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Abelsen B, Pedersen K, Løyland HI, Aandahl E. Expanding general practice with interprofessional teams: a mixed-methods patient perspective study. BMC Health Serv Res 2023; 23:1327. [PMID: 38037165 PMCID: PMC10691031 DOI: 10.1186/s12913-023-10322-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 11/14/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND Across healthcare systems, current health policies promote interprofessional teamwork. Compared to single-profession general practitioner care, interprofessional primary healthcare teams are expected to possess added capacity to care for an increasingly complex patient population. This study aims to explore patients' experiences when their usual primary healthcare encounter with general practice shifts from single-profession general practitioner care to interprofessional team-based care. METHODS Qualitative and quantitative data were collected through interviews and a survey among Norwegian patients. The interviews included ten patients (five women and five men) aged between 28 and 89, and four next of kin (all women). The qualitative analysis was carried out using thematic analysis and a continuity framework. The survey included 287 respondents, comprising 58 per cent female and 42 per cent male participants, aged 18 years and above. The respondents exhibited multiple diagnoses and often a lengthy history of illness. All participants experienced the transition to interprofessional teamwork at their general practitioner surgery as part of a primary healthcare team pilot. RESULTS The interviewees described team-based care as more fitting and better coordinated, including more time and more learning than with single-profession general practitioner care. Most survey respondents experienced improvements in understanding and mastering their health problems. Multi-morbid elderly interviewees and interviewees with mental illness shared experiences of improved information continuity. They found that important concerns they had raised with the nurse were known to the general practitioner and vice versa. None of the interviewees expressed dissatisfaction with the inclusion of a nurse in their general practitioner relationship. Several interviewees noted improved access to care. The nurse was seen as a strengthening link to the general practitioner. The survey respondents expressed strong agreement with being followed up by a nurse. The interviewees trusted that it was their general practitioner who controlled what happened to them in the general practitioner surgery. CONCLUSION From the patients' perspective, interprofessional teamwork in general practice can strengthen management, informational, and relational continuity. However, a prerequisite seems to be a clear general practitioner presence in the team.
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Affiliation(s)
- Birgit Abelsen
- Department of Community Medicine, National Centre for Rural Medicine, UiT The Arctic University of Norway, Postbox 6050 Langnes, 9037, Tromsø, Norway.
| | - Kine Pedersen
- Oslo Economics, Klingenberggata 7, Oslo, 0161, Norway
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Marzo-Castillejo M, Vela-Vallespín C, Mascort Roca J, Guiriguet Capdevila C, Codern-Bové N, Borras JM. [Health professionals' perspective about women's experiences during the diagnostic process of ovarian cancer in Catalonia: Qualitative study]. Aten Primaria 2023; 55:102619. [PMID: 37043975 PMCID: PMC10119712 DOI: 10.1016/j.aprim.2023.102619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/09/2023] [Accepted: 03/14/2023] [Indexed: 04/14/2023] Open
Abstract
OBJECTIVE To identify missed opportunities in the diagnosis of ovarian cancer (OC) in the public health system of Catalonia, through the analysis of the perceptions of health professionals on the stories's experiences of OC patients. DESIGN Qualitative exploratory-descriptive study, with two focus groups. SETTING Primary Care, November 2017. PARTICIPANTS Thirty-four professionals based on theoretical sampling: 21 family doctors, 8 professionals from sexual and reproductive health centres and 5 hospital gynaecologists. METHODS Participants discussed the different diagnostic pathways for women with OC through the presentation of flowcharts which were developed with three storie's and experiences of OC patients. RESULTS Three themes with various sub-themes were identified as follow: a)lack of cancer diagnostic suspicion (lack of knowledge of symptoms of OC, anamnesis and physical examination overlooked, fragmentation of patient's care and bias and prejudice); b)difficulties in activating the diagnostic process (limited access to tests, unequal accessibility to gynaecology and lack of follow-up); and c)absence of fast-track referral system. CONCLUSIONS The results offer insight into the difficulties of early diagnosis of OC in our setting. We believe that their identification will allow the development of strategies to improve diagnostic accuracy and quality of care for women with OC in our setting.
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Affiliation(s)
- Mercè Marzo-Castillejo
- Unitat Suport a la Recerca Metropolitana Sud, Institut Català de la Salut (ICS); Institut d'Investigació en Atenció Primària Jordi Gol (IDIAPJGol), Hospitalet de Llobregat, Barcelona, España.
| | - Carmen Vela-Vallespín
- CAP Riu Nord i Riu Sud, Institut Català de la Salut (ICS), Santa Coloma de Gramenet, Barcelona; Unitat Suport a la Recerca Metropolitana Nord, Institut d'Investigació en Atenció Primària Jordi Gol (IDIAPJGol), Mataró, Barcelona, España
| | - Juanjo Mascort Roca
- CAP Florida Sud, Institut Català de la Salut (ICS), Hospitalet de Llobregat, Barcelona; Departament de Ciències Clíniques, Facultat de Medicina, Universitat de Barcelona, Barcelona, España
| | - Carolina Guiriguet Capdevila
- Sistema d'Informació dels Serveis d'Atenció Primària (SISAP), Institut Català de la Salut (ICS), Universitat de Barcelona, Barcelona, España
| | - Núria Codern-Bové
- Escola Universitària d'Infermeria i Teràpia Ocupacional de Terrassa, Terrassa, Barcelona; Universitat Autònoma Barcelona. ÀreaQ (Evaluation and Qualitative Research), Barcelona, España
| | - Josep M Borras
- Departamento de Ciencias Clínicas, Universidad de Barcelona; Instituto de Investigación Biomédica de Bellvitge (IDIBELL), Hospitalet de Llobregat, Barcelona, España
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Ebdrup NH, Riis AH, Ramlau-Hansen CH, Bay B, Lyngsø J, Rytter D, Jørgensen MJ, Knudsen UB. Healthcare Use in the Five Years Before a First Infertility Diagnosis: A Danish Register-Based Case–Control Study in the CROSS-TRACKS Cohort. Clin Epidemiol 2022; 14:677-688. [PMID: 35586868 PMCID: PMC9109896 DOI: 10.2147/clep.s360292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 04/25/2022] [Indexed: 11/26/2022] Open
Abstract
Purpose Infertility may affect somatic and mental health later in life. Nevertheless, health status before diagnosed infertility is sparsely studied in women. We aimed to describe healthcare use in primary and secondary care before a first infertility diagnosis and compare use between cases and controls. Materials and Methods The case–control study was based on register data and used incidence density sampling. From the CROSS-TRACKS Cohort, we included women residing in the Horsens area in Denmark in 2012–2018 (n = 54,175). Eligible women were aged 18–40 years, nulliparous, and living in heterosexual relationships. Cases were women with a first infertility diagnosis in the Danish National Patient Registry (index date). Five controls were matched on age, birth year, and calendar time. Through linkage to Danish national health registries, we identified general practitioner (GP) attendance, paraclinical examinations, hospital contacts, diagnoses, and redeemed prescriptions. Healthcare use from one year to five years before index date was compared with conditional logistic regression. Results We identified 711 cases and 3555 controls. At one year before index date, cases consulted their GP (odds ratio (OR) = 5.2, 95% confidence interval (CI): 3.2, 8.3) and visited hospital (OR = 1.2, 95% CI: 1.0, 1.4) and redeemed prescriptions (OR = 2.3 95% CI: 1.9, 2.7) more often compared to controls. Cases more often had blood and hemoglobin tests performed, redeemed more drugs related to genitourinary and hormonal diseases, and were more often diagnosed with endocrine and genitourinary diseases in the year before a first infertility diagnosis compared to controls. Cases and controls had comparable healthcare use from five years to one year before a first infertility diagnosis. Conclusion Cases and controls had similar healthcare use from five years to one year before a first infertility diagnosis. However, cases had a higher healthcare use in the year preceding a first infertility diagnosis compared to controls.
