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Al-Azri M, Al-Baimani K, Al-Awaisi H, Al-Mandhari Z, Al-Khamayasi J, Al-Lawati Y, Panchatcharam SM. Knowledge of symptoms, time to presentation and barriers to medical help-seeking among Omani women diagnosed with breast cancer: a cross-sectional study. BMJ Open 2021; 11:e043976. [PMID: 33478965 PMCID: PMC7825262 DOI: 10.1136/bmjopen-2020-043976] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To identify knowledge of breast cancer (BC) symptoms, time taken to consult a doctor and factors contributing to delays in medical help-seeking. DESIGN A cross-sectional study of Omani women diagnosed with BC. SETTING The two main teaching hospitals in Oman: Royal Hospital and Sultan Qaboos University Hospital. PARTICIPANTS Adult Omani women recently diagnosed with BC. TOOLS The Breast Module of the Cancer Awareness Measure and the International Cancer Benchmarking Partnership questionnaire were used to collect data. RESULTS A total of 300 women with BC participated (response rate: 91.0%). The mean age at diagnosis was 43.0±12.50 years and 33.5% were diagnosed at stage III or IV. Although most women (74.4%) recognised breast/armpit lumps to be a symptom of BC, less than half identified other symptoms, including breast/armpit pain (44.0%), changes in the position of the nipple (36.2%), redness (31.7%), fatigue (26.3%), weight loss (23.4%) and loss of appetite (20.8%). While most (91.6%) were aware that BC could be cured if detected early, only 66.4% sought medical help within a month of developing symptoms. Initial responses to symptoms included informing husbands (40.2%) or family members (36.5%). Barriers to seeking medical help included feeling scared (68.9%) and worried about what the doctor might find (62.8%). Highly educated women were more likely to recognise the following as BC symptoms: changes in nipple position (OR: 0.16, 95% CI 0.03 to 0.81), breast pain (OR: 0.10, 95% CI 0.01 to 0.86) and unexplained weight loss (OR: 0.18, 95% CI 0.04 to 0.88) (all p<0.05). CONCLUSIONS Although many Omani women with BC were aware of the importance of early diagnosis, most demonstrated inadequate knowledge of symptoms, did not prioritise seeking medical help and reported emotional barriers to help-seeking. More educational measures are needed to improve symptom recognition and address help-seeking barriers to minimise delays in diagnosis.
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Affiliation(s)
- Mohammed Al-Azri
- Family Medicine and Public Health, Sultan Qaboos University, Muscat, Oman
| | - Khalid Al-Baimani
- Oncology Unit, Department of Medicine, Sultan Qaboos University, Muscat, Oman
| | - Huda Al-Awaisi
- Nursing Directorate, Sultan Qaboos University Hospital, Sultan Qaboos University, Muscat, Oman
| | | | - Jasem Al-Khamayasi
- College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman
| | - Yaseen Al-Lawati
- College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman
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Harris M, Brekke M, Dinant GJ, Esteva M, Hoffman R, Marzo-Castillejo M, Murchie P, Neves AL, Smyrnakis E, Vedsted P, Aubin-Auger I, Azuri J, Buczkowski K, Buono N, Foreva G, Babić SG, Jacob E, Koskela T, Petek D, Šter MP, Puia A, Sawicka-Powierza J, Streit S, Thulesius H, Weltermann B, Taylor G. Primary care practitioners' diagnostic action when the patient may have cancer: an exploratory vignette study in 20 European countries. BMJ Open 2020; 10:e035678. [PMID: 33130560 PMCID: PMC7783622 DOI: 10.1136/bmjopen-2019-035678] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 08/04/2020] [Accepted: 08/05/2020] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Cancer survival rates vary widely between European countries, with differences in timeliness of diagnosis thought to be one key reason. There is little evidence on the way in which different healthcare systems influence primary care practitioners' (PCPs) referral decisions in patients who could have cancer.This study aimed to explore PCPs' diagnostic actions (whether or not they perform a key diagnostic test and/or refer to a specialist) in patients with symptoms that could be due to cancer and how they vary across European countries. DESIGN A primary care survey. PCPs were given vignettes describing patients with symptoms that could indicate cancer and asked how they would manage these patients. The likelihood of taking immediate diagnostic action (a diagnostic test and/or referral) in the different participating countries was analysed. Comparisons between the likelihood of taking immediate diagnostic action and physician characteristics were calculated. SETTING Centres in 20 European countries with widely varying cancer survival rates. PARTICIPANTS A total of 2086 PCPs answered the survey question, with a median of 72 PCPs per country. RESULTS PCPs' likelihood of immediate diagnostic action at the first consultation varied from 50% to 82% between countries. PCPs who were more experienced were more likely to take immediate diagnostic action than their peers. CONCLUSION When given vignettes of patients with a low but significant possibility of cancer, more than half of PCPs across Europe would take diagnostic action, most often by ordering diagnostic tests. However, there are substantial between-country variations.
