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Rubin G, Walter FM, Emery J, Hamilton W, Hoare Z, Howse J, Nixon C, Srivastava T, Thomas C, Ukoumunne OC, Usher-Smith JA, Whyte S, Neal RD. Electronic clinical decision support tool for assessing stomach symptoms in primary care (ECASS): a feasibility study. BMJ Open 2021; 11:e041795. [PMID: 33737422 PMCID: PMC7978254 DOI: 10.1136/bmjopen-2020-041795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 02/15/2021] [Accepted: 02/24/2021] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To determine the feasibility of a definitive trial in primary care of electronic clinical decision support (eCDS) for possible oesophago-gastric (O-G) cancer. DESIGN AND SETTING Feasibility study in 42 general practices in two regions of England, cluster randomised controlled trial design without blinding, nested qualitative and health economic evaluation. PARTICIPANTS Patients aged 55 years or older, presenting to their general practitioner (GP) with symptoms associated with O-G cancer. 530 patients (mean age 68 years, 58% female) participated. INTERVENTION Practices randomised 1:1 to usual care (control) or to receive a previously piloted eCDS tool for suspected cancer (intervention), for use at the discretion of the GPs, supported by a theory-based implementation package and ongoing support. We conducted semistructured interviews with GPs in intervention practices. Recruitment lasted 22 months. OUTCOMES Patient participation rate, use of eCDS, referrals and route to diagnosis, O-G cancer diagnoses; acceptability to GPs; cost-effectiveness. Participants followed up 6 months after index encounter. RESULTS From control and intervention practices, we screened 3841 and 1303 patients, respectively; 1189 and 434 were eligible, 392 and 138 consented to participate. Ten patients (1.9%) had O-G cancer. eCDS was used eight times in total by five unique users. GPs experienced interoperability problems between the eCDS tool and their clinical system and also found it did not fit with their workflow. Unexpected restrictions on software installation caused major problems with implementation. CONCLUSIONS The conduct of this study was hampered by technical limitations not evident during an earlier pilot of the eCDS tool, and by regulatory controls on software installation introduced by primary care trusts early in the study. This eCDS tool needed to integrate better with clinical workflow; even then, its use for suspected cancer may be infrequent. Any definitive trial of eCDS for cancer diagnosis should only proceed after addressing these constraints. TRIAL REGISTRATION NUMBER ISRCTN125595588.
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Affiliation(s)
- Greg Rubin
- Institute of Population Health Sciences, University of Newcastle upon Tyne, Newcastle upon Tyne, UK
| | - Fiona M Walter
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Jon Emery
- Department of General Practice and Centre for Cancer Research, University of Melbourne, Melbourne, Victoria, Australia
| | - Willie Hamilton
- Primary Care Diagnostics, University of Exeter Medical School, Exeter, UK
| | - Zoe Hoare
- North Wales Organisation for Randomised Trials in Health, Bangor University, Bangor, UK
| | - Jenny Howse
- School of Health and Life Sciences, Teesside University, Middlesbrough, UK
| | - Catherine Nixon
- School of Health and Life Sciences, Teesside University, Middlesbrough, UK
| | - Tushar Srivastava
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Chloe Thomas
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Obioha C Ukoumunne
- NIHR CLAHRC South West Peninsula (PenCLAHRC), University of Exeter Medical School, Exeter, UK
| | - Juliet A Usher-Smith
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Sophie Whyte
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Medina-Lara A, Grigore B, Lewis R, Peters J, Price S, Landa P, Robinson S, Neal R, Hamilton W, Spencer AE. Cancer diagnostic tools to aid decision-making in primary care: mixed-methods systematic reviews and cost-effectiveness analysis. Health Technol Assess 2020; 24:1-332. [PMID: 33252328 PMCID: PMC7768788 DOI: 10.3310/hta24660] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Tools based on diagnostic prediction models are available to help general practitioners diagnose cancer. It is unclear whether or not tools expedite diagnosis or affect patient quality of life and/or survival. OBJECTIVES The objectives were to evaluate the evidence on the validation, clinical effectiveness, cost-effectiveness, and availability and use of cancer diagnostic tools in primary care. METHODS Two systematic reviews were conducted to examine the clinical effectiveness (review 1) and the development, validation and accuracy (review 2) of diagnostic prediction models for aiding general practitioners in cancer diagnosis. Bibliographic searches were conducted on MEDLINE, MEDLINE In-Process, EMBASE, Cochrane Library and Web of Science) in May 2017, with updated searches conducted in November 2018. A decision-analytic model explored the tools' clinical effectiveness and cost-effectiveness in colorectal cancer. The model compared patient outcomes and costs between strategies that