ArticlesVariation in number of general practitioner consultations before hospital referral for cancer: findings from the 2010 National Cancer Patient Experience Survey in England
Introduction
Major policy initiatives in several countries aim to reduce the time between symptom onset and diagnosis of cancer (often called early diagnosis initiatives).1 These initiatives result from the belief that improvements in the timeliness of diagnosis will lead to detection of cancer at an earlier disease stage, in turn leading to improved survival.2 However, emerging evidence for determinants of early diagnosis is limited and complex.3, 4, 5, 6, 7 Greater and faster improvements in cancer survival than are currently possible could be achievable if variation in the processes and timeliness of cancer diagnosis were better elucidated, helping to focus (and stratify) research and policy initiatives where there is the greatest potential for improvement.8, 9
Most patients are diagnosed with cancer after having first visited their general practitioner (family doctor) with symptoms of the disease.10 The number of such visits before hospital referral is a measure of the quality of patient experience. Patients express a strong preference for avoiding the inconvenience and stress of reconsulting on several occasions with cancer symptoms before diagnostic (and then management) processes are started.11, 12, 13 In view of the well-recognised challenges in defining and measuring time intervals for diagnosis of cancer,14, 15 analysis of variation in the number of pre-referral consultations can usefully complement information that can be derived from measuring time intervals.
The number of pre-referral consultations is easier to define and measure than are time intervals (which can be more difficult to define conceptually and, in the context of patient surveys, recall accurately16). As a measure, it is also relevant to the efficiency of the health-care system and provides a direct link to the diagnostic process and interactions occurring during consultation with a general practitioner that can be targeted by subsequent quality improvement interventions and research.
For all these reasons the number of pre-referral primary care consultations of patients with cancer has great potential for use in the context of clinical audit and quality improvement efforts as indicated by a national safety review,14 and the inclusion of this measure in national audit initiatives17 and patient experience surveys. Such surveys are increasingly used to help assess the quality of health care alongside clinical outcomes.18, 19, 20 In England, surveys of the experience of patients with cancer were done in 2000, 2004, and 2010, and the UK Government has defined patient experience as one of the five domains of health-care quality.21, 22, 23
We analysed data from the 2010 National Cancer Patient Experience Survey in England, for the number of times patients with cancer had visited their general practitioner for symptoms relating to their cancer before they were referred to hospital. We aimed to identify variation in the number of consultations for patients with different cancers and sociodemographic characteristics.
Section snippets
Participants and procedures
We accessed data from the 2010 National Cancer Patient Experience Survey in England through the UK Data Archive.22 This survey was sent to patients who were treated for cancer in English National Health Service (NHS) hospitals during the first quarter of 2010. It was commissioned by the UK Department of Health, and undertaken by Quality Health (Chesterfield, UK), a specialised patient survey provider. All survey questions were subject to previous cognitive interview testing on samples of
Results
101 773 patients aged at least 16 years who were treated for their cancer either as inpatients or day cases in one of 158 NHS hospital trusts in England were invited to participate. Of those patients, 67 713 (67%) completed the survey.24 43 792 participants had one of the 24 studied cancers, had visited their general practitioner at least once before hospital referral for cancer, and provided a valid response to the question of how many times they had visited their general practitioner before
Discussion
With data from a national survey of patient experience we identified large variation in the number of times patients visit their general practitioner before hospital referral for suspected cancer. Patients with multiple myeloma, pancreatic cancer, stomach cancer, lung cancer, Hodgkin's lymphoma, colon cancer, and ovarian cancer were substantially more likely to have visited their general practitioner three or more times before hospital referral than were patients with rectal cancer. Younger
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