How the probability of presentation to a primary care clinician correlates with cancer survival rates: a European survey using vignettes.

OBJECTIVE: European cancer survival rates vary widely. System factors, including whether or not primary care physicians (PCPs) are gatekeepers, may account for some of these differences. This study explores where patients who may have cancer are likely to present for medical care in different European countries, and how probability of presentation to a primary care clinician correlates with cancer survival rates. DESIGN: Seventy-eight PCPs in a range of European countries assessed four vignettes representing patients who might have cancer, and consensus groups agreed how likely those patients were to present to different clinicians in their own countries. These data were compared with national cancer survival rates. SETTING: A total of 14 countries. SUBJECTS: Consensus groups of PCPs. MAIN OUTCOME MEASURES: Probability of initial presentation to a PCP for four clinical vignettes. RESULTS: There was no significant correlation between overall national 1-year relative cancer survival rates and the probability of initial presentation to a PCP (r = -0.16, 95% CI -0.39 to 0.08). Within that there was large variation depending on the type of cancer, with a significantly poorer lung cancer survival in countries where patients were more likely to initially consult a PCP (lung r = -0.57, 95% CI -0.83 to -0.12; ovary: r = -0.13, 95% CI -0.57 to 0.38; breast r = 0.14, 95% CI -0.36 to 0.58; bowel: r = 0.20, 95% CI -0.31 to 0.62). CONCLUSIONS: There were wide variations in the degree of gatekeeping between countries, with no simple binary model as to whether or not a country has a "PCP-as-gatekeeper" system. While there was case-by-case variation, there was no overall evidence of a link between a higher probability of initial consultation with a PCP and poorer cancer survival. KEY POINTS European cancer survival rates vary widely, and health system factors may account for some of these differences. The data from 14 European countries show a wide variation in the probability of initial presentation to a PCP. The degree to which PCPs act as gatekeepers varies considerably from country to country. There is no overall evidence of a link between a higher probability of initial presentation to a PCP and poorer cancer survival.

Exploring why European primary care physicians sometimes do not think of, or act on, a possible cancer diagnosis. A qualitative study.

BACKGROUND: While primary care physicians (PCPs) play a key role in cancer detection, they can find cancer diagnosis challenging, and some patients have considerable delays between presentation and onward referral. AIM: To explore European PCPs' experiences and views on cases where they considered that they had been slow to think of, or act on, a possible cancer diagnosis. DESIGN & SETTING: A multicentre European qualitative study, based on an online survey with open-ended questions, asking PCPs for their narratives about cases when they had missed a diagnosis of cancer. METHOD: Using maximum variation sampling, PCPs in 23 European countries were asked to describe what happened in a case where they were slow to think of a cancer diagnosis, and for their views on why it happened. Thematic analysis was used to analyse the data. RESULTS: A total of 158 PCPs completed the questionnaire. The main themes were as follows: patients' descriptions did not suggest cancer; distracting factors reduced PCPs' cancer suspicions; patients' hesitancy delayed the diagnosis; system factors not facilitating timely diagnosis; PCPs felt that they had acted wrongly; and problems with communicating adequately. CONCLUSION: The study identified six overarching themes that need to be addressed. Doing so should reduce morbidity and mortality in the small proportion of patients who have a significant, avoidable delay in their cancer diagnosis. The 'Swiss cheese' model of accident causation showed how the themes related to each other.

[Review of the program of early detection of cervical cancer in women in Primorsko-Goranska County in 2009]. / Rano otkrivanje raka vrata maternice u zena primorsko-goranske zupanije u 2009. Godini--prikaz programa.