included the use of the tools and those that did not, using the NHS perspective. We surveyed 4600 general practitioners in randomly selected UK practices to determine the proportions of general practices and general practitioners with access to, and using, cancer decision support tools. Association between access to these tools and practice-level cancer diagnostic indicators was explored. RESULTS Systematic review 1 - five studies, of different design and quality, reporting on three diagnostic tools, were included. We found no evidence that using the tools was associated with better outcomes. Systematic review 2 - 43 studies were included, reporting on prediction models, in various stages of development, for 14 cancer sites (including multiple cancers). Most studies relate to QCancer® (ClinRisk Ltd, Leeds, UK) and risk assessment tools. DECISION MODEL In the absence of studies reporting their clinical outcomes, QCancer and risk assessment tools were evaluated against faecal immunochemical testing. A linked data approach was used, which translates diagnostic accuracy into time to diagnosis and treatment, and stage at diagnosis. Given the current lack of evidence, the model showed that the cost-effectiveness of diagnostic tools in colorectal cancer relies on demonstrating patient survival benefits. Sensitivity of faecal immunochemical testing and specificity of QCancer and risk assessment tools in a low-risk population were the key uncertain parameters. SURVEY Practitioner- and practice-level response rates were 10.3% (476/4600) and 23.3% (227/975), respectively. Cancer decision support tools were available in 83 out of 227 practices (36.6%, 95% confidence interval 30.3% to 43.1%), and were likely to be used in 38 out of 227 practices (16.7%, 95% confidence interval 12.1% to 22.2%). The mean 2-week-wait referral rate did not differ between practices that do and practices that do not have access to QCancer or risk assessment tools (mean difference of 1.8 referrals per 100,000 referrals, 95% confidence interval -6.7 to 10.3 referrals per 100,000 referrals). LIMITATIONS There is little good-quality evidence on the clinical effectiveness and cost-effectiveness of diagnostic tools. Many diagnostic prediction models are limited by a lack of external validation. There are limited data on current UK practice and clinical outcomes of diagnostic strategies, and there is no evidence on the quality-of-life outcomes of diagnostic results. The survey was limited by low response rates. CONCLUSION The evidence base on the tools is limited. Research on how general practitioners interact with the tools may help to identify barriers to implementation and uptake, and the potential for clinical effectiveness. FUTURE WORK Continued model validation is recommended, especially for risk assessment tools. Assessment of the tools' impact on time to diagnosis and treatment, stage at diagnosis, and health outcomes is also recommended, as is further work to understand how tools are used in general practitioner consultations. STUDY REGISTRATION This study is registered as PROSPERO CRD42017068373 and CRD42017068375. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology programme and will be published in full in Health Technology Assessment; Vol. 24, No. 66. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Antonieta Medina-Lara
- Health Economics Group, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Bogdan Grigore
- Exeter Test Group, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Ruth Lewis
- North Wales Centre for Primary Care Research, Bangor University, Bangor, UK
| | - Jaime Peters
- Exeter Test Group, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Sarah Price
- Primary Care Diagnostics, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Paolo Landa
- Health Economics Group, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Sophie Robinson
- Peninsula Technology Assessment Group, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Richard Neal
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - William Hamilton
- Primary Care Diagnostics, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Anne E Spencer
- Health Economics Group, College of Medicine and Health, University of Exeter Medical School, Exeter, UK
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Lyratzopoulos G, Abel GA. Assessing patients at risk of symptomatic-but-as-yet-undiagnosed cancer in primary care using information from patient records. Br J Cancer 2020; 122:1729-1731. [PMID: 32291393 PMCID: PMC7283330 DOI: 10.1038/s41416-020-0828-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 03/10/2020] [Accepted: 03/13/2020] [Indexed: 12/26/2022] Open
Abstract
Evidence arising from primary care electronic health records can help to assess the risk of symptomatic-but-as-yet-undiagnosed cancer. Existing evidence and methodological innovations in this field of study hold further promise for improving the diagnostic process and achieving earlier diagnosis in cancer patients.
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Affiliation(s)
- Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare and Outcomes (ECHO) Group, Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK.
