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Venchiarutti RL, Clark JR, Palme CE, Dwyer P, Tahir ARM, Hill J, Ch'ng S, Elliott MS, Young JM. Associations between patient-level health literacy and diagnostic time intervals for head and neck cancer: A prospective cohort study. Head Neck 2024; 46:857-870. [PMID: 38213101 DOI: 10.1002/hed.27633] [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: 06/13/2023] [Revised: 12/20/2023] [Accepted: 12/31/2023] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND Health literacy (HL) comprises skills and knowledge required to understand, access, and make decisions about healthcare. Our aim was to examine associations between patient HL and time intervals (defined in the Aarhus statement) along the pathway to treatment of head and neck cancer (HNC). METHODS A prospective cohort study was conducted from October 2018 to March 2020. Participants completed the Health Literacy Questionnaire (HLQ®) and described key events and dates along the pathway to treatment using validated questionnaires. Correlations between six diagnostic time intervals and domains of HL were explored, and factors predicting exceeding maximum acceptable timeframes were assessed using logistic regression. RESULTS One hundred patients with a diagnosis of HNC within the preceding 6 months were recruited. HLQ® Domain 2 (sufficient information to manage health) was significantly negatively associated with four intervals: the patient interval (first symptom to first presentation), primary care interval (first presentation to referral to secondary care), diagnostic interval (first presentation to diagnosis), and total interval (first symptom to treatment onset); correlation coefficients -0.25 to -0.27 (P < 0.05). Domain 8 (ability to find good information) was significantly negatively associated with three intervals (primary care interval, diagnostic interval, and total interval; correlation coefficients -0.23 to -0.34; P < 0.05). Higher education, age, and comorbidity levels were associated with shorter patient and diagnostic intervals. CONCLUSIONS HL may be a potential target to improve timeliness of HNC diagnosis and reduce disparities in outcomes.
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Affiliation(s)
- Rebecca L Venchiarutti
- The University of Sydney, Faculty of Medicine and Health, Sydney School of Public Health, Camperdown, New South Wales, Australia
- Department of Head and Neck Surgery, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
| | - Jonathan R Clark
- Department of Head and Neck Surgery, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
- RPA Institute of Academic Surgery, Sydney Local Health District, Camperdown, New South Wales, Australia
- The University of Sydney, Faculty of Medicine and Health, Central Clinical School, Camperdown, New South Wales, Australia
| | - Carsten E Palme
- Department of Head and Neck Surgery, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
- RPA Institute of Academic Surgery, Sydney Local Health District, Camperdown, New South Wales, Australia
- The University of Sydney, Faculty of Medicine and Health, Central Clinical School, Camperdown, New South Wales, Australia
| | - Patrick Dwyer
- Department of Radiation Oncology, North Coast Cancer Institute, Lismore, New South Wales, Australia
| | - Abdul Rahim Mohd Tahir
- Department of Radiation Oncology, Mid North Coast Cancer Institute, Coffs Harbour, New South Wales, Australia
| | - Jacques Hill
- Department of Radiation Oncology, Mid North Coast Cancer Institute, Port Macquarie, New South Wales, Australia
| | - Sydney Ch'ng
- Department of Head and Neck Surgery, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
- RPA Institute of Academic Surgery, Sydney Local Health District, Camperdown, New South Wales, Australia
- The University of Sydney, Faculty of Medicine and Health, Central Clinical School, Camperdown, New South Wales, Australia
- Department of Plastic Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Michael S Elliott
- Department of Head and Neck Surgery, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
- The University of Sydney, Faculty of Medicine and Health, Central Clinical School, Camperdown, New South Wales, Australia
| | - Jane M Young
- The University of Sydney, Faculty of Medicine and Health, Sydney School of Public Health, Camperdown, New South Wales, Australia
- The Daffodil Centre, The University of Sydney, A Joint Venture with Cancer Council NSW, Camperdown, New South Wales, Australia
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Aboelkhir HAB, Elomri A, ElMekkawy TY, Kerbache L, Elakkad MS, Al-Ansari A, Aboumarzouk OM, El Omri A. A Bibliometric Analysis and Visualization of Decision Support Systems for Healthcare Referral Strategies. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16952. [PMID: 36554837 PMCID: PMC9778793 DOI: 10.3390/ijerph192416952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 10/24/2022] [Accepted: 11/14/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND The referral process is an important research focus because of the potential consequences of delays, especially for patients with serious medical conditions that need immediate care, such as those with metastatic cancer. Thus, a systematic literature review of recent and influential manuscripts is critical to understanding the current methods and future directions in order to improve the referral process. METHODS A hybrid bibliometric-structured review was conducted using both quantitative and qualitative methodologies. Searches were conducted of three databases, Web of Science, Scopus, and PubMed, in addition to the references from the eligible papers. The papers were considered to be eligible if they were relevant English articles or reviews that were published from January 2010 to June 2021. The searches were conducted using three groups of keywords, and bibliometric analysis was performed, followed by content analysis. RESULTS A total of 163 papers that were published in impactful journals between January 2010 and June 2021 were selected. These papers were then reviewed, analyzed, and categorized as follows: descriptive analysis (n = 77), cause and effect (n = 12), interventions (n = 50), and quality management (n = 24). Six future research directions were identified. CONCLUSIONS Minimal attention was given to the study of the primary referral of blood cancer cases versus those with solid cancer types, which is a gap that future studies should address. More research is needed in order to optimize the referral process, specifically for suspected hematological cancer patients.
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Affiliation(s)
| | - Adel Elomri
- College of Science and Engineering, Hamad Bin Khalifa University, Doha 34110, Qatar
| | - Tarek Y. ElMekkawy
- Department of Mechanical and Industrial Engineering, College of Engineering, Qatar University, Doha 2713, Qatar
| | - Laoucine Kerbache
- College of Science and Engineering, Hamad Bin Khalifa University, Doha 34110, Qatar
| | - Mohamed S. Elakkad
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha 3050, Qatar
| | - Abdulla Al-Ansari
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha 3050, Qatar
| | - Omar M. Aboumarzouk
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha 3050, Qatar
- College of Medicine, QU-Health, Qatar University, Doha 2713, Qatar
- School of Medicine, Dentistry and Nursing, The University of Glasgow, Glasgow G12 8QQ, UK
| | - Abdelfatteh El Omri
- Surgical Research Section, Department of Surgery, Hamad Medical Corporation, Doha 3050, Qatar
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Vázquez ML, Vargas I, Rubio-Valera M, Aznar-Lou I, Eguiguren P, Mogollón-Pérez AS, Torres AL, Peralta A, Dias S, Jervelund SS. Improving equity in access to early diagnosis of cancer in different healthcare systems of Latin America: protocol for the EquityCancer-LA implementation-effectiveness hybrid study. BMJ Open 2022; 12:e067439. [PMID: 36523219 PMCID: PMC9748968 DOI: 10.1136/bmjopen-2022-067439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Healthcare fragmentation, a main cause for delay in cancer diagnosis and treatment, contributes to high mortality in Latin America (LA), particularly among disadvantaged populations. This research focuses on integrated care interventions, which have been limitedly implemented in the region. The objective is to evaluate the contextual effectiveness of scaling-up an integrated care intervention to improve early diagnosis of frequent cancers in healthcare networks of Chile, Colombia and Ecuador. METHODS AND ANALYSIS This research is two pronged: (A) quasi-experimental design (controlled before and after) with an intervention and a control healthcare network in each LA country, using an implementation-effectiveness hybrid approach to assess the intervention process, effectiveness and costs; and (B) case study design to analyse access to diagnosis of most frequent cancers. Focusing on the most vulnerable socioeconomic population, it develops in four phases: (1) analysis of delays and barriers to early diagnosis (baseline); (2) intervention adaptation and implementation (primary care training, fast-track referral pathway and patient information); (3) intracountry evaluation of intervention and (4) cross-country analysis. Baseline and evaluation studies adopt mixed-methods qualitative (semistructured individual interviews) and quantitative (patient questionnaire survey) methods. For the latter, a sample size of 174 patients with cancer diagnosis per healthcare network and year was calculated to detect a proportions difference of 15%, before and after intervention (α=0.05; β=0.2) in a two-sided test. A participatory approach will be used to tailor the intervention to each context, led by a local steering committee (professionals, managers, policy makers, patients and researchers). ETHICS AND DISSEMINATION This study complies with international and national legal stipulations on ethics. It was approved by each country's ethical committee and informed consent will be obtained from participants. Besides the coproduction of knowledge with key stakeholders, it will be disseminated through strategies such as policy briefs, workshops, e-tools and scientific papers.
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Affiliation(s)
- Maria-Luisa Vázquez
- Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Barcelona, Spain
| | - Ingrid Vargas
- Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Barcelona, Spain
| | - Maria Rubio-Valera
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Spain
| | - Ignacio Aznar-Lou
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Research and Development Unit, Institut de Recerca Sant Joan de Deu, Barcelona, Spain
| | - Pamela Eguiguren
- Escuela de Salud Pública Dr. Salvador Allende Gossens, Facultad de Medicina, Universidad de Chile, Santiago de Chile, Chile
| | | | - Ana-Lucía Torres
- Public Health Institute, Pontificia Universidad Católica del Ecuador, Quito, Ecuador
| | - Andrés Peralta
- Public Health Institute, Pontificia Universidad Católica del Ecuador, Quito, Ecuador
| | - Sónia Dias
- NOVA National School of Public Health, Public Health Research Centre, NOVA University of Lisbon & Comprehensive Health Research Center (CHRC), Lisboa, Portugal
| | - Signe Smith Jervelund
- Department of Public Health, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Wiering B, Lyratzopoulos G, Hamilton W, Campbell J, Abel G. Concordance with urgent referral guidelines in patients presenting with any of six 'alarm' features of possible cancer: a retrospective cohort study using linked primary care records. BMJ Qual Saf 2022; 31:579-589. [PMID: 34607914 PMCID: PMC9304100 DOI: 10.1136/bmjqs-2021-013425] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 09/02/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Clinical guidelines advise GPs in England which patients warrant an urgent referral for suspected cancer. This study assessed how often GPs follow the guidelines, whether certain patients are less likely to be referred, and how many patients were diagnosed with cancer within 1 year of non-referral. METHODS We used linked primary care (Clinical Practice Research Datalink), secondary care (Hospital Episode Statistics) and cancer registration data. Patients presenting with haematuria, breast lump, dysphagia, iron-deficiency anaemia, post-menopausal or rectal bleeding for the first time during 2014-2015 were included (for ages where guidelines recommend urgent referral). Logistic regression was used to investigate whether receiving a referral was associated with feature type and patient characteristics. Cancer incidence (based on recorded diagnoses in cancer registry data within 1 year of presentation) was compared between those receiving and those not receiving referrals. RESULTS 48 715 patients were included, of which 40% (n=19 670) received an urgent referral within 14 days of presentation, varying by feature from 17% (dysphagia) to 68% (breast lump). Young patients (18-24 vs 55-64 years; adjusted OR 0.20, 95% CI 0.10 to 0.42, p<0.001) and those with comorbidities (4 vs 0 comorbidities; adjusted OR 0.87, 95% CI 0.80 to 0.94, p<0.001) were less likely to receive a referral. Associations between patient characteristics and referrals differed across features: among patients presenting with anaemia, breast lump or haematuria, those with multi-morbidity, and additionally for breast lump, more deprived patients were less likely to receive a referral. Of 29 045 patients not receiving a referral, 3.6% (1047) were diagnosed with cancer within 1 year, ranging from 2.8% for rectal bleeding to 9.5% for anaemia. CONCLUSIONS Guideline recommendations for action are not followed for the majority of patients presenting with common possible cancer features. A significant number of these patients developed cancer within 1 year of their consultation, indicating scope for improvement in the diagnostic process.
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Affiliation(s)
- Bianca Wiering
- University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Georgios Lyratzopoulos
- Epidemiology of Cancer Healthcare and Outcomes Group, Department of Behavioral Science and Health, Institute of Epidemiology and Health Care, University College London, London, UK
| | - Willie Hamilton
- University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
| | - John Campbell
- University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Gary Abel
- University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
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Coschi CH, Bainbridge D, Sussman J. Understanding the Attitudes and Beliefs of Oncologists Regarding the Transitioning and Sharing of Survivorship Care. Curr Oncol 2021; 28:5452-5465. [PMID: 34940093 PMCID: PMC8700375 DOI: 10.3390/curroncol28060454] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 12/12/2021] [Accepted: 12/16/2021] [Indexed: 01/23/2023] Open
Abstract
Transitioning survivorship care from oncologists to primary care physicians (PCPs) is a reasonable alternative to oncologist-led care. This study assessed oncologists’ attitudes and beliefs regarding sharing/transitioning survivorship care. A prospective survey of oncologists within a regional cancer program assessing self-reported barriers and facilitators to sharing/transitioning survivorship care was disseminated. In total, 63% (n = 39) of surveyed oncologists responded. Patient preference (89%) and anxiety (84%) are key to transition of care decisions; reduced remuneration (95%) and fewer longitudinal relationships (63%) do not contribute. Oncologists agreed that more patients could be shared/transitioned. Barriers include treatment-related toxicities (82% agree), tumor-specific factors (60–90% agree) and perception of PCP willingness to participate in survivorship care (47% agree). Oncologists appear willing to share/transition more survivors to PCPs, though barriers exist that warrant further study. Understanding these issues is critical to developing policies supporting comprehensive survivorship care models that address both cancer and non-cancer health needs. The demonstrated feasibility of this project warrants a larger-scale survey of oncologists with respect to the transition of survivorship care to PCPs, to further inform effective interventions to support high-quality survivorship care.