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Affiliation(s)
- Ninna Hinchely Ebdrup
- Department of Obstetrics and Gynecology, Fertility Clinic, Horsens Regional Hospital, Horsens, Denmark
- Department of Public Health, Aarhus University, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Correspondence: Ninna Hinchely Ebdrup, Department of Obstetrics and Gynecology, Fertility Clinic, Horsens Regional Hospital, Sundvej 30, Horsens, 8700, Denmark, Tel +45 28 47 21 11, Email
| | - Anders Hammerich Riis
- Department of Research, Regional Hospital Horsens, Horsens, Denmark
- Enversion A/S, Aarhus, Denmark
| | | | - Bjørn Bay
- Department of Obstetrics and Gynecology, Fertility Clinic, Horsens Regional Hospital, Horsens, Denmark
- Maigaard Fertility Clinic, Aarhus, Denmark
| | - Julie Lyngsø
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - Dorte Rytter
- Department of Public Health, Aarhus University, Aarhus, Denmark
| | | | - Ulla Breth Knudsen
- Department of Obstetrics and Gynecology, Fertility Clinic, Horsens Regional Hospital, Horsens, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Hultstrand C, Coe AB, Lilja M, Hajdarevic S. Shifting between roles of a customer and a seller - patients' experiences of the encounter with primary care physicians when suspicions of cancer exist. Int J Qual Stud Health Well-being 2021; 16:2001894. [PMID: 34784840 PMCID: PMC8604522 DOI: 10.1080/17482631.2021.2001894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
PURPOSE Sweden has tried to speed up the process of early cancer detection by standardization of care. This increased focus on early cancer detection provides people with a conflicting norm regarding the importance of recognizing possible cancer symptoms and the responsibility of not delaying seeking care.Based on existing norms about patients' responsibility and care seeking, this study explores how patients experience encounters with primary care physicians when they seek care for symptoms potentially indicating cancer. METHODS Thirteen semi-structured interviews were conducted with patients receiving care for symptoms indicative of cancer in one county in northern Sweden. Data was analysed with thematic analysis. RESULTS The common notion of describing patients as customers in a healthcare context does not sufficiently capture all aspects of what counts as being a person seeking care. Instead, people interacting with primary care face a twofold role in where they are required to take the role not only of customer but also of seller. Consequently, people shift between these two roles in order to legitimize their care seeking. CONCLUSIONS Standardization oversimplifies the complexity underlying patients' experience of care seeking and interaction with healthcare. Hence, healthcare must acknowledge the individual person within a standardized system.
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Affiliation(s)
- Cecilia Hultstrand
- Department of Nursing, Umeå University, Umeå, Sweden.,Department of Public Health and Clinical Medicine, Family Medicine, Umeå University, Umeå, Sweden
| | | | - Mikael Lilja
- Department of Public Health and Clinical Medicine, Unit of Research, Education, and Development, Östersund Hospital, Umeå University, Umeå, Sweden
| | - Senada Hajdarevic
- Department of Nursing, Umeå University, Umeå, Sweden.,Department of Public Health and Clinical Medicine, Family Medicine, Umeå University, Umeå, Sweden
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Golla V, Kaye DR. The Impact of Health Delivery Integration on Cancer Outcomes. Surg Oncol Clin N Am 2021; 31:91-108. [PMID: 34776068 DOI: 10.1016/j.soc.2021.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Although integrated health care has largely been associated with increases in prices and static or decreased quality across many disease states, it has shown some successes in improving cancer care. However, its impact is largely equivocal, making consensus statements difficult. Critically, integration does not necessarily translate to clinical coordination, which might be the true driver behind the success of integrated health care delivery. Moving forward, it is important to establish payment models that support clinical care coordination. Shifting from a fragmented health system to a coordinated one may improve evidence-based cancer care, outcomes, and value for patients.
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Affiliation(s)
- Vishnukamal Golla
- Duke National Clinician Scholars Program, 200 Morris St, Suite 3400, DUMC Box 104427, Durham, NC 27701, USA; Department of Surgery, Division of Urology, Duke University Medical Center, Durham, NC, USA; Duke Cancer Institute, Durham, NC, USA; Duke-Margolis Policy Center; Durham Veterans Affairs Health Care System, Durham, NC, USA.
| | - Deborah R Kaye
- Department of Surgery, Division of Urology, Duke University Medical Center, Durham, NC, USA; Duke Cancer Institute, Durham, NC, USA; Duke-Margolis Policy Center
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Broholm-Jørgensen M, Langkilde SM, Tjørnhøj-Thomsen T, Pedersen PV. 'Motivational work': a qualitative study of preventive health dialogues in general practice. BMC FAMILY PRACTICE 2020; 21:185. [PMID: 32900366 PMCID: PMC7487907 DOI: 10.1186/s12875-020-01249-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 08/17/2020] [Indexed: 11/10/2022]
Abstract
Background The aim of this article is to explore preventive health dialogues in general practice in the context of a pilot study of a Danish primary preventive intervention ‘TOF’ (a Danish acronym for ‘Early Detection and Prevention’) carried out in 2016. The intervention consisted of 1) a stratification of patients into one of four groups, 2) a digital support system for both general practitioners and patients, 3) an individual digital health profile for each patient, and 4) targeted preventive services in either general practice or a municipal health center. Methods The empirical material in this study was obtained through 10 observations of preventive health dialogues conducted in general practices and 18 semi-structured interviews with patients and general practitioners. We used the concept of ‘motivational work’ as an analytical lens for understanding preventive health dialogues in general practice from the perspectives of both general practitioners and patients. Results While the health dialogues in TOF sought to reveal patients’ motivations, understandings, and priorities related to health behavior, we find that the dialogues were treatment-oriented and structured around biomedical facts, numeric standards, and risk factor guidance. Overall, we find that numeric standards and quantification of motivation lessens the dialogue and interaction between General Practitioner and patient and that contextual factors relating to the intervention framework, such as a digital support system, the general practitioners’ perceptions of their professional position as well as the patients’ understanding of prevention —in an interplay—diminished the motivational work carried out in the health dialogues. Conclusion The findings show that the influence of different kinds of context adds to the complexity of prevention in the clinical encounter which help to explain why motivational work is difficult in general practice.
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Affiliation(s)
- Marie Broholm-Jørgensen
- National Institute of Public Health, Research Program on Health and Social Conditions, University of Southern Denmark, Studiestræde 6, 1455, Copenhagen K, Denmark.
| | - Siff Monrad Langkilde
- The Danish Centre for Urban Regeneration and Community Development, Hvidovre, Denmark
| | - Tine Tjørnhøj-Thomsen
- National Institute of Public Health, Research Program on Health and Social Conditions, University of Southern Denmark, Studiestræde 6, 1455, Copenhagen K, Denmark
| | - Pia Vivian Pedersen
- National Institute of Public Health, Research Program on Health and Social Conditions, University of Southern Denmark, Studiestræde 6, 1455, Copenhagen K, Denmark
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Baker R, Freeman GK, Haggerty JL, Bankart MJ, Nockels KH. Primary medical care continuity and patient mortality: a systematic review. Br J Gen Pract 2020; 70:e600-e611. [PMID: 32784220 PMCID: PMC7425204 DOI: 10.3399/bjgp20x712289] [Citation(s) in RCA: 112] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 02/20/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND A 2018 review into continuity of care with doctors in primary and secondary care concluded that mortality rates are lower with higher continuity of care. AIM This association was studied further to elucidate its strength and how causative mechanisms may work, specifically in the field of primary medical care. DESIGN AND SETTING Systematic review of studies published in English or French from database and source inception to July 2019. METHOD Original empirical quantitative studies of any design were included, from MEDLINE, Embase, PsycINFO, OpenGrey, and the library catalogue of the New York Academy of Medicine for unpublished studies. Selected studies included patients who were seen wholly or mostly in primary care settings, and quantifiable measures of continuity and mortality. RESULTS Thirteen quantitative studies were identified that included either cross-sectional or retrospective cohorts with variable periods of follow-up. Twelve of these measured the effect on all-cause mortality; a statistically significant protective effect of greater care continuity was found in nine, absent in two, and in one effects ranged from increased to decreased mortality depending on the continuity measure. The remaining study found a protective association for coronary heart disease mortality. Improved clinical responsibility, physician knowledge, and patient trust were suggested as causative mechanisms, although these were not investigated. CONCLUSION This review adds reduced mortality to the demonstrated benefits of there being better continuity in primary care for patients. Some patients may benefit more than others. Further studies should seek to elucidate mechanisms and those patients who are likely to benefit most. Despite mounting evidence of its broad benefit to patients, relationship continuity in primary care is in decline - decisive action is required from policymakers and practitioners to counter this.
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Affiliation(s)
- Richard Baker
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - George K Freeman
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | | | - M John Bankart
- Department of Health Sciences, University of Leicester, Leicester, UK
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Pereira da Veiga CR, Pereira da Veiga C, Drummond-Lage AP, Alves Wainstein AJ, Cristina de Melo A. Journey of the Patient With Melanoma: Understanding Resource Use and Bridging the Gap Between Dermatologist, Surgeon, and Oncologist in Different Health Care Systems. J Glob Oncol 2020; 5:1-8. [PMID: 31283414 PMCID: PMC6690632 DOI: 10.1200/jgo.19.00022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE New scientific evidence has led to modifications in the clinical practice of handling melanoma. In health care systems, there is currently a wide variety of clinical procedures to treat cancer, and the various routes have different effects on the survival of patients with cancer. Thus, this article aimed to evaluate the journey of patients with melanoma in the public and private health care systems in Brazil from the viewpoint of different medical professionals involved in the diagnosis and treatment of the disease. The study also considers the resources used for the complete delivery cycle of health care at different stages of the evolution of melanoma. METHODS We conducted a behavioral study by applying a questionnaire to a group of medical professionals. A nonprobabilistic sampling method for convenience was used, justified by the heterogeneous national incidence and the limited availability of medical professionals who diagnose and treat melanoma. RESULTS The questionnaire was answered by 138 doctors, including doctors from the Brazilian states with the highest concentration of medical specialists and regions with a higher melanoma incidence. The results of this study have the potential to enrich our understanding of the reality of Brazilian health care systems and, at the same time, allow us to discuss the multiple ways in which professionals from diverse specialist fields understand and explain decision making in health care. CONCLUSION Health care decision making is complex and, among other factors, depends on the diversity of available health resources and the knowledge of which treatments provide the greatest benefit to patients and greatest value to the system as a whole. This work can inform debates and reflection that are applicable not only in Brazil, but also in various other countries with similar realities.