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Affiliation(s)
- Michael Harris
- Department for Health, University of Bath, Bath, Somerset, UK
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Mette Brekke
- Department of General Practice and General Practice Research Unit, University of Oslo, Oslo, Norway
| | - Geert-Jan Dinant
- Department of General Practice, Maastricht University, Maastricht, The Netherlands
| | - Magdalena Esteva
- Balearic Islands Health Research Institute (IdISBa), Palma de Mallorca, Illes Balears, Spain
| | - Robert Hoffman
- Department of Family Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Peter Murchie
- Division of Applied Health Science, University of Aberdeen, Aberdeen, UK
| | - Ana Luísa Neves
- Centre for Health Policy, Imperial College London, London, UK
- Centre for Health Technology and Services Research, Department of Community Medicine, Information and Health Decision Sciences, University of Porto, Porto, Portugal
| | - Emmanouil Smyrnakis
- Laboratory of Primary Health Care, General Practice and Health Services Research, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Peter Vedsted
- Research Unit for General Practice, University of Aarhus, Aarhus, Denmark
| | - Isabelle Aubin-Auger
- Department of General Practice, Université Paris Diderot, Paris, Île-de-France, France
| | - Joseph Azuri
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Krzysztof Buczkowski
- Department of Family Medicine, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Nicola Buono
- Department of Family Medicine, National Society of Medical Education in General Practice (SNaMID), Prata Sannita, Italy
| | | | | | - Eva Jacob
- Primary Health Centre, Centro de Saúde Sarria, Sarria, Lugo, Spain
| | - Tuomas Koskela
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Davorina Petek
- Department of Family Medicine, Univerza v Ljubljani, Ljubljana, Slovenia
| | - Marija Petek Šter
- Department of Family Medicine, Univerza v Ljubljani, Ljubljana, Slovenia
| | - Aida Puia
- Family Medicine Department, Iuliu Hagieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | | | - Sven Streit
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Hans Thulesius
- Department of Research and Development, Lund University, Malmö, Sweden
| | - Birgitta Weltermann
- Institut für Hausarztmedizin, University of Bonn, Bonn, Nordrhein-Westfalen, Germany
| | - Gordon Taylor
- College of Medicine and Health, University of Exeter, Exeter, Devon, UK
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Arhi CS, Markar S, Burns EM, Bouras G, Bottle A, Hanna G, Aylin P, Ziprin P, Darzi A. Delays in referral from primary care are associated with a worse survival in patients with esophagogastric cancer. Dis Esophagus 2019; 32:1-11. [PMID: 30820525 DOI: 10.1093/dote/doy132] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 10/27/2018] [Accepted: 12/20/2018] [Indexed: 12/11/2022]
Abstract
NICE referral guidelines for suspected cancer were introduced to improve prognosis by reducing referral delays. However, over 20% of patients with esophagogastric cancer experience three or more consultations before referral. In this retrospective cohort study, we hypothesize that such a delay is associated with a worse survival compared with patients referred earlier. By utilizing Clinical Practice Research Datalink, a national primary care linked database, the first presentation, referral date, a number of consultations before referral and stage for esophagogastric cancer patients were determined. The risk of a referral after one or two consultations compared with three or more consultations was calculated for age and the presence of symptom fulfilling the NICE criteria. The risk of death according to the number of consultations before referral was determined, while accounting for stage and surgical management. 1307 patients were included. Patients referred after one (HR 0.80 95% CI 0.68-0.93 p = 0.005) or two consultations (HR 0.81 95% CI 0.67-0.98 p = 0.034) demonstrated significantly improved prognosis compared with those referred later. The risk of death was also lower for patients who underwent a resection, were younger or had an earlier stage at diagnosis. Those presenting with a symptom fulfilling the NICE criteria (OR 0.27 95% CI 0.21-0.35 p < 0.0001) were more likely to be referred earlier. This is the first study to demonstrate an association between a delay in referral and worse prognosis in esophagogastric patients. These findings should prompt further research to reduce primary care delays.