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Affiliation(s)
- Courtney H. Coschi
- Department of Medicine, McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5, Canada;
| | - Daryl Bainbridge
- Juravinski Hospital and Cancer Centre, Department of Oncology, McMaster University, 711 Concession Street, Hamilton, ON L8V 1C3, Canada;
| | - Jonathan Sussman
- Juravinski Hospital and Cancer Centre, Department of Oncology, McMaster University, 711 Concession Street, Hamilton, ON L8V 1C3, Canada;
- Hamilton Health Sciences Juravinski Cancer Centre, 699 Concession Street, Hamilton, ON L8V 5C2, Canada
- Correspondence:
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Maqueda Gonzalez R, Cerdán Santacruz C, García Septiem J, Blanco Terés L, Lopesino González JM, Fernández Jiménez G, Martín-Pérez E. Proctologic emergency consultation during COVID-19: Comparative cross-sectional cohort study. Cir Esp 2021; 99:660-665. [PMID: 34749925 DOI: 10.1016/j.cireng.2021.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 10/12/2020] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Proctologic issues entail a frequent reason for consultation in the emergency department (ED). We aim to analyze how the SARS-COV-2 pandemic has impacted in the demand for proctological consultations. MATERIAL AND METHOD Descriptive comparative retrospective study of cross-sectional cohorts of patients attending the ED for proctological complaints from March to April in 2020 and 2019. Demographic variables, comorbidities, reasons for consultation and diagnosis, treatment and readmission were included. Four periods were analyzed according to the different stages of the pandemic derived limitations. RESULTS A total of 191 patients were reviewed, 58 in 2020 and 133 in 2019 with an average age of 48 years (SD 20.1) and 112 (58.6%) males. The average number of daily consultations was 2.18 patients in 2019 versus 0.95 in 2020 (p=0.025) meaning a 56% reduction in consultations for proctological reasons. This difference in average consultations was significant in both periods of lockout (p=0.001) and previous de-escalation (p=0.014). The diagnosis distribution was similar between both periods; however, perianal abscesses doubled their rate in 2020, 22.4% versus 11.3% (p=0.045). There was an increasing need for surgery, 31% vs 15% (p=0.011) with no difference in outpatients regimen after emergency surgery (12.5% vs 7.5%, p=0.201). Three patients in 2020 required readmission to the ED (5.2% vs 12.9%, p=0.086). CONCLUSION There was a decrease of a 56% in proctologic emergency consultation, however, the need for surgery was twice more frequent during the study period. Reflection on the use of emergencies for proctological reasons is warranted.
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Affiliation(s)
- Rocío Maqueda Gonzalez
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario La Princesa, Madrid, Spain.
| | - Carlos Cerdán Santacruz
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario La Princesa, Madrid, Spain
| | - Javier García Septiem
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario La Princesa, Madrid, Spain
| | - Lara Blanco Terés
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario La Princesa, Madrid, Spain
| | | | - Guillermo Fernández Jiménez
- Unidad de Información Clínico-Asistencial, Servicio de Admisión y Documentación Clínica, Hospital Universitario La Princesa, Madrid, Spain
| | - Elena Martín-Pérez
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario La Princesa, Madrid, Spain
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Impact of the Presenting Symptom on Time Intervals and Diagnostic Routes of Patients with Symptomatic Oral Cancer. Cancers (Basel) 2021; 13:cancers13205163. [PMID: 34680312 PMCID: PMC8533728 DOI: 10.3390/cancers13205163] [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: 07/25/2021] [Revised: 09/28/2021] [Accepted: 10/11/2021] [Indexed: 11/17/2022] Open
Abstract
This investigation was aimed at determining the time intervals from the presenting symptoms until the beginning of oral cancer treatment and their relative contribution to the total time, and to assess the impact of the presenting symptom on diagnostic timelines and patient referral routes. A cross-sectional, ambispective study was designed to investigate symptomatic incident cases. The Aarhus statement was used as a conceptual framework. Strategies for minimizing potential recall biases were implemented. A sample of 181 patients was recruited (power: 99.5%; α = 0.05). The patient interval reached 58.2 days (95% CI, 40.3-76.2), which accounted for 74% of the whole prereferral interval and for more than one third of the total time interval. The presenting symptom (trigger for consultation) influenced both the number of primary care consultations and the length of time to diagnosis. General dental practitioners generated longer intervals to diagnosis (p < 0.005) and needed more consultations before referring a patient (RR = 0.76; 95% CI, 0.61-0.93), than general medical practitioners. The current study identifies the patient as the main target for interventions to improve awareness and reinforces the need for increased alertness amongst healthcare professionals about presenting symptoms of oral cancer and to diminish the number of prereferral consultations in order to optimize the primary care interval.
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Gondhowiardjo S, Hartanto S, Wirawan S, Jayalie VF, Astiti IAP, Panigoro SS, Sekarutami SM, Rachman A, Bachtiar A. Treatment delay of cancer patients in Indonesia: a reflection from a national referral hospital. MEDICAL JOURNAL OF INDONESIA 2021. [DOI: 10.13181/mji.oa.204296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Cancer is a complex disease requiring a multidisciplinary approach in establishing prompt diagnosis and treatment. Treatment in a timely manner is crucial for the outcomes. Hence, this study aimed to provide information on treatment delay including patient and provider delays and its associated factors.
METHODS Cancer patients were recruited conveniently in the outpatient clinic of Department of Radiation Oncology, Cipto Mangunkusumo Hospital, Indonesia between May and August 2015. All patients were asked to fill a questionnaire and interviewed in this cross-sectional study. Treatment delay was explored and categorized into patient delay and provider delay. Patient delay could be happened before (patient-delay-1) or after (patient-delay-2) the patient was diagnosed with cancer. Provider delay could be due to physician, system-diagnosis, and system-treatment delays.
RESULTS Among 294 patients, 86% patient had treatment delay. Patient delay was observed in 153 patients, and 43% of them had a history of alternative treatment. An older age (p = 0.047), lower educational level (p = 0.047), and history of alternative treatment (p<0.001) were associated with patient delay. Meanwhile, 214 patients had provider delay, and 9%, 36%, and 80% of them experienced physician, system-diagnosis, and system-treatment delays, respectively. All types of provider delay were associated with patient delay (p<0.001).
CONCLUSIONS Most of the patient had treatment delay caused by either patient or provider.
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Disbeschl S, Surgey A, Roberts JL, Hendry A, Lewis R, Goulden N, Hoare Z, Williams N, Anthony BF, Edwards RT, Law RJ, Hiscock J, Carson-Stevens A, Neal RD, Wilkinson C. Protocol for a feasibility study incorporating a randomised pilot trial with an embedded process evaluation and feasibility economic analysis of ThinkCancer!: a primary care intervention to expedite cancer diagnosis in Wales. Pilot Feasibility Stud 2021; 7:100. [PMID: 33883033 PMCID: PMC8059131 DOI: 10.1186/s40814-021-00834-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 04/07/2021] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Compared to the rest of Europe, the UK has relatively poor cancer outcomes, with late diagnosis and a slow referral process being major contributors. General practitioners (GPs) are often faced with patients presenting with a multitude of non-specific symptoms that could be cancer. Safety netting can be used to manage diagnostic uncertainty by ensuring patients with vague symptoms are appropriately monitored, which is now even more crucial due to the ongoing COVID-19 pandemic and its major impact on cancer referrals. The ThinkCancer! workshop is an educational behaviour change intervention aimed at the whole general practice team, designed to improve primary care approaches to ensure timely diagnosis of cancer. The workshop will consist of teaching and awareness sessions, the appointment of a Safety Netting Champion and the development of a bespoke Safety Netting Plan and has been adapted so it can be delivered remotely. This study aims to assess the feasibility of the ThinkCancer! intervention for a future definitive randomised controlled trial. METHODS The ThinkCancer! study is a randomised, multisite feasibility trial, with an embedded process evaluation and feasibility economic analysis. Twenty-three to 30 general practices will be recruited across Wales, randomised in a ratio of 2:1 of intervention versus control who will follow usual care. The workshop will be delivered by a GP educator and will be adapted iteratively throughout the trial period. Baseline practice characteristics will be collected via questionnaire. We will also collect primary care intervals (PCI), 2-week wait (2WW) referral rates, conversion rates and detection rates at baseline and 6 months post-randomisation. Participant feedback, researcher reflections and economic costings will be collected following each workshop. A process evaluation will assess implementation using an adapted Normalisation Measure Development (NoMAD) questionnaire and qualitative interviews. An economic feasibility analysis will inform a future economic evaluation. DISCUSSION This study will allow us to test and further develop a novel evidenced-based complex intervention aimed at general practice teams to expedite the diagnosis of cancer in primary care. The results from this study will inform the future design of a full-scale definitive phase III trial. TRIAL REGISTRATION ClinicalTrials.gov NCT04823559 .
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Affiliation(s)
- Stefanie Disbeschl
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, LL13 7YP, UK.
| | - Alun Surgey
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, LL13 7YP, UK
| | - Jessica L Roberts
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, LL13 7YP, UK
| | - Annie Hendry
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, LL13 7YP, UK
| | - Ruth Lewis
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, LL13 7YP, UK
| | - Nia Goulden
- North Wales Organisation for Randomised Trials in Health (NWORTH), Bangor University, The Normal Site, Holyhead Road, Gwynedd, LL57 2PZ, UK
| | - Zoe Hoare
- North Wales Organisation for Randomised Trials in Health (NWORTH), Bangor University, The Normal Site, Holyhead Road, Gwynedd, LL57 2PZ, UK
| | - Nefyn Williams
- Department of Primary Care and Mental Health, Institute of Population Health, University of Liverpool, Liverpool, L69 3GL, UK
| | - Bethany Fern Anthony
- Centre for Health Economics and Medicines Evaluation (CHEME), Bangor University, The Normal Site, Holyhead Road, Gwynedd, LL57 2PZ, UK
| | - Rhiannon Tudor Edwards
- Centre for Health Economics and Medicines Evaluation (CHEME), Bangor University, The Normal Site, Holyhead Road, Gwynedd, LL57 2PZ, UK
| | - Rebecca-Jane Law
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, LL13 7YP, UK
| | - Julia Hiscock
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, LL13 7YP, UK
| | - Andrew Carson-Stevens
- Division of Population Medicine, School of Medicine, Cardiff University, UHW Main Building, Heath Park, Cardiff, CF14 4XN, UK
| | - Richard D Neal
- Academic Unit of Primary Care, Leeds Institute of Health Sciences, University of Leeds, Worsley Building, Leeds, LS2 9NL, UK
| | - Clare Wilkinson
- North Wales Centre for Primary Care Research (NWCPCR), Bangor University, Cambrian 2, Wrexham Technology Park, Wrexham, LL13 7YP, UK
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Maqueda Gonzalez R, Cerdán Santacruz C, García Septiem J, Blanco Terés L, Lopesino González JM, Fernández Jiménez G, Martín-Pérez E. Proctologic emergency consultation during COVID-19: Comparative cross-sectional cohort study. Cir Esp 2020; 99:S0009-739X(20)30317-1. [PMID: 33218670 PMCID: PMC7584434 DOI: 10.1016/j.ciresp.2020.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 10/09/2020] [Accepted: 10/12/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Proctologic issues entail a frequent reason for consultation in the emergency department (ED). We aim to analyze how the SARS-COV-2 pandemic has impacted in the demand for proctological consultations. MATERIAL AND METHOD Descriptive comparative retrospective study of cross-sectional cohorts of patients attending the ED for proctological complaints from March to April in 2020 and 2019. Demographic variables, comorbidities, reasons for consultation and diagnosis, treatment and readmission were included. Four periods were analyzed according to the different stages of the pandemic derived limitations. RESULTS A total of 191 patients were reviewed, 58 in 2020 and 133 in 2019 with an average age of 48 years (SD 20.1) and 112 (58.6%) males. The average number of daily consultations was 2.18 patients in 2019 versus 0.95 in 2020 (p=0.025) meaning a 56% reduction in consultations for proctological reasons. This difference in average consultations was significant in both periods of lockout (p=0.001) and previous de-escalation (p=0.014). The diagnosis distribution was similar between both periods; however, perianal abscesses doubled their rate in 2020, 22.4% versus 11.3% (p=0.045). There was an increasing need for surgery, 31% vs 15% (p=0.011) with no difference in outpatients regimen after emergency surgery (12.5% vs 7.5%, p=0.201). Three patients in 2020 required readmission to the ED (5.2% vs 12.9%, p=0.086). CONCLUSION There was a decrease of a 56% in proctologic emergency consultation, however, the need for surgery was twice more frequent during the study period. Reflection on the use of emergencies for proctological reasons is warranted.
