Barriers, facilitators and pathways of a lung cancer screening (LCS) programme: COBELT co-design

 

Lung cancer (LC) is one of the most common causes of cancer death globally. Adults aged 55+, (ex)-smokers and living in areas of deprivation are at greater risk from lung cancer. Leading to a 20% decrease in mortality rates, screening with Low Dose CT (LDCT) is a promising means of detecting LC early. Autoantibody biomarker blood tests may play a role in identifying people suitable for LDCT screening, forming a national LCS programme. To increase the likelihood of the success of such a programme, suitable ways of providing the service must firstly be identified. A 2-phase co-design process, with 2 population groups. Group 1-Aged 55+, (ex)-smoker, high deprivation (N = 39). Group 2-Health and community professionals (N = 16). Phase 1: Interviews and focus groups. Conversations focussed on barriers, facilitators and potential pathways for the uptake and provision of a biomarker blood test and LCS. Phase 2: Interactive surveys (offline/online), focussing on the prioritisation of key barriers and solution generation. Qualitative data was transcribed and analysed using thematic analysis. Descriptive statistics were generated for quantitative data. Phase 1 identified key barriers, facilitators and pathways for uptake and provision. Service users indicated options for uptake and a means to embed the programme in the community as essential. From the perspective of providers, capacity and time for provision were key. Phase 2 found a home test kit was the preferred method of blood test for service users (independently or with assistance). Service providers leaned towards provision via venesection. Barriers were ranked by service users, the most dominant barrier was Fear of test result. Working in a collaborative manner has led to the identification of new knowledge and insights regarding the best means to target a future LCS programme to those who may benefit most. Future implementation of such a programme should consider the results from this study.

This is a CSO funded project.

Key messages

This process has illuminated key barriers, facilitators and pathway options that could improve the implementation of a LCS programme, using an autoantibody blood test to identify LDCT candidates. Measures to overcome barriers from both the perspective of the service users and providers are necessary to ensure the success of the LCS programme.

Business Process Modelling is an Essential Part of a Requirements Analysis

To perform a requirements analysis of the barriers to conducting research linking of primary care, genetic and cancer data.

We extended our initial data-centric approach to include socio-culturalandbusinessrequirements.Wecreatedreferencemodels of core data requirements common to most studies using unified modelling language (UML), dataflow diagrams (DFD) and business process modelling notation (BPMN). We conducted a stakeholder analysis and constructed DFD and UML diagrams for use cases based on simulated research studies. We used research output as a sensitivity analysis.

Differences between the reference model and use cases identified study specific data requirements. The stakeholder analysis identified: tensions, changes in specification, some indifference from data providers and enthusiastic informaticians urging inclusion of socio-cultural context. We identified requirements to collect information at three levels: microdata items, which need to be semantically interoperable, meso-the medical record and data extraction, and macro-the health system and socio-cultural issues. BPMN clarified complex business requirements among data providers and vendors; and additional geographical requirements for patients to be represented in both linked datasets. High quality research output was the norm for most repositories.

Reference models provide high-level schemata of the core data requirements. However, business requirements’ modelling identifies stakeholder issues and identifies what needs to be addressed to enable participation.

'Thinking that somebody's going to delay [a tonsillectomy] for one to two years is quite horrifying really': a qualitative feasibility study for the NAtional Trial of Tonsillectomy IN Adults (NATTINA Part 2)

OBJECTIVES

Level one evidence on the value of adult tonsillectomy versus non-surgical management remains scarce. Before embarking on a costly national randomised controlled trial, it is essential to establish its feasibility.

DESIGN

Feasibility study with in-depth qualitative and cognitive interviews.

SETTING

ENT staff and patients were recruited from nine hospital centres across England and Scotland.

PARTICIPANTS

Patients who were referred for tonsillectomy (n = 15), a convenience sample of general practitioners (n = 11) and ear, nose and throat staff (n = 22).