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Affiliation(s)
| | | | | | | | - Andreia Cristina de Melo
- Brazilian National Cancer Institute, Hospital do Câncer II, Rio de Janeiro, Rio de Janeiro, Brazil
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Adoyo MA. Landscape analysis of healthcare policy: the instrumental role of governance in HIV/AIDS services integration framework. Pan Afr Med J 2020; 36:27. [PMID: 32774604 PMCID: PMC7388594 DOI: 10.11604/pamj.2020.36.27.22795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 04/18/2020] [Indexed: 11/25/2022] Open
Abstract
Introduction Low and middle-income countries HIV/AIDS interventions are yet to achieve the desired levels of health outcome due to lack of effectiveness and efficiency in programming, a challenge associated with resource limitations, fragmented services, complexities in population and disease characteristics including political landscape. The objective of this study was to establish the instrumental role of governance in the implementation of HIV/AIDS services integration policy framework, with focus on organization structure, participation in decision making, collaboration, stakeholder engagement, political commitment as study variables. Methods Using a mixed method design, a total number of 30 health workers, 5 county AIDS services coordinators (CASCOs), 8 sub-CASCOs and 3 representatives of inter coordinating committee were interviewed in compliance with ethical protocols. Multi-stage sampling techniques was used to select counties in Kenya, health institutions and respondents. Quantitative and qualitative data was generated by administering semi structured questionnaire and key informant interview guide. Results Generated from excel sheet and NVivo software indicate that organization structures existed and clarity and ease of work varied across the different levels of care. Collaboration efforts, however varied, created synergy in policy framework implementation and political commitment complemented the various leadership actions for successful implementation of integration policy framework. Conclusion Governance role is indispensable in the implementation of health policy framework. Policy makers need accurate epidemiological and demographic information to implement contextualized policy framework necessary for sustained improvement in health outcomes.
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Non-attendance at urgent referral appointments for suspected cancer: a qualitative study to gain understanding from patients and GPs. Br J Gen Pract 2019; 69:e850-e859. [PMID: 31748378 PMCID: PMC6863680 DOI: 10.3399/bjgp19x706625] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 08/20/2019] [Indexed: 11/05/2022] Open
Abstract
Background The 2-week-wait urgent referral policy in the UK has sought to improve cancer outcomes by accelerating diagnosis and treatment. However, around 5–7% of symptomatic referred patients cancel or do not attend their hospital appointment. While subsequent cancer diagnosis was less likely in non-attenders, those with a diagnosis had worse early mortality outcomes. Aim To examine how interpersonal, communication, social, and organisational factors influence a patient’s non-attendance. Design and setting Qualitative study in GP practices in one Northern English city. Method In-depth, individual interviews were undertaken face-to-face or by telephone between December 2016 and May 2018, followed by thematic framework analysis. Results In this study 21 GPs, and 24 patients who did not attend or had cancelled their appointment were interviewed, deriving a range of potential explanations for non-attendance, including: system flaws; GP difficulties with booking appointments; patient difficulties with navigating the appointment system, particularly older patients and those from more deprived areas; patients leading ‘difficult lives’; and patients’ expectations of the referral, informed by their beliefs, circumstances, priorities, and the perceived prognosis. GPs recognised the importance of communication with the patient, particularly the need to tailor communication to perceived patient understanding and anxiety. GPs and practices varied in their responses to patient non-attendance, influenced by time pressures and perceptions of patient responsibility. Conclusion Failure to be seen within 2 weeks of urgent referral resulted from a number of patient and provider factors. The urgent referral process in general practice and cancer services should accommodate patient perceptions and responses, facilitate referral and attendance, and enable responses to patient non-attendance.
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Jefferson L, Atkin K, Sheridan R, Oliver S, Macleod U, Hall G, Forbes S, Green T, Allgar V, Knapp P. Non-attendance at urgent referral appointments for suspected cancer: a qualitative study to gain understanding from patients and GPs. Br J Gen Pract 2019:bjgp1919X706625. [PMID: 31740457 DOI: 10.3399/bjgp1919x706625] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 08/20/2019] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND The 2-week-wait urgent referral policy in the UK has sought to improve cancer outcomes by accelerating diagnosis and treatment. However, around 5-7% of symptomatic referred patients cancel or do not attend their hospital appointment. While subsequent cancer diagnosis was less likely in non-attenders, those with a diagnosis had worse early mortality outcomes. AIM To examine how interpersonal, communication, social, and organisational factors influence a patient's non-attendance. DESIGN AND SETTING Qualitative study in GP practices in one Northern English city. METHOD In-depth, individual interviews were undertaken face-to-face or by telephone between December 2016 and May 2018, followed by thematic framework analysis. RESULTS In this study 21 GPs, and 24 patients who did not attend or had cancelled their appointment were interviewed, deriving a range of potential explanations for non-attendance, including: system flaws; GP difficulties with booking appointments; patient difficulties with navigating the appointment system, particularly older patients and those from more deprived areas; patients leading 'difficult lives'; and patients' expectations of the referral, informed by their beliefs, circumstances, priorities, and the perceived prognosis. GPs recognised the importance of communication with the patient, particularly the need to tailor communication to perceived patient understanding and anxiety. GPs and practices varied in their responses to patient non-attendance, influenced by time pressures and perceptions of patient responsibility. CONCLUSION Failure to be seen within 2 weeks of urgent referral resulted from a number of patient and provider factors. The urgent referral process in general practice and cancer services should accommodate patient perceptions and responses, facilitate referral and attendance, and enable responses to patient non-attendance.
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Affiliation(s)
| | | | | | - Steven Oliver
- University of York, Hull York Medical School, Hull and York
| | - Una Macleod
- University of Hull, Hull York Medical School, Hull and York
| | - Geoff Hall
- University of Leeds and Leeds Teaching Hospitals NHS Trust, Leeds
| | | | - Trish Green
- University of Hull, Hull York Medical School, Hull and York
| | | | - Peter Knapp
- University of York, Hull York Medical School, Hull and York
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Rudebeck CE. Relationship based care - how general practice developed and why it is undermined within contemporary healthcare systems. Scand J Prim Health Care 2019; 37:335-344. [PMID: 31299870 PMCID: PMC6713111 DOI: 10.1080/02813432.2019.1639909] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Objective: Investigating the state of generalism in medicine from the outlook of general practice. Line of argument: General practice developed when its pioneers, in continuing relationships, learnt to know their patients through the variety of medical situations. From the 50s, there is an increasing literature on the virtues and challenges of relationship based general practice, and register-based research indicate its benefits. Generalist perspectives and person-centeredness are implemented in specialised care and medical education but need to be complemented by an input from relationship based general practice. The politically defined aim of primary care is not to balance the draw-backs of specialisation, but to provide medicine at the primary care level. In Sweden, and increasingly even in traditional strongholds of general practice, team-based primary care is thought to respond to increasing demands, filtering out non- and minor disease through triage, practicing task distribution, and moving the GP to a secondary level working with the 'really sick', in all a decline in direct contact between patient and GP. Conclusions: When this happens, clinical medicine as a whole becomes drained of the practice of its human dimension. The lack of absolute proof of medical benefits cannot justify a disregard of the value of mutual knowledge and trust in the relationship, but still, in several countries, relationshipbased general practice will be hard to achieve for GPs planning their career. If the political winds should change, a sustaining profession of GPs preserving their relational ethos inside the team model, may be prepared to reform primary care. KEY POINTS Proclaiming both biomedical breadth and the trustful relationship between doctor and patient, as a specialty, general practice embodies medical generalism. A direct input from the patient's personal GP is necessary to make specialised care become more comprehensive and individualised. In reality, the team, practicing triage and task distribution, is increasingly replacing the doctor-patient relationship as working mode in primary care When the disease rather than the doctor-patient relationship, becomes the organising principle of primary care, medicine as a whole will be drained of the practice of its human dimension.
