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Hayes H, Meacock R, Stokes J, Sutton M. The effect of local hospital waiting times on GP referrals for suspected cancer. PLoS One 2024; 19:e0294061. [PMID: 38718085 PMCID: PMC11078401 DOI: 10.1371/journal.pone.0294061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 10/24/2023] [Indexed: 05/12/2024] Open
Abstract
INTRODUCTION Reducing waiting times is a major policy objective in publicly-funded healthcare systems. However, reductions in waiting times can produce a demand response, which may offset increases in capacity. Early detection and diagnosis of cancer is a policy focus in many OECD countries, but prolonged waiting periods for specialist confirmation of diagnosis could impede this goal. We examine whether urgent GP referrals for suspected cancer patients are responsive to local hospital waiting times. METHOD We used annual counts of referrals from all 6,667 general practices to all 185 hospital Trusts in England between April 2012 and March 2018. Using a practice-level measure of local hospital waiting times based on breaches of the two-week maximum waiting time target, we examined the relationship between waiting times and urgent GP referrals for suspected cancer. To identify whether the relationship is driven by differences between practices or changes over time, we estimated three regression models: pooled linear regression, a between-practice estimator, and a within-practice estimator. RESULTS Ten percent higher rates of patients breaching the two-week wait target in local hospitals were associated with higher volumes of referrals in the pooled linear model (4.4%; CI 2.4% to 6.4%) and the between-practice estimator (12.0%; CI 5.5% to 18.5%). The relationship was not statistically significant using the within-practice estimator (1.0%; CI -0.4% to 2.5%). CONCLUSION The positive association between local hospital waiting times and GP demand for specialist diagnosis was caused by practices with higher levels of referrals facing longer local waiting times. Temporal changes in waiting times faced by individual practices were not related to changes in their referral volumes. GP referrals for diagnostic cancer services were not found to respond to waiting times in the short-term. In this setting, it may therefore be possible to reduce waiting times by increasing supply without consequently increasing demand.
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Affiliation(s)
- Helen Hayes
- Office of Health Economics (OHE), London, United Kingdom
- Health Organisation, Policy and Economics (HOPE), Centre for Primary Care & Health Services Research, School of Health Sciences, The University of Manchester, Manchester, United Kingdom
| | - Rachel Meacock
- Health Organisation, Policy and Economics (HOPE), Centre for Primary Care & Health Services Research, School of Health Sciences, The University of Manchester, Manchester, United Kingdom
| | - Jonathan Stokes
- Health Organisation, Policy and Economics (HOPE), Centre for Primary Care & Health Services Research, School of Health Sciences, The University of Manchester, Manchester, United Kingdom
- MRC/CSO Social & Public Health Sciences Unit, School of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Matt Sutton
- Health Organisation, Policy and Economics (HOPE), Centre for Primary Care & Health Services Research, School of Health Sciences, The University of Manchester, Manchester, United Kingdom
- Centre for Health Economics, Monash University, Melbourne, Victoria, Australia
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Lewis J, Burton C. Understanding the consequences of GP referral thresholds: taking the instrumental approach. BMJ Qual Saf 2023; 32:309-311. [PMID: 36707245 DOI: 10.1136/bmjqs-2022-015557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2023] [Indexed: 01/28/2023]
Affiliation(s)
- Jen Lewis
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Christopher Burton
- Academic Unit of Primary Medical Care, University of Sheffield, Sheffield, UK
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3