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Affiliation(s)
| | - S Markar
- Department of Surgery and Cancer, St Mary's Hospital Campus
| | - E M Burns
- Department of Surgery and Cancer, St Mary's Hospital Campus
| | - G Bouras
- Department of Surgery and Cancer, St Mary's Hospital Campus
| | - A Bottle
- School of Public Health, Imperial College London, Dorset Rise, London, UK
| | - G Hanna
- Department of Surgery and Cancer, St Mary's Hospital Campus
| | - P Aylin
- School of Public Health, Imperial College London, Dorset Rise, London, UK
| | - P Ziprin
- Department of Surgery and Cancer, St Mary's Hospital Campus
| | - A Darzi
- Department of Surgery and Cancer, St Mary's Hospital Campus
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Nicholson BD, Goyder CR, Bankhead CR, Toftegaard BS, Rose PW, Thulesius H, Vedsted P, Perera R. Responsibility for follow-up during the diagnostic process in primary care: a secondary analysis of International Cancer Benchmarking Partnership data. Br J Gen Pract 2018; 68:e323-e332. [PMID: 29686134 PMCID: PMC5916079 DOI: 10.3399/bjgp18x695813] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 12/05/2017] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND It is unclear to what extent primary care practitioners (PCPs) should retain responsibility for follow-up to ensure that patients are monitored until their symptoms or signs are explained. AIM To explore the extent to which PCPs retain responsibility for diagnostic follow-up actions across 11 international jurisdictions. DESIGN AND SETTING A secondary analysis of survey data from the International Cancer Benchmarking Partnership. METHOD The authors counted the proportion of 2879 PCPs who retained responsibility for each area of follow-up (appointments, test results, and non-attenders). Proportions were weighted by the sample size of each jurisdiction. Pooled estimates were obtained using a random-effects model, and UK estimates were compared with non-UK ones. Free-text responses were analysed to contextualise quantitative findings using a modified grounded theory approach. RESULTS PCPs varied in their retention of responsibility for follow-up from 19% to 97% across jurisdictions and area of follow-up. Test reconciliation was inadequate in most jurisdictions. Significantly fewer UK PCPs retained responsibility for test result communication (73% versus 85%, P = 0.04) and non-attender follow-up (78% versus 93%, P<0.01) compared with non-UK PCPs. PCPs have developed bespoke, inconsistent solutions to follow-up. In cases of greatest concern, 'double safety netting' is described, where both patient and PCP retain responsibility. CONCLUSION The degree to which PCPs retain responsibility for follow-up is dependent on their level of concern about the patient and their primary care system's properties. Integrated systems to support follow-up are at present underutilised, and research into their development, uptake, and effectiveness seems warranted.
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Affiliation(s)
- Brian D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Clare R Goyder
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Clare R Bankhead
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Peter W Rose
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Hans Thulesius
- Department of Clinical Sciences, Lund University, Växjö, Sweden
| | - Peter Vedsted
- Research Unit for General Practice, Aarhus University, Aarhus, Denmark
| | - Rafael Perera
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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5
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Harris M, Frey P, Esteva M, Gašparović Babić S, Marzo-Castillejo M, Petek D, Petek Ster M, Thulesius H. How the probability of presentation to a primary care clinician correlates with cancer survival rates: a European survey using vignettes. Scand J Prim Health Care 2017; 35:27-34. [PMID: 28277044 PMCID: PMC5361416 DOI: 10.1080/02813432.2017.1288692] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE European cancer survival rates vary widely. System factors, including whether or not primary care physicians (PCPs) are gatekeepers, may account for some of these differences. This study explores where patients who may have cancer are likely to present for medical care in different European countries, and how probability of presentation to a primary care clinician correlates with cancer survival rates. DESIGN Seventy-eight PCPs in a range of European countries assessed four vignettes representing patients who might have cancer, and consensus groups agreed how likely those patients were to present to different clinicians in their own countries. These data were compared with national cancer survival rates. SETTING A total of 14 countries. SUBJECTS Consensus groups of PCPs. MAIN OUTCOME MEASURES Probability of initial presentation to a PCP for four clinical vignettes. RESULTS There was no significant correlation between overall national 1-year relative cancer survival rates and the probability of initial presentation to a PCP (r = -0.16, 95% CI -0.39 to 0.08). Within that there was large variation depending on the type of cancer, with a significantly poorer lung cancer survival in countries where patients were more likely to initially consult a PCP (lung r = -0.57, 95% CI -0.83 to -0.12; ovary: r = -0.13, 95% CI -0.57 to 0.38; breast r = 0.14, 95% CI -0.36 to 0.58; bowel: r = 0.20, 95% CI -0.31 to 0.62). CONCLUSIONS There were wide variations in the degree of gatekeeping between countries, with no simple binary model as to whether or not a country has a "PCP-as-gatekeeper" system. While there was case-by-case variation, there was no overall evidence of a link between a higher probability of initial consultation with a PCP and poorer cancer survival. KEY POINTS European cancer survival rates vary widely, and health system factors may account for some of these differences. The data from 14 European countries show a wide variation in the probability of initial presentation to a PCP. The degree to which PCPs act as gatekeepers varies considerably from country to country. There is no overall evidence of a link between a higher probability of initial presentation to a PCP and poorer cancer survival.
