Excising squamous cell carcinomas: comparing the performance of GPs, hospital skin specialists and other hospital specialists.

BACKGROUND: GPs have no defined role in the excision of squamous cell carcinomas (SCCs). Current guidelines recommend that all skin lesions suspicious of SCC should be referred urgently to secondary care. Evidence regarding current management of SCC in primary care is limited. Existing audit data suggest that up to 10% of SCCs may be excised in primary care. GPs may be able to have a greater role in the management of SCC but more evidence is required before this can be advocated. OBJECTIVE: To compare the practice of GPs, skin specialists (dermatologists and plastic surgeons) and other hospital specialists in excising SCCs. Methods . A retrospective analysis of all SCCs excised in the Grampian region between 1 January and 31 December 2005. A total of 1184 reports were rated for source and adequacy of excision. RESULTS: GPs excised 23.7% of all SCC-positive biopsies. Whether the biopsy had been performed by a GP or a hospital skin specialist made no significant difference to excision adequacy. However, GPs were significantly more likely to excise adequately than hospital non-specialists (P < 0.001). Infrequent GP excisers appear to perform as well as frequent excisers in adequately excising SCCs. CONCLUSIONS: GPs excise a considerable number of SCCs in primary care. GPs compare favourably to skin specialists in excising SCCs. The performance of infrequent GP excisers does not appear to differ significantly from that of frequent GP excisers. Further work is required to define more clearly the role of GPs in the management of SCCs.

Comparing diagnostic delay in cancer: a cross-sectional study in three European countries with primary care-led health care systems.

BACKGROUND: The principal aim of this study was to determine the feasibility of a large-scale comparative study, between the UK, the Netherlands and Sweden, to investigate whether delays in the diagnostic pathway of cancer might explain differences in cancer survival between countries. METHODS: Following a planning meeting to agree the format of a data collection instrument, data on delays in the cancer diagnostic pathway were abstracted from primary care-held medical records. Data were collected on 50 cases each (total of 150) from practices in each of Grampian, Northeast Scotland; Maastricht, the Netherlands and Skane, Sweden. Data were entered into SPSS 18.0 for analysis. RESULTS: Data on delays in the cancer diagnostic pathway were readily available from primary care-held case records. However, data on demographic variables, cancer stage at diagnosis and treatment were less well recorded. There was no significant difference between countries in the way in which cases were referred from primary to secondary care. There was no significant difference between countries in the time delay between a patient presenting in primary care and being referred to secondary care. Median delay between referral and first appointment in secondary care [19 (8.0-47.5) days] was significantly longer in Scotland that in Sweden [1.0 (0-31.5) days] and the Netherlands [5.5 (0-31.5) days] (P < 0.001). Secondary care delay (between first appointment in secondary care and diagnosis) in Scotland [22.5 (0-39.5) days] was also significantly longer than in Sweden [14.0 (4.5-31.5) days] and the Netherlands [3.5 (0-16.5) days] (P = 0.003). Finally, overall delay in Scotland [53.5 (30.3-96.3) days] was also significantly longer than in Sweden [32.0 (14.0-71.0) days] and the Netherlands [22.0 (7.0-60.3) days] (P = 0.003). CONCLUSIONS: A large-scale study comparing cancer delays in European countries and based on primary care-held records is feasible but would require supplementary sources of data in order to maximize information on demographic variables, the cancer stage at diagnosis and treatment details. Such a large-scale study is timely and desirable since our findings suggest systematic differences in the way cancer is managed in the three countries.

European differences in cancer survival: report of an international symposium of general practitioners from three countries exploring primary and secondary care delay.

BACKGROUND: There are several potential delays in the cancer diagnostic pathway: patient delay, primary care delay and secondary care delay. People in the UK have poorer five-year survival from many cancers compared with people in European countries with similar healthcare systems. The reasons for this are not clear, although it has been postulated that UK patients may present with cancer at a later stage. We are conducting a study to investigate the feasibility of comparing diagnostic delays in different European countries. METHODS: (conduct of the symposium): A half-day, round-table symposium was convened with seven general practitioners (GPs) and single primary care researchers from Sweden (Malmö), the Netherlands (Maastricht) and Scotland (Aberdeen). In Session One the group had a broad-ranging discussion comparing and contrasting their different working contexts and how these might impact on the cancer diagnostic pathway. In Session Two the group considered two case studies from Scotland, applying their own local experience and the insights generated in Session One to identify common and divergent issues. When it had finished the facilitator drafted a detailed report of the symposium which was supported by reference to the individual participants' notes which had been collected at the end of the symposium. RESULTS: (consensus views reached): Sweden, the Netherlands and Scotland have strong traditions of primary care acting in a gate-keeping role. People with cancer in the three countries following a broadly similar cancer diagnostic pathway. In Sweden and the Netherlands GPs have direct unscreened access to a greater range of investigations than in Scotland. In Scotland there is a greater reliance on specialist guidelines than in the Netherlands or Sweden. Future research in the UK could explore the potential contribution of increased GP access to investigations and revised referral guidelines.