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Affiliation(s)
- Carl Edvard Rudebeck
- Research Unit, Kalmar County Council, Kalmar, Sweden
- CONTACT Carl Edvard Rudebeck Djurgårdsgatan 7, SE-59341 Västervik, Sweden
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Primary health care factors associated with late presentation of cancer in Saudi Arabia. JOURNAL OF RADIOTHERAPY IN PRACTICE 2019. [DOI: 10.1017/s1460396919000232] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractIntroduction:Delays in the diagnosis of cancer were found to be a worldwide matter, and the early cancer detection has been targeted as a way to improve survival. Quantitative studies from Saudi Arabia reported a high number of cancer cases presenting at cancer centres for the first time with more advanced stages of the disease progression compared to Western countries without exploring the reasons for this phenomenon. Worldwide research identified several factors that contribute to delay in the diagnosis and treatment of cancer which were attributed to both patient and healthcare system. However, it was argued that variation in the operation of health systems and the socio-cultural context across countries makes it difficult to generalise findings beyond individuals’ countries. This necessitates country specific research to investigate why patients in Saudi Arabia present to cancer centres with late/advanced stages of their diseases.Research aim and objectives:The aim of this study is to identify and explore the factors that contribute to late-stage presentation of common cancers in Saudi Arabia. The main objective of this study is to understand the help seeking journey taken by patients with cancer from the time they discovered or felt their symptoms until the time they have their treatment initiated.Methods:Qualitative interviewing was used to collect data from 20 patients and 15 health professionals. The interviews were transcribed and then were subjected to the thematic analysis using a framework approach developed by Ritchie and Spencer (1994).Results:While some findings support what previous studies found as contributing factors responsible for delayed presentation of common cancers, this study identified several factors, which are believed to be country-specific. The ‘role of General Practitioner (GP)’, ‘challenges facing GPs’ and ‘ambiguity of the referral system’ were found to be factors that contribute to delay in the diagnosis and treatment of cancer in Saudi Arabia.Conclusion:This research identified several factors that need to be investigated in the future using quantitative methods. There is a need to investigate the extent of using alternative medicine and its possible association with late presentation of cancer.
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Association between GPs' suspicion of cancer and patients' usual consultation pattern in primary care: a cross-sectional study. Br J Gen Pract 2019; 69:e80-e87. [PMID: 30642908 DOI: 10.3399/bjgp19x700769] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 07/13/2018] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Patients who rarely consult a GP in the 19-36 months before a cancer diagnosis have more advanced cancer at diagnosis and a worse prognosis. To ensure more timely diagnosis of cancer, the GP should suspect cancer as early as possible. AIM To investigate the GP's suspicion of cancer according to the patient with cancer's usual consultation pattern in general practice. DESIGN AND SETTING A cross-sectional study based on survey data from general practice of 3985 Danish patients diagnosed with cancer from May 2010 to August 2010, and linked to national register data. METHOD Using logistic regression analysis with restricted cubic splines, the odds ratio (OR) of the GP to suspect cancer as a function of the patient's number of face-to-face consultations with the GP in the 19-36 months before a cancer diagnosis was estimated. RESULTS GPs' cancer suspicion decreased with higher usual consultation frequency in general practice. A significant decreasing trend in ORs for cancer suspicion was seen across usual consultation categories overall (P<0.001) and for each sex (males: P<0.05; females: P<0.05). GPs' cancer suspicion was lower in patients aged <55 years in both rare and frequent attenders compared with average attenders. CONCLUSION GPs suspect cancer more often in rare attenders ≥55 years. GPs' cancer suspicion was lower in younger patients (<55 years), in both rare and frequent attenders. GPs should be aware of possible missed opportunities for cancer diagnosis in young attenders and use safety netting to reduce the risk of missing a cancer diagnosis.
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Ziebland S, Rasmussen B, MacArtney J, Hajdarevic S, Sand Andersen R. How wide is the Goldilocks Zone in your health system? J Health Serv Res Policy 2019; 24:52-56. [PMID: 30060724 DOI: 10.1177/1355819618790985] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
In astrophysics, the 'Goldilocks Zone' describes the circumstellar habitable zone, in which planets, sufficiently similar to Earth, could support human life. The children's story of Goldilocks and the Three Bears, one of the most popular fairy tales in the English language, uses this metaphor to describe conditions for life that are neither too hot nor too cold and neither too close to the sun nor too far from its warmth. We propose that the 'Goldilocks Zone' also offers an apt metaphor for the struggle that people face when deciding if and when to consult a health care provider with a possible health problem. Drawing on decades of research in Denmark, England and Sweden on people's accounts of their experiences of accessing health care, this essay considers the ambivalence of health care seeking that individuals face in identifying when it is 'just right' to consult a general practitioner and the steps that health systems and individual clinicians might take to widen the zone.
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Affiliation(s)
- Sue Ziebland
- 1 Professor of Medical Sociology, Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Birgit Rasmussen
- 2 Professor, Department of Health Sciences, Lund University, Sweden
| | - John MacArtney
- 3 Senior Qualitative Researcher, Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | | | - Rikke Sand Andersen
- 5 Associate Professor, Research Centre for Cancer Diagnosis in Primary Care, Aarhus Universitet, Denmark
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Silina V, Kalda R. Challenges for clinical practice and research in family medicine in reducing the risk of chronic diseases. Notes on the EGPRN Spring Conference 2017 in Riga. Eur J Gen Pract 2018; 24:112-117. [PMID: 29393709 PMCID: PMC5804728 DOI: 10.1080/13814788.2018.1429594] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 12/30/2017] [Accepted: 01/12/2018] [Indexed: 11/15/2022] Open
Abstract
Chronic diseases in most cases belong to the category of non-communicable diseases (NCDs), which are the main cause of mortality globally. Cardiovascular diseases, diabetes, chronic obstructive pulmonary disease and cancer are the four NCDs responsible for 82% of NCD deaths. Prevention of NCDs implies health promotion activities that encourage healthy lifestyle and limit the initial onset of chronic diseases. Prevention also includes early detection activities, such as screening at-risk populations, as well as strategies for appropriate management of existing diseases and related complications. Early intervention, reducing morbidity and mortality rates could be an appealing idea for patients, physicians and governmental institutions but could also cause harm. Healthcare is undergoing profound changes, and the role of technology in diagnostics and management of chronic diseases in primary healthcare (PHC) is increasing remarkably. However, studies show that the standards of care for chronic diseases and preventive care are met by less than 50%. We still lack clear standards for patients with multiple chronic diseases. The applicability of a single evidence-based guideline to multimorbid patients is limited and can be problematic. Well-designed PHC studies focusing on the impact of medical interventions on morbidity, mortality and quality of life in the fields of early diagnosis, early treatment and multimorbidity are still needed.
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Affiliation(s)
- Vija Silina
- Department of Family Medicine, Riga Stradins UniversityRigaLatvia
| | - Ruth Kalda
- Institute of Family Medicine and Public Health, University of TartuTartuEstonia
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Contatore OA, Malfitano APS, Barros NFD. CUIDADOS EM SAÚDE: SOCIABILIDADES CUIDADORAS E SUBJETIVIDADES EMANCIPADORAS. PSICOLOGIA & SOCIEDADE 2018. [DOI: 10.1590/1807-0310/2018v30177179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
Abstract
Resumo Embora predominem as aplicações técnico/tecnológicas na assistência à saúde como parâmetro e qualificação das ações de cuidado cresce a valorização de uma atenção que abranja mais amplamente a vida dos sujeitos, frente ao reconhecimento que o apoio social e a preocupação afetiva são constitutivos e fundamentais para a efetivação do cuidado. Objetivou-se apreender as reflexões sobre o cuidado à saúde enfocando os aspectos de sociabilidade e de subjetividade. Para tanto, realizou-se uma revisão sistemática de literatura, entre 2003 e 2013, em dez bases de dados. De 262 artigos identificados, foram selecionados 36 que enfocam a subjetividade nas ações de cuidado. Há um questionamento acerca do potencial de cuidado biomédico e suas limitações para atender às múltiplas demandas implícitas nos processos de saúde e doença. Conclui-se que a subjetividade e, em seu interior, a sociabilidade, são partes intrínsecas das ações de cuidado.
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Malmström M, Rasmussen BH, Bernhardson BM, Hajdarevic S, Eriksson LE, Andersen RS, MacArtney JI. It is important that the process goes quickly, isn't it?" A qualitative multi-country study of colorectal or lung cancer patients' narratives of the timeliness of diagnosis and quality of care. Eur J Oncol Nurs 2018; 34:82-88. [PMID: 29784144 DOI: 10.1016/j.ejon.2018.04.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 03/21/2018] [Accepted: 04/06/2018] [Indexed: 12/21/2022]
Abstract
PURPOSE The emphasis on early diagnosis to improve cancer survival has been a key factor in the development of cancer pathways across Europe. The aim of this analysis was to explore how the emphasis on early diagnosis and timely treatment is reflected in patient's accounts of care, from the first suspicion of colorectal or lung cancer to their treatment in Denmark, England and Sweden. METHOD We recruited 155 patients in Denmark, England and Sweden who were within six months of being diagnosed with lung or colorectal cancer. Data were collected via semi-structured narrative interviews and analysed using a thematic approach. RESULTS Participants' accounts of quality of care were closely related to how quickly (or not) diagnosis, treatment and/or healthcare processes went. Kinetic metaphors as a description of care (such as treadmill) could be interpreted positively as participants were willing to forgo some degree of control and accept disruption to their lives to ensure more timely care. Drawing on wider cultural expectations of the benefits of diagnosing and treating cancer quickly, some participants were concerned that the waiting times between interventions might allow time for the cancer to grow. CONCLUSIONS Initiatives emphasising the timeliness of diagnosis and treatment are reflected in the ways some patients experience their care. However, these accounts were open to further contextualisation about what speed of healthcare processes meant for evaluating the quality of their care. Healthcare professionals could therefore be an important patient resource in providing reassurance and support about the timeliness of diagnosis or treatment.