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Affiliation(s)
- Michael Harris
- Department for Health, University of Bath, Bath, United Kingdom
- CONTACT Michael Harris Gore Cottage, Old Gore Lane, Emborough, Radstock, BA3 4SJ, UK
| | - Peter Frey
- Berner Institut für Hausarztmedizin, Universität Bern, Bern, Switzerland
| | - Magdalena Esteva
- Majorca Primary Health Care Department & Instituto de Investigación sanitaria Illes Balears (idISBA), Palma Mallorca, Spain
| | - Svjetlana Gašparović Babić
- Department for Health Education and Health Promotion, Teaching Institute of Public Health of Primorsko-Goranska County, University of Rijeka, Rijeka, Croatia
| | - Mercè Marzo-Castillejo
- Unitat de Suport a la Recerca, IDIAP Jordi Gol, Direcció d'Atenció Primària Costa de Ponent, Institut Català de la Salut, Cornellà de Llobregat, 08940, Spain
| | - Davorina Petek
- Department of Family Medicine, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Marija Petek Ster
- Department of Family Medicine, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Hans Thulesius
- Department of Clinical Sciences, Lund University, Lund, Sweden
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Htun H, Elwood J, Ioannides S, Fishman T, Lawrenson R. Investigations and referral for suspected cancer in primary care in New Zealand-A survey linked to the International Cancer Benchmarking Partnership. Eur J Cancer Care (Engl) 2017; 26. [DOI: 10.1111/ecc.12634] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2016] [Indexed: 11/29/2022]
Affiliation(s)
- H.W. Htun
- Department of Epidemiology and Biostatistics; School of Population Health; University of Auckland; Auckland New Zealand
| | - J.M. Elwood
- Department of Epidemiology and Biostatistics; School of Population Health; University of Auckland; Auckland New Zealand
| | - S.J. Ioannides
- Department of Epidemiology and Biostatistics; School of Population Health; University of Auckland; Auckland New Zealand
| | - T. Fishman
- Department of General Practice and Primary Health Care; School of Population Health; University of Auckland; Auckland New Zealand
| | - R. Lawrenson
- Waikato Clinical Campus; University of Auckland; Hamilton New Zealand
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Barisic A, Kish M, Gilbert J, Mittmann N, Moineddin R, Sisler J, Vedsted P, Grunfeld E. Family physician access to and wait times for cancer diagnostic investigations: Regional differences among 3 provinces. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2016; 62:e599-e607. [PMID: 27737995 PMCID: PMC5063786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To examine provincial and regional differences in FPs' direct access to cancer diagnostic investigations and advice from other specialists regarding investigations and referrals, and to explore FPs' perceptions about wait times for diagnostic investigations and receipt of results. DESIGN A cross-sectional, online survey. SETTING British Columbia, Manitoba, and Ontario. PARTICIPANTS A sample of FPs from participating provinces. MAIN OUTCOME MEASURES Direct FP access to various diagnostic investigations and advice from other specialists regarding investigations and referrals; FPs' perceptions about wait times for diagnostic investigations ordered directly; and FPs' perceptions about wait times for results. RESULTS A total of 1054 surveys were completed by FPs from British Columbia (n = 229), Manitoba (n = 228), and Ontario (n = 597). Distance from a cancer centre was not significantly associated with direct access to or wait times for diagnostic investigations for most of the investigations studied; however, provincial differences were observed. Family physicians in Manitoba and British Columbia were 30% to 45% less likely to report having direct access to endoscopy and some imaging investigations compared with FPs in Ontario. Family physicians in Manitoba and British Columbia were also at increased odds of waiting longer than 12 weeks for endoscopy investigations and longer than 4 weeks for imaging investigations compared with FPs in Ontario. Most FPs reported wait times of less than 2 weeks for imaging results; however, the proportion of FPs who waited longer than 2 weeks for colonoscopy results ranged from 15% in Ontario to 96% in British Columbia. CONCLUSION Given the disparities observed among provinces, there is an opportunity for provinces to learn from one another to improve direct access to and shorten wait times for diagnostic investigations. This in turn has the potential to shorten the primary care interval for cancer diagnostic assessment.
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Affiliation(s)
- Andriana Barisic
- Senior Research Associate for the Ontario Renal Network of Cancer Care Ontario in Toronto, Ont, and was with the Department of Prevention and Cancer Control at the time of manuscript development.