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Affiliation(s)
- Rocío Maqueda Gonzalez
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario La Princesa, Madrid, Spain.
| | - Carlos Cerdán Santacruz
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario La Princesa, Madrid, Spain
| | - Javier García Septiem
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario La Princesa, Madrid, Spain
| | - Lara Blanco Terés
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario La Princesa, Madrid, Spain
| | | | - Guillermo Fernández Jiménez
- Unidad de Información Clínico-Asistencial, Servicio de Admisión y Documentación Clínica, Hospital Universitario La Princesa, Madrid, Spain
| | - Elena Martín-Pérez
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario La Princesa, Madrid, Spain
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11
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Bailey JA, Hanbali N, Premji K, Bunce J, Mashlab S, Simpson JA, Humes DJ, Banerjea A. Thrombocytosis helps to stratify risk of colorectal cancer in patients referred on a 2-week-wait pathway. Int J Colorectal Dis 2020; 35:1347-1350. [PMID: 32358719 PMCID: PMC7320058 DOI: 10.1007/s00384-020-03597-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Primary care studies suggest that thrombocytosis (platelet counts > 400 × 109/L) is associated with an increased risk of colorectal cancer (CRC). We aimed to establish whether this marker has significant stratification value in patients seen in secondary care. METHODS A retrospective review of 2991 patients referred to our colorectal 2-week-wait (2WW) pathway between August 2014 and August 2017. Patient demographics were recorded prospectively, and local electronic records systems were used to retrieve full blood counts (FBC) and cancer diagnoses. Patients with no recent platelet count at the time of referral or incomplete records were excluded. RESULTS 2236 patients were included in this evaluation. There was no significant difference in the age distribution of those with thrombocytosis and those without. There were significantly more females in the thrombocytosis group (72.1% vs 53.9%, chi-squared 24.63, p < 0.0001). 130 CRCs were detected (5.8%) and patients with thrombocytosis were more likely to have CRC (OR 2.62, 95% CI 1.60-4.30). The CRC diagnosis rate was significantly higher in females with thrombocytosis (10.3% vs 2.9%, chi-squared 19.41, p < 0.0001) and males with thrombocytosis (16.1% vs 7.9%, chi-squared 4.62, p = 0.032). CONCLUSION Thrombocytosis appears to have stratification value in the 2WW population. Further evaluation of its value alone or in combination with other stratification tests is required.
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Affiliation(s)
- J A Bailey
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, E Floor West Block, QMC Campus, Nottingham, NG7 2UH, UK.
| | - N Hanbali
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, E Floor West Block, QMC Campus, Nottingham, NG7 2UH, UK
| | - K Premji
- Department of Clinical Chemistry, City Hospital, Nottingham University Hospitals NHS Trust, Nottingham, NG5 1PB, UK
| | - J Bunce
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, E Floor West Block, QMC Campus, Nottingham, NG7 2UH, UK
| | - S Mashlab
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, E Floor West Block, QMC Campus, Nottingham, NG7 2UH, UK
| | - J A Simpson
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, E Floor West Block, QMC Campus, Nottingham, NG7 2UH, UK
| | - D J Humes
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, E Floor West Block, QMC Campus, Nottingham, NG7 2UH, UK
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Clinical Sciences Building, City Hospital, Nottingham, NG5 1PB, UK
| | - A Banerjea
- Nottingham Colorectal Service, Nottingham University Hospitals NHS Trust, E Floor West Block, QMC Campus, Nottingham, NG7 2UH, UK
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12
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Cheewakriangkrai C, Kietpeerakool C, Charoenkwan K, Pattanittum P, John D, Aue‐aungkul A, Lumbiganon P. Health education interventions to promote early presentation and referral for women with symptoms of endometrial cancer. Cochrane Database Syst Rev 2020; 3:CD013253. [PMID: 32168393 PMCID: PMC7069600 DOI: 10.1002/14651858.cd013253.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Diagnosis of endometrial (womb) cancer is normally made at an early stage, as most women with the disease experience abnormal vaginal bleeding, which prompts them to seek medical advice. However, delays in presentation and referral can result in delay in diagnosis and management, which can lead to unfavourable treatment outcomes. This is particularly a problem for pre- and peri-menopausal women. Providing educational information to women and healthcare providers regarding symptoms relating to endometrial cancer may raise awareness of the disease and reduce delayed treatment. OBJECTIVES To assess the effectiveness of health education interventions targeting healthcare providers, or individuals, or both, to promote early presentation and referral for women with endometrial cancer symptoms. SEARCH METHODS We searched CENTRAL, MEDLINE and Embase. We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of review articles. SELECTION CRITERIA We planned to include randomised controlled trials (RCTs), both individually randomised and cluster-RCTs. In the absence of RCTs we planned to include well-designed non-randomised studies (NRS) with a parallel comparison assessing the benefits of any type of health education interventions. DATA COLLECTION AND ANALYSIS Two review authors independently evaluated whether potentially relevant studies met the inclusion criteria for the review, but none were found. MAIN RESULTS A comprehensive search of the literature yielded the following results: CENTRAL (1022 references), MEDLINE (2874 references), and Embase (2820 references). After de-duplication, we screened titles and abstracts of 4880 references and excluded 4864 that did not meet the review inclusion criteria. Of the 16 references that potentially met the review inclusion, we excluded all 16 reports after reviewing the full texts. We did not identify any ongoing trials. AUTHORS' CONCLUSIONS There is currently an absence of evidence to indicate the effectiveness of health education interventions involving healthcare providers or individuals or both to promote early presentation and referral for women with endometrial cancer symptoms. High-quality RCTs are needed to assess whether health education interventions enhance early presentation and referral. If health education interventions can be shown to reduce treatment delays in endometrial cancer, further studies would be required to determine which interventions are most effective.
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Affiliation(s)
- Chalong Cheewakriangkrai
- Faculty of Medicine, Chiang Mai UniversityDepartment of Obstetrics and Gynecology110 Intawaroros RoadMuangChiang MaiThailand50200
| | - Chumnan Kietpeerakool
- Khon Kaen UniversityDepartment of Obstetrics and Gynaecology, Faculty of Medicine123 Mitraparb RoadAmphur MuangKhon KaenThailand40002
| | - Kittipat Charoenkwan
- Faculty of Medicine, Chiang Mai UniversityDepartment of Obstetrics and Gynecology110 Intawaroros RoadMuangChiang MaiThailand50200
| | - Porjai Pattanittum
- Khon Kaen UniversityDepartment of Epidemiology and Biostatistics, Public Health FacultyMitraparp RoadMueng DistrictKhon KaenKhon KaenThailand40002
| | | | - Apiwat Aue‐aungkul
- Khon Kaen UniversityDepartment of Obstetrics and Gynaecology, Faculty of Medicine123 Mitraparb RoadAmphur MuangKhon KaenThailand40002
| | - Pisake Lumbiganon
- Khon Kaen UniversityDepartment of Obstetrics and Gynaecology, Faculty of Medicine123 Mitraparb RoadAmphur MuangKhon KaenThailand40002
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13
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Decision support tools to improve cancer diagnostic decision making in primary care: a systematic review. Br J Gen Pract 2019; 69:e809-e818. [PMID: 31740460 DOI: 10.3399/bjgp19x706745] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 08/26/2019] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND The diagnosis of cancer in primary care is complex and challenging. Electronic clinical decision support tools (eCDSTs) have been proposed as an approach to improve GP decision making, but no systematic review has examined their role in cancer diagnosis. AIM To investigate whether eCDSTs improve diagnostic decision making for cancer in primary care and to determine which elements influence successful implementation. DESIGN AND SETTING A systematic review of relevant studies conducted worldwide and published in English between 1 January 1998 and 31 December 2018. METHOD Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched, and a consultation of reference lists and citation tracking was carried out. Exclusion criteria included the absence of eCDSTs used in asymptomatic populations, and studies that did not involve support delivered to the GP. The most relevant Joanna Briggs Institute Critical Appraisal Checklists were applied according to study design of the included paper. RESULTS Of the nine studies included, three showed improvements in decision making for cancer diagnosis, three demonstrated positive effects on secondary clinical or health service outcomes such as prescribing, quality of referrals, or cost-effectiveness, and one study found a reduction in time to cancer diagnosis. Barriers to implementation included trust, the compatibility of eCDST recommendations with the GP's role as a gatekeeper, and impact on workflow. CONCLUSION eCDSTs have the capacity to improve decision making for a cancer diagnosis, but the optimal mode of delivery remains unclear. Although such tools could assist GPs in the future, further well-designed trials of all eCDSTs are needed to determine their cost-effectiveness and the most appropriate implementation methods.
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14
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Cheewakriangkrai C, Kietpeerakool C, Aue-aungkul A, Charoenkwan K, Pattanittum P, John D, Lumbiganon P. Health education interventions to promote early presentation and referral for women with symptoms of endometrial cancer. Hippokratia 2019. [DOI: 10.1002/14651858.cd013253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Chalong Cheewakriangkrai
- Faculty of Medicine, Chiang Mai University; Department of Obstetrics and Gynecology; 110 Intawaroros Road Muang Chiang Mai Thailand 50200
| | - Chumnan Kietpeerakool
- Khon Kaen University; Department of Obstetrics and Gynaecology, Faculty of Medicine; 123 Mitraparb Road Amphur Muang Khon Kaen Thailand 40002
| | - Apiwat Aue-aungkul
- Khon Kaen University; Department of Obstetrics and Gynaecology, Faculty of Medicine; 123 Mitraparb Road Amphur Muang Khon Kaen Thailand 40002
| | - Kittipat Charoenkwan
- Faculty of Medicine, Chiang Mai University; Department of Obstetrics and Gynecology; 110 Intawaroros Road Muang Chiang Mai Thailand 50200
| | - Porjai Pattanittum
- Khon Kaen University; Department of Epidemiology and Biostatistics, Public Health Faculty; Mitraparp Road Mueng District Khon Kaen Khon Kaen Thailand 40002
| | | | - Pisake Lumbiganon
- Khon Kaen University; Department of Obstetrics and Gynaecology, Faculty of Medicine; 123 Mitraparb Road Amphur Muang Khon Kaen Thailand 40002
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15
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Langton S, Rijken JA, Bankhead CR, Plüddemann A, Leemans CR. Referrals for head and neck cancer in England and The Netherlands: an international qualitative study of the views of secondary-care surgical specialists. Br J Oral Maxillofac Surg 2019; 57:116-124. [PMID: 30661829 DOI: 10.1016/j.bjoms.2018.12.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 12/30/2018] [Indexed: 02/04/2023]
Abstract
One-year survival after head and neck cancer in England has been reported to be worse than that in Europe, despite five-year conditional survival being similar, which implies that patients present later in England. One country with better rates is The Netherlands. There are many possible causes, one of which may be the system of referral from primary to secondary care. We have compared the views of secondary care specialists in the two countries about their systems for referral, and identified aspects that might have an impact on outcomes. We organised semistructured qualitative interviews of surgical specialists in head and neck cancer in England and The Netherlands (n=12 in each). The most common theme was communication between primary care and specialists. Surgeons in England identified this as the aspect most lacking under the English "two-week" rule, while Dutch specialists felt that the good communication in their system was one of its best points. Other themes included the educational needs of primary care practitioners, criticism of "tick box" referrals in England, and too many patients referred who do not have cancer. Overall, specialists in both countries identified good aspects of their respective referral systems, but those in England felt strongly that the "two-week" rule/NICE guidance system could be improved with better direct communication between primary and secondary care, which might improve the speed and quality of referrals, reduce unnecessary ones, and assist in educating primary care physicians. It is not clear whether such improvements would improve survival, but further research and piloting of such a system should be considered in England.
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Affiliation(s)
| | - J A Rijken
- Amsterdam UMC, Vrije Universiteit Amsterdam, Otolaryngology/Head and Neck Surgery, Cancer Center Amsterdam, De Boelelaan, Amsterdam, Netherlands.
| | - C R Bankhead
- Nuffield Department of Primary Care Health Sciences, University of Oxford.
| | - A Plüddemann
- Nuffield Department of Primary Care Health Sciences, University of Oxford.
| | - C R Leemans
- Amsterdam UMC, Vrije Universiteit Amsterdam, Otolaryngology/Head and Neck Surgery, Cancer Center Amsterdam, De Boelelaan, Amsterdam, Netherlands.
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16
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Patient and primary care delays in the diagnostic pathway of gynaecological cancers: a systematic review of influencing factors. Br J Gen Pract 2019; 69:e106-e111. [PMID: 30642909 PMCID: PMC6355279 DOI: 10.3399/bjgp19x700781] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 09/24/2018] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Gynaecological cancers are the second most common female cancer type, with survival rates in the UK lower than in many comparable countries. A potentially important factor in the UK's poorer cancer outcomes is diagnostic delay; gynaecological cancers are the cancer type most likely to be affected by less timely diagnosis. AIM To examine current evidence for factors that contribute to patient and primary care delays in the diagnostic pathway of gynaecological cancer. DESIGN AND SETTING A systematic review of the available literature. METHOD PRISMA guidelines were followed. MEDLINE and Embase databases and the Cochrane Library were searched using three terms: primary care; gynaecological cancer; and delay. Citation lists of all identified articles were searched. Two authors independently screened the titles, abstracts, and full texts of publications. Data extraction was performed by one author and quality assured by a second reviewer in a 20% sample of selected articles. Synthesis was narrative. RESULTS A total of 1253 references was identified, of which 37 met the inclusion criteria. Factors associated with delayed diagnosis were categorised as either patient factors (patient demographics, symptoms or knowledge, and presentation to the GP) or primary care factors (doctor factors: patient demographics, symptoms or knowledge, and referral process); and system factors (such as limited access to investigations). CONCLUSION Delayed diagnosis in the patient and primary care intervals of the diagnostic journey of gynaecological cancer is complex and multifactorial. This review identifies areas of future research that could lead to interventions to enable prompter diagnosis of gynaecological cancers.
