Contribution of primary care organisation and specialist care provider to variation in GP referrals for suspected cancer: ecological analysis of national data

Progress and priorities in reducing the time to cancer diagnosis

Key developments in early diagnosis research and policy since the publication of the highly cited BJC review "Is increased time to diagnosis and treatment associated with poorer outcomes?" by Neal et al. in 2015 are summarised. Progress achieved since 2015 is described and priorities for further research identified.

A Bibliometric Analysis and Visualization of Decision Support Systems for Healthcare Referral Strategies

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.

Ethnic inequalities in routes to diagnosis of cancer: a population-based UK cohort study

BACKGROUND

UK Asian and Black ethnic groups have poorer outcomes for some cancers and are less likely to report a positive care experience than their White counterparts. This study investigated ethnic differences in the route to diagnosis (RTD) to identify areas in patients' cancer journeys where inequalities lie, and targeted intervention might have optimum impact.

METHODS

We analysed data of 243,825 patients with 10 cancers (2006-2016) from the RTD project linked to primary care data. Crude and adjusted proportions of patients diagnosed via six routes (emergency, elective GP referral, two-week wait (2WW), screen-detected, hospital, and Other routes) were calculated by ethnicity. Adjusted odds ratios (including two-way interactions between cancer and age, sex, IMD, and ethnicity) determined cancer-specific differences in RTD by ethnicity.

RESULTS

Across the 10 cancers studied, most patients were diagnosed via 2WW (36.4%), elective GP referral (23.2%), emergency (18.2%), hospital routes (10.3%), and screening (8.61%). Patients of Other ethnic group had the highest proportion of diagnosis via the emergency route, followed by White patients. Asian and Black group were more likely to be GP-referred, with the Black and Mixed groups also more likely to follow the 2WW route. However, there were notable cancer-specific differences in the RTD by ethnicity.

CONCLUSION

Our findings suggest that, where inequalities exist, the adverse cancer outcomes among Asian and Black patients are unlikely to be arising solely from a poorer diagnostic process.

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

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.

Are deprivation-specific cancer survival patterns similar according to individual-based and area-based measures? A cohort study of patients diagnosed with five malignancies in England and Wales, 2008-2016

OBJECTIVE

To investigate if measured inequalities in cancer survival differ when using individual-based ('person') compared with area-based ('place') measures of deprivation for three socioeconomic dimensions: income, deprivation and occupation.

DESIGN

Cohort study.

SETTING

Data from the Office for National Statistics Longitudinal Study of England and Wales, UK, linked to the National Cancer Registration Database.

PARTICIPANTS

Patients diagnosed with cancers of the colorectum, breast, prostate, bladder or with non-Hodgkin's lymphoma during the period 2008-2016.

PRIMARY AND SECONDARY OUTCOME MEASURES

Differentials in net survival between groups defined by individual wage, occupation and education compared with those obtained from corresponding area-level metrics using the English and Welsh Indices of Multiple Deprivation.

RESULTS

Survival was negatively associated with area-based deprivation irrespective of the type analysed, although a trend from least to most deprived was not always observed. Socioeconomic differences were present according to individually-measured socioeconomic groups although there was an absence of a consistent 'gradient' in survival. The magnitude of differentials was similar for area-based and individually-derived measures of deprivation, which was unexpected.

CONCLUSION

These unique data suggest that the socioeconomic influence of 'person' is different to that of 'place' with respect to cancer outcomes. This has implications for health policy aimed at reducing inequalities. Further research could consider the separate and additional influence of area-based deprivation over individual-level characteristics (contextual effects) as well as investigate the geographic, socioeconomic and healthcare-related characteristics of areas with poor outcomes in order to inform policy intervention.

