Patient-reported diagnostic intervals to colorectal cancer diagnosis in the Midland region of New Zealand: a prospective cohort study.

BACKGROUND AND OBJECTIVES: New Zealand (NZ) has high rates of colorectal cancer (CRC) but low rates of early detection. The majority of CRC is diagnosed through general practice, where lengthy diagnostic intervals are common. We investigated factors contributing to diagnostic delay in a cohort of patients newly diagnosed with CRC. METHODS: Patients were recruited from the Midland region and interviewed about their diagnostic experience using a questionnaire based on a modified Model of Pathways to Treatment framework and SYMPTOM questionnaire. Descriptive statistics were used to describe the population characteristics. Chi-square analysis and logistic regression were used to analyse factors influencing diagnostic intervals. RESULTS: Data from 176 patients were analysed, of which 65 (36.9%) experienced a general practitioner (GP) diagnostic interval of >120 days and 96 (54.5%) experienced a total diagnostic interval (TDI) > 120 days. Patients reporting rectal bleeding were less likely to experience a long TDI (odds ratio [OR] 0.34, 95% confidence interval [CI]: 0.14-0.78) and appraisal/help-seeking interval (OR, 0.19, 95% CI: 0.06-0.59). Patients <60 were more likely to report a longer appraisal/help-seeking interval (OR, 3.32, 95% CI: 1.17-9.46). Female (OR, 2.19, 95% CI: 1.08-4.44) and Maori patients (OR, 3.18, 95% CI: 1.04-9.78) were more likely to experience a long GP diagnostic interval. CONCLUSION: NZ patients with CRC can experience long diagnostic intervals, attributed to patient and health system factors. Young patients, Maori, females, and patients experiencing change of bowel habit may be at particular risk. We need to increase symptom awareness of CRC for patients and GPs. Concentrated efforts are needed to ensure equity for Maori in access to screening, diagnostics, and treatment.

New Zealand has high rates of colorectal cancer but low rates of early detection. We interviewed newly diagnosed patients about their diagnostic experience to identify factors influencing time to diagnosis. More than half of patients experienced a long diagnostic interval. Young patients, Maori, females, and patients experiencing changes of bowel habit may be at particular risk for long intervals. With the diagnostic difficulty of colorectal cancer (CRC), we need to increase CRC symptom awareness for patients and general practitioners.

Outcomes from colonoscopy following referral from New Zealand general practice: a retrospective analysis.

BACKGROUND: New Zealand has high rates of colorectal cancer (CRC) but poor outcomes. Most patients with CRC are diagnosed following referral from general practice, where a general practitioner (GP) assesses symptoms according to national guidelines. All referred patients are then re-prioritised by the hospital system. The first objective of this study was to identify what proportion of patients referred by general practice to surgical/gastroenterology at Waikato District Health Board (DHB) had a colonoscopy. The second objective was to determine what proportion of these referrals have an underlying CRC and the factors associated with the likelihood of this diagnosis. METHODS: This study is a retrospective analysis of e-referral data for patients aged 30-70+ who were referred from 75 general practices to general surgery, gastroenterology or direct to colonoscopy at Waikato DHB, 01 January 2015-31 December 2017. Primary and secondary outcome measures included the proportion and characteristics of patients who were having colonoscopy, and of those, who were diagnosed with CRC. Data were analysed using chi square and logistic regression. RESULTS: 6718/20648 (32.5%) patients had a colonoscopy and 372 (5.5%) of these were diagnosed with CRC. The probability of having CRC following a colonoscopy increased with age (p value < 0.001). Females (p value < 0.001), non-Maori (p value < 0.001), and patients with a high suspicion of cancer (HSCan) label originating from their GP were more likely to have a colonoscopy, while the odds ratio of Maori having a colonoscopy was 0.66 (95% CI 0.60-0.73). The odds ratio of a CRC diagnosis following colonoscopy was 1.67 (95% CI 1.35-2.07) for men compared to women, and 2.34 (95% CI 1.70-3.22) for those with a GP HSCan label. Of the 585 patients referred with a GP HSCan, 423 (72.3%) were reprioritised by the hospital and 55 patients had their diagnosis unnecessarily delayed. CONCLUSIONS: If a GP refers a patient with an HSCan, and the patient receives a colonoscopy, then the likelihood of having CRC is almost 15.0%. This would suggest that these patients should be routinely prioritised without further triage by the hospital. Further research is needed to understand why Maori are less likely to receive a colonoscopy following referral from general practice.

How do colorectal cancer patients rate their GP: a mixed methods study.