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17
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Stanciu MA, Law RJ, Nafees S, Hendry M, Yeo ST, Hiscock J, Lewis R, Edwards RT, Williams NH, Brain K, Brocklehurst P, Carson-Stevens A, Dolwani S, Emery J, Hamilton W, Hoare Z, Lyratzopoulos G, Rubin G, Smits S, Vedsted P, Walter F, Wilkinson C, Neal RD. Development of an intervention to expedite cancer diagnosis through primary care: a protocol. BJGP Open 2018; 2:bjgpopen18X101595. [PMID: 30564728 PMCID: PMC6189786 DOI: 10.3399/bjgpopen18x101595] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 04/16/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND GPs can play an important role in achieving earlier cancer diagnosis to improve patient outcomes, for example through prompt use of the urgent suspected cancer referral pathway. Barriers to early diagnosis include individual practitioner variation in knowledge, attitudes, beliefs, professional expectations, and norms. AIM This programme of work (Wales Interventions and Cancer Knowledge about Early Diagnosis [WICKED]) will develop a behaviour change intervention to expedite diagnosis through primary care and contribute to improved cancer outcomes. DESIGN & SETTING Non-experimental mixed-method study with GPs and primary care practice teams from Wales. METHOD Four work packages will inform the development of the behaviour change intervention. Work package 1 will identify relevant evidence-based interventions (systematic review of reviews) and will determine why interventions do or do not work, for whom, and in what circumstances (realist review). Work package 2 will assess cancer knowledge, attitudes, and behaviour of GPs, as well as primary care teams' perspectives on cancer referral and investigation (GP survey, discrete choice experiment [DCE], interviews, and focus groups). Work package 3 will synthesise findings from earlier work packages using the behaviour change wheel as an overarching theoretical framework to guide intervention development. Work package 4 will test the feasibility and acceptability of the intervention, and determine methods for measuring costs and effects of subsequent behaviour change in a randomised feasibility trial. RESULTS The findings will inform the design of a future effectiveness trial, with concurrent economic evaluation, aimed at earlier diagnosis. CONCLUSION This comprehensive, evidence-based programme will develop a complex GP behaviour change intervention to expedite the diagnosis of symptomatic cancer, and may be applicable to countries with similar healthcare systems.
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Affiliation(s)
- Marian Andrei Stanciu
- Research Officer, North Wales Centre for Primary Care Research, Bangor University, Wrexham, UK
| | - Rebecca-Jane Law
- Research Officer, North Wales Centre for Primary Care Research, Bangor University, Wrexham, UK
| | - Sadia Nafees
- Research Project Support Officer, North Wales Centre for Primary Care Research, Bangor University, Wrexham, UK
| | - Maggie Hendry
- Research Fellow, North Wales Centre for Primary Care Research, Bangor University, Wrexham, UK
| | - Seow Tien Yeo
- Research Fellow, Centre for Health Economics and Medicines Evaluation (CHEME), Bangor University, Bangor, UK
| | - Julia Hiscock
- Research Fellow, North Wales Centre for Primary Care Research, Bangor University, Wrexham, UK
| | - Ruth Lewis
- Research Fellow in Health Sciences Research, North Wales Centre for Primary Care Research, Bangor University, Wrexham, UK
| | - Rhiannon T Edwards
- Professor of Health Economics, Centre for Health Economics and Medicines Evaluation (CHEME), Bangor University, Bangor, UK
| | - Nefyn H Williams
- Professor in Primary Care, Department of Health Services Research, University of Liverpool, Liverpool, UK
| | - Katherine Brain
- Professor, Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Paul Brocklehurst
- Professor in Health Services Research, North Wales Organisation for Randomised Trials in Health, Bangor University, Bangor, UK
| | - Andrew Carson-Stevens
- Clinical Reader, Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Sunil Dolwani
- Senior Clinical Lecturer, Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Jon Emery
- Professor of Primary Care Cancer Research, Department of General Practice and Centre for Cancer Research, University of Melbourne, Melbourne, Australia
| | - William Hamilton
- Professor of Primary Care Diagnostics, Discovery Research Group, University of Exeter, Exeter, UK
| | - Zoe Hoare
- Principal Trial Statistician, North Wales Organisation for Randomised Trials in Health, Bangor University, Bangor, UK
| | - Georgios Lyratzopoulos
- Professor of Cancer Epidemiology, Department of Behavioural Science and Health, University College London, London, UK
| | - Greg Rubin
- Professor of General Practice and Primary Care, Institute of Health and Society, University of Newcastle, Newcastle, UK
| | - Stephanie Smits
- Research Associate, Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Peter Vedsted
- Professor, Research Director, Department of Public Health, Research Centre for Cancer Diagnosis, Research Unit for General Practice, Aarhus University, Aarhus, Denmark
- Professor, Research Director, Department of Clinical Medicine, University Clinic for Innovative Health Care Delivery, Silkeborg Hospital, Aarhus University, Aarhus, Denmark
| | - Fiona Walter
- Principal Researcher in Primary Care Cancer Research, Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Clare Wilkinson
- Professor of General Practice, North Wales Centre for Primary Care Research, Bangor University, Wrexham, UK
| | - Richard D Neal
- Professor of Primary Care Oncology, Academic Unit of Primary Care, Institute of Health Sciences, University of Leeds, Leeds, UK
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18
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Malalasekera A, Nahm S, Blinman PL, Kao SC, Dhillon HM, Vardy JL. How long is too long? A scoping review of health system delays in lung cancer. Eur Respir Rev 2018; 27:27/149/180045. [PMID: 30158277 PMCID: PMC9488868 DOI: 10.1183/16000617.0045-2018] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 06/13/2018] [Indexed: 01/31/2023] Open
Abstract
Earlier access to lung cancer specialist (LCS) care improves survival, highlighting the need for streamlined patient referral. International guidelines recommend 14-day maximum time intervals from general practitioner (GP) referral to first LCS appointment (“GP–LCS interval”), and diagnosis to treatment (“treatment interval”). We compared time intervals in lung cancer care against timeframe benchmarks, and explored barriers and facilitators to timely care. We conducted a scoping review of literature from MEDLINE, Embase, Scopus and hand searches. Primary end-points were GP–LCS and treatment intervals. Performance against guidelines and factors responsible for delays were explored. We used descriptive statistics and nonparametric Wilcoxon rank sum tests to compare intervals in studies reporting fast-track interventions. Of 1343 identified studies, 128 full-text articles were eligible. Only 33 (26%) studies reported GP–LCS intervals, with an overall median of 7 days and distributions largely meeting guidelines. Overall, 52 (41%) studies reported treatment intervals, with a median of 27 days, and distributions of times falling short of guidelines. There was no effect of fast-track interventions on reducing time intervals. Lack of symptoms and multiple procedures or specialist visits were suggested causes for delay. Although most patients with lung cancer see a specialist within a reasonable timeframe, treatment commencement is often delayed. There is regional variation in establishing timeliness of care. Delays to lung cancer care occur, especially in secondary care; variation in timeframe guidelines needs addressinghttp://ow.ly/hZt730kvKAb
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Affiliation(s)
- Ashanya Malalasekera
- Sydney Medical School, University of Sydney, Sydney, Australia.,Concord Cancer Centre, Concord Repatriation General Hospital, Sydney, Australia
| | - Sharon Nahm
- Concord Cancer Centre, Concord Repatriation General Hospital, Sydney, Australia
| | - Prunella L Blinman
- Concord Cancer Centre, Concord Repatriation General Hospital, Sydney, Australia
| | - Steven C Kao
- Sydney Medical School, University of Sydney, Sydney, Australia.,Chris O'Brien Lifehouse, Sydney, Australia
| | - Haryana M Dhillon
- Centre for Medical Psychology & Evidence-based Decision-making, University of Sydney, Sydney, Australia
| | - Janette L Vardy
- Sydney Medical School, University of Sydney, Sydney, Australia.,Concord Cancer Centre, Concord Repatriation General Hospital, Sydney, Australia.,Centre for Medical Psychology & Evidence-based Decision-making, University of Sydney, Sydney, Australia
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19
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Emery JD, Gray V, Walter FM, Cheetham S, Croager EJ, Slevin T, Saunders C, Threlfall T, Auret K, Nowak AK, Geelhoed E, Bulsara M, Holman CDJ. The Improving Rural Cancer Outcomes Trial: a cluster-randomised controlled trial of a complex intervention to reduce time to diagnosis in rural cancer patients in Western Australia. Br J Cancer 2017; 117:1459-1469. [PMID: 28926528 PMCID: PMC5680459 DOI: 10.1038/bjc.2017.310] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 07/19/2017] [Accepted: 08/14/2017] [Indexed: 11/28/2022] Open
Abstract
Background: Rural Australians have poorer survival for most common cancers, due partially to later diagnosis. Internationally, several initiatives to improve cancer outcomes have focused on earlier presentation to healthcare and timely diagnosis. We aimed to measure the effect of community-based symptom awareness and general practice-based educational interventions on the time to diagnosis in rural patients presenting with breast, prostate, colorectal or lung cancer in Western Australia. Methods: 2 × 2 factorial cluster randomised controlled trial. Community Intervention: cancer symptom awareness campaign tailored for rural Australians. GP intervention: resource card with symptom risk assessment charts and local cancer referral pathways implemented through multiple academic detailing visits. Trial Area A received the community symptom awareness and Trial Area B acted as the community campaign control region. Within both Trial Areas general practices were randomised to the GP intervention or control. Primary outcome: total diagnostic interval (TDI). Results: 1358 people with incident breast, prostate, colorectal or lung cancer were recruited. There were no significant differences in the median or ln mean TDI at either intervention level (community intervention vs control: median TDI 107.5 vs 92 days; ln mean difference 0.08 95% CI −0.06–0.23 P=0.27; GP intervention vs control: median TDI 97 vs 96.5 days; ln mean difference 0.004 95% CI −0.18–0.19 P=0.99). There were no significant differences in the TDI when analysed by factorial design, tumour group or sub-intervals of the TDI. Conclusions: This is the largest trial to test the effect of community campaign or GP interventions on timeliness of cancer diagnosis. We found no effect of either intervention. This may reflect limited dose of the interventions, or the limited duration of follow-up. Alternatively, these interventions do not have a measurable effect on time to cancer diagnosis.
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Affiliation(s)
- Jon D Emery
- Department of General Practice and The Centre for Cancer Research, The University of Melbourne, Melbourne, VIC, Australia.,School of Primary, Aboriginal and Rural Health Care, The University of Western Australia, Crawley, WA, Australia.,The Primary Care Unit, Department of Public Health & Primary Care, University of Cambridge, Cambridge, UK
| | - Victoria Gray
- School of Primary, Aboriginal and Rural Health Care, The University of Western Australia, Crawley, WA, Australia.,School of Population Health, The University of Western Australia, Crawley, WA, Australia.,Education and Research Division, Cancer Council Western Australia, Subiaco, WA, Australia
| | - Fiona M Walter
- School of Primary, Aboriginal and Rural Health Care, The University of Western Australia, Crawley, WA, Australia.,The Primary Care Unit, Department of Public Health & Primary Care, University of Cambridge, Cambridge, UK.,General Practice and Primary Health Care Academic Centre, Melbourne Medical School, The University of Melbourne, Melbourne, VIC, Australia
| | - Shelley Cheetham
- School of Primary, Aboriginal and Rural Health Care, The University of Western Australia, Crawley, WA, Australia.,School of Nursing, Midwifery and Paramedicine, Curtin University, Bentley, WA, Australia
| | - Emma J Croager
- Education & Research Division, Cancer Council Western Australia; School of Psychology and Speech Pathology, Curtin University, Bentley, WA, Australia
| | - Terry Slevin
- Education & Research Division, Cancer Council Western Australia; School of Psychology and Speech Pathology, Curtin University, Bentley, WA, Australia
| | - Christobel Saunders
- School of Surgery, The University of Western Australia, Crawley, WA, Australia
| | - Timothy Threlfall
- Western Australia Cancer Registry, The Department of Health of Western Australia, Perth, WA, Australia
| | - Kirsten Auret
- Rural Clinical School of Western Australia, The University of Western Australia, Albany, WA, Australia
| | - Anna K Nowak
- School of Medicine, The University of Western Australia, Crawley, WA, Australia.,Department of Medical Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Elizabeth Geelhoed
- School of Population Health, The University of Western Australia, Crawley, WA, Australia
| | - Max Bulsara
- Institute for Health Research, University of Notre Dame, Freemantle, WA, Australia
| | - C D'Arcy J Holman
- School of Population Health, The University of Western Australia, Crawley, WA, Australia
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Varela-Centelles P, Seoane J, Lopez-Cedrun JL, Fernandez-Sanroman J, García-Martin JM, Takkouche B, Alvarez-Novoa P, Seoane-Romero JM. The length of patient and primary care time interval in the pathways to treatment in symptomatic oral cancer. A quantitative systematic review. Clin Otolaryngol 2017. [PMID: 28627802 DOI: 10.1111/coa.12919] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES To examine the relative length of the patient and primary care intervals in symptomatic oral cancer. DESIGN Quantitative systematic review. SEARCH STRATEGY Oral cancer OR oral squamous cell carcinoma OR oropharyngeal cancer AND time interval OR diagnostic delay. SETTING Primary and secondary care. PARTICIPANTS Oral and oropharyngeal cancer patients. MAIN OUTCOME MEASURES We computed five measures (patient, primary care, diagnosis, total diagnosis and total treatment intervals). Most studies did not provide any dispersion measure. We then used the sample size of each study to compute a weighted average of the mean intervals. When the median was provided, we assumed normality of the distribution of the means and used the median as a proxy of the mean. RESULTS A total of 1089 articles were identified, and 22 met the inclusion criteria, reporting on 2710 patients from Europe, USA, India, Australia, Japan, Argentina and Iran. The weighted average of patient interval was 80.3 days. Primary care interval was five times shorter: 15.8 days. The diagnostic interval was appreciably shorter (47.9 days) when compared with the patient interval during symptomatic period. CONCLUSIONS Patient interval represents the major component of waiting times since the detection of the first signs/symptoms to the definitive diagnosis of oral cancer. Thus, strategies focused on high-risk patients should be prioritised. Interventions aimed at optimising the health systems should be implemented by monitoring and facilitating diagnostic and treatment pathways of patients with oral cancer.