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Affiliation(s)
- Marlene Malmström
- The Institute for Palliative Care, Lund University and Region Skåne, Sweden; Lund University, Department of Health Sciences, Lund, Sweden.
| | - Birgit H Rasmussen
- The Institute for Palliative Care, Lund University and Region Skåne, Sweden; Lund University, Department of Health Sciences, Lund, Sweden
| | - Britt-Marie Bernhardson
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE-171 77 Stockholm, Sweden
| | | | - Lars E Eriksson
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE-171 77 Stockholm, Sweden; School of Health Sciences, City, University of London, London EC1V 0HB, United Kingdom; Department of Infectious Diseases, Karolinska University Hospital, SE-141 86 Stockholm, Sweden
| | - Rikke Sand Andersen
- Research Centre for Cancer Diagnosis in Primary Care, Research Unit of General Practice & Department of Anthropology, Aarhus University, Denmark
| | - John I MacArtney
- Health Experiences Research Group, Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
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Maringe C, Pashayan N, Rubio FJ, Ploubidis G, Duffy SW, Rachet B, Raine R. Trends in lung cancer emergency presentation in England, 2006-2013: is there a pattern by general practice? BMC Cancer 2018; 18:615. [PMID: 29855264 PMCID: PMC5984417 DOI: 10.1186/s12885-018-4476-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 05/02/2018] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Emergency presentations (EP) represent over a third of all lung cancer admissions in England. Such presentations usually reflect late stage disease and are associated with poor survival. General practitioners (GPs) act as gate-keepers to secondary care and so we sought to understand the association between GP practice characteristics and lung cancer EP. METHODS Data on general practice characteristics were extracted for all practices in England from the Quality Outcomes Framework, the Health and Social Care Information Centre, the GP Patient Survey, the Cancer Commissioning Toolkit and the area deprivation score for each practice. After linking these data to lung cancer patient registrations in 2006-2013, we explored trends in three types of EP, patient-led, GP-led and 'other', by general practice characteristics and by socio-demographic characteristics of patients. RESULTS Overall proportions of lung cancer EP decreased from 37.9% in 2006 to 34.3% in 2013. Proportions of GP-led EP nearly halved during this period, from 28.3 to 16.3%, whilst patient-led emergency presentations rose from 62.1 to 66.7%. When focusing on practice-specific levels of EP, 14% of general practices had higher than expected proportions of EP at least once in 2006-13, but there was no evidence of clustering of patients within practice, meaning that none of the practice characteristics examined explained differing proportions of EP by practice. CONCLUSION We found that the high proportion of lung cancer EP is not the result of a few practices with very abnormal patterns of EP, but of a large number of practices susceptible to reaching high proportions of EP. This suggests a system-wide issue, rather than problems with specific practices. High proportions of lung cancer EP are mainly the result of patient-initiated attendances in A&E. Our results demonstrate that interventions to encourage patients not to bypass primary care must be system wide rather than targeted at specific practices.
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Affiliation(s)
- Camille Maringe
- Cancer Survival Group, London School of Hygiene and Tropical Medicine, Keppel street, London, WC1E 7HT UK
| | - Nora Pashayan
- University College London, Department of Applied Health Research, London, UK
| | - Francisco Javier Rubio
- Cancer Survival Group, London School of Hygiene and Tropical Medicine, Keppel street, London, WC1E 7HT UK
| | - George Ploubidis
- Centre for Longitudinal Studies, Department of Social Science, UCL - Institute of Education, University College London, London, UK
| | - Stephen W. Duffy
- Queen Mary University of London, Wolfson Institute of Preventive Medicine, Centre for Cancer Prevention, London, UK
| | - Bernard Rachet
- Cancer Survival Group, London School of Hygiene and Tropical Medicine, Keppel street, London, WC1E 7HT UK
| | - Rosalind Raine
- University College London, Department of Applied Health Research, London, UK
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Pedersen AF, Forbes L, Brain K, Hvidberg L, Wulff CN, Lagerlund M, Hajdarevic S, Quaife SL, Vedsted P. Negative cancer beliefs, recognition of cancer symptoms and anticipated time to help-seeking: an international cancer benchmarking partnership (ICBP) study. BMC Cancer 2018; 18:363. [PMID: 29609534 PMCID: PMC5879768 DOI: 10.1186/s12885-018-4287-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 03/21/2018] [Indexed: 12/03/2022] Open
Abstract
Background Understanding what influences people to seek help can inform interventions to promote earlier diagnosis of cancer, and ultimately better cancer survival. We aimed to examine relationships between negative cancer beliefs, recognition of cancer symptoms and how long people think they would take to go to the doctor with possible cancer symptoms (anticipated patient intervals). Methods Telephone interviews of 20,814 individuals (50+) in the United Kingdom, Australia, Canada, Denmark, Norway and Sweden were carried out using the Awareness and Beliefs about Cancer Measure (ABC). ABC included items on cancer beliefs, recognition of cancer symptoms and anticipated time to help-seeking for cough and rectal bleeding. The anticipated time to help-seeking was dichotomised as over one month for persistent cough and over one week for rectal bleeding. Results Not recognising persistent cough/hoarseness and unexplained bleeding as cancer symptoms increased the likelihood of a longer anticipated patient interval for persistent cough (OR = 1.66; 95%CI = 1.47–1.87) and rectal bleeding (OR = 1.90; 95%CI = 1.58–2.30), respectively. Endorsing four or more out of six negative beliefs about cancer increased the likelihood of longer anticipated patient intervals for persistent cough and rectal bleeding (OR = 2.18; 95%CI = 1.71–2.78 and OR = 1.97; 95%CI = 1.51–2.57). Many negative beliefs about cancer moderated the relationship between not recognising unexplained bleeding as a cancer symptom and longer anticipated patient interval for rectal bleeding (p = 0.005). Conclusions Intervention studies should address both negative beliefs about cancer and knowledge of symptoms to optimise the effect. Electronic supplementary material The online version of this article (10.1186/s12885-018-4287-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anette Fischer Pedersen
- Research Unit for General Practice and Research Centre for Cancer Diagnosis in Primary Care (CaP), Aarhus University, Bartholins Allé 2, 8000, Aarhus C, Denmark.
| | - Lindsay Forbes
- King's College London Promoting Early Cancer Presentation Group, Capital House, 42 Weston Street, London, SE1 3QD, UK
| | - Kate Brain
- Cochrane Institute of Primary Care and Public Health, Neuadd Meirionydd, School of Medicine, Cardiff University, Heath Park, Cardiff, CF14 4YS, UK
| | - Line Hvidberg
- Research Unit for General Practice and Research Centre for Cancer Diagnosis in Primary Care (CaP), Aarhus University, Bartholins Allé 2, 8000, Aarhus C, Denmark
| | - Christian Nielsen Wulff
- Department of Oncology, Aarhus University Hospital, Norrebrogade 44, 8000, Aarhus C, Denmark
| | - Magdalena Lagerlund
- Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Tomtebodavägen 18A, Stockholm, Sweden
| | | | - Samantha L Quaife
- Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, Gower Street, WC1E 6BT, London, UK
| | - Peter Vedsted
- Research Unit for General Practice and Research Centre for Cancer Diagnosis in Primary Care (CaP), Aarhus University, Bartholins Allé 2, 8000, Aarhus C, Denmark
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Nicholas L, Fischbein R, Falletta L, Baughman K. Twin-Twin Transfusion Syndrome and Maternal Symptomatology-An Exploratory Analysis of Patient Experiences When Reporting Complaints. J Patient Exp 2017; 5:134-139. [PMID: 29978030 PMCID: PMC6022942 DOI: 10.1177/2374373517736760] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objective: The aim of this study was to assess patient experiences when reporting symptoms of twin–twin transfusion syndrome (TTTS) to their health-care providers. Methodology: The study utilized an online, retrospective survey of women, over the age of 18, who were living in the United States at the time of their pregnancy and had completed a TTTS pregnancy. Results: Three hundred sixty-seven cases were included for analysis. Nearly half of the respondents (45.2%) reported experiencing maternal symptoms prior to TTTS diagnosis. The average number of symptoms experienced was 2.85. The average gestational week of symptom onset was 18.2. A total of 76.2% of respondents experiencing symptoms shared these concerns with their health-care provider; however, slightly more than half (51.2%) believed that the provider dismissed their complaints. Conclusions: Results suggest a disconnect between patients’ reporting TTTS symptoms and health-care providers responding attentively, as perceived by the patient. It would be advantageous for health-care providers to inform women pregnant with a monochorionic–diamniotic pregnancy to immediately report the presence of any symptom described in the present research, which may be associated with any number of twin pregnancy–related complications.
