2WW) referrals, quality and outcomes framework (QOF) achievements and socio-demographic factors (age, gender and deprivation). RESULTS Our analysis using comprehensive nationwide data found that the following practice level factors have significant associations with a lower proportion of emergency diagnosis of cancer: increased trust and confidence in the practice healthcare professionals; higher 2WW referral and conversion rate; higher total practice QOF score and higher satisfaction with appointment times or higher proportion able to see preferred GP. Our results also show that practices in more deprived areas are significantly associated with a higher proportion of emergency diagnoses of cancer. CONCLUSIONS Regional cancer networks should focus their efforts in increasing both the quantity and appropriateness of 2WW referrals from primary care. In addition, primary care clinicians should be supported to undertake high quality consultations, thus building trust with patients and ensuring continuity of care.
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Affiliation(s)
- Kevin Joyce
- Suffolk County Council and West Suffolk Foundation Trust, Suffolk, IP33 2QZ, UK
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Cancer detection via primary care urgent referral and association with practice characteristics: a retrospective cross-sectional study in England from 2009/2010 to 2018/2019. Br J Gen Pract 2021; 71:e826-e835. [PMID: 34544690 PMCID: PMC8463132 DOI: 10.3399/bjgp.2020.1030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 05/17/2021] [Indexed: 11/17/2022] Open
Abstract
Background There is substantial variation in the use of urgent suspected cancer referral (2-week wait [2WW]) between practices. Aim To examine the change in use of 2WW referrals in England over 10 years (2009/2010 to 2018/2019) and the practice and population factors associated with cancer detection. Design and setting Retrospective cross-sectional study of English general practices and their 2WW referral and Cancer Waiting Times database detection data (all cancers other than non-melanoma skin cancers) from 2009/2010 to 2018/2019. Method A retrospective study conducted using descriptive statistics of changes over 10 years in 2WW referral data. Yearly linear regression models were used to determine the association between cancer detection rates and quintiles of practice and population characteristics. Predicted cancer detection rates were calculated, as well as the difference between lowest to highest quintiles. Results Over the 10 years studied there were 14.89 million 2WW referrals (2.24 million in 2018/2019), and 2.68 million new cancer diagnoses, of which 1.26 million were detected following 2WW. The detection rate increased from 41% to 52% over the time period. In 2018/2019 an additional 66 172 cancers were detected via 2WW compared with 2009/2010. Higher cancer detection via 2WW referrals was associated with larger practices and those with younger GPs. From 2016/2017 onwards more deprived practice populations were associated with decreased cancer detection. Conclusion From 2009/2010 to 2018/2019 2WW referrals increased on average by 10% year on year. The most consistent association with higher cancer detection was found for larger practices and those with younger GPs, though these differences became attenuated over time. The more recent association between increased practice deprivation and lower cancer detection is a cause for concern. The COVID-19 pandemic has led to significant impacts on 2WW referral activity and the impact on patient outcomes will need to be studied.
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Kostopoulou O, Nurek M, Delaney BC. Disentangling the Relationship between Physician and Organizational Performance: A Signal Detection Approach. Med Decis Making 2020; 40:746-755. [PMID: 32608327 PMCID: PMC7457451 DOI: 10.1177/0272989x20936212] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 05/14/2020] [Indexed: 01/30/2023]
Abstract
Background. In previous research, we employed a signal detection approach to measure the performance of general practitioners (GPs) when deciding about urgent referral for suspected lung cancer. We also explored associations between provider and organizational performance. We found that GPs from practices with higher referral positive predictive value (PPV; chance of referrals identifying cancer) were more reluctant to refer than those from practices with lower PPV. Here, we test the generalizability of our findings to a different cancer. Methods. A total of 252 GPs responded to 48 vignettes describing patients with possible colorectal cancer. For each vignette, respondents decided whether urgent referral to a specialist was needed. They then completed the 8-item Stress from Uncertainty scale. We measured GPs' discrimination (d') and response bias (criterion; c) and their associations with organizational performance and GP demographics. We also measured correlations of d' and c between the 2 studies for the 165 GPs who participated in both. Results. As in the lung study, organizational PPV was associated with response bias: in practices with higher PPV, GPs had higher criterion (b = 0.05 [0.03 to 0.07]; P < 0.001), that is, they were less inclined to refer. As in the lung study, female GPs were more inclined to refer than males (b = -0.17 [-0.30 to -0.105]; P = 0.005). In a mediation model, stress from uncertainty did not explain the gender difference. Only response bias correlated between the 2 studies (r = 0.39, P < 0.001). Conclusions. This study confirms our previous findings regarding the relationship between provider and organizational performance and strengthens the finding of gender differences in referral decision making. It also provides evidence that response bias is a relatively stable feature of GP referral decision making.
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Affiliation(s)
- Olga Kostopoulou
- Imperial College London, Department of Surgery and Cancer, London, UK
| | - Martine Nurek
- Imperial College London, Department of Surgery and Cancer, London, UK
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Round T, Gildea C, Ashworth M, Møller H. Association between use of urgent suspected cancer referral and mortality and stage at diagnosis: a 5-year national cohort study. Br J Gen Pract 2020; 70:e389-e398. [PMID: 32312762 PMCID: PMC7176359 DOI: 10.3399/bjgp20x709433] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 12/16/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND There is considerable variation between GP practices in England in their use of urgent referral pathways for suspected cancer. AIM To determine the association between practice use of urgent referral and cancer stage at diagnosis and cancer patient mortality, for all cancers and the most common types of cancer (colorectal, lung, breast, and prostate). DESIGN AND SETTING National cohort study of 1.4 million patients diagnosed with cancer in England between 2011 and 2015. METHOD The cohort was stratified according to quintiles of urgent referral metrics. Cox proportional hazards regression was used to quantify risk of death, and logistic regression to calculate odds of late-stage (III/IV) versus early-stage (I/II) cancers in relation to referral quintiles and cancer type. RESULTS Cancer patients from the highest referring practices had a lower hazard of death (hazard ratio [HR] = 0.96; 95% confidence interval [CI] = 0.95 to 0.97), with similar patterns for individual cancers: colorectal (HR = 0.95; CI = 0.93 to 0.97); lung (HR = 0.95; CI = 0.94 to 0.97); breast (HR = 0.96; CI = 0.93 to 0.99); and prostate (HR = 0.88; CI = 0.85 to 0.91). Similarly, for cancer patients from these practices, there were lower odds of late-stage diagnosis for individual cancer types, except for colorectal cancer. CONCLUSION Higher practice use of referrals for suspected cancer is associated with lower mortality for the four most common types of cancer. A significant proportion of the observed mortality reduction is likely due to earlier stage at diagnosis, except for colorectal cancer. This adds to evidence supporting the lowering of referral thresholds and consequent increased use of urgent referral for suspected cancer.
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Affiliation(s)
- Thomas Round
- School of Population Health and Environmental Sciences, King's College London, London, and National Cancer Registration and Analysis Service, Public Health England, London
| | - Carolynn Gildea
- National Cancer Registration and Analysis Service, Public Health England, London
| | - Mark Ashworth
- School of Population Health and Environmental Sciences
| | - Henrik Møller
- School of Cancer and Pharmaceutical Sciences, King's College London, London
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