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Affiliation(s)
- P Varela-Centelles
- Primary Care, EOXI Lugo, Cervo, e Monforte, Galician Health Service, Lugo, Spain.,Stomatology Department, University of Santiago de Compostela, Santiago de Compostela (A Coruña), Spain
| | - J Seoane
- Stomatology Department, University of Santiago de Compostela, Santiago de Compostela (A Coruña), Spain
| | - J L Lopez-Cedrun
- Service of Oral and Maxillofacial Surgery, A Coruña University Hospital, Galician Health Service, A Coruña, Spain
| | - J Fernandez-Sanroman
- Service of Oral and Maxillofacial Surgery, POVISA Hospital, Vigo (Pontevedra), Spain
| | - J M García-Martin
- Department of Medical-Surgical Specialities, University of Oviedo, Oviedo, Spain
| | - B Takkouche
- Department of Preventive Medicine, University of Santiago de Compostela, Santiago de Compostela (A Coruña), Spain
| | - P Alvarez-Novoa
- Stomatology Department, University of Santiago de Compostela, Santiago de Compostela (A Coruña), Spain
| | - J M Seoane-Romero
- Stomatology Department, University of Santiago de Compostela, Santiago de Compostela (A Coruña), Spain
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Abstract
Aim To measure the knowledge, perceptions, and practices of Jordanian primary healthcare practitioners (PHCPs) (physicians, nurses, midwives, and nurse aids) employed in Jordanian Ministry of Health (MoH) primary health clinics with respect to counseling on cancer (cancer screening, the signs and symptoms of cancer, and referral for specialized care). BACKGROUND Integration of oncology services within primary care is a means of enhancing cancer early detection, and requires involvement of skilled. In the Middle East, little is known about PHCPs' potential to be providers of such services. METHODS A questionnaire measuring PHCP perceptions and practices related to counseling on cancer screening and diagnosis was distributed to PHCPs across MoH clinics covering the main regions of Jordan. Findings A total of 322 practitioners responded (75.1% response). Across most activities involving cancer detection, no more than 30% reported performing activities. Roughly half of PHCPs expressed discomfort at providing cancer-related counseling and at least 43% of non-physicians expressed limited confidence in cancer-related counseling. Confidence was a consistent predictor of provision of counseling and confidence in turn was associated with having greater knowledge, having positive a valuation of counseling, and being a physician. Results reveal points where educational efforts can strengthen PHCPs' provision of cancer control-related services.
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Honein-AbouHaidar GN, Stuart-McEwan T, Waddell T, Salvarrey A, Smylie J, Dobrow MJ, Brouwers MC, Gagliardi AR. How do organisational characteristics influence teamwork and service delivery in lung cancer diagnostic assessment programmes? A mixed-methods study. BMJ Open 2017; 7:e013965. [PMID: 28235969 PMCID: PMC5337676 DOI: 10.1136/bmjopen-2016-013965] [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: 12/25/2022] Open
Abstract
OBJECTIVES Diagnostic assessment programmes (DAPs) can reduce wait times for cancer diagnosis, but optimal DAP design is unknown. This study explored how organisational characteristics influenced multidisciplinary teamwork and diagnostic service delivery in lung cancer DAPs. DESIGN A mixed-methods approach integrated data from descriptive qualitative interviews and medical record abstraction at 4 lung cancer DAPs. Findings were analysed with the Integrated Team Effectiveness Model. SETTING 4 DAPs at 2 teaching and 2 community hospitals in Canada. PARTICIPANTS 22 staff were interviewed about organisational characteristics, target service benchmarks, and teamwork processes, determinants and outcomes; 314 medical records were reviewed for actual service benchmarks. RESULTS Formal, informal and asynchronous team processes enabled service delivery and yielded many perceived benefits at the patient, staff and service levels. However, several DAP characteristics challenged teamwork and service delivery: referral volume/workload, time since launch, days per week of operation, rural-remote population, number and type of full-time/part-time human resources, staff colocation, information systems. As a result, all sites failed to meet target benchmarks (from referral to consultation median 4.0 visits, median wait time 35.0 days). Recommendations included improved information systems, more staff in all specialties, staff colocation and expanded roles for patient navigators. Findings were captured in a conceptual framework of lung cancer DAP teamwork determinants and outcomes. CONCLUSIONS This study identified several DAP characteristics that could be improved to facilitate teamwork and enhance service delivery, thereby contributing to knowledge of organisational determinants of teamwork and associated outcomes. Findings can be used to update existing DAP guidelines, and by managers to plan or evaluate lung cancer DAPs. Ongoing research is needed to identify ideal roles for navigators, and staffing models tailored to case volumes.
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Affiliation(s)
| | - Terri Stuart-McEwan
- Gattuso Rapid Diagnosis Centre, University Health Network, Toronto, Ontario, Canada
| | - Tom Waddell
- Division of Thoracic Surgery, University Health Network, Toronto, Ontario, Canada
| | - Alexandra Salvarrey
- Division of Thoracic Surgery, University Health Network, Toronto, Ontario, Canada
| | - Jennifer Smylie
- Ages Cancer Assessment Clinic, Ottawa Hospital, Ottawa, Canada
| | - Mark J Dobrow
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Melissa C Brouwers
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Anna R Gagliardi
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
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ACC/AHA Special Report: Clinical Practice Guideline Implementation Strategies: A Summary of Systematic Reviews by the NHLBI Implementation Science Work Group. J Am Coll Cardiol 2017; 69:1076-1092. [DOI: 10.1016/j.jacc.2016.11.004] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Sussman J, Bainbridge D, Evans WK. Towards Integrating Primary Care with Cancer Care: A Regional Study of Current Gaps and Opportunities in Canada. Healthc Policy 2017; 12:50-65. [PMID: 28277204 PMCID: PMC5344363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Better integration between cancer care systems and primary care physicians (PCPs) is a goal of most healthcare systems, but little direction exists on how this can be achieved. This study systematically examined the extent of integration between PCPs and a regional cancer program (RCP) to identify opportunities for improvement. METHOD Cross-sectional survey of all practising PCPs in the region of interest using a study-specific instrument based on a three-tier conceptualization of integration. RESULTS Among the 473 PCPs who responded (63% response rate), perceived role clarity and the desire for greater involvement in patient care varied across the care trajectory. Specific gaps were identified in PCPs' understanding of the referral process and patient follow-up after treatment. CONCLUSION Our novel survey of PCPs explicated the strategies that could improve their integration in cancer care, including mechanisms to support PCPs in the initial diagnosis of their patients and standardized post-treatment transition plans outlining care roles and responsibilities.
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Chan WV, Pearson TA, Bennett GC, Cushman WC, Gaziano TA, Gorman PN, Handler J, Krumholz HM, Kushner RF, MacKenzie TD, Sacco RL, Smith SC, Stevens VJ, Wells BL, Castillo G, Heil SKR, Stephens J, Vann JCJ. ACC/AHA Special Report: Clinical Practice Guideline Implementation Strategies: A Summary of Systematic Reviews by the NHLBI Implementation Science Work Group: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2017; 135:e122-e137. [PMID: 28126839 DOI: 10.1161/cir.0000000000000481] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND In 2008, the National Heart, Lung, and Blood Institute convened an Implementation Science Work Group to assess evidence-based strategies for effectively implementing clinical practice guidelines. This was part of a larger effort to update existing clinical practice guidelines on cholesterol, blood pressure, and overweight/obesity. OBJECTIVES Review evidence from the published implementation science literature and identify effective or promising strategies to enhance the adoption and implementation of clinical practice guidelines. METHODS This systematic review was conducted on 4 critical questions, each focusing on the adoption and effectiveness of 4 intervention strategies: (1) reminders, (2) educational outreach visits, (3) audit and feedback, and (4) provider incentives. A scoping review of the Rx for Change database of systematic reviews was used to identify promising guideline implementation interventions aimed at providers. Inclusion and exclusion criteria were developed a priori for each question, and the published literature was initially searched up to 2012, and then updated with a supplemental search to 2015. Two independent reviewers screened the returned citations to identify relevant reviews and rated the quality of each included review. RESULTS Audit and feedback and educational outreach visits were generally effective in improving both process of care (15 of 21 reviews and 12 of 13 reviews, respectively) and clinical outcomes (7 of 12 reviews and 3 of 5 reviews, respectively). Provider incentives showed mixed effectiveness for improving both process of care (3 of 4 reviews) and clinical outcomes (3 reviews equally distributed between generally effective, mixed, and generally ineffective). Reminders showed mixed effectiveness for improving process of care outcomes (27 reviews with 11 mixed and 3 generally ineffective results) and were generally ineffective for clinical outcomes (18 reviews with 6 mixed and 9 generally ineffective results). Educational outreach visits (2 of 2 reviews), reminders (3 of 4 reviews), and provider incentives (1 of 1 review) were generally effective for cost reduction. Educational outreach visits (1 of 1 review) and provider incentives (1 of 1 review) were also generally effective for cost-effectiveness outcomes. Barriers to clinician adoption or adherence to guidelines included time constraints (8 reviews/overviews); limited staffing resources (2 overviews); timing (5 reviews/overviews); clinician skepticism (5 reviews/overviews); clinician knowledge of guidelines (4 reviews/overviews); and higher age of the clinician (1 overview). Facilitating factors included guideline characteristics such as format, resources, and end-user involvement (6 reviews/overviews); involving stakeholders (5 reviews/overviews); leadership support (5 reviews/overviews); scope of implementation (5 reviews/overviews); organizational culture such as multidisciplinary teams and low-baseline adherence (9 reviews/overviews); and electronic guidelines systems (3 reviews). CONCLUSION The strategies of audit and feedback and educational outreach visits were generally effective in improving both process of care and clinical outcomes. Reminders and provider incentives showed mixed effectiveness, or were generally ineffective. No general conclusion could be reached about cost effectiveness, because of limitations in the evidence. Important gaps exist in the evidence on effectiveness of implementation interventions, especially regarding clinical outcomes, cost effectiveness and contextual issues affecting successful implementation.
