The cancer care experiences of gay, lesbian and bisexual patients: A secondary analysis of data from the UK Cancer Patient Experience Survey.

Understanding the effects of population diversity on cancer-related experiences is a priority in oncology care. Previous research demonstrates inequalities arising from variation in age, gender and ethnicity. Inequalities and sexual orientation remain underexplored. Here, we report, for the first time in the UK, a quantitative secondary analysis of the 2013 UK National Cancer Patient Experience Survey which contains 70 questions on specific aspects of care, and six on overall care experiences. 68,737 individuals responded, of whom 0.8% identified as lesbian, gay or bisexual. Controlling for age, gender and concurrent mental health comorbidity, logistic regression models applying post-estimate probability Wald tests explored response differences between heterosexual, bisexual and lesbian/gay respondents. Significant differences were found for 16 questions relating to: (1) a lack of patient-centred care and involvement in decision-making, (2) a need for health professional training and revision of information resources to negate the effects of heteronormativity and (3) evidence of substantial social isolation through cancer. These findings suggest a pattern of inequality, with less positive cancer experiences reported by lesbian, gay and (especially) bisexual respondents. Poor patient-professional communication and heteronormativity in the healthcare setting potentially explain many of the differences found. Social isolation is problematic for this group and warrants further exploration.

Identifying people at higher risk of melanoma across the U.K.: a primary-care-based electronic survey.

BACKGROUND: Melanoma incidence is rising rapidly worldwide among white populations. Defining higher-risk populations using risk prediction models may help targeted screening and early detection approaches. OBJECTIVES: To assess the feasibility of identifying people at higher risk of melanoma using the Williams self-assessed clinical risk estimation model in U.K. primary care. METHODS: We recruited participants from the waiting rooms of 22 general practices covering a total population of > 240 000 in three U.K. regions: Eastern England, North East Scotland and North Wales. Participants completed an electronic questionnaire using tablet computers. The main outcome was the mean melanoma risk score using the Williams melanoma risk model. RESULTS: Of 9004 people approached, 7742 (86%) completed the electronic questionnaire. The mean melanoma risk score for the 7566 eligible participants was 17·15 ± 8·51, with small regional differences [lower in England compared with Scotland (P = 0·001) and Wales (P < 0·001), mainly due to greater freckling and childhood sunburn among Scottish and Welsh participants]. After weighting to the age and sex distribution, different potential cut-offs would allow between 4% and 20% of the population to be identified as higher risk, and those groups would contain 30% and 60%, respectively of those likely to develop melanoma. CONCLUSIONS: Collecting data on the melanoma risk profile of the general population in U.K. primary care is both feasible and acceptable for patients in a general practice setting, and provides opportunities for new methods of real-time risk assessment and risk stratified cancer interventions.

The relative length of the patient and the primary care interval in patients with 28 common and rarer cancers.

BACKGROUND: Appreciating variation in the length of pre- or post-presentation diagnostic intervals can help prioritise early diagnosis interventions with either a community or a primary care focus. METHODS: We analysed data from the first English National Audit of Cancer Diagnosis in Primary Care on 10 953 patients with any of 28 cancers. We calculated summary statistics for the length of the patient and the primary care interval and their ratio, by cancer site. RESULTS: Interval lengths varied greatly by cancer. Laryngeal and oropharyngeal cancers had the longest median patient intervals, whereas renal and bladder cancer had the shortest (34.5 and 30 compared with 3 and 2 days, respectively). Multiple myeloma and gallbladder cancer had the longest median primary care intervals, and melanoma and breast cancer had the shortest (20.5 and 20 compared with 0 and 0 days, respectively). Mean patient intervals were longer than primary care intervals for most (18 of 28) cancers, and notably so (two- to five-fold greater) for 10 cancers (breast, melanoma, testicular, vulval, cervical, endometrial, oropharyngeal, laryngeal, ovarian and thyroid). CONCLUSIONS: The findings support the continuing development and evaluation of public health interventions aimed at shortening patient intervals, particularly for cancers with long patient interval and/or high patient interval over primary care interval ratio.

Is increased time to diagnosis and treatment in symptomatic cancer associated with poorer outcomes? Systematic review.

