Does an increase in visits to general practice indicate a malignancy?

Electronic safety-netting tool features considered important by UK general practice staff: an interview and Delphi consensus study

BACKGROUND

The potential of the electronic health record to support safety netting has been recognised and a number of electronic safety-netting (E-SN) tools developed.

AIM

To establish the most important features of E-SN tools.

DESIGN & SETTING

User-experience interviews followed by a Delphi study in a primary care setting in the UK.

METHOD

The user-experience interviews were carried out remotely with primary care staff who had trialled the EMIS E-SN toolkit for suspected cancer. An electronic modified Delphi approach was used, with primary care staff involved in safety netting in any capacity, to measure consensus on tool features.

RESULTS

Thirteen user-experience interviews were carried out and features of E-SN tools seen as important formed the majority of the features included in the Delphi study. Three rounds of Delphi survey were administered. Sixteen responders (64%) completed all three rounds, and 28 out of 44 (64%) features reached consensus. Primary care staff preferred tools that were general in scope.

CONCLUSION

Primary care staff indicated that tools that were not specific to cancer or any other disease, and had features that promoted their flexible, efficient, and integrated use, were important. However, when the important features were discussed with the patient and public involvement (PPI) group, they expressed disappointment that features they believed would make E-SN tools robust and provide a safety net that is difficult to fall through did not reach consensus. The successful adoption of E-SN tools will rely on an evidence base of their effectiveness. Efforts should be made to assess the impact of these tools on patient outcomes.

A machine learning tool for identifying non-metastatic colorectal cancer in primary care

BACKGROUND

Primary health care (PHC) is often the first point of contact when diagnosing colorectal cancer (CRC). Human limitations in processing large amounts of information warrant the use of machine learning as a diagnostic prediction tool for CRC.

AIM

To develop a predictive model for identifying non-metastatic CRC (NMCRC) among PHC patients using diagnostic data analysed with machine learning.

DESIGN AND SETTING

A case-control study containing data on PHC visits for 542 patients >18 years old diagnosed with NMCRC in the Västra Götaland Region, Sweden, during 2011, and 2,139 matched controls.

METHOD

Stochastic gradient boosting (SGB) was used to construct a model for predicting the presence of NMCRC based on diagnostic codes from PHC consultations during the year before the date of cancer diagnosis and the total number of consultations. Variables with a normalised relative influence (NRI) >1% were considered having an important contribution to the model. Risks of having NMCRC were calculated using odds ratios of marginal effects.

RESULTS

Of the 361 variables used as predictors in the stochastic gradient boosting model, 184 had non-zero influence, with 16 variables having NRI >1% and a combined NRI of 63.3%. Variables representing anaemia and bleeding had a combined NRI of 27.6%. The model had a sensitivity of 73.3% and a specificity of 83.5%. Change in bowel habit had the highest odds ratios of marginal effects at 28.8.

CONCLUSION

Machine learning is useful for identifying variables of importance for predicting NMCRC in PHC. Malignant diagnoses may be hidden behind benign symptoms such as haemorrhoids.

Use of primary health care and radiological imaging preceding a diagnosis of rheumatoid arthritis: a nationwide cohort study in Denmark

OBJECTIVE

To explore health-care use in the 12 months preceding a diagnosis of RA in Denmark.

METHODS

We conducted a population-based cohort study using data from national registries. Every patient diagnosed with RA in 2014-18 was matched to 10 reference individuals without RA from the Danish background population. Health-care use was defined as contacts to general practitioners, contacts to private practicing physiotherapists, and X-rays of hands and/or feet performed in primary or secondary care. We estimated the monthly contact rates for patients and references in the 12 months preceding the diagnosis, and we compared incidence rates for health-care use in each month between the two groups while adjusting for sociodemographic characteristics and comorbidity.

RESULTS

We included 7427 patients with RA and 74 270 references. Patients with RA had increasing contact rates with general practitioners and physiotherapists from 6 to 8 months before the diagnosis. Compared with references, women with RA had statistically significantly more contacts to general practitioners and physiotherapists during all 12 months. A similar contact pattern was seen in men, albeit less distinct. The number of X-rays increased slightly from 8 months before the diagnosis, with a steep increase in the last 3 months.

CONCLUSION

Increased contacts to general practitioners and physiotherapists were seen in all 12 months preceding the RA diagnosis, intensifying in the last 6 to 8 months. Imaging increased from 3 months before the diagnosis. This indicates an opportunity to expedite referral to specialist care and ensure earlier diagnosis of RA.

Healthcare practices that increase the quality of care in cancer trajectories from a general practice perspective: a scoping review

OBJECTIVE

General practice plays an important role in cancer trajectories, and cancer patients request the continuous involvement of general practice. The objective of this scoping review was to identify healthcare practices that increase the quality of care in cancer trajectories from a general practice perspective.