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Affiliation(s)
- Wiley V Chan
- Implementation Science Work Group, National Heart, Lung, and Blood Institute. Center for Translation Research and Implementation Science; National Heart, Lung, and Blood Institute. Veterans Affairs Medical Center, Memphis, TN. Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute. American Institutes for Research conducted the systematic review under a contract with the National Heart, Lung, and Blood Institute
| | - Thomas A Pearson
- Implementation Science Work Group, National Heart, Lung, and Blood Institute. Center for Translation Research and Implementation Science; National Heart, Lung, and Blood Institute. Veterans Affairs Medical Center, Memphis, TN. Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute. American Institutes for Research conducted the systematic review under a contract with the National Heart, Lung, and Blood Institute
| | - Glen C Bennett
- Implementation Science Work Group, National Heart, Lung, and Blood Institute. Center for Translation Research and Implementation Science; National Heart, Lung, and Blood Institute. Veterans Affairs Medical Center, Memphis, TN. Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute. American Institutes for Research conducted the systematic review under a contract with the National Heart, Lung, and Blood Institute
| | - William C Cushman
- Implementation Science Work Group, National Heart, Lung, and Blood Institute. Center for Translation Research and Implementation Science; National Heart, Lung, and Blood Institute. Veterans Affairs Medical Center, Memphis, TN. Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute. American Institutes for Research conducted the systematic review under a contract with the National Heart, Lung, and Blood Institute
| | - Thomas A Gaziano
- Implementation Science Work Group, National Heart, Lung, and Blood Institute. Center for Translation Research and Implementation Science; National Heart, Lung, and Blood Institute. Veterans Affairs Medical Center, Memphis, TN. Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute. American Institutes for Research conducted the systematic review under a contract with the National Heart, Lung, and Blood Institute
| | - Paul N Gorman
- Implementation Science Work Group, National Heart, Lung, and Blood Institute. Center for Translation Research and Implementation Science; National Heart, Lung, and Blood Institute. Veterans Affairs Medical Center, Memphis, TN. Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute. American Institutes for Research conducted the systematic review under a contract with the National Heart, Lung, and Blood Institute
| | - Joel Handler
- Implementation Science Work Group, National Heart, Lung, and Blood Institute. Center for Translation Research and Implementation Science; National Heart, Lung, and Blood Institute. Veterans Affairs Medical Center, Memphis, TN. Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute. American Institutes for Research conducted the systematic review under a contract with the National Heart, Lung, and Blood Institute
| | - Harlan M Krumholz
- Implementation Science Work Group, National Heart, Lung, and Blood Institute. Center for Translation Research and Implementation Science; National Heart, Lung, and Blood Institute. Veterans Affairs Medical Center, Memphis, TN. Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute. American Institutes for Research conducted the systematic review under a contract with the National Heart, Lung, and Blood Institute
| | - Robert F Kushner
- Implementation Science Work Group, National Heart, Lung, and Blood Institute. Center for Translation Research and Implementation Science; National Heart, Lung, and Blood Institute. Veterans Affairs Medical Center, Memphis, TN. Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute. American Institutes for Research conducted the systematic review under a contract with the National Heart, Lung, and Blood Institute
| | - Thomas D MacKenzie
- Implementation Science Work Group, National Heart, Lung, and Blood Institute. Center for Translation Research and Implementation Science; National Heart, Lung, and Blood Institute. Veterans Affairs Medical Center, Memphis, TN. Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute. American Institutes for Research conducted the systematic review under a contract with the National Heart, Lung, and Blood Institute
| | - Ralph L Sacco
- Implementation Science Work Group, National Heart, Lung, and Blood Institute. Center for Translation Research and Implementation Science; National Heart, Lung, and Blood Institute. Veterans Affairs Medical Center, Memphis, TN. Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute. American Institutes for Research conducted the systematic review under a contract with the National Heart, Lung, and Blood Institute
| | - Sidney C Smith
- Implementation Science Work Group, National Heart, Lung, and Blood Institute. Center for Translation Research and Implementation Science; National Heart, Lung, and Blood Institute. Veterans Affairs Medical Center, Memphis, TN. Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute. American Institutes for Research conducted the systematic review under a contract with the National Heart, Lung, and Blood Institute
| | - Victor J Stevens
- Implementation Science Work Group, National Heart, Lung, and Blood Institute. Center for Translation Research and Implementation Science; National Heart, Lung, and Blood Institute. Veterans Affairs Medical Center, Memphis, TN. Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute. American Institutes for Research conducted the systematic review under a contract with the National Heart, Lung, and Blood Institute
| | - Barbara L Wells
- Implementation Science Work Group, National Heart, Lung, and Blood Institute. Center for Translation Research and Implementation Science; National Heart, Lung, and Blood Institute. Veterans Affairs Medical Center, Memphis, TN. Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute. American Institutes for Research conducted the systematic review under a contract with the National Heart, Lung, and Blood Institute
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Chauhan BF, Jeyaraman MM, Mann AS, Lys J, Skidmore B, Sibley KM, Abou-Setta AM, Zarychanski R. Behavior change interventions and policies influencing primary healthcare professionals' practice-an overview of reviews. Implement Sci 2017; 12:3. [PMID: 28057024 PMCID: PMC5216570 DOI: 10.1186/s13012-016-0538-8] [Citation(s) in RCA: 109] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 12/13/2016] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND There is a plethora of interventions and policies aimed at changing practice habits of primary healthcare professionals, but it is unclear which are the most appropriate, sustainable, and effective. We aimed to evaluate the evidence on behavior change interventions and policies directed at healthcare professionals working in primary healthcare centers. METHODS Study design: overview of reviews. DATA SOURCE MEDLINE (Ovid), Embase (Ovid), The Cochrane Library (Wiley), CINAHL (EbscoHost), and grey literature (January 2005 to July 2015). STUDY SELECTION two reviewers independently, and in duplicate, identified systematic reviews, overviews of reviews, scoping reviews, rapid reviews, and relevant health technology reports published in full-text in the English language. DATA EXTRACTION AND SYNTHESIS two reviewers extracted data pertaining to the types of reviews, study designs, number of studies, demographics of the professionals enrolled, interventions, outcomes, and authors' conclusions for the included studies. We evaluated the methodological quality of the included studies using the AMSTAR scale. For the comparative evaluation, we classified interventions according to the behavior change wheel (Michie et al.). RESULTS Of 2771 citations retrieved, we included 138 reviews representing 3502 individual studies. The majority of systematic reviews (91%) investigated behavior and practice changes among family physicians. Interactive and multifaceted continuous medical education programs, training with audit and feedback, and clinical decision support systems were found to be beneficial in improving knowledge, optimizing screening rate and prescriptions, enhancing patient outcomes, and reducing adverse events. Collaborative team-based policies involving primarily family physicians, nurses, and pharmacists were found to be most effective. Available evidence on environmental restructuring and modeling was found to be effective in improving collaboration and adherence to treatment guidelines. Limited evidence on nurse-led care approaches were found to be as effective as general practitioners in patient satisfaction in settings like asthma, cardiovascular, and diabetes clinics, although this needs further evaluation. Evidence does not support the use of financial incentives to family physicians, especially for long-term behavior change. CONCLUSIONS Behavior change interventions including education, training, and enablement in the context of collaborative team-based approaches are effective to change practice of primary healthcare professionals. Environmental restructuring approaches including nurse-led care and modeling need further evaluation. Financial incentives to family physicians do not influence long-term practice change.
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Affiliation(s)
- Bhupendrasinh F Chauhan
- College of Pharmacy, University of Manitoba, Winnipeg, Canada.
- Children's Hospital Research Institute of Manitoba, Winnipeg, Canada.
- George & Fay Yee Centre for Healthcare Innovation, Winnipeg, MB, Canada.
| | - Maya M Jeyaraman
- George & Fay Yee Centre for Healthcare Innovation, Winnipeg, MB, Canada
| | | | - Justin Lys
- George & Fay Yee Centre for Healthcare Innovation, Winnipeg, MB, Canada
| | | | - Kathryn M Sibley
- George & Fay Yee Centre for Healthcare Innovation, Winnipeg, MB, Canada
- Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Ahmed M Abou-Setta
- George & Fay Yee Centre for Healthcare Innovation, Winnipeg, MB, Canada
- Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Ryan Zarychanski
- George & Fay Yee Centre for Healthcare Innovation, Winnipeg, MB, Canada
- Community Health Sciences, University of Manitoba, Winnipeg, Canada
- Department of Haematology and Medical Oncology, CancerCare Manitoba, Winnipeg, Canada
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
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Linkage and Referral to HIV and Other Medical and Social Services: A Focused Literature Review for Sexually Transmitted Disease Prevention and Control Programs. Sex Transm Dis 2016; 43:S76-82. [PMID: 26779689 DOI: 10.1097/olq.0000000000000290] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Sexually transmitted disease (STD) program and clinic staff play an important role in providing linkage and referrals to programs and services that address the complex medical and psychosocial needs of their clients. We synthesized recent published literature related to effective practices for linkage to care for HIV and referral to other medical and social services. METHODS Three PubMed searches were conducted to identify relevant studies published since 2004 on (1) linkage to HIV care, (2) referral within STD clinical contexts, and (3) (review articles only) referral practices among all medical specialties. Systematic review procedures were not used. RESULTS Thirty-three studies were included in this review. Studies highlight the limited value of passive referral practices and the increased effectiveness of active referral and linkage practices. Numerous studies on linkage to HIV care suggest that case management approaches, cultural-linguistic concordance between linkage staff and clients, and structural features such as colocation facilitate timely linkage to care. Integration of other medical and social services such as family planning and alcohol screening services into STD settings may be optimal but resource-intensive. Active referral practices such as having a written referral protocols and agreements, using information technology to help transfer information between providers, and making appointments for clients may offer some benefit. Few studies included information on program costs associated with linkage and referral. CONCLUSIONS Recent literature provides some guideposts for STD program and clinical staff to use in determining their approach to helping link and refer clients to needed care. Much experience with these issues within STD services remains unpublished, and key gaps in the literature remain.
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Fast-track access to urologic care for patients with macroscopic haematuria is efficient and cost-effective: results from a prospective intervention study. Br J Cancer 2016; 115:770-5. [PMID: 27560554 PMCID: PMC5046212 DOI: 10.1038/bjc.2016.265] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 07/22/2016] [Accepted: 08/01/2016] [Indexed: 01/28/2023] Open
Abstract
Background: The delay between onset of macroscopic haematuria and diagnosis of bladder cancer is often long. Methods: We evaluated timely diagnosis and health-care costs for patients with macroscopic haematuria given fast-track access to diagnostics. During a 15-month period, a telephone hotline for fast-track diagnostics was provided in nine Swedish municipalities for patients aged ⩾50 years with macroscopic haematuria. The control group comprised 101 patients diagnosed with bladder cancer in the same catchment area with macroscopic haematuria who underwent regular diagnostic process. Results: In all 275 patients who called ‘the Red Phone' hotline were investigated, and 47 of them (17%) were diagnosed with cancer and 36 of those had bladder cancer. Median time from patient-reported haematuria to diagnosis was 29 (interquartile range (IQR) 14−104) days and 50 (IQR 27−165) days in the intervention and the control group, respectively (P=0.03). The median health-care costs were lower in the intervention group (655 (IQR 655−655) EUR) than in the control group (767 (IQR 490−1096) EUR) (P=0.002). Conclusions: Direct access to urologic expertise and fast-track diagnostics is motivated for patients with macroscopic haematuria to reduce diagnostic intervals and lower health-care expenditures.
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Miles A, McClements PL, Steele RJC, Redeker C, Sevdalis N, Wardle J. Perceived diagnostic delay and cancer-related distress: a cross-sectional study of patients with colorectal cancer. Psychooncology 2016; 26:29-36. [PMID: 26868950 DOI: 10.1002/pon.4093] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 11/25/2015] [Accepted: 01/15/2016] [Indexed: 12/20/2022]
Abstract
OBJECTIVE This study aimed to examine the effect of perceived diagnostic delay on cancer-related distress and determine whether fear of cancer-recurrence and quality of life mediate this relationship. METHODS Cross-sectional study in which 311 colorectal cancer (CRC) survivors in Scotland completed a survey, which included questions on cancer-related distress (IES-R), perceived diagnostic delay, quality of life (trial outcome index of the FACT-C: FACT-C TOI) and fear of cancer recurrence. Fifteen patients withheld consent to data matching with medical records, leaving a sample size of 296. Participants were an average of 69 years old (range 56 to 81) and between 3.5 and 12 years post-diagnosis. Multiple regressions were used to test predictors of distress and regression and bootstrapping to test for mediation. RESULTS Perceived diagnostic delay was correlated with higher cancer-related distress, while objective markers of diagnostic delay (disease stage at diagnosis and treatment received) were not. Some of the relationship between perceived diagnostic delay and cancer-related distress was mediated by quality of life, but not by fear of cancer recurrence. CONCLUSIONS Perceived diagnostic delay was associated with higher cancer-related distress among CRC survivors. While poorer quality of life partly explained such associations, fear of cancer recurrence, stage at diagnosis and treatment did not. The exact features of diagnostic delay that are associated with cancer-related distress remain unclear. Future research should examine the experiences patients go through prior to diagnosis that may increase distress, in an effort to improve our understanding of the factors affecting emotional wellbeing among CRC survivors. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Anne Miles
- Department of Psychological Sciences, Birkbeck, University of London, London, UK
| | - Paula L McClements
- Information Services Division, NHS National Services Scotland, Edinburgh, UK
| | - Robert J C Steele
- Centre for Research into Cancer Prevention and Screening, Cancer Division, Medical Research Institute, Ninewells Medical School, Dundee, UK
| | - Claudia Redeker
- Department of Psychological Sciences, Birkbeck, University of London, London, UK
| | - Nick Sevdalis
- Centre for Implementation Science, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Jane Wardle
- Health Behaviour Research Centre, Institute of Epidemiology and Public Health, University College London, London, UK
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Redaniel MT, Ridd M, Martin RM, Coxon F, Jeffreys M, Wade J. Rapid diagnostic pathways for suspected colorectal cancer: views of primary and secondary care clinicians on challenges and their potential solutions. BMJ Open 2015; 5:e008577. [PMID: 26493457 PMCID: PMC4620164 DOI: 10.1136/bmjopen-2015-008577] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES To ascertain the challenges associated with implementation of the 2-week wait referral criteria and waiting time targets for colorectal cancer and to identify recommendations for improvements to the pathway. DESIGN Qualitative research using semistructured interviews and applying thematic analysis using the method of constant comparison. SETTING 10 primary care surgeries and 6 secondary care centres from 3 geographical areas in the England. PARTICIPANTS Purposive sample of 24 clinicians (10 general practitioners (GPs), 7 oncologists and 7 colorectal surgeons). RESULTS GPs and specialists highlighted delays in patient help-seeking, difficulties applying the colorectal cancer referral criteria due to their low predictive value, and concerns about the stringent application of targets because of potential impact on individual care and associated penalties for breaching. Promoting patient awareness and early presentation, clarifying predictive symptoms, allowing flexibility, optimising resources and maximising care coordination were suggested as improvements. CONCLUSIONS Challenges during diagnosis and treatment persist, with guidelines and waiting time targets producing the perception of unintended harms at individual and organisational levels. This has led to variations in how guidelines are implemented. These require urgent evaluation, so that effective practices can be adopted more widely.