BACKGROUND: It is unclear whether more timely cancer diagnosis brings favourable outcomes, with much of the previous evidence, in some cancers, being equivocal. We set out to determine whether there is an association between time to diagnosis, treatment and clinical outcomes, across all cancers for symptomatic presentations. METHODS: Systematic review of the literature and narrative synthesis. RESULTS: We included 177 articles reporting 209 studies. These studies varied in study design, the time intervals assessed and the outcomes reported. Study quality was variable, with a small number of higher-quality studies. Heterogeneity precluded definitive findings. The cancers with more reports of an association between shorter times to diagnosis and more favourable outcomes were breast, colorectal, head and neck, testicular and melanoma. CONCLUSIONS: This is the first review encompassing many cancer types, and we have demonstrated those cancers in which more evidence of an association between shorter times to diagnosis and more favourable outcomes exists, and where it is lacking. We believe that it is reasonable to assume that efforts to expedite the diagnosis of symptomatic cancer are likely to have benefits for patients in terms of improved survival, earlier-stage diagnosis and improved quality of life, although these benefits vary between cancers.

Impact of investigations in general practice on timeliness of referral for patients subsequently diagnosed with cancer: analysis of national primary care audit data.

BACKGROUND: For patients with symptoms of possible cancer who do not fulfil the criteria for urgent referral, initial investigation in primary care has been advocated in the United Kingdom and supported by additional resources. The consequence of this strategy for the timeliness of diagnosis is unknown. METHODS: We analysed data from the English National Audit of Cancer Diagnosis in Primary Care on patients with lung (1494), colorectal (2111), stomach (246), oesophagus (513), pancreas (327), and ovarian (345) cancer relating to the ordering of investigations by the General Practitioner and their nature. Presenting symptoms were categorised according to National Institute for Health and Care Excellence (NICE) guidance on referral for suspected cancer. We used linear regression to estimate the mean difference in primary-care interval by cancer, after adjustment for age, gender, and the symptomatic presentation category. RESULTS: Primary-care investigations were undertaken in 3198/5036 (64%) of cases. The median primary-care interval was 16 days (IQR 5-45) for patients undergoing investigation and 0 days (IQR 0-10) for those not investigated. Among patients whose symptoms mandated urgent referral to secondary care according to NICE guidelines, between 37% (oesophagus) and 75% (pancreas) were first investigated in primary care. In multivariable linear regression analyses stratified by cancer site, adjustment for age, sex, and NICE referral category explained little of the observed prolongation associated with investigation. INTERPRETATION: For six specified cancers, investigation in primary care was associated with later referral for specialist assessment. This effect was independent of the nature of symptoms. Some patients for whom urgent referral is mandated by NICE guidance are nevertheless investigated before referral. Reducing the intervals between test order, test performance, and reporting can help reduce the prolongation of primary-care intervals associated with investigation use. Alternative models of assessment should be considered.

Comparison of cancer diagnostic intervals before and after implementation of NICE guidelines: analysis of data from the UK General Practice Research Database.

BACKGROUND: The primary aim was to use routine data to compare cancer diagnostic intervals before and after implementation of the 2005 NICE Referral Guidelines for Suspected Cancer. The secondary aim was to compare change in diagnostic intervals across different categories of presenting symptoms. METHODS: Using data from the General Practice Research Database, we analysed patients with one of 15 cancers diagnosed in either 2001-2002 or 2007-2008. Putative symptom lists for each cancer were classified into whether or not they qualified for urgent referral under NICE guidelines. Diagnostic interval (duration from first presented symptom to date of diagnosis in primary care records) was compared between the two cohorts. RESULTS: In total, 37,588 patients had a new diagnosis of cancer and of these 20,535 (54.6%) had a recorded symptom in the year prior to diagnosis and were included in the analysis. The overall mean diagnostic interval fell by 5.4 days (95% CI: 2.4-8.5; P<0.001) between 2001-2002 and 2007-2008. There was evidence of significant reductions for the following cancers: (mean, 95% confidence interval) kidney (20.4 days, -0.5 to 41.5; P=0.05), head and neck (21.2 days, 0.2-41.6; P=0.04), bladder (16.4 days, 6.6-26.5; P≤0.001), colorectal (9.0 days, 3.2-14.8; P=0.002), oesophageal (13.1 days, 3.0-24.1; P=0.006) and pancreatic (12.6 days, 0.2-24.6; P=0.04). Patients who presented with NICE-qualifying symptoms had shorter diagnostic intervals than those who did not (all cancers in both cohorts). For the 2007-2008 cohort, the cancers with the shortest median diagnostic intervals were breast (26 days) and testicular (44 days); the highest were myeloma (156 days) and lung (112 days). The values for the 90th centiles of the distributions remain very high for some cancers. Tests of interaction provided little evidence of differences in change in mean diagnostic intervals between those who did and did not present with symptoms specifically cited in the NICE Guideline as requiring urgent referral. CONCLUSION: We suggest that the implementation of the 2005 NICE Guidelines may have contributed to this reduction in diagnostic intervals between 2001-2002 and 2007-2008. There remains considerable scope to achieve more timely cancer diagnosis, with the ultimate aim of improving cancer outcomes.