Pre-diagnostic routes to colorectal cancer in Central New Zealand: factors that lead to emergency presentation and longer diagnostic intervals at primary and secondary level care

Introduction Although international large-scale studies have investigated routes to diagnosis for colorectal cancer, there is limited information on how New Zealanders seek help for bowel symptoms across different pre-diagnostic routes. Aim To better understand pre-diagnostic routes for colorectal cancer, including the characteristics of patients and key events associated with each route. Methods This study was a retrospective audit of hospital administrative and medical records for 120 patients with a confirmed diagnosis of colorectal cancer between 2016 and 2017. All patients were receiving care at one of two hospitals in central New Zealand; one urban and one rural. Extracted data were used to: categorise pre-diagnostic routes for colorectal cancer; describe the characteristics of people who presented by each route; and compare key events in the diagnostic and treatment intervals for people who presented by each route. Results Six routes to the diagnosis of colorectal cancer were identified. The three main routes included: routine general practitioner (GP) referral (28%, 95% CI: 21-37%), emergency presentation (27%, 95% CI: 20-35%), and other outpatient services (26%, 95% CI: 19-34%). Patients diagnosed by routine GP referral had the longest time to diagnosis, impacting on timeliness of treatment. Discussion This study has generated detailed insights about pre-diagnostic routes for colorectal cancer in New Zealand and shown consistency with findings from previously published international research. The granular findings can now inform areas for person- and system-level interventions that, in turn, could be tested in future studies to minimise emergency department and late presentations for colorectal cancer treatment in New Zealand.

Using cancer risk algorithms to improve risk estimates and referral decisions

Background

Cancer risk algorithms were introduced to clinical practice in the last decade, but they remain underused. We investigated whether General Practitioners (GPs) change their referral decisions in response to an unnamed algorithm, if decisions improve, and if changing decisions depends on having information about the algorithm and on whether GPs overestimated or underestimated risk.

Methods

157 UK GPs were presented with 20 vignettes describing patients with possible colorectal cancer symptoms. GPs gave their risk estimates and inclination to refer. They then saw the risk score of an unnamed algorithm and could update their responses. Half of the sample was given information about the algorithm's derivation, validation, and accuracy. At the end, we measured their algorithm disposition. We analysed the data using multilevel regressions with random intercepts by GP and vignette.

Results

We find that, after receiving the algorithm's estimate, GPs' inclination to refer changes 26% of the time and their decisions switch entirely 3% of the time. Decisions become more consistent with the NICE 3% referral threshold (OR 1.45 [1.27, 1.65], p < .001). The algorithm's impact is greatest when GPs have underestimated risk. Information about the algorithm does not have a discernible effect on decisions but it results in a more positive GP disposition towards the algorithm. GPs' risk estimates become better calibrated over time, i.e., move closer to the algorithm.

Conclusions

Cancer risk algorithms have the potential to improve cancer referral decisions. Their use as learning tools to improve risk estimates is promising and should be further investigated.

Cancer detection via primary care urgent referral and association with practice characteristics: a retrospective cross-sectional study in England from 2009/2010 to 2018/2019

Background

There is substantial variation in the use of urgent suspected cancer referral (2-week wait [2WW]) between practices.

Aim

To examine the change in use of 2WW referrals in England over 10 years (2009/2010 to 2018/2019) and the practice and population factors associated with cancer detection.

Design and setting

Retrospective cross-sectional study of English general practices and their 2WW referral and Cancer Waiting Times database detection data (all cancers other than non-melanoma skin cancers) from 2009/2010 to 2018/2019.

Method

A retrospective study conducted using descriptive statistics of changes over 10 years in 2WW referral data. Yearly linear regression models were used to determine the association between cancer detection rates and quintiles of practice and population characteristics. Predicted cancer detection rates were calculated, as well as the difference between lowest to highest quintiles.

Results

Over the 10 years studied there were 14.89 million 2WW referrals (2.24 million in 2018/2019), and 2.68 million new cancer diagnoses, of which 1.26 million were detected following 2WW. The detection rate increased from 41% to 52% over the time period. In 2018/2019 an additional 66 172 cancers were detected via 2WW compared with 2009/2010. Higher cancer detection via 2WW referrals was associated with larger practices and those with younger GPs. From 2016/2017 onwards more deprived practice populations were associated with decreased cancer detection.

Conclusion

From 2009/2010 to 2018/2019 2WW referrals increased on average by 10% year on year. The most consistent association with higher cancer detection was found for larger practices and those with younger GPs, though these differences became attenuated over time. The more recent association between increased practice deprivation and lower cancer detection is a cause for concern. The COVID-19 pandemic has led to significant impacts on 2WW referral activity and the impact on patient outcomes will need to be studied.