MAIN OUTCOME MEASURES

To ascertain whether ear, nose and throat staff would be willing to randomise patients to the treatment arms. To assess general practitioners' willingness to refer patients to the NAtional Trial of Tonsillectomy IN Adults (NATTINA) centres. To assess patients' willingness to be randomised and the acceptability of the deferred surgery treatment arm. To ascertain whether the study could progress to the pilot trial stage.

RESULTS

Ear, nose and throat staff and general practitioners were willing to randomise patients to the proposed NATTINA. Not all ENT staff were in equipoise concerning the treatment pathways. Patients were reluctant to be randomised into the deferred surgery group if they had already waited a substantial time before being referred.

CONCLUSIONS

Findings suggest that the NATTINA may not be feasible. Proposed methods could not be realistically assessed without a pilot trial. Due to the importance of the question, as evidenced by NATTINA clinicians, and strong support from ENT staff, the pilot trial proceeded, with modifications.

Business Process Modelling is an Essential Part of a Requirements Analysis. Contribution of EFMI Primary Care Working Group

OBJECTIVES

To perform a requirements analysis of the barriers to conducting research linking of primary care, genetic and cancer data.

METHODS

We extended our initial data-centric approach to include socio-cultural and business requirements. We created reference models of core data requirements common to most studies using unified modelling language (UML), dataflow diagrams (DFD) and business process modelling notation (BPMN). We conducted a stakeholder analysis and constructed DFD and UML diagrams for use cases based on simulated research studies. We used research output as a sensitivity analysis.

RESULTS

Differences between the reference model and use cases identified study specific data requirements. The stakeholder analysis identified: tensions, changes in specification, some indifference from data providers and enthusiastic informaticians urging inclusion of socio-cultural context. We identified requirements to collect information at three levels: micro- data items, which need to be semantically interoperable, meso- the medical record and data extraction, and macro- the health system and socio-cultural issues. BPMN clarified complex business requirements among data providers and vendors; and additional geographical requirements for patients to be represented in both linked datasets. High quality research output was the norm for most repositories.

CONCLUSIONS

Reference models provide high-level schemata of the core data requirements. However, business requirements' modelling identifies stakeholder issues and identifies what needs to be addressed to enable participation.

Economic evaluation of early administration of prednisolone and/or aciclovir for the treatment of Bell's palsy

OBJECTIVES

Bell's palsy (BP), which causes facial paralysis, affects 11-40 people per 100 000 per annum in the UK. Its cause is unknown but as many as 30% of patients have continuing facial disfigurement, psychological difficulties and occasionally facial pain. We present an randomised controlled trial (RCT)-based economic evaluation of the early administration of steroids (prednisolone) and/or antivirals (acyclovir) compared to placebo, for treatment of BP.

METHODS

The RCT was not powered to detect differences in the cost-effectiveness; therefore, we adopted a decision analytic model approach as a way of gaining precision in our cost-effectiveness comparisons [e.g. prednisolone only (PO) versus acyclovir only versus prednisolone and acyclovir versus placebo, prednisolone versus no prednisolone (NP) and acyclovir versus no acyclovir]. We assumed that trial interventions affect the probability of being cured/not cured but their consequences are independent of the initial therapy. We used the percentage of individuals with a complete recovery (based on House-Brackmann grade = 1) at 9 months and Quality Adjusted Life Years (e.g. derived on responses to the Health Utilities Index III) as measures of effectiveness. Other parameter estimates were obtained from trial data.

RESULTS

PO dominated-i.e. was less costly and more effective-all other therapy strategies in the four arms model [77% probability of cost-effective (CE)]. Moreover, Prednisolone dominated NP (77% probability of being CE at 30 000 UK pounds threshold) while no acyclovir dominated aciclovir (85% chance of CE), in the two arms models, respectively.

CONCLUSIONS

Treatment of BP with prednisolone is likely to be considered CE while treatment with acyclovir is highly unlikely to be considered CE. Further data on costs and utilities would be useful to confirm findings.

