Guideline discordant diagnostic care: when do primary care referrals not reflect guidelines for suspected cancer?

Problem

Survival of patients with cancer in the United Kingdom lags behind that of patients in many similar countries around the world. Earlier diagnosis of cancer is one way in which cancer survival rates may be improved. One key service focused on improving the timeliness of diagnosis is the fast-track referral system known as the two-week wait pathway. NICE guidelines advise general practitioners which patients warrant a fast-track (two-week wait) referral to hospital. However, guidelines are only effective to the degree that they are implemented. This study aims to investigate how often GPs follow the guidelines and whether certain types of patients are more or less likely to be referred.

Approach

The Clinical Practice Research Datalink (CPRD) linked to Hospital Episode Statistics (HES) data for the period from 2014 to 2016 will be used. Patients presenting with haematuria, PR bleeding, breast lump, post-menopausal bleeding, dysphagia or anaemia for the first time during 2014-2016 will be included. Logistic regression analyses will be used in order to investigate whether patient characteristics, and the nature of symptoms affect whether patients receive a referral. Data on patient characteristics such as age, gender, ethnicity, comorbidities and level of deprivation will be derived from the CPRD data.

Findings

The study is ongoing, but will have made enough progress in order to present our findings at the conference. We will provide insight into the number of patients with one or more of the above-mentioned symptoms who should have received a “two-week wait” referral for suspected cancer, but who were not referred. We will also present information regarding which patients are more or less likely to receive a referral based on the symptoms they present with, and on patient characteristics such as age, gender, ethnicity, comorbidities and level of deprivation.

Consequences

Our findings will help to identify patients who are more likely to experience delay. Appreciating which patient groups are at greater risk of non-referral against guideline recommendations can help target improvement efforts. For example, these findings may be used by schemes such as CRUK cancer facilitators and Macmillan GPs to directly influence practice or alternatively they could inform educational materials and novel interventions targeting early diagnosis.