INTRODUCTION: Cervical cancer is the most common cancer in women, the second most frequent malignancy in women and the second most common cause of death in women suffering from cancer worldwide. In 2009, in the Primorje-Goranska County 52 (4.1%) women were hospitalized for the treatment of cervical cancer. AIM: The aim of this paper is to show the methodology and results of the County program in 2009. METHODS: The County Institute of Public Health (IPH) has been conducting this screening program systematically since 2006. In 2009, screening was conducted at six gynecologic practices with coverage of 6000 women. Prior to Program performance, the IPH provide the gynecologists with all necessary logistics (brushes for cytobrush technique, Pap tests, addressed envelopes, invitation letters and patient questionnaires). The gynecologists include women by random choice, each gynecologist around 1000 women of the specified age group. They send invitations to women with specified date and time of testing. Swabs are referred to the Cytology Laboratory, Rijeka University Hospital Center in Rijeka. For the purpose of this Program, IPH has designed a questionnaire for women, containing 13 questions. Patients give the questionnaires back to the gynecologists, who send them to the IPH for statistical analysis. Data collected from the questionnaires and Pap test findings are entered in a specially designed computer program. During Program implementation, the IPH, gynecologists and cytologists work together to improve the quality of testing. For the purpose of education of women about sexual health and to improving the response rate, IPH has created and distributed 10,000 educational brochures entitled Sexual health of women, the knowledge is power. RESULTS: In 2009, the response rate in the Program was 41.9% (n=2514). Cytologic analysis of Pap tests yielded 94.5% of negative results and 5.1% of abnormal findings. Adequacy of 99.6% of Pap smears was satisfactory, while 0.4% of samples were of poor quality that could not be analyzed. Results showed 66.7% of women to undergo gynecologic examination once a year, whereas 17.9% of women had not been for gynecologic examination for more than 3 years. The majority (90.7%) of women that participated in the Program were visiting the chosen gynecologist at primary health care. DISCUSSION: Throughout the Program implementation, the leading problem continued to be low turnout of gynecologists for inclusion in the Program and poor turnout of invited women. The cause of this problem lies in the insufficient number of gynecologic teams and too many women in care of one gynecologist. This problem points to the need of restructuring of primary health care for women with emphasis on the number of health professionals. Results of the analysis of two questions in the questionnaire indicated inadequate knowledge of women about the importance of regular gynecologic control. When planning screening program in the coming years, attention should be focused on the motivation of women of younger age groups as well as those that are irregularly controlled. CONCLUSION: Organized screening can reduce the risk and mortality of cervical cancer. It is also known that with a relatively small investment but with better health care organization, the response of women can increase. Taking into account the threat posed by cervical cancer for women's health and social burden, the need of prevention strategies, primarily screening tests, is clear as a means for early detection of the problem and timely removal of abnormal cells.

Identifying important health system factors that influence primary care practitioners' referrals for cancer suspicion: a European cross-sectional survey.

OBJECTIVES: Cancer survival and stage of disease at diagnosis and treatment vary widely across Europe. These differences may be partly due to variations in access to investigations and specialists. However, evidence to explain how different national health systems influence primary care practitioners' (PCPs') referral decisions is lacking.This study analyses health system factors potentially influencing PCPs' referral decision-making when consulting with patients who may have cancer, and how these vary between European countries. DESIGN: Based on a content-validity consensus, a list of 45 items relating to a PCP's decisions to refer patients with potential cancer symptoms for further investigation was reduced to 20 items. An online questionnaire with the 20 items was answered by PCPs on a five-point Likert scale, indicating how much each item affected their own decision-making in patients that could have cancer. An exploratory factor analysis identified the factors underlying PCPs' referral decision-making. SETTING: A primary care study; 25 participating centres in 20 European countries. PARTICIPANTS: 1830 PCPs completed the survey. The median response rate for participating centres was 20.7%. OUTCOME MEASURES: The factors derived from items related to PCPs' referral decision-making. Mean factor scores were produced for each country, allowing comparisons. RESULTS: Factor analysis identified five underlying factors: PCPs' ability to refer; degree of direct patient access to secondary care; PCPs' perceptions of being under pressure; expectations of PCPs' role; and extent to which PCPs believe that quality comes before cost in their health systems. These accounted for 47.4% of the observed variance between individual responses. CONCLUSIONS: Five healthcare system factors influencing PCPs' referral decision-making in 20 European countries were identified. The factors varied considerably between European countries. Knowledge of these factors could assist development of health service policies to produce better cancer outcomes, and inform future research to compare national cancer diagnostic pathways and outcomes.