Familial breast cancer: management of 'lower risk' referrals

Up to 40% of referrals from primary care to ‘breast cancer family clinics’ prove to be of women whose assessed risk falls below the guidelines' threshold for management in secondary or tertiary care, despite recommendations that they should be screened out at primary care level. A randomised trial, involving 87 such women referred to the Tayside Familial Breast Cancer Service compared two ways of communicating risk information, letter or personal interview. Both were found to be acceptable to referred women and to their family doctors, although the former expressed a slight preference for interview. Only four women returned to their family doctors with continuing concerns about breast cancer. Nevertheless, understanding of information provided by either route was unsatisfactory, with apparent confusion about both absolute and relative risks of breast cancer. Substantial minorities appear to believe that they are at no increased risk at all, or even below the population level of risk, while others remain convinced that their personal risk has been underestimated. Family history record forms, completed by the referred women, preferably with the assistance of relatives, are crucial to full assessment of familial risk but one quarter of women referred to the Tayside Familial Breast Cancer Service currently do not complete and return these forms ahead of their clinic appointment. Further collaboration between primary care and the Breast Cancer Family Service is required to improve provision for concerned women whose risks fall below the threshold for special surveillance and to maximise effective use of the family history record form.

Control, compare and communicate: designing control charts to summarise efficiently data from multiple quality indicators

Summarising the complex data generated by multiple cross sectional quality indicators in a way that patients, clinicians, managers and policymakers find useful is challenging. A common approach is aggregation to create summary measures such as star ratings and balanced score cards, but these may conceal the detail needed to focus quality improvement. We propose an alternative way of summarising and presenting multiple quality indicators, suitable for use for quality improvement and governance. This paper discusses (1) control charts for repeated measurements of single processes as used in industrial statistical process control (SPC); (2) control charts for cross sectional comparison of many institutions for a single quality indicator (rarely used in industry but commonly proposed for health care); and (3) small multiple graphics which combine control chart signal extraction with efficient graphical presentations for multiple indicators.

A study of telephone screening and direct observation of surgical wound infections after discharge from hospital

Post-discharge surveillance of surgical site infection is necessary if accurate rates of infection following surgery are to be available. We undertook a prospective study of 376 knee and hip replacements in 366 patients in order to estimate the rate of orthopaedic surgical site infection in the community. The inpatient infection was 3.1% and the post-discharge infection rate was 2.1%. We concluded that the use of telephone interviews of patients to identify the group at highest risk of having a surgical site infection (those who think they have an infection) with rapid follow-up by a professional trained to diagnose infection according to agreed criteria is an effective method of identifying infection after discharge from hospital.

Rationing decisions: from diversity to consensus

As rationing decisions become more of an immediate reality for healthcare practitioners it is important to design mechanisms that facilitate carefully deliberated outcomes. No individual can be expected to be able to cover wide debate on their own, so an exercise has been designed that helps generate consensus decisions from diverse opinions. The exercise was piloted with two groups, an undergraduate medical class and the members of a general practice. Though the aims were different for each group, the tool was useful to both for producing the desired outcomes. Expert and non-expert knowledge were drawn upon and rationing prioritisation lists regarding funding of infertility treatment were generated. A description of the exercise and the results produced by the two groups are provided, as well as the theoretical placement for the significance of forming consensus from diversity.

Factors influencing time from presentation to treatment of colorectal and breast cancer in urban and rural areas

Stage at diagnosis and survival from cancer vary according to where people live, suggesting some may have delays in diagnosis. The aim of this study was to determine if time from presentation to treatment was longer for colorectal and breast cancer patients living further from cancer centres, and identify other important factors in delay. Data were collected on 1097 patients with breast and 1223 with colorectal cancer in north and northeast Scotland. Women with breast cancer who lived further from cancer centres were treated more quickly than those living closer to cancer centres (P=0.011). Multilevel modelling found that this was largely due to them receiving earlier treatment at hospitals other than cancer centres. Breast lump, change in skin contour, lymphadenopathy, more symptoms and signs, and increasing age predicted faster treatment. Screen detected cancers and private referrals were treated more quickly. For colorectal cancer, time to treatment was similar for people in rural and urban areas. Quicker treatment was associated with palpable rectal or abdominal masses, tenesmus, abdominal pain, frequent GP consultations, age between 50 and 74 years, tumours of the transverse colon, and iron medication at presentation. Delay was associated with past anxiety or depression. There was variation between general practices and treatment appeared quicker at practices with more female general practitioners.