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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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Svedahl ER, Pape K, Austad B, Vie GÅ, Anthun KS, Carlsen F, Bjørngaard JH. Effects of GP characteristics on unplanned hospital admissions and patient safety. A 9-year follow-up of all Norwegian out-of-hours contacts. Fam Pract 2022; 39:381-388. [PMID: 34694363 PMCID: PMC9155163 DOI: 10.1093/fampra/cmab120] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND There are substantial differences in hospital referrals between general practitioners (GPs); however, there is little research on the consequences for patient safety and further healthcare use. OBJECTIVE To investigate associations between out-of-hours GP characteristics, unplanned hospital admissions, and patient safety. METHODS This cohort study included all Norwegian out-of-hours services contacts from 2008 to 2016, linked to registry data on patient characteristics, healthcare use and death, and GP age, sex, specialist status, out-of-hours service experience, and prior admission proportion. We estimated the impact from GP characteristics on (i) immediate unplanned hospital admissions for "all conditions," (ii) immediate unplanned hospital admissions for "critical conditions," (iii) 30-day unplanned hospital admissions, (iv) 30-day hospital costs, and (v) 30-day risk of death. To limit confounding, we matched patients in groups by age, time, and location, with an assumption of random assignment of GPs to patients with this design. RESULTS Patients under the care of older and male GPs had fewer immediate unplanned hospital admissions, but the effects on cumulative 30-day unplanned hospital admissions and costs were small. The GPs' prior admission proportion was strongly associated with both immediate and 30-day unplanned hospital admissions. Higher prior admission proportion was also associated with admitting more patients with critical conditions. There was little evidence of any associations between GP characteristics and 30-day risk of death. CONCLUSIONS GPs' prior admission proportion was strongly associated with unplanned hospital admissions. We found little effects on 30-day mortality, but more restrictive referral practices may threaten patient safety through missing out on critical cases.
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Affiliation(s)
- Ellen Rabben Svedahl
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Kristine Pape
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Bjarne Austad
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Gunnhild Åberge Vie
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Kjartan Sarheim Anthun
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Health Research, SINTEF Digital, Trondheim, Norway
| | - Fredrik Carlsen
- Department of Economics, Norwegian University of Science and Technology, Trondheim, Norway
| | - Johan Håkon Bjørngaard
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway.,Faculty of Nursing and Health Sciences, Nord University, Levanger, Norway
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5
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Olsen F, Jacobsen BK, Heuch I, Tveit KM, Balteskard L. Equitable access to cancer patient pathways in Norway - a national registry-based study. BMC Health Serv Res 2021; 21:1272. [PMID: 34823515 PMCID: PMC8613926 DOI: 10.1186/s12913-021-07250-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 10/29/2021] [Indexed: 11/13/2022] Open
Abstract
Background In 2015, cancer patient pathways (CPP) were implemented in Norway to reduce unnecessary non-medical delay in the diagnostic process and start of treatment. The main aim of this study was to investigate the equality in access to CPPs for patients with either lung, colorectal, breast or prostate cancer in Norway. Methods National population-based data on individual level from 2015 to 2017 were used to study two proportions; i) patients in CPPs without the cancer diagnosis, and ii) cancer patients included in CPPs. Logistic regression was applied to examine the associations between these proportions and place of residence (hospital referral area), age, education, income, comorbidity and travel time to hospital. Results Age and place of residence were the two most important factors for describing the variation in proportions. For the CPP patients, inconsistent differences were found for income and education, while for the cancer patients the probability of being included in a CPP increased with income. Conclusions The age effect can be related to both the increasing risk of cancer and increasing number of GP and hospital contacts with age. The non-systematic results for CPP patients according to income and education can be interpreted as equitable access, as opposed to the systematic differences found among cancer patients in different income groups. The inequalities between income groups among cancer patients and the inequalities based on the patients’ place of residence, for both CPP and cancer patients, are unwarranted and need to be addressed. Supplementary Information The online version contains supplementary material available at (10.1186/s12913-021-07250-1).