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Affiliation(s)
- Lauren Nicholas
- Department of Liberal Arts, D'Youville College, Buffalo, NY, USA
| | - Rebecca Fischbein
- Department of Family and Community Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Lynn Falletta
- College of Public Health, Kent State University, Kent, OH, USA
| | - Kristin Baughman
- Department of Family and Community Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
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Lewis L, Marcu A, Whitaker K, Maguire R. Patient factors influencing symptom appraisal and subsequent adjustment to oesophageal cancer: A qualitative interview study. Eur J Cancer Care (Engl) 2017; 27. [PMID: 28857296 DOI: 10.1111/ecc.12745] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2017] [Indexed: 02/06/2023]
Abstract
Oesophageal cancer (EC) is characterised by vague symptoms and is often diagnosed at an advanced stage, leading to poor outcomes. Therefore, we aimed to investigate whether there might be any patient factors contributing to delay in EC diagnosis, and focused on the symptom appraisal and help-seeking strategies of people diagnosed with EC in the UK. Semi-structured interviews were conducted with 14 patients aged >18 years with localised EC at point of diagnosis. Purposive sampling was used to include patients from 1 to 9 months post-diagnosis. Analysis of the interviews identified three main themes: Interpreting symptoms, Triggers to seeking help and Making sense of an unfamiliar cancer. Findings suggested that participants normalised symptoms or used previous health experiences as a means to interpret their symptoms. The majority of participants were not alarmed by their symptoms, mainly because they had very little knowledge of EC specific symptoms. Lack of knowledge also influenced participants' sense-making of their diagnosis. The findings highlight that the process of symptom appraisal in EC is likely to be inaccurate, which may hinder early presentation and thus diagnosis. Public health campaigns communicating EC specific symptoms, however, could shorten the appraisal period and lead to earlier diagnosis.
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Affiliation(s)
- Liane Lewis
- School of Health Sciences, Faculty of Health & Medical Sciences, University of Surrey, Guildford, UK
| | - Afrodita Marcu
- School of Health Sciences, Faculty of Health & Medical Sciences, University of Surrey, Guildford, UK
| | - Katriina Whitaker
- School of Health Sciences, Faculty of Health & Medical Sciences, University of Surrey, Guildford, UK
| | - Roma Maguire
- School of Health Sciences, Faculty of Health & Medical Sciences, University of Surrey, Guildford, UK
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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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Help seeking for cancer 'alarm' symptoms: a qualitative interview study of primary care patients in the UK. Br J Gen Pract 2016; 65:e96-e105. [PMID: 25624313 PMCID: PMC4325458 DOI: 10.3399/bjgp15x683533] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Delay in help seeking for cancer ‘alarm’ symptoms has been identified as a contributor to delayed diagnosis. Aim To understand people’s help-seeking decision making for cancer alarm symptoms, without imposing a cancer context. Design and setting Community-based, qualitative interview study in the UK, using purposive sampling by sex, socioeconomic status, and prior help seeking, with framework analysis of transcripts. Method Interviewees (n = 48) were recruited from a community-based sample (n = 1724) of adults aged ≥50 years who completed a health survey that included a list of symptoms. Cancer was not mentioned. Participants reporting any of 10 cancer alarm symptoms (n = 915) and who had consented to contact (n = 482) formed the potential pool from which people were invited to an interview focusing on their symptom experiences. Results Reasons for help seeking included symptom persistence, social influence, awareness/fear of a link with cancer, and ‘just instinct’. Perceiving the symptom as trivial or ‘normal’ was a deterrent, as was stoicism, adopting self-management strategies, and fear of investigations. Negative attitudes to help seeking were common. Participants did not want to be seen as making a fuss, did not want to waste the doctor’s time, and were sometimes not confident that the GP could help. Conclusion Decision making about cancer alarm symptoms was complex. Recognition of cancer risk almost always motivated help seeking (more so than the fear of cancer being a deterrent), assisted by recent public-awareness campaigns. As well as symptom persistence motivating help seeking, it could also have the reverse effect. Negative attitudes to help seeking were significant deterrents.
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Worrying about wasting GP time as a barrier to help-seeking: a community-based, qualitative study. Br J Gen Pract 2016; 66:e474-82. [PMID: 27215569 PMCID: PMC4917050 DOI: 10.3399/bjgp16x685621] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 03/15/2016] [Indexed: 12/28/2022] Open
Abstract
Background Worrying about wasting GP time is frequently cited as a barrier to help-seeking for cancer symptoms. Aim To explore the circumstances under which individuals feel that they are wasting GP time. Design and setting Community-based, qualitative interview studies that took place in London, the South East and the North West of England. Method Interviewees (n = 62) were recruited from a sample (n = 2042) of adults aged ≥50 years, who completed a ‘health survey’ that included a list of cancer ‘alarm’ symptoms. Individuals who reported symptoms at baseline that were still present at the 3-month follow-up (n = 271), and who had also consented to be contacted (n = 215), constituted the pool of people invited for interview. Analyses focused on accounts of worrying about wasting GP time. Results Participants were worried about wasting GP time when time constraints were visible, while dismissive interactions with their GP induced a worry of unnecessary help-seeking. Many felt that symptoms that were not persistent, worsening, or life-threatening did not warrant GP attention. Additionally, patients considered it time-wasting when they perceived attention from nurses or pharmacists to be sufficient, or when appointment structures (for example, ‘one issue per visit’) were not adhered to. Close relationships with GPs eased worries about time-wasting, while some patients saw GPs as fulfilling a service financed by taxpayers. Conclusion Worrying about wasting GP time is a complex barrier to help-seeking. GP time and resource scarcity, symptom gravity, appointment etiquette, and previous GP interactions contribute to increasing worries. Friendly GP relationships, economic reasoning, and a focus on the GP’s responsibilities as a medical professional reduce this worry.
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Rubin G, Berendsen A, Crawford SM, Dommett R, Earle C, Emery J, Fahey T, Grassi L, Grunfeld E, Gupta S, Hamilton W, Hiom S, Hunter D, Lyratzopoulos G, Macleod U, Mason R, Mitchell G, Neal RD, Peake M, Roland M, Seifert B, Sisler J, Sussman J, Taplin S, Vedsted P, Voruganti T, Walter F, Wardle J, Watson E, Weller D, Wender R, Whelan J, Whitlock J, Wilkinson C, de Wit N, Zimmermann C. The expanding role of primary care in cancer control. Lancet Oncol 2015; 16:1231-72. [PMID: 26431866 DOI: 10.1016/s1470-2045(15)00205-3] [Citation(s) in RCA: 355] [Impact Index Per Article: 39.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 07/25/2015] [Accepted: 07/27/2015] [Indexed: 12/21/2022]
Abstract
The nature of cancer control is changing, with an increasing emphasis, fuelled by public and political demand, on prevention, early diagnosis, and patient experience during and after treatment. At the same time, primary care is increasingly promoted, by governments and health funders worldwide, as the preferred setting for most health care for reasons of increasing need, to stabilise health-care costs, and to accommodate patient preference for care close to home. It is timely, then, to consider how this expanding role for primary care can work for cancer control, which has long been dominated by highly technical interventions centred on treatment, and in which the contribution of primary care has been largely perceived as marginal. In this Commission, expert opinion from primary care and public health professionals with academic and clinical cancer expertise—from epidemiologists, psychologists, policy makers, and cancer specialists—has contributed to a detailed consideration of the evidence for cancer control provided in primary care and community care settings. Ranging from primary prevention to end-of-life care, the scope for new models of care is explored, and the actions needed to effect change are outlined. The strengths of primary care—its continuous, coordinated, and comprehensive care for individuals and families—are particularly evident in prevention and diagnosis, in shared follow-up and survivorship care, and in end-of-life care. A strong theme of integration of care runs throughout, and its elements (clinical, vertical, and functional) and the tools needed for integrated working are described in detail. All of this change, as it evolves, will need to be underpinned by new research and by continuing and shared multiprofessional development.
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Affiliation(s)
- Greg Rubin
- School of Medicine, Pharmacy and Health, Durham University, Stockton on Tees, UK.