Patient experiences of the urgent cancer referral pathway-Can the NHS do better? Semi-structured interviews with patients with upper gastrointestinal cancer

Background

Timeliness is viewed as a key feature of health‐care quality. Internationally, this is challenging. In England, cancer waiting time targets are currently not being met. For example, between 2015 and 2018 only 71% of patients with upper gastrointestinal (UGI) cancer started treatment within the recommended 62 days of referral.

Objective

We explored patients’ experiences to identify areas for service improvement.

Design

Semi‐structured interviews were conducted.

Setting and participants

Twenty patients who were referred through the urgent (two‐week) GP referral route and were within six months of receiving first treatment were recruited.

Data analysis

Data from the interviews were analysed thematically.

Results

Four themes were developed: organization of care; diagnosis; support; and views and expectations of the NHS. Patients described cross‐cutting issues such as complex and varied pathways and uncertainty about what would happen next. They felt daunted by the intensity and speed of investigations. They were presented with a recommended course of action rather than options and had little involvement in decision making. They were grateful for care, reluctant to complain and resigned to the status quo.

Discussion and conclusions

In order to meet patient needs, the NHS needs to improve communication and streamline pathways. Future cancer pathways also need to be designed to support shared decision making, be truly person‐centred and informed by patient experience.

Disentangling the Relationship between Physician and Organizational Performance: A Signal Detection Approach

Background. In previous research, we employed a signal detection approach to measure the performance of general practitioners (GPs) when deciding about urgent referral for suspected lung cancer. We also explored associations between provider and organizational performance. We found that GPs from practices with higher referral positive predictive value (PPV; chance of referrals identifying cancer) were more reluctant to refer than those from practices with lower PPV. Here, we test the generalizability of our findings to a different cancer. Methods. A total of 252 GPs responded to 48 vignettes describing patients with possible colorectal cancer. For each vignette, respondents decided whether urgent referral to a specialist was needed. They then completed the 8-item Stress from Uncertainty scale. We measured GPs' discrimination (d') and response bias (criterion; c) and their associations with organizational performance and GP demographics. We also measured correlations of d' and c between the 2 studies for the 165 GPs who participated in both. Results. As in the lung study, organizational PPV was associated with response bias: in practices with higher PPV, GPs had higher criterion (b = 0.05 [0.03 to 0.07]; P < 0.001), that is, they were less inclined to refer. As in the lung study, female GPs were more inclined to refer than males (b = -0.17 [-0.30 to -0.105]; P = 0.005). In a mediation model, stress from uncertainty did not explain the gender difference. Only response bias correlated between the 2 studies (r = 0.39, P < 0.001). Conclusions. This study confirms our previous findings regarding the relationship between provider and organizational performance and strengthens the finding of gender differences in referral decision making. It also provides evidence that response bias is a relatively stable feature of GP referral decision making.

Association between use of urgent suspected cancer referral and mortality and stage at diagnosis: a 5-year national cohort study

Background

There is considerable variation between GP practices in England in their use of urgent referral pathways for suspected cancer.

Aim

To determine the association between practice use of urgent referral and cancer stage at diagnosis and cancer patient mortality, for all cancers and the most common types of cancer (colorectal, lung, breast, and prostate).

Design and setting

National cohort study of 1.4 million patients diagnosed with cancer in England between 2011 and 2015.

Method

The cohort was stratified according to quintiles of urgent referral metrics. Cox proportional hazards regression was used to quantify risk of death, and logistic regression to calculate odds of late-stage (III/IV) versus early-stage (I/II) cancers in relation to referral quintiles and cancer type.

Results

Cancer patients from the highest referring practices had a lower hazard of death (hazard ratio [HR] = 0.96; 95% confidence interval [CI] = 0.95 to 0.97), with similar patterns for individual cancers: colorectal (HR = 0.95; CI = 0.93 to 0.97); lung (HR = 0.95; CI = 0.94 to 0.97); breast (HR = 0.96; CI = 0.93 to 0.99); and prostate (HR = 0.88; CI = 0.85 to 0.91). Similarly, for cancer patients from these practices, there were lower odds of late-stage diagnosis for individual cancer types, except for colorectal cancer.

Conclusion

Higher practice use of referrals for suspected cancer is associated with lower mortality for the four most common types of cancer. A significant proportion of the observed mortality reduction is likely due to earlier stage at diagnosis, except for colorectal cancer. This adds to evidence supporting the lowering of referral thresholds and consequent increased use of urgent referral for suspected cancer.