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Affiliation(s)
- Frank Olsen
- Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway. .,Centre for Clinical Documentation and Evaluation (SKDE), Northern Norway Regional Health Authority, Tromsø, Norway.
| | - Bjarne K Jacobsen
- Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway.,Centre for Clinical Documentation and Evaluation (SKDE), Northern Norway Regional Health Authority, Tromsø, Norway.,Centre for Sami Health Research, UiT The Arctic University of Norway, Tromsø, Norway
| | - Ivar Heuch
- Department of Mathematics, University of Bergen, Bergen, Norway
| | - Kjell M Tveit
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Lise Balteskard
- Centre for Clinical Documentation and Evaluation (SKDE), Northern Norway Regional Health Authority, Tromsø, Norway
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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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Cabrera LY, Nowak GR, McCright AM, Achtyes E, Bluhm R. A qualitative study of key stakeholders' perceived risks and benefits of psychiatric electroceutical interventions. HEALTH, RISK & SOCIETY 2021; 23:217-235. [PMID: 35574212 PMCID: PMC9103575 DOI: 10.1080/13698575.2021.1979194] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Amid a renewed interest in alternatives to psychotherapy and medication to treat depression, there is limited data as to how different stakeholders perceive of the risks and benefits of psychiatric electroceutical interventions (PEIs), including electroconvulsive therapy (ECT) and deep brain stimulation (DBS). To address this gap, we conducted 48 semi-structured interviews, including 16 psychiatrists, 16 persons diagnosed with depression, and 16 members of the general public. To provide a basis of comparison, we asked participants to also compare each modality to front-line therapies for depression and to neurosurgical procedures used for non-psychiatric conditions. Across all stakeholder groups, perceived memory loss was the most frequently mentioned potential risk with ECT. The most discussed benefits across all stakeholder groups were efficacy and quick response. Psychiatrists most often referenced effectiveness when discussing ECT, while patients and the public did so when discussing DBS. Taken as a whole, these data highlight stakeholders' contrasting perspectives on the risks and benefits of electroceuticals.
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Affiliation(s)
- Laura Y Cabrera
- Center for Neural Engineering, Department of Engineering Science and Mechanics, Pennsylvania State University, University Park, PA, United States
- Rock Ethics Institute, Pennsylvania State University, University Park, PA, United States
| | - Gerald R Nowak
- Department of Sociology, Michigan State University, East Lansing, MI, United States
| | - Aaron M McCright
- Department of Sociology, Michigan State University, East Lansing, MI, United States
| | - Eric Achtyes
- Division of Psychiatry and Behavioral Medicine, Michigan State University, East Grand Rapids, MI, United States
- Pine Rest Christian Mental Health Services, Grand Rapids, MI, United States
| | - Robyn Bluhm
- Lyman Briggs College and Department of Philosophy, Michigan State University, East Lansing, MI, United States
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8
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Shashar S, Ellen M, Codish S, Davidson E, Novack V. Medical Practice Variation Among Primary Care Physicians: 1 Decade, 14 Health Services, and 3,238,498 Patient-Years. Ann Fam Med 2021; 19:30-37. [PMID: 33431388 PMCID: PMC7800753 DOI: 10.1370/afm.2627] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 07/14/2020] [Accepted: 07/24/2020] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Variation in medical practice is associated with poorer health outcomes, increased costs, disparities in care, and increased burden on the public health system. In the present study, we sought to describe and assess inter- and intra-primary care physician variation, adjusted for patient and clinic characteristics, over a decade of practice and across a broad range of health services. METHODS We assessed practice patterns of 251 primary care physicians in southern Israel. For each of 14 health services (imaging tests, cardiac tests, laboratory tests, and specialist visits) we described interphysician and intraphysician variation, adjusted for patient case mix and clinic characteristics, using the coefficient of variation. The adjusted rates were assessed by generalized linear negative-binomial mixed models. RESULTS The variation between physicians was on average 3-fold greater than the variation of individual physician practice over the years. Services with low utilization were associated with greater inter- and intraphysician variation: rs = (-0.58), P = .03 and rs = (-0.39), P = .17, respectively. In addition, physician utilization ranks averaged over all health services were consistent across the 14 health services (intraclass correlation coefficient, 0.94; 95% CI, 0.93-0.95). CONCLUSIONS Our results show greater variation in practice patterns between physicians than for individual physicians over the years. It appears that the variation remains high even after adjustment for patient and clinic characteristics and that the individual physician utilization patterns are stable across health services. We propose that personal behavioral characteristics of medical practitioners might explain this variation.