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Affiliation(s)
- Maria Theresa Redaniel
- NIHR CLAHRC West, University of Bristol, Bristol, UK
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Matthew Ridd
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Richard M Martin
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Fareeda Coxon
- Northern Centre for Cancer Care, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, Newcastle upon Tyne, UK
| | - Mona Jeffreys
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Julia Wade
- School of Social and Community Medicine, University of Bristol, Bristol, UK
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Gold R, Hollombe C, Bunce A, Nelson C, Davis JV, Cowburn S, Perrin N, DeVoe J, Mossman N, Boles B, Horberg M, Dearing JW, Jaworski V, Cohen D, Smith D. Study protocol for "Study of Practices Enabling Implementation and Adaptation in the Safety Net (SPREAD-NET)": a pragmatic trial comparing implementation strategies. Implement Sci 2015; 10:144. [PMID: 26474759 PMCID: PMC4609090 DOI: 10.1186/s13012-015-0333-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 10/05/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Little research has directly compared the effectiveness of implementation strategies in any setting, and we know of no prior trials directly comparing how effectively different combinations of strategies support implementation in community health centers. This paper outlines the protocol of the Study of Practices Enabling Implementation and Adaptation in the Safety Net (SPREAD-NET), a trial designed to compare the effectiveness of several common strategies for supporting implementation of an intervention and explore contextual factors that impact the strategies' effectiveness in the community health center setting. METHODS/DESIGN This cluster-randomized trial compares how three increasingly hands-on implementation strategies support adoption of an evidence-based diabetes quality improvement intervention in 29 community health centers, managed by 12 healthcare organizations. The strategies are as follows: (arm 1) a toolkit, presented in paper and electronic form, which includes a training webinar; (arm 2) toolkit plus in-person training with a focus on practice change and change management strategies; and (arm 3) toolkit, in-person training, plus practice facilitation with on-site visits. We use a mixed methods approach to data collection and analysis: (i) baseline surveys on study clinic characteristics, to explore how these characteristics impact the clinics' ability to implement the tools and the effectiveness of each implementation strategy; (ii) quantitative data on change in rates of guideline-concordant prescribing; and (iii) qualitative data on the "how" and "why" underlying the quantitative results. The outcomes of interest are clinic-level results, categorized using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework, within an interrupted time-series design with segmented regression models. This pragmatic trial will compare how well each implementation strategy works in "real-world" practices. DISCUSSION Having a better understanding of how different strategies support implementation efforts could positively impact the field of implementation science, by comparing practical, generalizable methods for implementing clinical innovations in community health centers. Bridging this gap in the literature is a critical step towards the national long-term goal of effectively disseminating and implementing effective interventions into community health centers. TRIAL REGISTRATION ClinicalTrials.gov, NCT02325531.
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Affiliation(s)
- Rachel Gold
- Kaiser Permanente Northwest Center for Health Research, 3800 N. Interstate Avenue, Portland, OR, 97227, USA.
- OCHIN, Inc., 1881 SW Naito Parkway, Portland, OR, 97201, USA.
| | - Celine Hollombe
- Kaiser Permanente Northwest Center for Health Research, 3800 N. Interstate Avenue, Portland, OR, 97227, USA.
| | - Arwen Bunce
- Kaiser Permanente Northwest Center for Health Research, 3800 N. Interstate Avenue, Portland, OR, 97227, USA.
| | | | - James V Davis
- Kaiser Permanente Northwest Center for Health Research, 3800 N. Interstate Avenue, Portland, OR, 97227, USA.
| | - Stuart Cowburn
- OCHIN, Inc., 1881 SW Naito Parkway, Portland, OR, 97201, USA.
| | - Nancy Perrin
- Kaiser Permanente Northwest Center for Health Research, 3800 N. Interstate Avenue, Portland, OR, 97227, USA.
| | - Jennifer DeVoe
- OCHIN, Inc., 1881 SW Naito Parkway, Portland, OR, 97201, USA.
- Oregon Health Science University, 3181 S.W. Sam Jackson Park Rd., Portland, OR, 97239, USA.
| | - Ned Mossman
- OCHIN, Inc., 1881 SW Naito Parkway, Portland, OR, 97201, USA.
| | - Bruce Boles
- Kaiser Permanente Care Management Institute, 1 Kaiser Plaza, 16 L, Oakland, CA, 94612, USA.
| | - Michael Horberg
- Mid-Atlantic Permanente Research Institute, 2101 East Jefferson Street 3 West, Rockville, MD, 20852, USA.
| | - James W Dearing
- College of Communication Arts and Sciences, Michigan State University, 404 Wilson Road, 473, East Lansing, MI, 48824, USA.
| | - Victoria Jaworski
- Multnomah County Public Health Department, 426 SW Stark St, 8th Floor, Portland, OR, 97204, USA.
| | - Deborah Cohen
- Oregon Health Science University, 3181 S.W. Sam Jackson Park Rd., Portland, OR, 97239, USA.
| | - David Smith
- Kaiser Permanente Northwest Center for Health Research, 3800 N. Interstate Avenue, Portland, OR, 97227, USA.
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Jiwa M, Meng X, O'Shea C, Magin P, Dadich A, Pillai V. How do general practitioners manage patients with cancer symptoms? A video-vignette study. BMJ Open 2015; 5:e008525. [PMID: 26369800 PMCID: PMC4577966 DOI: 10.1136/bmjopen-2015-008525] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVES Determine how general practitioners (GPs) manage patients with cancer symptoms. DESIGN GPs reviewed 24 video-vignettes and case notes on patients with cancer symptoms and indicated whether they would refer the patient and/or prescribe medication, and/or undertake further investigation. According to available guidelines, all cases warranted a referral to a specialist or further investigations. SETTING Australian primary care sector. PARTICIPANTS 102 practising GPs participated in this study, including trainees. INTERVENTIONS The research was part of a larger randomised controlled trial testing a referral pro forma; however, this paper reports on management decisions made throughout the study. PRIMARY AND SECONDARY OUTCOME MEASURES This paper reports on how the participants would manage the patients depicted in each vignette. RESULTS In more than one-in-eight cases, the patient was not investigated or referred. Patient management varied significantly by cancer type (p<0.001). For two key reasons, colorectal cancer was the chosen referent category. First, it represents a prevalent type of cancer. Second, in this study, colorectal cancer symptoms were managed in a similar proportion of options-that is, prescription, referral or investigation. Compared with vignettes featuring colorectal cancer participants were less likely to manage breast, bladder, endometrial, and lung cancers with a 'prescription only' or 'referral only' option. They were less likely to manage prostate cancer with a 'prescription only', yet more likely to manage it with a 'referral with investigation'. With regard to pancreatic and cervical cancers, participants were more likely to manage these with a 'referral only' or a 'referral with investigation'. CONCLUSIONS Some patients may receive a delayed cancer diagnosis, even when they present with typical cancer symptoms to a GP who can access relevant diagnostic tests. TRIAL REGISTRATION NUMBER ACTRN12611000760976.
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Affiliation(s)
- Moyez Jiwa
- Melbourne Clinical School, School of Medicine Sydney, University of Notre Dame, Werribee, Victoria, Australia
| | - Xingqiong Meng
- School of Medicine, Flinders University, Adelaide, South Australia, Australia
| | - Carolyn O'Shea
- Victorian Metropolitan Alliance, Hawthorn, Victoria, Australia
| | - Parker Magin
- Discipline of General Practice, University of Newcastle, Callaghan, New South Wales, Australia
| | - Ann Dadich
- School of Business, University of Western Sydney, Parramatta, New South Wales, Australia
| | - Vinita Pillai
- Department of Medical Education, Curtin University, Perth, Western Australia, Australia
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Views of general practitioners and head and neck surgeons on the referral system for suspected cancer: a survey. The Journal of Laryngology & Otology 2015; 129:893-7. [PMID: 26235148 DOI: 10.1017/s0022215115001723] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The two-week wait referral system for suspected cancer was introduced in the National Health Service in 2000. This study aimed to identify areas for improvement to the two-week wait system by seeking the opinions of doctors working in primary and secondary care. METHOD A questionnaire was distributed to general practitioners and head and neck surgeons within North West England with ethical consent. RESULTS Twenty-seven general practitioners and 15 head and neck surgeons responded. Of the general practitioners, 59.3 per cent declared that they never attend training on referrals in this specialty. Overall, 59.3 per cent of general practitioners and 86.7 per cent of head and neck surgeons felt that the two-week wait system could be improved. CONCLUSION The main areas for further work are development of pre-referral communication between primary and secondary care along with development of practical educational measures for general practitioners.
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Luck J, York LS, Bowman C, Gale RC, Smith N, Asch SM. Implementing a user-driven online quality improvement toolkit for cancer care. J Oncol Pract 2015; 11:e421-7. [PMID: 25852141 DOI: 10.1200/jop.2014.003012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Peer-to-peer collaboration within integrated health systems requires a mechanism for sharing quality improvement lessons. The Veterans Health Administration (VA) developed online compendia of tools linked to specific cancer quality indicators. We evaluated awareness and use of the toolkits, variation across facilities, impact of social marketing, and factors influencing toolkit use. METHODS A diffusion of innovations conceptual framework guided the collection of user activity data from the Toolkit Series SharePoint site and an online survey of potential Lung Cancer Care Toolkit users. RESULTS The VA Toolkit Series site had 5,088 unique visitors in its first 22 months; 5% of users accounted for 40% of page views. Social marketing communications were correlated with site usage. Of survey respondents (n = 355), 54% had visited the site, of whom 24% downloaded at least one tool. Respondents' awareness of the lung cancer quality performance of their facility, and facility participation in quality improvement collaboratives, were positively associated with Toolkit Series site use. Facility-level lung cancer tool implementation varied widely across tool types. CONCLUSION The VA Toolkit Series achieved widespread use and a high degree of user engagement, although use varied widely across facilities. The most active users were aware of and active in cancer care quality improvement. Toolkit use seemed to be reinforced by other quality improvement activities. A combination of user-driven tool creation and centralized toolkit development seemed to be effective for leveraging health information technology to spread disease-specific quality improvement tools within an integrated health care system.
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Affiliation(s)
- Jeff Luck
- Oregon State University, Corvallis, OR; Veterans Administration (VA) Greater Los Angeles Healthcare System, Los Angeles; VA Palo Alto Health Care System; and Stanford University, Palo Alto, CA
| | - Laura S York
- Oregon State University, Corvallis, OR; Veterans Administration (VA) Greater Los Angeles Healthcare System, Los Angeles; VA Palo Alto Health Care System; and Stanford University, Palo Alto, CA
| | - Candice Bowman
- Oregon State University, Corvallis, OR; Veterans Administration (VA) Greater Los Angeles Healthcare System, Los Angeles; VA Palo Alto Health Care System; and Stanford University, Palo Alto, CA
| | - Randall C Gale
- Oregon State University, Corvallis, OR; Veterans Administration (VA) Greater Los Angeles Healthcare System, Los Angeles; VA Palo Alto Health Care System; and Stanford University, Palo Alto, CA
| | - Nina Smith
- Oregon State University, Corvallis, OR; Veterans Administration (VA) Greater Los Angeles Healthcare System, Los Angeles; VA Palo Alto Health Care System; and Stanford University, Palo Alto, CA
| | - Steven M Asch
- Oregon State University, Corvallis, OR; Veterans Administration (VA) Greater Los Angeles Healthcare System, Los Angeles; VA Palo Alto Health Care System; and Stanford University, Palo Alto, CA
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Rubin G, Gildea C, Wild S, Shelton J, Ablett-Spence I. Assessing the impact of an English national initiative for early cancer diagnosis in primary care. Br J Cancer 2015; 112 Suppl 1:S57-64. [PMID: 25734381 PMCID: PMC4385977 DOI: 10.1038/bjc.2015.43] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND The Cancer Networks Supporting Primary Care programme was a National Health Service (NHS) initiative in England between 2011 and 2013 that aimed to better understand and improve referral practices for suspected cancer. METHODS A mixed methods evaluation using semi-structured interviews with purposefully sampled key stakeholders and an analysis of Cancer Waiting Times and Hospital Episode Statistics data for all 8179 practices in England were undertaken. We compared periods before (2009/10) and at the end (2012/13) of the initiative for practices taking up any one of four specified quality improvement initiatives expected to change referral practice in the short to medium term and those that did not. RESULTS Overall, 38% of general practices were involved in at least one of four quality improvement activities (clinical audit, significant event analysis, use of risk assessment tools and development of practice plans). Against an overall 29% increase in urgent cancer referrals between 2009/10 and 2012/13, these practices had a significantly higher increase in referral rate, with reduced between-practice variation. There were no significant differences between the two groups in conversion, detection or emergency presentation rates. Key features of successful implementation at practice and network level reported by participants included leadership, organisational culture and physician involvement. Concurrent health service reforms created organisational uncertainty and limited the programme's effectiveness. CONCLUSIONS Specific primary care initiatives promoted by cancer networks had an additional and positive impact on urgent referrals for suspected cancer. Successful engagement with the programmes depended on effective and well-supported leadership by cancer networks and their general practitioner (GP) leads.