Menopause-related workload in general practice 1996-2005: a retrospective study in the UK.

BACKGROUND: Women with menopausal symptoms often consult with a health professional. Recently, hormone replacement therapy (HRT) prescribing has declined but the impact of this change on other aspects of general practice workload is unclear. OBJECTIVE: To investigate whether the menopause remains a workload issue. METHODS: A retrospective observational study of UK general practice (General Practice Research Database) using four random samples of 25000 women aged 45-64 years registered with a general practice during 1996, 1999, 2002 and 2005. We calculated the incidence and prevalence of menopause-related consultation; gynaecology referrals; prescriptions for HRT, clonidine and antidepressants during each year; examined patterns over time and investigated whether the types of preparations had changed. RESULTS: The prevalence and incidence of menopause-related consultation fell-from 18.1% of women aged 45-64 years consulting at least once in 1996 to 10.4% in 2005. Over time, the proportion of women consulting about the menopause who were not prescribed HRT or clonidine increased. The incidence and prevalence of HRT decreased, mainly between 2002 and 2005. The proportion of women prescribed oral HRT fell while the proportion prescribed cream or pessaries/suppositories increased, particularly among women without a hysterectomy. Referrals to gynaecology and the incidence and prevalence of clonidine prescribing increased but remained uncommon. Patterns of antidepressant prescribing did not appear menopause related. CONCLUSION: Although menopause-related workload has decreased over time, in 2005, over 10% of women aged 45-64 years consulted for a menopause-related matter. This suggests that the menopause remains an important part of UK general practice work.

GP-led melanoma follow-up: views and feelings of patient recipients.

OBJECTIVES: The aim of this study was to explore the practical experiences and feelings of people with cutaneous malignant melanoma about receiving structured melanoma follow-up from their general practitioner (GP) as an alternative to traditional hospital-based follow-up. DESIGN: Semi-structured audio-taped telephone interviews were conducted with patient recipients of a GP-led follow-up programme for people with cutaneous malignant melanoma. SUBJECTS: Eighteen people with cutaneous malignant melanoma that had received structured GP-led routine follow-up for cutaneous malignant melanoma took part in this study. RESULTS: GP-led melanoma follow-up worked well from the perspectives patients. Patients appreciated convenience of the system, less rushed appointments with more thorough examinations, a more pleasant atmosphere and greater continuity of care. They regarded the GP-led follow-up positively, irrespective of distance from the major cancer centre. Concerns expressed included awareness that most GPs had less experience of melanoma than hospital specialists. CONCLUSIONS: GP-led melanoma follow-up is feasible and is generally viewed positively by those patients that have experienced it.

GP-led melanoma follow-up: the practical experience of GPs.

OBJECTIVES: To explore how GP-led melanoma follow-up had actually worked from the perspective of GPs by exploring in detail the practical experience of GPs running the programme. DESIGN: Semi-structured audio-taped telephone interviews with GPs delivering a GP-led follow-up programme for people with cutaneous malignant melanoma. SUBJECTS: Seventeen GPs currently delivering structured GP-led routine follow-up for people with cutaneous melanoma. RESULTS: GP-led melanoma follow-up worked well from the perspectives of GPs. The GPs felt that they were well equipped and supported in undertaking the follow-up consultations and recognized that they were freeing up hospital consultant time. They felt that patients appreciated the convenience of GP-led follow-up. The GPs felt that a robust recall system, initial training with regular refreshers and effective consultant backup were vital components of a successful long-term programme. CONCLUSIONS: GP-led melanoma follow-up is feasible and, provided certain concerns can be addressed, GPs are willing to provide it.