Elsevier

The Lancet Oncology

Volume 13, Issue 4, April 2012, Pages 353-365
The Lancet Oncology

Articles
Variation in number of general practitioner consultations before hospital referral for cancer: findings from the 2010 National Cancer Patient Experience Survey in England

https://doi.org/10.1016/S1470-2045(12)70041-4Get rights and content

Summary

Background

Information from patient surveys can help to identify patient groups and cancers with the greatest potential for improvement in the experience and timeliness of cancer diagnosis. We aimed to examine variation in the number of pre-referral consultations with a general practitioner between patients with different cancers and sociodemographic characteristics.

Methods

We analysed data from 41 299 patients with 24 different cancers who took part in the 2010 National Cancer Patient Experience Survey in England. We examined variation in the number of general practitioner consultations with cancer symptoms before hospital referral to diagnose cancer. Logistic regression was used to identify independent predictors of three or more pre-referral consultations, adjusting for cancer type, age, sex, deprivation quintile, and ethnic group.

Findings

We identified wide variation between cancer types in the proportion of patients who had visited their general practitioner three or more times before hospital referral (7·4% [625 of 8408] for breast cancer and 10·1% [113 of 1124] for melanoma; 41·3% [193 of 467] for pancreatic cancer and 50·6% [939 of 1854] for multiple myeloma). In multivariable analysis, with patients with rectal cancer as the reference group, those with subsequent diagnosis of multiple myeloma (odds ratio [OR] 3·42, 95% CI 3·01–3·90), pancreatic cancer (2·35, 1·91–2·88), stomach cancer (1·96, 1·65–2·34), and lung cancer (1·68, 1·48–1·90) were more likely to have had three or more pre-referral consultations; conversely patients with subsequent diagnosis of breast cancer (0·19; 0·17–0·22), melanoma (0·34, 0·27–0·43), testicular cancer (0·47, 0·33–0·67), and endometrial cancer (0·59, 0·49–0·71) were more likely to have been referred to hospital after only one or two consultations. The probability of three or more pre-referral consultations was greater in young patients (OR for patients aged 16–24 years vs 65–74 years 2·12, 95% CI 1·63–2·75; p<0·0001), those from ethnic minorities (OR for Asian vs white 1·73, 1·45–2·08; p<0·0001; OR for black vs white 1·83, 1·51–2·23; p<0·0001), and women (OR for women vs men 1·28, 1·21–1·36; p<0·0001). We identified strong evidence of interactions between cancer type and age group and sex (p<0·0001 for both), and between age and ethnicity (p=0·0013). The model including these interactions showed a particularly strong sex effect for bladder cancer (OR for women vs men 2·31, 95% CI 1·98–2·69) and no apparent ethnic group differences in young patients aged 16–24 years, whilst the only cancers without an apparent age gradient were testicular cancer and mesothelioma.

Interpretation

Our findings could help to prioritise and stratify early diagnosis initiatives and research, focusing on patients with cancers and sociodemographic characteristics with the largest potential for improvement.

Funding

None.

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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