Patients diagnosed with cancer in Britain have poorer survival than those from many similar countries. This is partly attributed to the fact that, in the UK, patients tend to be diagnosed with more advanced cancer than elsewhere. As part of a strategy to combat this, guidelines for general practitioners (GPs) were updated in 2015 advising on which patients should be referred to hospital for investigation using a fast-track system known as the "two-week wait" (TWW). In this study we will examine how often GPs follow the guidelines and whether certain types of patients (e.g. men/women, old/young) or patients with certain symptoms are more or less likely to be urgently referred when the guidelines suggest they should be. We will then examine whether these differences are explainable, for example due to urinary infections in women which may have the same symptom as bladder cancer. Finally, we will examine differences in following guidelines between different doctors and in different practices. By identifying what types of patients are not being referred according to guidelines we can improve education materials for doctors. If we find large variation by doctors in whether guidelines are followed it may be possible to target improvement efforts at certain doctors.
In 2015, the National Institute for Health and Care Excellence (NICE) released updated guidelines for recognition and referral of suspected cancer in primary care, with the intention of increasing the proportion of cancer patients being diagnosed with early stage disease. However, guidelines are only effective to the degree that they are implemented. We will examine patients identified with any of the following symptoms during 2014 to 2016: haematuria, rectal bleeding, breast lump, post-menopausal bleeding, dysphagia and anaemia, to assess the extent to which symptom-based recommendations about referrals included in NICE guidelines are followed. The guidelines for these symptoms have remained largely unchanged in the updated guidelines. Patients are included whether or not they are subsequently diagnosed with cancer, reflecting that at initial presentation a diagnosis has not been made. It is important to examine guideline implementation among all patients for which urgent referral is mandated, not only those subsequently found to have cancer. Mixed effects models will be used to assess the variability in adherence to guidelines between patient groups, presenting symptoms and between practices/GPs. Haematuria in women will provide an exemplar condition, to examine how often apparent guideline discordance is justified by firm evidence of alternative diagnosis (urinary tract infection-related antibiotic prescription/retesting). Appreciating which patient groups are at greater risk of non-referral against guideline recommendations can help target improvement efforts.
Two week wait referral; Urinary tract infection treatment; Cancer diagnosis
Gary Abel - Chief Investigator - University of Exeter
Gary Abel - Corresponding Applicant - University of Exeter
Bianca Wiering - Collaborator - University of Exeter
Georgios Lyratzopoulos - Collaborator - University College London ( UCL )
John Campbell - Collaborator - University of Exeter
William Hamilton - Collaborator - University of Exeter
HES Outpatient;NCRAS Cancer Registration Data;ONS Death Registration Data;Patient Level Index of Multiple Deprivation