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Affiliation(s)
- G Rubin
- School of Medicine, Pharmacy and Health, Wolfson Research Institute, Durham University, Queen's Campus, Stockton-on-Tees TS17 6BH, UK
| | - C Gildea
- PHE Knowledge and Intelligence Team (East Midlands), 5 Old Fulwood Road, Sheffield S10 3TG, UK
| | - S Wild
- PHE Knowledge and Intelligence Team (East Midlands), 5 Old Fulwood Road, Sheffield S10 3TG, UK
| | - J Shelton
- Care Quality Commission, 103-105 Bunhill Row, London EC1Y 8TG, UK
| | - I Ablett-Spence
- School of Medicine, Pharmacy and Health, Wolfson Research Institute, Durham University, Queen's Campus, Stockton-on-Tees TS17 6BH, UK
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Emery JD, Gray V, Walter FM, Cheetham S, Croager EJ, Slevin T, Saunders C, Threlfall T, Auret K, Nowak AK, Geelhoed E, Bulsara M, Holman CDJ. The Improving Rural Cancer Outcomes (IRCO) Trial: a factorial cluster-randomised controlled trial of a complex intervention to reduce time to diagnosis in rural patients with cancer in Western Australia: a study protocol. BMJ Open 2014; 4:e006156. [PMID: 25231496 PMCID: PMC4166137 DOI: 10.1136/bmjopen-2014-006156] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION While overall survival for most common cancers in Australia is improving, the rural-urban differential has been widening, with significant excess deaths due to lung, colorectal, breast and prostate cancer in regional Australia. Internationally a major focus on understanding variations in cancer outcomes has been later presentation to healthcare and later diagnosis. Approaches to reducing time to diagnosis of symptomatic cancer include public symptom awareness campaigns and interventions in primary care to improve early cancer detection. This paper reports the protocol of a factorial cluster-randomised trial of community and general practice (GP) level interventions to reduce the time to diagnosis of cancer in rural Western Australia (WA). METHODS AND ANALYSIS The community intervention is a symptom awareness campaign tailored for rural Australians delivered through a community engagement model. The GP intervention includes a resource card with symptom risk assessment charts and local referral pathways implemented through multiple academic detailing visits and case studies. Participants are eligible if recently diagnosed with breast, colorectal, lung or prostate cancer who reside in specific regions of rural WA with a planned sample size of 1350. The primary outcome is the Total Diagnostic Interval, defined as the duration from first symptom (or date of cancer screening test) to cancer diagnosis. Secondary outcomes include cancer stage, healthcare utilisation, disease-free status, survival at 2 and 5 years and cost-effectiveness. ETHICS AND DISSEMINATION Ethics approval has been granted by the University of Western Australia and from all relevant hospital recruitment sites in WA. RESULTS Results of this trial will be reported in peer-reviewed publications and in conference presentations. TRIAL REGISTRATION NUMBER Australian New Zealand Clinical Trials Registry (ANZCTR). ACTRN12610000872033.
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Affiliation(s)
- Jon D Emery
- General Practice and Primary Health Care Academic Centre, Melbourne Medical School, The University of Melbourne, Melbourne, Australia
- School of Primary, Aboriginal and Rural Health Care, The University of Western Australia, Crawley, Australia
| | - Victoria Gray
- School of Primary, Aboriginal and Rural Health Cancer, The University of Western Australia, Crawley, Australia
- School of Population Health, The University of Western Australia, Crawley, Western Australia, Australia
- Education and Research Division, Cancer Council Western Australia, Perth, Western Australia, Australia
| | - Fiona M Walter
- The Primary Care Unit, Department of Public Health & Primary Care, University of Cambridge, Cambridge, UK
| | - Shelley Cheetham
- School of Primary, Aboriginal and Rural Health Cancer, The University of Western Australia, Crawley, Australia
| | - Emma J Croager
- Education and Research Division, Cancer Council Western Australia, Perth, Western Australia, Australia
- Centre for Behavioural Research in Cancer Control, Curtin University, Perth, Western Australia, Australia
| | - Terry Slevin
- Education and Research Division, Cancer Council Western Australia, Perth, Western Australia, Australia
- Centre for Behavioural Research in Cancer Control, Curtin University, Perth, Western Australia, Australia
| | - Christobel Saunders
- School of Surgery, The University of Western Australia, Perth, Western Australia, Australia
| | - Tim Threlfall
- The Department of Health of Western Australia, Western Australia Cancer Registry, Australia
| | - Kirsten Auret
- Rural Clinical School of WA, The University of Western Australia, Perth, Western Australia, Australia
| | - Anna K Nowak
- School of Medicine and Pharmacology, The University of Western Australia, Crawley, Australia
| | - Elizabeth Geelhoed
- School of Population Health, The University of Western Australia, Crawley, Western Australia, Australia
| | - Max Bulsara
- Institute of Health and Rehabilitation Research, Notre Dame University, Freemantle, Australia
| | - C D'Arcy J Holman
- School of Population Health, The University of Western Australia, Crawley, Western Australia, Australia
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Comparison of cancer diagnostic intervals before and after implementation of NICE guidelines: analysis of data from the UK General Practice Research Database. Br J Cancer 2013; 110:584-92. [PMID: 24366304 PMCID: PMC3915139 DOI: 10.1038/bjc.2013.791] [Citation(s) in RCA: 154] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Revised: 11/04/2013] [Accepted: 11/19/2013] [Indexed: 12/18/2022] Open
Abstract
Background: The primary aim was to use routine data to compare cancer diagnostic intervals before and after implementation of the 2005 NICE Referral Guidelines for Suspected Cancer. The secondary aim was to compare change in diagnostic intervals across different categories of presenting symptoms. Methods: Using data from the General Practice Research Database, we analysed patients with one of 15 cancers diagnosed in either 2001–2002 or 2007–2008. Putative symptom lists for each cancer were classified into whether or not they qualified for urgent referral under NICE guidelines. Diagnostic interval (duration from first presented symptom to date of diagnosis in primary care records) was compared between the two cohorts. Results: In total, 37 588 patients had a new diagnosis of cancer and of these 20 535 (54.6%) had a recorded symptom in the year prior to diagnosis and were included in the analysis. The overall mean diagnostic interval fell by 5.4 days (95% CI: 2.4–8.5; P<0.001) between 2001–2002 and 2007–2008. There was evidence of significant reductions for the following cancers: (mean, 95% confidence interval) kidney (20.4 days, −0.5 to 41.5; P=0.05), head and neck (21.2 days, 0.2–41.6; P=0.04), bladder (16.4 days, 6.6–26.5; P⩽0.001), colorectal (9.0 days, 3.2–14.8; P=0.002), oesophageal (13.1 days, 3.0–24.1; P=0.006) and pancreatic (12.6 days, 0.2–24.6; P=0.04). Patients who presented with NICE-qualifying symptoms had shorter diagnostic intervals than those who did not (all cancers in both cohorts). For the 2007–2008 cohort, the cancers with the shortest median diagnostic intervals were breast (26 days) and testicular (44 days); the highest were myeloma (156 days) and lung (112 days). The values for the 90th centiles of the distributions remain very high for some cancers. Tests of interaction provided little evidence of differences in change in mean diagnostic intervals between those who did and did not present with symptoms specifically cited in the NICE Guideline as requiring urgent referral. Conclusion: We suggest that the implementation of the 2005 NICE Guidelines may have contributed to this reduction in diagnostic intervals between 2001–2002 and 2007–2008. There remains considerable scope to achieve more timely cancer diagnosis, with the ultimate aim of improving cancer outcomes.
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Hurt CN, Roberts K, Rogers TK, Griffiths GO, Hood K, Prout H, Nelson A, Fitzgibbon J, Barham A, Thomas-Jones E, Edwards RT, Yeo ST, Hamilton W, Tod A, Neal RD. A feasibility study examining the effect on lung cancer diagnosis of offering a chest X-ray to higher-risk patients with chest symptoms: protocol for a randomized controlled trial. Trials 2013; 14:405. [PMID: 24279296 PMCID: PMC4222751 DOI: 10.1186/1745-6215-14-405] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Accepted: 11/13/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In order to improve lung cancer survival in the UK, a greater proportion of resectable cancers must be diagnosed. It is likely that resectability rates would be increased by more timely diagnosis. Aside from screening, the only way of achieving this is to reduce the time to diagnosis in symptomatic cancers. Currently, lung cancers are mainly diagnosed by general practitioners (GPs) using the National Institute for Health and Clinical Excellence (NICE) guidelines for urgent referral for chest X-ray, which recommend urgent imaging or referral for patients who have one of a number of chest symptoms for more than 3 weeks. We are proposing to expand this recommendation to include one of a number of chest symptoms of any duration in higher-risk patients. METHODS/DESIGN We intend to conduct a trial of imaging in these higher-risk patients and compare it with NICE guidelines to see if imaging improves stage at diagnosis and resection rates. This trial would have to be large (and consequently resource-intensive) because most of these patients will not have lung cancer, making optimal design crucial. We are therefore conducting a pilot trial that will ascertain the feasibility of running a full trial and provide key information that will be required in order to design the full trial. DISCUSSION This trial will assess the feasibility and inform the design of a large, UK-wide, clinical trial of a change to the NICE guidelines for urgent referral for chest X-ray for suspected lung cancer. It utilizes a combination of workshop, health economic, quality of life, qualitative, and quantitative methods in order to fully assess feasibility. TRIAL REGISTRATION Clinicaltrials.gov NCT01344005.
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Affiliation(s)
- Christopher N Hurt
- Wales Cancer Trials Unit, School of Medicine, Cardiff University, Cardiff, UK
| | - Kirsty Roberts
- Wales Cancer Trials Unit, School of Medicine, Cardiff University, Cardiff, UK
| | - Trevor K Rogers
- Doncaster Royal Infirmary, Doncaster and Bassetlaw NHS Foundation Trust, Doncaster, UK
| | - Gareth O Griffiths
- Wales Cancer Trials Unit, School of Medicine, Cardiff University, Cardiff, UK
| | - Kerry Hood
- South East Wales Cancer Trials Unit, School of Medicine, Cardiff University, Cardiff, UK
| | - Hayley Prout
- Marie Curie Palliative Care Research Centre School of Medicine, Cardiff University, Cardiff, UK
| | - Annmarie Nelson
- Marie Curie Palliative Care Research Centre School of Medicine, Cardiff University, Cardiff, UK
| | | | | | - Emma Thomas-Jones
- South East Wales Cancer Trials Unit, School of Medicine, Cardiff University, Cardiff, UK
| | | | - Seow Tien Yeo
- Centre for Health Economics and Medicines Evaluation, Bangor University, Gwynedd, UK
| | | | - Angela Tod
- Centre for Health and Social Care Research, Sheffield Hallam University, Sheffield, UK
| | - Richard D Neal
- North Wales Centre for Primary Care Research, Bangor University, Wrexham, UK
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Abstract
Primary care providers have important roles across the cancer continuum, from encouraging screening and accurate diagnosis to providing care during and after treatment for both the cancer and any comorbid conditions. Evidence shows that higher cancer screening participation rates are associated with greater involvement of primary care. Primary care providers are pivotal in reducing diagnostic delay, particularly in health systems that have long waiting times for outpatient diagnostic services. However, so-called fast-track systems designed to speed up hospital referrals are weakened by significant variation in their use by general practitioners (GPs), and affect the associated conversion and detection rates. Several randomized controlled trials have shown primary care-led follow-up care to be equivalent to hospital-led care in terms of patient wellbeing, recurrence rates and survival, and might be less costly. For primary care-led follow-up to be successful, appropriate guidelines must be incorporated, clear communication must be provided and specialist care must be accessible if required. Finally, models of long-term cancer follow-up are needed that provide holistic care and incorporate management of co-morbid conditions. We discuss all these aspects of primary care, focusing on the most common cancers managed at the GP office-breast, colorectal, prostate, lung and cervical cancers.
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Round T, Steed L, Shankleman J, Bourke L, Risi L. Primary care delays in diagnosing cancer: what is causing them and what can we do about them? J R Soc Med 2013; 106:437-40. [PMID: 24108536 DOI: 10.1177/0141076813504744] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Thomas Round
- Primary Care and Public Health Sciences, King's College London, Capital House, London SE1 3QD, UK
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