| | - Maxine Kish
- Research Associate at Cancer Care Ontario and was a master's student in the Department of Pharmacology and Toxicology at the University of Toronto
| | - Julie Gilbert
- Staff scientist and Manager of Research and Evaluation at Cancer Care Ontario and Adjunct Professor in the Institute for Health Policy, Management and Evaluation at the University of Toronto
| | | | - Rahim Moineddin
- Professor and a senior biostatistician in the Department of Family and Community Medicine at the University of Toronto
| | - Jeffrey Sisler
- Chair of the College of Family Physicians of Canada's Cancer Care Program of the Section of Communities of Practice in Family Medicine and Vice-Dean of the Office of Continuing Competency and Assessment in the Faculty of Health Sciences and Professor in the Department of Family Medicine at the University of Manitoba in Winnipeg
| | - Peter Vedsted
- Professor in the Research Unit for General Practice in the Department of Public Health at Aarhus University in Denmark
| | - Eva Grunfeld
- Giblon Professor and Vice-Chair of Research in the Department of Family and Community Medicine at the University of Toronto and Director of Knowledge Translation Research in the Health Services Research Program at the Ontario Institute for Cancer Research
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Toftegaard BS, Bro F, Falborg AZ, Vedsted P. Impact of continuing medical education in cancer diagnosis on GP knowledge, attitude and readiness to investigate - a before-after study. BMC FAMILY PRACTICE 2016; 17:95. [PMID: 27460041 PMCID: PMC4962470 DOI: 10.1186/s12875-016-0496-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 07/20/2016] [Indexed: 01/18/2023]
Abstract
Background Continuing medical education (CME) in earlier cancer diagnosis was launched in Denmark in 2012 as part of the Danish National Cancer Plan. The CME programme was introduced to improve the recognition among general practitioners (GPs) of symptoms suggestive of cancer and improve the selection of patients requiring urgent investigation. This study aims to explore the effect of CME on GP knowledge about cancer diagnosis, attitude towards own role in cancer detection, self-assessed readiness to investigate and cancer risk assessment of urgently referred patients. Methods We conducted a before-after study in the Central Denmark Region including 831 GPs assigned to one of eight geographical clusters. All GPs were invited to participate in the CME at three-week intervals between clusters. A questionnaire focusing on knowledge, attitude and clinical vignettes was sent to each GP one month before and seven months after the CME. The GPs were also asked to assess the risk of cancer in patients urgently referred to a fast-track cancer pathway during an eight-month period. CME-participating GPs were compared with reference (non-participating) GPs by analysing before-after differences. Results One quarter of all GPs participated in the CME. 202 GPs (24.3 %) completed both the baseline and the follow-up questionnaires. 532 GPs (64.0 %) assessed the risk of cancer before the CME and 524 GPs (63.1 %) assessed the risk of cancer after the CME in urgently referred consecutive patients. Compared to the reference group, CME-participating GPs statistically significantly improved their understanding of a rational probability of diagnosing cancer among patients urgently referred for suspected cancer, increased their knowledge of cancer likelihood in a 50-year-old referred patient and lowered the assessed risk of cancer in urgently referred patients. Conclusions The standardised CME lowered the GP-assessed cancer risk of urgently referred patients, whereas the effect on knowledge about cancer diagnosis and attitude towards own role in cancer detection was limited. No effect was found on the GPs’ readiness to investigate. CME may be effective for optimising the interpretation of cancer symptoms and thereby improve the selection of patients for urgent cancer referral. Trial registration NCT02069470 on ClinicalTrials.gov. Retrospectively registered, 1/29/2014. Electronic supplementary material The online version of this article (doi:10.1186/s12875-016-0496-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Berit Skjødeberg Toftegaard
- Research Unit for General Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, DK-8000, Aarhus, Denmark. .,Research Centre for Cancer Diagnosis in Primary Care (CaP), Department of Public Health, Aarhus University, Bartholins Allé 2, DK-8000, Aarhus, Denmark. .,Section for General Medical Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, DK-8000, Aarhus, Denmark.
| | - Flemming Bro
- Research Unit for General Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, DK-8000, Aarhus, Denmark.,Section for General Medical Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, DK-8000, Aarhus, Denmark
| | - Alina Zalounina Falborg
- Research Unit for General Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, DK-8000, Aarhus, Denmark.,Research Centre for Cancer Diagnosis in Primary Care (CaP), Department of Public Health, Aarhus University, Bartholins Allé 2, DK-8000, Aarhus, Denmark.,Section for General Medical Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, DK-8000, Aarhus, Denmark
| | - Peter Vedsted
- Research Unit for General Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, DK-8000, Aarhus, Denmark.,Research Centre for Cancer Diagnosis in Primary Care (CaP), Department of Public Health, Aarhus University, Bartholins Allé 2, DK-8000, Aarhus, Denmark.,Section for General Medical Practice, Department of Public Health, Aarhus University, Bartholins Allé 2, DK-8000, Aarhus, Denmark
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Nicholson BD, Oke JL, Rose PW, Mant D. Variation in Direct Access to Tests to Investigate Cancer: A Survey of English General Practitioners. PLoS One 2016; 11:e0159725. [PMID: 27447931 PMCID: PMC4957804 DOI: 10.1371/journal.pone.0159725] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 07/07/2016] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND The 2015 NICE guidelines for suspected cancer recommend that English General Practitioners have direct access to diagnostic tests to investigate symptoms of cancer that do not meet the criteria for urgent referral. We aimed to identify the proportion of GPs in England with direct access to these tests. METHODS We recruited 533 English GPs through a national clinical research network to complete an online survey about direct access to laboratory, radiology, and endoscopy tests in the three months leading up to the release of the 2015 NICE guidance. If they had direct access to a diagnostic test, GPs were asked about the time necessary to arrange a test and receive a report. Results are reported by NHS sub-region and, adjusting for sampling, for England as a whole. RESULTS Almost all GPs reported direct access to x-ray and laboratory investigations except faecal occult blood testing (54%, 95% CI 49-59%) and urine protein electrophoresis (89%, 95% CI 84-92%). Fewer GPs had direct access to CT scans (54%, 95% CI 49-59%) or endoscopy (colonoscopy 32%, 95% CI 28-37%; gastroscopy 72%, 95% CI 67-77%). There was significant variation in direct access between NHS regions for the majority of imaging tests-for example, from 20 to 85% to MRI. Apart from x-ray, very few GPs (1-22%) could access radiology and endoscopy within the timescales recommended by NICE. The modal request to test time was 2-4 weeks for routine radiology and 4-6 weeks for routine endoscopy with results taking another 1-2 weeks. CONCLUSION At the time that the 2015 NICE guideline was released, local investment was required to not only provide direct access but also reduce the interval between request and test and speed up reporting. Further research using our data as a benchmark is now required to identify whether local improvements in direct access have been achieved in response to the NICE targets. If alternative approaches to test access are to be proposed they must be piloted comprehensively and underpinned by robust effectiveness data.
