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. A key service aimed at improving UK cancer survival rates (through improved diagnostic timeliness) is the fast-track referral system known as the two-week wait pathway. Guidelines advise general practitioners which patients warrant a two-week wait referral. 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
We used linked primary care (Clinical Practice Research Datalink) and secondary care (Hospital Episode Statistics) data. Patients presenting with haematuria, rectal bleeding, breast lump, post-menopausal bleeding, dysphagia or iron-deficiency anaemia for the first time during 2014-2015 were included (for patients of those ages where NICE guidelines recommend two-week wait referral). For patients presenting with haematuria, either the second or third GP visit was defined as the index consultation where patients had received treatment for urinary tract infection during earlier visits. A composite outcome reflecting whether a two-week wait referral or an urgent referral had taken place was used since both reflect the need for an urgent clinical assessment. Multilevel logistic regression was used to investigate whether the referral composite outcome was associated with symptoms and patient characteristics (age, gender, comorbidities and deprivation level).
Findings
Considering referrals made within 14 days of first presentation with a recorded symptom indicate a high percentage of patients do not receive a two-week wait or urgent referral, varying from 81.8% (rectal bleeding) to 33.3% (breast lump). There is evidence that referrals are associated with age (p<0.001), and comorbidities (p<0.05), with young patients and patients with comorbidities less likely to receive a referral. Associations between patient characteristics and referrals differ by symptom. More deprived patients with breast lumps, female patients with haematuria and anaemia patients with multi-morbidity were less likely to receive a referral. Furthermore, early evidence suggests that around 4.0% of patients not receiving a referral were diagnosed with cancer in the next year.
Consequences
Actions recommended in authoritative guidelines often do not occur for patients presenting with common possible cancer symptoms. Appreciating those patient groups which are at greater risk of non-referral when compared with guideline recommendations may help target improvement efforts in cancer diagnosis in primary care. For example, these findings may be used alongside schemes such as CRUK’s cancer facilitators and Macmillan GPs to directly influence practice. Alternatively, they could inform educational materials and novel interventions targeting early diagnosis.