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Affiliation(s)
- Sagi Shashar
- Clinical Research Center, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er-Sheva, Israel
| | - Moriah Ellen
- Department of Health Services Management, Guilford Glazer Faculty of Business and Management, Ben Gurion University of the Negev, Be'er-Sheva, Israel.,Institute of Health Policy Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,McMaster Health Forum, McMaster University, Hamilton, Ontario, Canada
| | - Shlomi Codish
- Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er-Sheva, Israel
| | - Ehud Davidson
- General Management, Clalit Health Services, Tel-Aviv, Israel
| | - Victor Novack
- Clinical Research Center, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er-Sheva, Israel
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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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Round T, Abel G. Seeing the wood and the trees: the impact of the healthcare system on variation in primary care referrals. BMJ Qual Saf 2019; 29:274-276. [PMID: 31822513 DOI: 10.1136/bmjqs-2019-010356] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2019] [Indexed: 01/23/2023]
Affiliation(s)
- Thomas Round
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Gary Abel
- Medical School (Primary Care), University of Exeter, Exeter, UK
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11
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Burton C, O'Neill L, Oliver P, Murchie P. Contribution of primary care organisation and specialist care provider to variation in GP referrals for suspected cancer: ecological analysis of national data. BMJ Qual Saf 2019; 29:296-303. [PMID: 31586938 DOI: 10.1136/bmjqs-2019-009469] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Revised: 07/12/2019] [Accepted: 09/13/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To examine how much of the variation between general practices in referral rates and cancer detection rates is attributable to local health services rather than the practices or their populations. DESIGN Ecological analysis of national data on fast-track referrals for suspected cancer from general practices. Data were analysed at the levels of general practice, primary care organisation (Clinical Commissioning Group) and secondary care provider (Acute Hospital Trust) level. Analysis of variation in detection rate was by multilevel linear and Poisson regression. SETTING 6379 group practices with data relating to more than 50 cancer cases diagnosed over the 5 years from 2013 to 2017. OUTCOMES Proportion of observed variation attributable to primary and secondary care organisations in standardised fast-track referral rate and in cancer detection rate before and after adjustment for practice characteristics. RESULTS Primary care organisation accounted for 21% of the variation between general practices in the standardised fast-track referral rate and 42% of the unadjusted variation in cancer detection rate. After adjusting for standardised fast-track referral rate, primary care organisation accounted for 31% of the variation in cancer detection rate (compared with 18% accounted for by practice characteristics). In areas where a hospital trust was the main provider for multiple primary care organisations, hospital trusts accounted for the majority of the variation attributable to local health services (between 63% and 69%). CONCLUSION This is the first large-scale finding that a substantial proportion of the variation between general practitioner practices in referrals is attributable to their local healthcare systems. Efforts to reduce variation need to focus not just on individual practices but on local diagnostic service provision and culture at the interface of primary and secondary care.