BACKGROUND: New Zealand (NZ) has a high incidence of colorectal cancer (CRC) and low rates of early diagnosis. With screening not yet nationwide, the majority of CRC is diagnosed through general practice. A good patient-general practitioner (GP) relationship can facilitate prompt diagnosis, but when there is a breakdown in this relationship, delays can occur. Delayed diagnosis of CRC in NZ receives a disproportionally high number of complaints directed against GPs, suggesting deficits in the patient-GP connection. We aimed to investigate patient-reported confidence and ratings of their GP following the diagnostic process. METHODS: This study is a mixed methods analysis of responses to a structured questionnaire and free text comments from patients newly diagnosed with CRC in the Midland region of NZ. A total of 195 patients responded to the structured questionnaire, and 113 patients provided additional free text comments. Descriptive statistics were used to describe the study population and chi square analysis determined the statistical significance of factors possibly linked to delay. Free text comments were analysed using a thematic framework. RESULTS: Most participants rated their GP as 'Very good/Good' at communication with patients about their health conditions and involving them in decisions about their care, and 6.7% of participants rated their overall level of confidence and trust in their GP as 'Not at all'. Age, gender, ethnicity and a longer diagnostic interval were associated with lower confidence and trust. Free text comments were grouped in to three themes: 1. GP Interpersonal skills; (communication, listening, taking patient symptoms seriously), 2. Technical competence; (speed of referral, misdiagnoses, lack of physical examination), and 3. Organisation of general practice care; (appointment length, getting an appointment, continuity of care). CONCLUSIONS: Maori, females, and younger participants were more likely to report low confidence and trust in their GP. Participants associate a poor diagnostic experience with deficits in the interpersonal and technical skills of their GP, and health system factors within general practice. Short appointment times, access to appointments and poor GP continuity are important components of how patients assess their experience and are particularly important to ensure equal access for Maori patients.

Why does New Zealand have such poor outcomes from colorectal cancer?: the importance of the pre-diagnostic period.

INTRODUCTION Over 3000 cases of colorectal cancer (CRC) are diagnosed annually in New Zealand. The proportion of late stage diagnoses is higher than in similar countries, and highest in Maori and Pacific patients. Survival outcomes are poorer than for people in Australia and poor for Maori and Pacific peoples. A regional screening programme is not yet available to the entire target population (60-74 years). AIM This study reviews research investigating the pre-diagnostic pathway for CRC in New Zealand and how this may contribute to poorer outcomes. METHODS This was a scoping review of original articles examining the pre-diagnostic period for CRC published on the PubMed database between 2009 and 2019. Findings were interpreted within the Model of Pathways to Treatment framework and in context of international evidence. RESULTS In total, 83 publications were assessed; eight studies were included. Studies were mainly older than 5 years, qualitative, and focused on screening. Facilitatory factors for the appraisal and help-seeking intervals increased CRC public awareness and the critical role of general practitioners. No specific facilitatory or inhibitory factors were identified for the diagnostic interval, but two studies found that time frames did not meet national and international targets. One study discovered longer pre-diagnostic intervals were associated with younger age at diagnosis. DISCUSSION Limited recent research has investigated the CRC pre-diagnostic pathways in NZ. Identification of facilitatory and inhibitory factors and implementation of appropriate strategies to improve them alongside the wider uptake of the screening programme may improve stage at diagnosis and outcomes for New Zealand CRC patients.

Barriers and facilitators to colorectal cancer diagnosis in New Zealand: a qualitative study.

BACKGROUND: New Zealand (NZ) has high rates of colorectal cancer but low rates of early diagnosis. Due to a lack of understanding of the pre-diagnostic experience from the patient's perspective, it is necessary to investigate potential patient and health system factors that contribute to longer diagnostic intervals. Previous qualitative studies have discussed delays using The Model of Pathways to Treatment, but this has not been explored in the NZ context. This study aimed to understand the patient experience and perception of their general practitioner (GP) through the diagnostic process in the Waikato region of NZ. In particular, we sought to investigate potential barriers and facilitators that contribute to longer diagnostic intervals. METHODS: Ethical approval for this study was granted by the New Zealand Health and Disability Ethics Committee. Twenty-eight participants, diagnosed with colorectal cancer, were interviewed about their experience. Semi-structured interviews were audio recorded, transcribed verbatim and analysed thematically using The Model of Pathways to Treatment framework (intervals: appraisal, help-seeking, diagnostic). RESULTS: Participant appraisal of symptoms was a barrier to prompt diagnosis, particularly if symptoms were normalised, intermittent, or isolated in occurrence. Successful self-management techniques also resulted in delayed help-seeking. However if symptoms worsened, disruption to work and daily routines were important facilitators to seeking a GP consultation. Participants positively appraised GPs if they showed good technical competence and were proactive in investigating symptoms. Negative GP appraisals were associated with a lack of physical examinations and misdiagnosis, and left participants feeling dehumanised during the diagnostic process. However high levels of GP interpersonal competence could override poor technical competence, resulting in an overall positive experience, even if the cancer was diagnosed at an advanced stage. Maori participants often appraised symptoms inclusive of their sociocultural environment and considered the impact of their symptoms in relation to family. CONCLUSIONS: The findings of this study highlight the importance of tailored colorectal cancer symptom communication in health campaigns, and indicate the significance of the interpersonal competence aspect of GP-patient interactions. These findings suggest that interpersonal competence be overtly displayed in all GP interactions to ensure a higher likelihood of a positive experience for the patient.