Factors influencing time from presentation to treatment of colorectal and breast cancer in urban and rural areas

Stage at diagnosis and survival from cancer vary according to where people live, suggesting some may have delays in diagnosis. The aim of this study was to determine if time from presentation to treatment was longer for colorectal and breast cancer patients living further from cancer centres, and identify other important factors in delay. Data were collected on 1097 patients with breast and 1223 with colorectal cancer in north and northeast Scotland. Women with breast cancer who lived further from cancer centres were treated more quickly than those living closer to cancer centres (P=0.011). Multilevel modelling found that this was largely due to them receiving earlier treatment at hospitals other than cancer centres. Breast lump, change in skin contour, lymphadenopathy, more symptoms and signs, and increasing age predicted faster treatment. Screen detected cancers and private referrals were treated more quickly. For colorectal cancer, time to treatment was similar for people in rural and urban areas. Quicker treatment was associated with palpable rectal or abdominal masses, tenesmus, abdominal pain, frequent GP consultations, age between 50 and 74 years, tumours of the transverse colon, and iron medication at presentation. Delay was associated with past anxiety or depression. There was variation between general practices and treatment appeared quicker at practices with more female general practitioners.

A validated logistic regression model to identify coronary heart disease patients within primary care databases in the United kingdom

We established the optimal search strategy for identifying coronary heart disease (CHD) patients within the Electronic Patient Record (EPR) of 'paperless' family practices in the UK. Multiple logistic regression modelling (MLRM) and Receiver Operating Characteristic (ROC) curves were used to develop the query. The selected search strategy was validated at 2 additional paperless family practices.

What is health informatics?

Health informatics is a relatively recent jargon term for a subject that may be of great interest to health services researchers and policy makers. Most countries with highly developed health systems are investing heavily in computer hardware and software in the expectation of higher quality for lower costs. Recent systematic reviews have indeed demonstrated the health benefits of a range of electronic tools, particularly in the areas of prevention and therapeutic monitoring. However, there remains a relative lack of published evaluations of informatics tools and methods. Uncritical adoption of new systems based on the pressures of technological push continue to discredit policy makers who have had to commit significant resources despite inadequate information on what can be realistically expected from a proposed system. There are great opportunities for researchers interested in evaluation to fill the vacuum left by informaticists who are too busy writing their next line of code.

Private health care in Australia: why the government should intervene

The 30 percent health insurance rebate is popular. Both major political parties are committed to it. However,merely pump priming health funds will not guarantee that essential private services remain available to relievethe pressures on public hospitals. It is time for a more interventionist role by government to ensure essentialprivate hospital services remain affordable and accessible for vulnerable people.

Approximating the number of monomer-dimer coverings in periodic lattices

Our starting point is an algorithm of Kenyon, Randall, and Sinclair, which is built upon the ideas of Jerrum and Sinclair, giving an approximation to crucial parameters of the monomer-dimer covering problem in polynomial time. We make two key improvements to their algorithm: we greatly reduce the number of simulations that must be run by estimating good values of the generating function parameter, and we greatly reduce the number of steps that must be taken in each simulation by aggregating to a simulation with at most five states. The result is an algorithm that is computationally feasible for modestly sized meshes. We use our algorithm on two- and three-dimensional problems, computing approximations to the coefficients of the generating function and some limiting values.

Contraindications to metformin therapy in patients with Type 2 diabetes--a population-based study of adherence to prescribing guidelines

AIMS

To define the number of people in Tayside, Scotland (population 349 303) with Type 2 diabetes who use metformin, the incidence of contraindications to its continued use in these people and the proportion that discontinued metformin treatment following the development of a contraindication.

METHODS

Retrospective cohort study of the incidence of contraindications to metformin in all patients with Type 2 diabetes using metformin from January 1993 to June 1995. The contraindications of acute myocardial infarction, cardiac failure, renal impairment and chronic liver disease were identified by: the regional diabetes information system, biochemistry database and hospital admissions database and a database of all encashed community prescriptions.