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Affiliation(s)
- Christopher Burton
- Academic Unit of Primary Medical Care, University of Sheffield, Sheffield, UK
| | - Luke O'Neill
- Academic Unit of Primary Medical Care, University of Sheffield, Sheffield, UK
| | - Phillip Oliver
- Academic Unit of Primary Medical Care, University of Sheffield, Sheffield, UK
| | - Peter Murchie
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
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12
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Hilsden R, Leeper R, Koichopolos J, Vandelinde JD, Parry N, Thompson D, Myslik F. Point-of-care biliary ultrasound in the emergency department (BUSED): implications for surgical referral and emergency department wait times. Trauma Surg Acute Care Open 2018; 3:e000164. [PMID: 30109274 PMCID: PMC6078236 DOI: 10.1136/tsaco-2018-000164] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 05/24/2018] [Accepted: 06/05/2018] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Patients with uncomplicated biliary disease frequently present to the emergency department for assessment. To improve bedside clinical decision making, biliary point-of-care ultrasound (POCUS) in the emergency department has emerged as a diagnostic tool. The purpose of this study is to analyze the usefulness of POCUS in predicting the need for surgical intervention in biliary disease. METHODS A retrospective study of patients visiting the emergency department who received a biliary POCUS from December 1, 2016 to July 15, 2017 was performed. The physician interpretations of the biliary POCUS scans were collected, as well as data from the electronic health records including lab values, the subsequent use of diagnostic imaging, surgical consultation or intervention, and 28 days follow-up for representation or complication. RESULTS Two hundred and eighty-three patients were identified as having received biliary POCUS. Of the patients referred to general surgery who received biliary POCUS 43% received a cholecystectomy. For the outcome of cholecystectomy, the finding of gallstones on POCUS was 55% sensitive (95% CI 40% to 70%) and 92% specific (95% CI 87% to 95%). A sonographic Murphy's sign was 16% sensitive (95% CI 7% to 30%) but 95% specific (95% CI 92% to 97%) and, gallbladder wall thickness was 18% sensitive (95% CI 9% to 33%) and 98% specific (95% CI 95% to 99%). Patients who received POCUS but did not proceed to confirmatory radiology department imaging had a shorter length of stay (433 min ± 50 min vs. 309 min ± 30 min, P<0.001). DISCUSSION Point-of-care biliary ultrasound performed by emergency physicians provides timely access to diagnostic information. Positive findings of gallstones and increased gallbladder wall thickness are highly predictive of the need for surgical intervention, and use of POCUS is associated with shorter ER visits. LEVEL OF EVIDENCE Retrospective cohort study, level III.
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Affiliation(s)
- Richard Hilsden
- Department of Surgery, Western University, London, Ontario, Canada
| | - Rob Leeper
- Department of Surgery, Western University, London, Ontario, Canada
- Division of Critical Care Medicine, Western University, London, Ontario, Canada
| | | | | | - Neil Parry
- Department of Surgery, Western University, London, Ontario, Canada
- Division of Critical Care Medicine, Western University, London, Ontario, Canada
| | - Drew Thompson
- Division of Emergency Medicine, Western University, London, Ontario, Canada
| | - Frank Myslik
- Division of Emergency Medicine, Western University, London, Ontario, Canada
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13
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Abdominal symptoms and cancer in the abdomen: prospective cohort study in European primary care. Br J Gen Pract 2018; 68:e301-e310. [PMID: 29632003 DOI: 10.3399/bjgp18x695777] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 11/20/2017] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Different abdominal symptoms may signal cancer, but their role is unclear. AIM To examine associations between abdominal symptoms and subsequent cancer diagnosed in the abdominal region. DESIGN AND SETTING Prospective cohort study comprising 493 GPs from surgeries in Norway, Denmark, Sweden, Scotland, Belgium, and the Netherlands. METHOD Over a 10-day period, the GPs recorded consecutive consultations and noted: patients who presented with abdominal symptoms pre-specified on the registration form; additional data on non-specific symptoms; and features of the consultation. Eight months later, data on all cancer diagnoses among all study patients in the participating general practices were requested from the GPs. RESULTS Consultations with 61 802 patients were recorded and abdominal symptoms were documented in 6264 (10.1%) patients. Malignancy, both abdominal and non-abdominal, was subsequently diagnosed in 511 patients (0.8%). Among patients with a new cancer in the abdomen (n = 251), 175 (69.7%) were diagnosed within 180 days after consultation. In a multivariate model, the highest sex- and age-adjusted hazard ratio (HR) was for the single symptom of rectal bleeding (HR 19.1, 95% confidence interval = 8.7 to 41.7). Positive predictive values of >3% were found for macroscopic haematuria, rectal bleeding, and involuntary weight loss, with variations according to age and sex. The three symptoms relating to irregular bleeding had particularly high specificity in terms of colorectal, uterine, and bladder cancer. CONCLUSIONS A patient with undiagnosed cancer may present with symptoms or no symptoms. Irregular bleeding must always be explained. Abdominal pain occurs with all types of abdominal cancer and several symptoms may signal colorectal cancer. The findings are important as they influence how GPs think and act, and how they can contribute to an earlier diagnosis of cancer.
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