DESIGN, SETTING, AND SUBJECTS

A scoping review of the literature published in Danish or English from 2010 to 2020 was conducted. Data was collected using identified keywords and indexed terms in several databases (PubMed, MEDLINE, EBSCO CINAHL, Scopus, and ProQuest), contacting key experts, searching through reference lists, and reports from selected health political, research- and interest organizations' websites.

MAIN OUTCOME MEASURES

We identified healthcare practices in cancer trajectories that increase quality care. Identified healthcare practices were grouped into four contextual domains and allocated to defined phases in the cancer trajectory. The results are presented according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for scoping reviews (PRISMA-ScR).

RESULTS

A total of 45 peer-reviewed and six non-peer-reviewed articles and reports were included. Quality of care increases in all phases of the cancer trajectory when GPs listen carefully to the full story and use action plans. After diagnosis, quality of care increases when GPs and practice staff have a proactive care approach, act as interpreters of diagnosis, treatment options, and its consequences, and engage in care coordination with specialists in secondary care involving the patient.

CONCLUSION

This scoping review identified healthcare practices that increase the quality of care in cancer trajectories from a general practice perspective. The results support general practice in investigating own healthcare practices and identifying possibilities for quality improvement.KEY POINTSIdentified healthcare practices in general practice that increase the quality of care in cancer trajectories:Listen carefully to the full storyUse action plans and time-out-consultationsPlan and provide proactive careAct as an interpreter of diagnosis, treatment options, and its consequences for the patientCoordinate care with specialists, patients, and caregivers with mutual respectIdentified barriers for quality of care in cancer trajectories are:Time constraints in consultationsLimited accessibility for patients and caregiversHealth practices to increase the quality of care should be effective, safe, people-centered, timely, equitable, integrated, and efficient. These distinctions of quality of care, support general practice in investigating and improving quality of care in cancer trajectories.

Does changing healthcare use signal opportunities for earlier detection of cancer? A review of studies using information from electronic patient records

BACKGROUND

It has been proposed that changes in healthcare use before cancer diagnosis could signal opportunities for quicker detection, but systematic appreciation of such evidence is lacking. We reviewed studies examining pre-diagnostic changes in healthcare utilisation (e.g. rates of GP or hospital consultations, prescriptions or diagnostic tests) among patients subsequently diagnosed with cancer.

METHODS

We identified studies through Pubmed searches complemented by expert elicitation. We extracted information on the earliest time point when diagnosis could have been possible for at least some cancers, together with variation in the length of such 'diagnostic windows' by tumour and patient characteristics.

RESULTS

Across twenty-eight studies, changes in healthcare use were observable at least six months pre-diagnosis for many common cancers, and potentially even earlier for colorectal cancer, multiple myeloma and brain tumours. Early changes were also identified for brain and colon cancer sub-sites.

CONCLUSION

Changing healthcare utilisation patterns before diagnosis indicate that future improvements in diagnostic technologies or services could help to shorten diagnostic intervals for cancer. There is greatest potential for quicker diagnosis for certain cancer types and patient groups, which can inform priorities for the development of decision support tools.

Socioeconomic position and prediagnostic health care contacts in children with cancer in Denmark: a nationwide register study

Background

While underlying mechanisms and pathways of social inequalities in cancer survival have been extensively examined in adults, this is less so for children with cancer. Hypothesized mechanisms include prediagnostic utilization of and navigation through the health care system, which may differ by socioeconomic resources of the families. In this nationwide register-based study we investigated the association between measures of family socioeconomic position in relation to prediagnostic health care contacts and stage of disease at diagnosis in children with cancer in Denmark.

Methods

We identified all children diagnosed with a cancer at ages 0–15 years in 1998–2016 (N = 3043) from the Danish Childhood Cancer Registry. We obtained comprehensive information on measures of socioeconomic position, parental health and prediagnostic contacts to both general practitioners and hospitals 24 months prior to diagnosis from various national registries. We fitted multivariable conditional logistic regression models for the association of family socioeconomic and health-related variables with firstly, frequent health care contacts and secondly, advanced stage.

Results

We found higher odds ratios (OR) of frequent both overall and emergency health care contacts in the last 3 months before diagnosis in children from households with short parental education and mixed affiliation to work market, when compared to children with high family socioeconomic position. Further, children of parents with depression or of non-Western origin, respectively, had higher OR for frequent overall and emergency contacts. We found no association between socioeconomic position, parental health and stage of disease.

Conclusion

Families with socioeconomic disadvantage, non-Western origin or depression more frequently utilize prediagnostic health care services, both generally and in the acute setting, indicating that some disadvantaged families may struggle to navigate the health care system when their child is sick. Reassuringly, this was not reflected in disparities in stage at diagnosis. In order to improve the diagnostic process and potentially reduce health care contacts, attention and support should be given to families with a high number of health care contacts over a short period of time.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08837-x.