| | - Annette Berendsen
- Department of General Practice, University of Groningen, Groningen, Netherlands
| | | | - Rachel Dommett
- School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Craig Earle
- Ontario Institute for Cancer Research, Toronto, ON, Canada
| | - Jon Emery
- Department of General Practice, University of Melbourne, Melbourne, VIC, Australia
| | - Tom Fahey
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Luigi Grassi
- Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Ferrara, Italy
| | - Eva Grunfeld
- Ontario Institute for Cancer Research, Toronto, ON, Canada
| | - Sumit Gupta
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | | | | | - David Hunter
- School of Medicine, Pharmacy and Health, Durham University, Stockton on Tees, UK
| | | | - Una Macleod
- Hull-York Medical School, University of Hull, Hull, UK
| | - Robert Mason
- Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Geoffrey Mitchell
- Faculty of Medicine and Biomedical Sciences, University of Queensland, Brisbane, QLD, Australia
| | - Richard D Neal
- North Wales Centre for Primary Care Research, Bangor University, Bangor, Wales
| | | | - Martin Roland
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Bohumil Seifert
- Department of General Practice, Charles University, Prague, Czech Republic
| | - Jeff Sisler
- Department of Family Medicine, University of Manitoba, Winnipeg, MB, Canada
| | | | - Stephen Taplin
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, USA
| | - Peter Vedsted
- Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Teja Voruganti
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Fiona Walter
- Department of General Practice, University of Groningen, Groningen, Netherlands
| | - Jane Wardle
- Department of Epidemiology and Public Health, University College London, London, UK
| | - Eila Watson
- Department of Clinical Health Care, Oxford Brookes University, Oxford, UK
| | - David Weller
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | | | - Jeremy Whelan
- Research Department of Oncology, University College London, London, UK
| | - James Whitlock
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Clare Wilkinson
- North Wales Centre for Primary Care Research, Bangor University, Bangor, Wales
| | - Niek de Wit
- Department of General Practice, University Medical Center Utrecht, Utrecht, Netherlands
| | - Camilla Zimmermann
- Division of Medical Oncology and Haematology, Department of Medicine, University of Toronto, Toronto, ON, Canada
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Quality deviations in cancer diagnosis: prevalence and time to diagnosis in general practice. Br J Gen Pract 2015; 64:e92-8. [PMID: 24567622 DOI: 10.3399/bjgp14x677149] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND High quality in every phase of cancer diagnosis is important to optimise the prognosis for the patient. General practice plays an important role in this phase. AIM The aim was to describe the prevalence and the types of quality deviations (QDs) that arise during the diagnostic pathway in general practice as assessed by GPs and to analyse the association between these QDs, the cancer type, and the GP's interpretation of presenting symptoms as well as the influence on the diagnostic interval. DESIGN AND SETTING A Danish retrospective cohort study based on questionnaire data from 1466 GPs on 5711 incident patients with cancer identified in the Danish National Patient Registry (response rate = 71.4%). The GP was involved in diagnosing in 4036 cases. METHOD Predefined QDs were prompted with the possibility for free text. QD prevalence was estimated as was the association between QDs and diagnosis, the GP's symptom interpretation, and time to diagnosis. RESULTS QDs were present for 30.4% (95% confidence interval [CI] = 29.0 to 31.9) of cancer patients. The most prevalent QD was 'retrospectively, one or more of my clinical decisions were less optimal'. QDs were most prevalent among patients with vague symptoms (24.1% for alarm symptoms versus 39.5% for vague symptoms [P<0.001]). QD presence implied a 41-day (95% CI = 38.4 to 43.6) longer median diagnostic interval. CONCLUSION GPs noted at least one QD, which often involved clinical decisions, for one-third of all cancer patients. QDs were more likely among patients with vague symptoms and increased the diagnostic interval considerably.
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Lyratzopoulos G, Vedsted P, Singh H. Understanding missed opportunities for more timely diagnosis of cancer in symptomatic patients after presentation. Br J Cancer 2015; 112 Suppl 1:S84-91. [PMID: 25734393 PMCID: PMC4385981 DOI: 10.1038/bjc.2015.47] [Citation(s) in RCA: 106] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
The diagnosis of cancer is a complex, multi-step process. In this paper, we highlight factors involved in missed opportunities to diagnose cancer more promptly in symptomatic patients and discuss responsible mechanisms and potential strategies to shorten intervals from presentation to diagnosis. Missed opportunities are instances in which post-hoc judgement indicates that alternative decisions or actions could have led to more timely diagnosis. They can occur in any of the three phases of the diagnostic process (initial diagnostic assessment; diagnostic test performance and interpretation; and diagnostic follow-up and coordination) and can involve patient, doctor/care team, and health-care system factors, often in combination. In this perspective article, we consider epidemiological 'signals' suggestive of missed opportunities and draw on evidence from retrospective case reviews of cancer patient cohorts to summarise factors that contribute to missed opportunities. Multi-disciplinary research targeting such factors is important to shorten diagnostic intervals post presentation. Insights from the fields of organisational and cognitive psychology, human factors science and informatics can be extremely valuable in this emerging research agenda. We provide a conceptual foundation for the development of future interventions to minimise the occurrence of missed opportunities in cancer diagnosis, enriching current approaches that chiefly focus on clinical decision support or on widening access to investigations.
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Affiliation(s)
- G Lyratzopoulos
- Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London WC1E 6BT, UK
- Department of Public Health and Primary Care, Cambridge Centre for Health Services Research, University of Cambridge, Institute of Public Health, Forvie Site, Robinson Way, Cambridge CB2 0SR, UK
| | - P Vedsted
- Department of Public Health, Research Unit for General Practice, Research Centre for Cancer Diagnosis in Primary Care (CaP), Aarhus University, DK-Bartholins Allé, 8000 Aarhus, Denmark
| | - H Singh
- Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and the Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston TX 77030, US
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Dobson CM, Russell AJ, Rubin GP. Patient delay in cancer diagnosis: what do we really mean and can we be more specific? BMC Health Serv Res 2014; 14:387. [PMID: 25217105 PMCID: PMC4175269 DOI: 10.1186/1472-6963-14-387] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 09/08/2014] [Indexed: 01/07/2023] Open
Abstract
Background Early diagnosis is a key focus of cancer control because of its association with survival. Delays in diagnosis can occur throughout the diagnostic pathway, within any one of its three component intervals: the patient interval, the primary care interval and the secondary care interval. Discussion A key focus for help-seeking research in patients with symptoms of cancer has been the concept of ‘delay’. The literature is plagued by definitional and semantic problems, which serve to hinder comparison between studies. Use of the word ‘delay’ has been criticised as judgemental and potentially stigmatising, because of its implications of intent. However, the suggested alternatives (time to presentation, appraisal interval, help-seeking interval and postponement of help-seeking) still fail to accurately define the concept in hand, and often conflate three quite separate ideas; that of an interval, that of an unacceptably long interval, and that of a specific event which caused delay in the diagnostic process. We discuss the need to disentangle current terminology and suggest the term ‘prolonged interval’ as a more appropriate alternative. Most studies treat the patient interval as a dichotomous variable, with cases beyond a specified time point classified as ‘delay’. However, there are inconsistencies in both where this line is drawn, ranging from one week to three months, and how, with some studies imposing seemingly arbitrary time points, others utilising the median as a divisive tool or exploring quartiles within their data. This not only makes comparison problematic, but, as many studies do not differentiate between cancer site, also imposes boundaries which are not necessarily site-relevant. We argue that analysis of the patient interval should be based on presenting symptom, as opposed to pathology, to better reflect the context of the help-seeking interval, and suggest how new definitional boundaries could be developed. Summary The word ‘delay’ is currently (conf)used to describe diverse conceptualisations of ‘delay’ and more mindful, and discerning language needs to be developed to enable a more sophisticated discussion. By stratifying help-seeking by presenting symptom(s), more accurate and informative analyses could be produced which, in turn, would result in more accurately targeted early diagnosis interventions.
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Brown S, Castelli M, Hunter DJ, Erskine J, Vedsted P, Foot C, Rubin G. How might healthcare systems influence speed of cancer diagnosis: a narrative review. Soc Sci Med 2014; 116:56-63. [PMID: 24980792 PMCID: PMC4124238 DOI: 10.1016/j.socscimed.2014.06.030] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2013] [Revised: 05/29/2014] [Accepted: 06/20/2014] [Indexed: 12/13/2022]
Abstract
Striking differences exist in outcomes for cancer between developed countries with comparable healthcare systems. We compare the healthcare systems of 3 countries (Denmark, Norway, Sweden), 3 UK jurisdictions (England, Wales and Northern Ireland), 3 Canadian provinces (British Columbia, Manitoba, Ontario) and 2 Australian states (New South Wales, Victoria) using a framework which assesses the possible contribution of primary care systems to a range of health outcomes, drawing on key characteristics influencing population health. For many of the characteristics we investigated there are no significant differences between those countries with poorer cancer outcomes (England and Denmark) and the rest. In particular, regulation, financing, the existence of patient lists, the GP gatekeeping role, direct access to secondary care, the degree of comprehensiveness of primary care services, the level of cost sharing and the type of primary care providers within healthcare systems were not specifically and consistently associated with differences between countries. Factors that could have an influence on patient and professional behaviour, and consequently contribute to delays in cancer diagnosis and poorer cancer outcomes in some countries, include centralisation of services, free movement of patients between primary care providers, access to secondary care, and the existence of patient list systems. It was not possible to establish a causal correlation between healthcare system characteristics and cancer outcomes. Further studies should explore in greater depth the associations between single health system factors and cancer outcomes, recognising that in complex systems where context is all-important, it will be difficult to establish causal relationships. Better understanding of the interaction between healthcare system variables and patient and professional behaviour may generate new hypotheses for further research. We examined cancer outcomes in six developed countries with comparable healthcare systems. Clear differences exist in cancer outcomes between countries with comparable healthcare systems. Centralisation, movement of patients between providers, access to secondary care, and list systems appear influential. Better understanding of interactions between system variables and patient and professional behaviour may improve outcomes.