| | - Gary A Abel
- University of Exeter Medical School, Smeall Building, St. Luke's Campus, Exeter, EX1 2 LU, UK
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Understanding implementation and usefulness of electronic clinical decision support (eCDS) for melanoma in English primary care: a qualitative investigation. BJGP Open 2019; 3:bjgpopen18X101635. [PMID: 31049415 PMCID: PMC6480861 DOI: 10.3399/bjgpopen18x101635] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 11/21/2018] [Indexed: 01/01/2023] Open
Abstract
Background Timely diagnosis of the serious skin cancer melanoma can improve patient outcomes. Clinical guidelines suggest that GPs use checklists, such as the 7-point checklist (7PCL), to assess pigmented lesions. In 2016, the 7PCL was disseminated by EMIS as an electronic clinical decision support (eCDS) tool. Aim To understand GP and patient perspectives on the implementation and usefulness of the eCDS. Design & setting Semi-structured interviews with GPs and patients were undertaken. The interviews took place in four general practices in the south east of England following consultations using the eCDS for suspicious pigmented lesions. Method Data were collected from semi-structured face-to-face interviews with GPs and from telephone interviews with patients. They were recorded and transcribed verbatim. The Consolidated Framework for Implementation Research (CFIR) underpinned the analysis using thematic approaches. Results A total of 14 interviews with GPs and 14 interviews with patients were undertaken. Most GPs reported that, as the eCDS was embedded in the medical record, it was useful, easy to use, time-efficient, and could facilitate patient–GP communication. They were less clear that it could meet policy or patient needs to improve early diagnosis, and some felt that it could lead to unnecessary referrals. Few felt that it had been sufficiently implemented at practice level. More felt confident with their own management of moles, and that the eCDS could be most useful for borderline decision-making. No patients were aware that the eCDS had been used during their consultation. Conclusion Successful implementation of a new tool, such as eCDS for melanoma, requires GPs to perceive its value and understand how it can best be integrated into clinical practice. Disseminating a tool without such explanations is unlikely to promote its adoption into routine practice.
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Lyratzopoulos G. Electronic patient records research to aid diagnostic reasoning for possible cancer in primary care. Br J Gen Pract 2018; 68:408-409. [PMID: 30166371 PMCID: PMC6104858 DOI: 10.3399/bjgp18x698585] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Affiliation(s)
- Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare & Outcomes (ECHO) Group, Department of Behavioural Science and Health, University College London and THIS (The Health Improvement Studies) Institute, University of Cambridge, Cambridge
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Rubin G, Walter F, Emery J, de Wit N. Reimagining the diagnostic pathway for gastrointestinal cancer. Nat Rev Gastroenterol Hepatol 2018; 15:181-188. [PMID: 29410534 DOI: 10.1038/nrgastro.2018.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
A crisis is looming for the diagnosis of gastrointestinal cancers, one grounded only partly in the steady increase in their overall incidence. Public demand for diagnostic tests to be undertaken early and at lower levels of risk is reflected in early diagnosis being a widely held policy objective for reasons of both clinical outcome and patient experience. In the UK, urgent referrals for suspected lower gastrointestinal cancer have increased by 78% in the past 6 years, with parallel increases in endoscopy and imaging activity. Such growth in demand is unsustainable with current models of care. If gastrointestinal cancer diagnosis is to be affordable, the roles of professionals and their interactions with each other will need to be reframed while retaining public confidence in the process. In this Perspective, we consider how the relationship between medical specialists and generalists could be redefined to make better use of the skills of each while delivering optimal clinical outcomes and a good patient experience.
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Affiliation(s)
- Greg Rubin
- Institute of Health and Society, Newcastle University, Sir James Spence Institute, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP, UK
| | - Fiona Walter
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB1 8RN, UK
| | - Jon Emery
- Centre for Cancer Research and Department of General Practice, University of Melbourne, Victoria Comprehensive Cancer Centre, 305 Grattan Street, Melbourne, Victoria 3010, Australia
| | - Niek de Wit
- Julius Center for Health Sciences and Primary Care University Medical Center, Utrecht, Netherlands
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Emery JD, Gray V, Walter FM, Cheetham S, Croager EJ, Slevin T, Saunders C, Threlfall T, Auret K, Nowak AK, Geelhoed E, Bulsara M, Holman CDJ. The Improving Rural Cancer Outcomes Trial: a cluster-randomised controlled trial of a complex intervention to reduce time to diagnosis in rural cancer patients in Western Australia. Br J Cancer 2017; 117:1459-1469. [PMID: 28926528 PMCID: PMC5680459 DOI: 10.1038/bjc.2017.310] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 07/19/2017] [Accepted: 08/14/2017] [Indexed: 11/28/2022] Open
Abstract
Background: Rural Australians have poorer survival for most common cancers, due partially to later diagnosis. Internationally, several initiatives to improve cancer outcomes have focused on earlier presentation to healthcare and timely diagnosis. We aimed to measure the effect of community-based symptom awareness and general practice-based educational interventions on the time to diagnosis in rural patients presenting with breast, prostate, colorectal or lung cancer in Western Australia. Methods: 2 × 2 factorial cluster randomised controlled trial. Community Intervention: cancer symptom awareness campaign tailored for rural Australians. GP intervention: resource card with symptom risk assessment charts and local cancer referral pathways implemented through multiple academic detailing visits. Trial Area A received the community symptom awareness and Trial Area B acted as the community campaign control region. Within both Trial Areas general practices were randomised to the GP intervention or control. Primary outcome: total diagnostic interval (TDI). Results: 1358 people with incident breast, prostate, colorectal or lung cancer were recruited. There were no significant differences in the median or ln mean TDI at either intervention level (community intervention vs control: median TDI 107.5 vs 92 days; ln mean difference 0.08 95% CI −0.06–0.23 P=0.27; GP intervention vs control: median TDI 97 vs 96.5 days; ln mean difference 0.004 95% CI −0.18–0.19 P=0.99). There were no significant differences in the TDI when analysed by factorial design, tumour group or sub-intervals of the TDI. Conclusions: This is the largest trial to test the effect of community campaign or GP interventions on timeliness of cancer diagnosis. We found no effect of either intervention. This may reflect limited dose of the interventions, or the limited duration of follow-up. Alternatively, these interventions do not have a measurable effect on time to cancer diagnosis.