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Affiliation(s)
- Brian D. Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, OX26GG, United Kingdom
| | - Jason L. Oke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, OX26GG, United Kingdom
| | - Peter W. Rose
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, OX26GG, United Kingdom
| | - David Mant
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, OX26GG, United Kingdom
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Elwood JM, Aye PS, Tin Tin S. Increasing Disadvantages in Cancer Survival in New Zealand Compared to Australia, between 2000-05 and 2006-10. PLoS One 2016; 11:e0150734. [PMID: 26938056 PMCID: PMC4777383 DOI: 10.1371/journal.pone.0150734] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 02/17/2016] [Indexed: 11/19/2022] Open
Abstract
New Zealand has lower cancer survival compared to its neighbour Australia. If this were due to long established differences between the two patient populations, it might be expected to be either constant in time, or decreasing, as improving health services deals with inequities. In this study we compared trends in relative cancer survival ratios in New Zealand and Australia between 2000-05 and 2006-10, using data from the New Zealand Cancer Registry and the Australian Institute for Health and Welfare. Over this period, Australia showed significant improvements (6.0% in men, 3.0% in women) in overall 5-year cancer survival, with substantial increases in survival from major cancer sites such as lung, bowel, prostate, and breast cancers. New Zealand had only a 1.8% increase in cancer survival in men and 1.3% in women, with non-significant changes in survival from lung and bowel cancers, although there were increases in survival from prostate and breast cancers. For all cancers combined, and for lung and bowel cancer, the improvements in survival and the greater improvements in Australia were mainly in 1-year survival, suggesting factors related to diagnosis and presentation. For breast cancer, the improvements were similar in each country and seen in survival after the first year. The findings underscore the need to accelerate the efforts to improve early diagnosis and optimum treatment for New Zealand cancer patients to catch up with the progress in Australia.
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Affiliation(s)
- J. Mark Elwood
- Section of Epidemiology and Biostatistics, School of Population Health, University of Auckland, Auckland, New Zealand
- * E-mail:
| | - Phyu Sin Aye
- Section of Epidemiology and Biostatistics, School of Population Health, University of Auckland, Auckland, New Zealand
| | - Sandar Tin Tin
- Section of Epidemiology and Biostatistics, School of Population Health, University of Auckland, Auckland, New Zealand
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11
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International variation in adherence to referral guidelines for suspected cancer: a secondary analysis of survey data. Br J Gen Pract 2016; 66:e106-13. [PMID: 26740607 DOI: 10.3399/bjgp16x683449] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 05/08/2015] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Variation in cancer survival persists between comparable nations and appears to be due, in part, to primary care practitioners (PCPs) having different thresholds for acting definitively in response to cancer-related symptoms. AIM To explore whether cancer guidelines, and adherence to them, differ between jurisdictions and impacts on PCPs' propensity to take definitive action on cancer-related symptoms. DESIGN AND SETTING A secondary analysis of survey data from six countries (10 jurisdictions) participating in the International Cancer Benchmarking Partnership. METHOD PCPs' responses to five clinical vignettes presenting symptoms and signs of lung (n = 2), colorectal (n = 2), and ovarian cancer (n = 1) were compared with investigation and referral recommendations in cancer guidelines. RESULTS Nine jurisdictions had guidelines covering the two colorectal vignettes. For the lung vignettes, although eight jurisdictions had guidelines for the first, the second was covered by a Swedish guideline alone. Only the UK and Denmark had an ovarian cancer guideline. Survey responses of 2795 PCPs (crude response rate: 12%) were analysed. Guideline adherence ranged from 20-82%. UK adherence was lower than other jurisdictions for the lung vignette covered by the guidance (47% versus 58%; P <0.01) but similar (45% versus 46%) or higher (67% versus 38%; P <0.01) for the two colorectal vignettes. PCPs took definitive action least often when a guideline recommended a non-definitive action or made no recommendation. UK PCPs adhered to recommendations for definitive action less than their counterparts (P <0.01). There wasno association between jurisdictional guideline adherence and 1-year survival. CONCLUSION Cancer guideline content is variable between similarly developed nations and poor guideline adherence does not explain differential survival. Guidelines that fail to cover high-risk presentations or that recommend non-definitive action may reduce definitive diagnostic action.