A systematic scoping review of interventions to integrate physical and mental healthcare for people with serious mental illness and substance use disorders.

Integrated care approaches have been recommended to remove barriers to healthcare and improve the physical health outcomes of people living with serious mental illness (SMI) and/or substance use disorders (SUDs). The aim of this systematic scoping review was to describe empirical investigations of interventions designed to integrate physical, mental, and addiction healthcare for this population. An iterative and systematic search of five electronic databases (Medline (Ovid), PsycINFO, CINAHL, Embase (Ovid) and Scopus) was conducted to identify peer-reviewed articles published between January 2000 and April 2019. Two reviewers independently screened publications in two successive stages of title and abstract screening, followed by full-text screening of eligible publications. Data from each included publication were extracted independently by two reviewers using a standardised spreadsheet. A total of 28 eligible publications were identified, representing 25 unique studies. Over half of the included studies investigated the use of case managers to provide self-management skills or to coordinate mental and physical healthcare (n = 14). Other interventions examined the co-location of services (n = 9) and the implementation of screening and referral pathways to specialist treatment (n = 2). Less than half of the included studies described a framework, theory or model that was underpinning the intervention tested. While some aspects of integrated care have been identified and addressed by interventions, other key dimensions have not been considered, such as shared decision-making. Identification of a comprehensive model of integrated care is recommended to inform the development and evaluation of future interventions for people with SMI/SUDs.

Clinical pharmacist facilitators in primary care: a descriptive study of their roles and services provided in general practices of southern New Zealand.

INTRODUCTION Internationally, the inclusion of pharmacists into general practice as clinical pharmacy facilitators has improved patient outcomes. However, clinical pharmacists are relatively new to southern New Zealand general practices and their range of services has not been studied. AIMS To describe the implementation of clinical pharmacist services in general practices in the Southern region; to examine the tasks conducted by clinical pharmacy facilitators; and to determine the characteristics of patients who access this service. METHODS The establishment and development of the clinical pharmacy facilitator role was determined by documentation held within the local Primary Health Organisation. The activities performed by clinical pharmacy facilitators were collected from patient medical records for the period 31 March 2015 to 31 March 2018. To describe the characteristics of patients receiving these services, a retrospective case note review of patients seen by the facilitators was conducted. RESULTS The clinical pharmacy facilitator role was initiated with three pharmacists in three geographical locations across the region. Within 18 months, the number of facilitators was increased to eight. As a result of collaboration with the general practice team, 42% of referrals came from general practitioners directly. Overall, 2621 medicine-related problems were identified in 2195 patients. Dosage adjustment was the most common recommendation made by pharmacy facilitators. They consulted mostly older patients and patients taking five or more medicines. DISCUSSION With effective collaboration, clinical pharmacy facilitators can play a key role in optimisation of medicines therapy.

Health Care Utilisation and Health Needs of People with Severe COPD in the Southern Region of New Zealand: A Retrospective Case Note Review.

We examined health care utilisation and needs of people with severe COPD in the low-population-density setting of the Southern Region of New Zealand (NZ). We undertook a retrospective case note review of patients with COPD coded as having an emergency department attendance and/or admission with at least one acute exacerbation during 2015 to hospitals in the Southern Region of NZ. Data were collected and analysed from 340 case notes pertaining to: demographics, hospital admissions, outpatient contacts, pulmonary rehabilitation, advance care planning and comorbidities. Geometric mean (95%CI) length of stay for hospital admissions in urban and rural hospitals was 3.0 (2.7-3.4) and 4.0 (2.9-5.4) days respectively. More patients were from areas of higher deprivation but median hospital length of stay for patients from the least deprived areas was 2.0 days longer than others (p = 0.04). There was a median of 4 (range 0-16) comorbidities and 10 medications (range 0-25) per person. Of 169 cases where data was available, 26 (15%) were offered, 17 (10%) declined, and 5 (3%) completed, pulmonary rehabilitation at or in the year prior to the index admission. Patients were less likely to be offered pulmonary rehabilitation if they lived >20km away from the hospital where it took place (odds ratio of 0.12 for those living further away [95%CI 0.02-0.93, p = 0.04]). There were deficits in care: provision and uptake of non-pharmacological interventions was suboptimal and unevenly distributed across the region. Further research is needed to develop and evaluate strategies for delivering non-pharmacological interventions in this setting.