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Affiliation(s)
- Jon D Emery
- Department of General Practice and The Centre for Cancer Research, The University of Melbourne, Melbourne, VIC, Australia.,School of Primary, Aboriginal and Rural Health Care, The University of Western Australia, Crawley, WA, Australia.,The Primary Care Unit, Department of Public Health & Primary Care, University of Cambridge, Cambridge, UK
| | - Victoria Gray
- School of Primary, Aboriginal and Rural Health Care, The University of Western Australia, Crawley, WA, Australia.,School of Population Health, The University of Western Australia, Crawley, WA, Australia.,Education and Research Division, Cancer Council Western Australia, Subiaco, WA, Australia
| | - Fiona M Walter
- School of Primary, Aboriginal and Rural Health Care, The University of Western Australia, Crawley, WA, Australia.,The Primary Care Unit, Department of Public Health & Primary Care, University of Cambridge, Cambridge, UK.,General Practice and Primary Health Care Academic Centre, Melbourne Medical School, The University of Melbourne, Melbourne, VIC, Australia
| | - Shelley Cheetham
- School of Primary, Aboriginal and Rural Health Care, The University of Western Australia, Crawley, WA, Australia.,School of Nursing, Midwifery and Paramedicine, Curtin University, Bentley, WA, Australia
| | - Emma J Croager
- Education & Research Division, Cancer Council Western Australia; School of Psychology and Speech Pathology, Curtin University, Bentley, WA, Australia
| | - Terry Slevin
- Education & Research Division, Cancer Council Western Australia; School of Psychology and Speech Pathology, Curtin University, Bentley, WA, Australia
| | - Christobel Saunders
- School of Surgery, The University of Western Australia, Crawley, WA, Australia
| | - Timothy Threlfall
- Western Australia Cancer Registry, The Department of Health of Western Australia, Perth, WA, Australia
| | - Kirsten Auret
- Rural Clinical School of Western Australia, The University of Western Australia, Albany, WA, Australia
| | - Anna K Nowak
- School of Medicine, The University of Western Australia, Crawley, WA, Australia.,Department of Medical Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Elizabeth Geelhoed
- School of Population Health, The University of Western Australia, Crawley, WA, Australia
| | - Max Bulsara
- Institute for Health Research, University of Notre Dame, Freemantle, WA, Australia
| | - C D'Arcy J Holman
- School of Population Health, The University of Western Australia, Crawley, WA, Australia
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Abstract
Much time, effort and investment goes into the diagnosis of symptomatic cancer, with the expectation that this approach brings clinical benefits. This investment of resources has been particularly noticeable in the UK, which has, for several years, appeared near the bottom of international league tables for cancer survival in economically developed countries. In this Review, we examine expedited diagnosis of cancer from four perspectives. The first relates to the potential for clinical benefits of expedited diagnosis of symptomatic cancer. Limited evidence from clinical trials is available, but the considerable observational evidence suggests benefits can be obtained from this approach. The second perspective considers how expedited diagnosis can be achieved. We concentrate on data from the UK, where extensive awareness campaigns have been conducted, and initiatives in the primary-care setting, including clinical decision support, have all occurred during a period of considerable national policy change. The third section considers the most appropriate patients for cancer investigations, and the possible community settings for identification of such patients; UK national guidance for selection of patients for investigation is discussed. Finally, the health economics of expedited diagnosis are reviewed, although few studies provide definitive evidence on this topic.
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Affiliation(s)
- Willie Hamilton
- University of Exeter, College House, St Luke's Campus, Exeter EX2 4TE, UK
| | - Fiona M Walter
- Department of Public Health &Primary Care, University of Cambridge, Cambridge CB1 8RN, UK
| | - Greg Rubin
- School of Medicine, Pharmacy and Health, Wolfson Building, Queen's Campus, University of Durham, Stockton-on-Tees TS17 6BH, UK
| | - Richard D Neal
- North Wales Centre for Primary Care Research, Bangor University, Gwenfro Unit 5, Wrexham Technology Park, Wrexham LL13 7YP, UK
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