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12
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Rose PW, Rubin G, Perera-Salazar R, Almberg SS, Barisic A, Dawes M, Grunfeld E, Hart N, Neal RD, Pirotta M, Sisler J, Konrad G, Toftegaard BS, Thulesius H, Vedsted P, Young J, Hamilton W. Explaining variation in cancer survival between 11 jurisdictions in the International Cancer Benchmarking Partnership: a primary care vignette survey. BMJ Open 2015; 5:e007212. [PMID: 26017370 PMCID: PMC4452748 DOI: 10.1136/bmjopen-2014-007212] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES The International Cancer Benchmarking Partnership (ICBP) is a collaboration between 6 countries and 12 jurisdictions with similar primary care-led health services. This study investigates primary care physician (PCP) behaviour and systems that may contribute to the timeliness of investigating for cancer and subsequently, international survival differences. DESIGN A validated survey administered to PCPs via the internet set out in two parts: direct questions on primary care structure and practice relating to cancer diagnosis, and clinical vignettes, assessing management of scenarios relating to the diagnosis of lung, colorectal or ovarian cancer. PARTICIPANTS 2795 PCPs in 11 jurisdictions: New South Wales and Victoria (Australia), British Columbia, Manitoba, Ontario (Canada), England, Northern Ireland, Wales (UK), Denmark, Norway and Sweden. PRIMARY AND SECONDARY OUTCOME MEASURES Analysis compared the cumulative proportion of PCPs in each jurisdiction opting to investigate or refer at each phase for each vignette with 1-year survival, and conditional 5-year survival rates for the relevant cancer and jurisdiction. Logistic regression was used to explore whether PCP characteristics or system differences in each jurisdiction affected the readiness to investigate. RESULTS 4 of 5 vignettes showed a statistically significant correlation (p<0.05 or better) between readiness to investigate or refer to secondary care at the first phase of each vignette and cancer survival rates for that jurisdiction. No consistent associations were found between readiness to investigate and selected PCP demographics, practice or health system variables. CONCLUSIONS We demonstrate a correlation between the readiness of PCPs to investigate symptoms indicative of cancer and cancer survival rates, one of the first possible explanations for the variation in cancer survival between ICBP countries. No specific health system features consistently explained these findings. Some jurisdictions may consider lowering thresholds for PCPs to investigate for cancer-either directly, or by specialist referral, to improve outcomes.
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Affiliation(s)
- Peter W Rose
- Department of Primary Health Care Sciences, University of Oxford, Oxford, UK
| | - Greg Rubin
- School of Medicine and Health, Wolfson Research Institute, Durham University, Stockton-on-Tees, UK
| | | | - Sigrun Saur Almberg
- Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Andriana Barisic
- Department of Prevention and Cancer Control, Cancer Care Ontario, Toronto, Ontario, Canada
| | - Martin Dawes
- Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada
| | - Eva Grunfeld
- Knowledge Translation Research Network Health Services Research Program, Ontario Institute for Cancer Research, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nigel Hart
- School of Medicine, Dentistry and Biomedical Sciences—Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Richard D Neal
- North Wales Centre for Primary Care Research, Bangor University, Wrexham, UK
| | - Marie Pirotta
- Department of General Practice, Primary Health Care Research Evaluation and Development, Carlton, Victoria, Australia
| | - Jeffrey Sisler
- Division of Continuing Professional Development, Department of Family Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Gerald Konrad
- Department of Family Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Hans Thulesius
- Department of Clinical Sciences, Kronoberg County Research Council, Växjö, Sweden
| | - Peter Vedsted
- Research Unit for General Practice, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Jane Young
- Department of Cancer Epidemiology, Public Health, School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Willie Hamilton
- Primary Care Diagnostics, University of Exeter Medical School, Exeter, UK
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Toftegaard BS, Bro F, Vedsted P. A geographical cluster randomised stepped wedge study of continuing medical education and cancer diagnosis in general practice. Implement Sci 2014; 9:159. [PMID: 25377520 PMCID: PMC4229614 DOI: 10.1186/s13012-014-0159-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 10/16/2014] [Indexed: 01/07/2023] Open
Abstract
Background Denmark has inferior cancer survival rates compared with many European countries. The main reason for this is suggested to be late diagnosis at advanced cancer stages. Cancer diagnostic work-up begins in general practice in 85% of all cancer cases. Thus, general practitioners (GPs) play a key role in the diagnostic process. The latest Danish Cancer Plan included continuing medical education (CME) on early cancer diagnosis in general practice to improve early diagnosis. This dual aims of this protocol are, first, to describe the conceptualisation, operationalisation and implementation of the CME and, second, to describe the study design and outcomes chosen to evaluate the effects of the CME. Methods/Design The intervention is a CME in early cancer diagnosis targeting individual GPs. It was developed by a step-wise approach. Barriers for early cancer diagnosis at GP level were identified systematically and analysed using the behaviour system involving capability, opportunity and motivation described by Michie et al. The study will be designed as a geographical cluster randomised stepped wedge study. The study population counts 836 GPs from 417 general practices in the Central Denmark Region, geographically divided into eight clusters. GPs from each cluster will be invited to a CME meeting at a certain date three weeks apart. The primary outcomes will be primary care interval and GP referral rate on cancer suspicion. Data will be obtained from national registries, GP-completed forms on patients referred to cancer fast-track pathways and GP-completed online questionnaires before and after the intervention. Discussion To our knowledge, this will be the first study to measure the effect of a theory-based CME in early cancer diagnosis at three levels: GP knowledge and attitude, GP activity and patient outcomes. The achieved knowledge will contribute to the understanding of whether and how general practice’s ability to perform cancer diagnosis may be improved. Trial registration Registered as NCT02069470 on ClinicalTrials.gov. Electronic supplementary material The online version of this article (doi:10.1186/s13012-014-0159-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Berit Skjødeberg Toftegaard
- Research Unit for General Practice, Aarhus University, Bartholins Allé 2, DK-8000, Aarhus, Denmark. .,Research Centre for Cancer Diagnosis in Primary Care (CaP), Aarhus University, Bartholins Allé 2, DK-8000, Aarhus, Denmark. .,Department of Public Health, Section for General Medical Practice, Bartholins Allé 2, DK-8000, Aarhus, Denmark.