Multimorbidity in Maori and Pacific patients: cross-sectional study in a Dunedin general practice.

INTRODUCTION Multimorbidity is a major issue in primary health care. AIM To determine the prevalence of multimorbidity and polypharmacy in one general practice in relation to age, sex and socioeconomic deprivation in Maori and Pacific patients. METHODS A cross-sectional study using data manually extracted from electronic medical records was conducted using a stratified random sample of Maori and Pacific patients aged ≥ 35 years who were enrolled with a large urban Dunedin general practice. The data were analysed to identify the number and type of morbidities, and prevalence of multimorbidity and polypharmacy in relation to age, sex and socioeconomic deprivation. RESULTS Half (52.5% [95% CI 44.5-60.4]) of Maori and 64.3% (95% CI 51.9-75.4) of Pacific patients had multimorbidity; 22.8% (95% CI 16.6-30.1) of Maori and 10.0% (95% CI 4.1-19.5) of Pacific patients had physical and mental health co-morbidity. Fewer (13.6% [95% CI 8.7-19.8]) Maori than Pacific patients (32.9% [95% CI 22.1-45.1]) had polypharmacy. The prevalence of multimorbidity in both Maori and Pacific patients increased with age and with increasing levels of socioeconomic deprivation. The eight most prevalent chronic conditions in both Maori and Pacific patients were obesity, anxiety or depression, hypertension, asthma or chronic obstructive pulmonary disease, gout, diabetes, cardiovascular disease and osteoarthritis. CONCLUSION The high prevalence of multimorbidity in Maori and Pacific patients requires the New Zealand health system to deliver culturally competent primary health care and to re-orientate health-care delivery around multimorbidity.

Palliative care in the community for cancer and end-stage cardiorespiratory disease: the views of patients, lay-carers and health care professionals.

Primary care plays an important role in delivering care to people who are dying. However, providing palliative care to people dying with conditions other than cancer may be more problematic, because it may be more difficult to establish an exact prognosis or to identify their needs. This article draws on qualitative research, which explored the views of health professionals, patients and their carers about care provided at the end of life. Differences between the care of people with cancer and those with end-stage cardiorespiratory disease were found in four main areas: management and progression of disease, communication and information, health care in the community and awareness of dying. The research shows that even in PHCTs (primary health care teams) committed to the delivery of palliative care, people dying with end-stage cardiorespiratory disease are less likely than those with cancer to receive full, and easily understood, information, to be aware that they are dying or to receive district nursing care. There is an increasing call for palliative care to be extended to all, but further work is needed to develop appropriate packages of care for those dying with conditions other than cancer.

Care of people dying with malignant and cardiorespiratory disease in general practice.

BACKGROUND: Provision of palliative care for people dying with malignant disease is a well-characterised aspect of general practice workload. The nature of end-of-life care of people with non-malignant disease is less well described. AIM: To compare the general practice care provided in the last year of life to people who died with malignant and with cardiorespiratory disease. DESIGN: Case record review. SETTING: Two Leicestershire general practices: one inner-city, one semi-rural; total practice population 26,000 people. METHOD: General practice review of the records of all people registered with the practices who died with malignant or cardiorespiratory disease between 1 August 2000 and 31 July 2002 to determine: cause and place of death, recorded comorbidity, palliative medication prescribed, number of consultations and continuity of care, receipt and duration of palliative care. RESULTS: When compared with people who died with cardiorespiratory disease, those who died with malignant disease were more likely to have had a terminal phase of their illness identified and to have been prescribed more palliative drugs. Both groups consulted a similar number of times, experienced similar continuity of care, had similar comorbidity, and were equally likely to die at home. CONCLUSION: People who died with cardiorespiratory disease were less likely to be in receipt of formally identified terminal care and were likely to have had fewer drugs prescribed for palliation than people with malignant disease, yet they make similar demands of practices. They are likely to have unmet needs with respect to palliation of symptoms.