RESULTS

One thousand eight hundred and forty seven subjects (26.3% of those with Type 2 diabetes) redeemed prescriptions for metformin. Of these, 3.5% were admitted with an acute myocardial infarction (71 episodes); 4.2% were admitted with cardiac failure (114 episodes); 21.0% received metformin and loop diuretics for cardiac failure concurrently; 4.8% developed renal impairment; and 2.8% developed chronic liver disease. The development of contraindications rarely resulted in discontinuation of metformin, for example only 17.5% and 25% stopped metformin after admission with acute myocardial infarction and development of renal impairment, respectively. In total, 24.5% of subjects receiving metformin, 6.4% of all people with Type 2 diabetes, had contraindications to its use. There was one episode of lactic acidosis in 4600 patient years.

CONCLUSIONS

This population-based study shows that 24.5% of patients prescribed metformin have contraindications to its use. Development of contraindications rarely results in discontinuation of metformin therapy. Despite this, lactic acidosis remains rare. Diabet. Med. 18, 483-488 (2001)

A descriptive feast but an evaluative famine: systematic review of published articles on primary care computing during 1980-97

OBJECTIVES

To appraise findings from studies examining the impact of computers on primary care consultations.

DESIGN

Systematic review of world literature from 1980 to 1997.

DATA SOURCES

5475 references were identified from electronic databases (Medline, Science Citation Index, Social Sciences Citation Index, Index of Scientific and Technical Proceedings, Embase, OCLC FirstSearch Proceedings), bibliographies, books, identified articles, and by authors active in the field. 1892 eligible abstracts were independently rated, and 89 studies met the inclusion criteria.

MAIN OUTCOME MEASURES

Effect on doctors' performance and patient outcomes; attitudes towards computerisation.

RESULTS

61 studies examined effects of computers on practitioners' performance, 17 evaluated their impact on patient outcome, and 20 studied practitioners' or patients' attitudes. Computer use during consultations lengthened the consultation. Reminder systems for preventive tasks and disease management improved process rates, although some returned to pre-intervention levels when reminders were stopped. Use of computers for issuing prescriptions increased prescribing of generic drugs, and use of computers for test ordering led to cost savings and fewer unnecessary tests. There were no negative effects on those patient outcomes evaluated. Doctors and patients were generally positive about use of computers, but issues of concern included their impact on privacy, the doctor-patient relationship, cost, time, and training needs.

CONCLUSIONS

Primary care computing systems can improve practitioner performance, particularly for health promotion interventions. This may be at the expense of patient initiated activities, making many practitioners suspicious of the negative impact on relationships with patients. There remains a dearth of evidence evaluating effects on patient outcomes.

NHSnet in Scottish primary care: lessons for the future

OBJECTIVE

To evaluate the primary care communications initiative, which introduced NHSnet to primary care in Scotland.

DESIGN

Semi-structured telephone interviews, postal questionnaire.

SETTING

All 15 Scottish health boards, random sample of 1 in 3 of all Scottish general practices.

PARTICIPANTS

Information management and technology managers of health boards, 355 practice managers in the general practices.

MAIN OUTCOME MEASURES

Variations between health boards in styles of project management, means of connection to NHSnet, costs to general practices, and training provided. Practices' levels of participation in initiative, initial use of NHSnet, and factors acting as incentives and disincentives to use of NHSnet.

RESULTS

99% of Scottish general practices agreed to participate in initiative. Health boards varied significantly in project management styles (from minimal to total control), the nature of the networks they established (intranets or direct connections), costs to practices (from nothing to pound125 per general practitioner per year), and training provided (from none to an extensive programme). In 56% of practices someone accessed NHSnet at least once a week. Practices varied considerably in amount of internet training received and staff groups targeted and in the intention to provide desktop access to NHSnet through a practice network.

CONCLUSION

The initiative has successfully introduced a network that links Scottish general practices, health boards, and hospital trusts. However local variation in this "national" initiative may affect its use in primary care. Health authorities and general practices in England and Wales may wish to note these findings in order to avoid unhelpful variation.