| | - Flemming Bro
- Research Unit for General Practice, Aarhus University, Bartholins Allé 2, DK-8000, Aarhus, Denmark. .,Department of Public Health, Section for General Medical Practice, Bartholins Allé 2, DK-8000, Aarhus, Denmark.
| | - Peter Vedsted
- Research Unit for General Practice, Aarhus University, Bartholins Allé 2, DK-8000, Aarhus, Denmark. .,Research Centre for Cancer Diagnosis in Primary Care (CaP), Aarhus University, Bartholins Allé 2, DK-8000, Aarhus, Denmark. .,Department of Public Health, Section for General Medical Practice, Bartholins Allé 2, DK-8000, Aarhus, Denmark.
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14
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Young JM, O'Halloran A, McAulay C, Pirotta M, Forsdike K, Stacey I, Currow D. Unconditional and conditional incentives differentially improved general practitioners' participation in an online survey: randomized controlled trial. J Clin Epidemiol 2014; 68:693-7. [PMID: 25450450 DOI: 10.1016/j.jclinepi.2014.09.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 09/08/2014] [Accepted: 09/12/2014] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To compare the impact of unconditional and conditional financial incentives on response rates among Australian general practitioners invited by mail to participate in an online survey about cancer care and to investigate possible differential response bias between incentive groups. STUDY DESIGN AND SETTING Australian general practitioners were randomly allocated to unconditional incentive (book voucher mailed with letter of invitation), conditional incentive (book voucher mailed on completion of the online survey), or control (no incentive). Nonresponders were asked to complete a small subset of questions from the online survey. RESULTS Among 3,334 eligible general practitioners, significantly higher response rates were achieved in the unconditional group (167 of 1,101, 15%) compared with the conditional group (118 of 1,111, 11%) (P = 0.0014), and both were significantly higher than the control group (74 of 1,122, 7%; both P < 0.001). Although more positive opinions about cancer care were expressed by online responders compared with nonresponders, there was no evidence that the magnitude of difference varied by the incentive group. The incremental cost for each additional 1% increase above the control group response rate was substantially higher for the unconditional incentive group compared with the conditional incentive group. CONCLUSION Both unconditional and conditional financial incentives significantly increased response with no evidence of differential response bias. Although unconditional incentives had the largest effect, the conditional approach was more cost-effective.
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Affiliation(s)
- Jane M Young
- Cancer Epidemiology and Services Research (CESR), Sydney School of Public Health, University of Sydney, Level 6 North, Lifehouse (C39Z), NSW 2006, Sydney, Australia.
| | - Anna O'Halloran
- Cancer Epidemiology and Services Research (CESR), Sydney School of Public Health, University of Sydney, Level 6 North, Lifehouse (C39Z), NSW 2006, Sydney, Australia
| | - Claire McAulay
- Cancer Epidemiology and Services Research (CESR), Sydney School of Public Health, University of Sydney, Level 6 North, Lifehouse (C39Z), NSW 2006, Sydney, Australia
| | - Marie Pirotta
- Department of General Practice, University of Melbourne, 200 Berkeley St, Carlton, VIC 3053, Australia
| | - Kirsty Forsdike
- Department of General Practice, University of Melbourne, 200 Berkeley St, Carlton, VIC 3053, Australia
| | - Ingrid Stacey
- Cancer Institute NSW, Australian Technology Park, Level 9, 8 Central Avenue, Everleigh, NSW 2015, Australia
| | - David Currow
- Cancer Institute NSW, Australian Technology Park, Level 9, 8 Central Avenue, Everleigh, NSW 2015, Australia
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