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Affiliation(s)
- Sally Brown
- School of Medicine, Pharmacy and Health, Durham University Queen's Campus, Wolfson Research Institute, Thornaby on Tees TS 17 6BH, UK.
| | - Michele Castelli
- School of Medicine, Pharmacy and Health, Durham University Queen's Campus, Wolfson Research Institute, Thornaby on Tees TS 17 6BH, UK
| | - David J Hunter
- School of Medicine, Pharmacy and Health, Durham University Queen's Campus, Wolfson Research Institute, Thornaby on Tees TS 17 6BH, UK
| | - Jonathan Erskine
- School of Medicine, Pharmacy and Health, Durham University Queen's Campus, Wolfson Research Institute, Thornaby on Tees TS 17 6BH, UK
| | - Peter Vedsted
- Department of Public Health, Bartholins Allé 2, Building 1260, 8000 Aarhus C, Denmark
| | - Catherine Foot
- The King's Fund, 11-13 Cavendish Square, London W1G 0AN, UK
| | - Greg Rubin
- School of Medicine, Pharmacy and Health, Durham University Queen's Campus, Wolfson Research Institute, Thornaby on Tees TS 17 6BH, UK
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Gyenwali D, Khanal G, Paudel R, Amatya A, Pariyar J, Onta SR. Estimates of delays in diagnosis of cervical cancer in Nepal. BMC WOMENS HEALTH 2014; 14:29. [PMID: 24533670 PMCID: PMC3932513 DOI: 10.1186/1472-6874-14-29] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 02/13/2014] [Indexed: 11/10/2022]
Abstract
BACKGROUND Cervical cancer is the leading cause of cancer related deaths among women in Nepal. The long symptom to diagnosis interval means that women have advanced disease at presentation. The aim of this study was to identify, estimate and describe the extent of different delays in diagnosis of cervical cancer in Nepal. METHODS A cross-sectional descriptive study was conducted in two tertiary cancer hospitals of Nepal. Face to face interview and medical records review were carried out among 110 cervical cancer patients. Total diagnostic delay was categorized into component delays: patient delay, health care providers delay, referral delay and diagnostic waiting time. RESULTS Total 110 patients recruited in the study represented 40 districts from all three ecological regions of the country. Median total diagnostic delay was 157 days with more than three fourth (77.3%) of the patients having longer total diagnostic delay of >90 days. Out of the total diagnostic delay, median patient delay, median health care provider delay, median referral delay and median diagnostic waiting time were 68.5 days, 40 days, 5 days and 9 days respectively. Majority of the patients had experienced longer delay of each type except referral delay. Fifty seven percent of the patients had experienced longer patient delay of >60 days, 90% had suffered longer health care provider delay of >1 week, 31.8% had longer referral delay of >1 week and 66.2% had waited >1 week at diagnostic center for final diagnosis. Variation in each type of delay was observed among women with different attributes and in context of health care service delivery. CONCLUSIONS Longer delays were observed in all the diagnostic pathways except for referral delay and diagnostic waiting time. Among the delays, patient delay is of crucial importance because of its longer span, although health care provider delay is equally important. In the context of limited screening services in Nepal, the efforts should be to reduce the diagnostic delay especially patient and health care provider delay for early detection and reduction of mortality rate of cervical cancer.
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Affiliation(s)
- Deepak Gyenwali
- Department of Community Medicine and Public Health, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal.
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Health-care delay in malignant melanoma: various pathways to diagnosis and treatment. Dermatol Res Pract 2014; 2014:294287. [PMID: 24516469 PMCID: PMC3913342 DOI: 10.1155/2014/294287] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Revised: 10/13/2013] [Accepted: 10/14/2013] [Indexed: 11/28/2022] Open
Abstract
We aimed to describe and compare patients diagnosed with malignant melanoma (MM), depending on their initial contact with care and with regard to age, sex, and MM type and thickness, and to explore pathways and time intervals (lead times) between clinics from the initial contact to diagnosis and treatment. The sample from northern Sweden was identified via the Swedish melanoma register. Data regarding pathways in health care were retrieved from patient records. In our unselected population of 71 people diagnosed with skin melanoma of SSM and NM types, 75% of patients were primarily treated by primary health-care centres (PHCs). The time interval (delay) from primary excision until registration of the histopathological assessment in the medical records was significantly longer in PHCs than in hospital-based and dermatological clinics (Derm). Thicker tumors were more common in the PHC group. Older patients waited longer times for wide excision. Most MM are excised rapidly at PHCs, but some patients may not be diagnosed and treated in time. Delay of registration of results from histopathological assessments within PHCs seems to be an important issue for future improvement. Exploring shortcomings in MM patients' clinical pathways is important to improve the quality of care and patient safety.
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Kähärä K, Tulisalo U, Grönlund J, Mattila KJ. Reactions to acute psychotic symptoms in a rural community. Nord J Psychiatry 2013; 67:334-8. [PMID: 23245633 DOI: 10.3109/08039488.2012.745603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Recognition of psychotic disorders constitutes a challenge to the population and health and social care. AIM To evaluate the reactions of the general population, professionals in the health and social services, and local politicians in light of the symptoms of a patient evincing acute psychotic mental symptoms. MATERIAL AND METHODS A postal questionnaire study was conducted in the rural Suupohja area in Finland. Three target groups: a randomized sample of residents aged 15-84 years (n = 1200), local social and healthcare personnel (n = 463) and politicians (n = 148) responded to alternatives in identifying the need and urgency of treatment. RESULTS Seventy-six per cent of residents, 85% of politicians and 87% of health and social employees recognized that the patient was in need of urgent support and treatment. A significant positive association was found in the resident cohort between recognizing urgent need for support and female gender. Forty-eight per cent of inhabitants, 69% of social and healthcare staff, and 65% of politicians estimated that appropriate care and access to care would be obtained in the acute outpatient care of the health centre. CONCLUSION Almost one quarter of residents were not aware of the patient's urgent need for acute mental healthcare. It is a challenge to promote the knowledge and sensitivity of the population in recognizing mental and psychotic symptoms. Also appropriate information is called for regarding local services and how to access the care.
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Affiliation(s)
- Kirsti Kähärä
- Kirsti Kähärä, M.D., Medical Director, Kauhajoki Health Centre , Prännärintie 8, 61800 Kauhajoki , Finland
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Thorsen O, Hartveit M, Baerheim A. General practitioners' reflections on referring: an asymmetric or non-dialogical process? Scand J Prim Health Care 2012; 30:241-6. [PMID: 23050793 PMCID: PMC3520419 DOI: 10.3109/02813432.2012.711190] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Identify and describe general practitioners' (GPs') reflections on and attitudes to the referral process and cooperation with hospital specialists. DESIGN Qualitative study using semi-structured focus-group interviews with GPs analysed using Giorgi's method as modified by Malterud. SETTING Interviews conducted over four months from November 2010 to February 2011. SUBJECTS 17 female and 14 male GPs aged 29 to 61 years from 21 different practices, who had practised for 3-35 years. MAIN OUTCOME MEASURES Description of GPs' views on the referral process. RESULTS GPs wished for improved dialogue with the hospital specialists. The referral process was often considered as asymmetric and sometimes humiliating. GPs saw the benefit of using templates in the referral process, but were sceptical concerning the use of mandatory fixed formats. CONCLUSIONS The referral process is essential for good patient care between general practice and specialist services. GPs consider referring as asymmetric and sometimes humiliating. The dichotomy between the wish for mutual dialogue and the convenience of using templates should be kept in mind when assuring quality of the referral process.
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Affiliation(s)
- Olav Thorsen
- Department of Public Health and Primary Health Care, University of Bergen, Norway.
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Johansen ML, Holtedahl KA, Rudebeck CE. How does the thought of cancer arise in a general practice consultation? Interviews with GPs. Scand J Prim Health Care 2012; 30:135-40. [PMID: 22747066 PMCID: PMC3443936 DOI: 10.3109/02813432.2012.688701] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Only a few patients on a GP's list develop cancer each year. To find these cases in the jumble of presented problems is a challenge. OBJECTIVE To explore how general practitioners (GPs) come to think of cancer in a clinical encounter. DESIGN Qualitative interviews with Norwegian GPs, who were invited to think back on consultations during which the thought of cancer arose. The 11 GPs recounted and reflected on 70 such stories from their practices. A phenomenographic approach enabled the study of variation in GPs' ways of experiencing. RESULTS Awareness of cancer could arise in several contexts of attention: (1) Practising basic knowledge: explicit rules and skills, such as alarm symptoms, epidemiology and clinical know-how; (2) Interpersonal awareness: being alert to changes in patients' appearance or behaviour and to cues in their choice of words, on a background of basic knowledge and experience; (3) Intuitive knowing: a tacit feeling of alarm which could be difficult to verbalize, but nevertheless was helpful. Intuition built on the earlier mentioned contexts: basic knowledge, experience, and interpersonal awareness; (4) Fear of cancer: the existential context of awareness could affect the thoughts of both doctor and patient. The challenge could be how not to think about cancer all the time and to find ways to live with insecurity without becoming over-precautious. CONCLUSION The thought of cancer arose in the relationship between doctor and patient. The quality of their interaction and the doctor's accuracy in perceiving and interpreting cues were decisive.
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