Measures of promptness of cancer diagnosis in primary care: secondary analysis of national audit data on patients with 18 common and rarer cancers.

BACKGROUND: Evidence is needed about the promptness of cancer diagnosis and associations between its measures. METHODS: We analysed data from the National Audit of Cancer Diagnosis in Primary Care 2009-10 exploring the association between the interval from first symptomatic presentation to specialist referral (the primary care interval, or 'interval' hereafter) and the number of pre-referral consultations. RESULTS: Among 13,035 patients with any of 18 different cancers, most (82%) were referred after 1 (58%) or 2 (25%) consultations (median intervals 0 and 15 days, respectively) while 9%, 4% and 5% patients required 3, 4 or 5+ consultations (median intervals 34, 47 and 97 days, respectively) (Spearman's r=0.70). The association was at least moderate for any cancer (Spearman's r range: 0.55 (prostate)-0.77 (brain)). Patients with cancers with a higher proportion of three or more pre-referral consultations typically also had longer median intervals (e.g., multiple myeloma) and vice versa (e.g., breast cancer). CONCLUSION: The number of pre-referral consultations has construct validity as a measure of the primary care interval. Developing interventions to reduce the number of pre-referral consultations can help improve the timeliness of cancer diagnosis, and constitutes a priority for early diagnosis initiatives and research.

The risk of a subsequent cancer diagnosis after herpes zoster infection: primary care database study.

BACKGROUND: Herpes zoster and cancer are associated with immunosuppression. Zoster occurs more often in patients with an established cancer diagnosis. Current evidence suggests some risk of cancer after zoster but is inconclusive. We aimed to assess the risk of cancer following zoster and the impact of prior zoster on cancer survival. METHODS: A primary care database retrospective cohort study was undertaken. Subjects with zoster were matched to patients without zoster. Risk of cancer following zoster was assessed by generating hazard ratios using Cox regression. Time to cancer was generated from the index date of zoster diagnosis. RESULTS: In total, 2054 cancers were identified in 74,029 patients (13,428 zoster, 60,601 matches). The hazard ratio for cancer diagnosis after zoster was 2.42 (95% confidence interval 2.21, 2.66) and the median time to cancer diagnosis was 815 days. Hazard ratios varied between cancers, and were highest in younger patients. There were more cancers in patients with zoster than those without for all age groups and both genders. Prior immunosuppression was not associated with change in risk, and diagnosis of zoster before cancer did not affect survival. CONCLUSION: This study establishes an association between zoster and future diagnosis of cancer having implications for cancer case finding after zoster diagnosis.

Investigating the cognitive precursors of emotional response to cancer stress: re-testing Lazarus's transactional model.

OBJECTIVES: Lazarus's Transactional Model of stress and coping underwent significant theoretical development through the 1990s to better incorporate emotional reactions to stress with their appraisal components. Few studies have robustly explored the full model. This study aimed to do so within the context of a major life event: cancer diagnosis. DESIGN: A repeated measures design was used whereby data were collected using self-report questionnaire at baseline (soon after diagnosis), and 3- and 6-month follow-up. METHODS: A total of 160 recently diagnosed cancer patients were recruited (mean time since diagnosis = 46 days). Their mean age was 64.2 years. Data on appraisals, core-relational themes, and emotions were collected. Data were analysed using both Spearman's correlation tests and multivariate regression modelling. RESULTS: Longitudinal analysis demonstrated weak correlation between change scores of theoretically associated components and some emotions correlated more strongly with cognitions contradicting theoretical expectations. Cross-sectional multivariate testing of the ability of cognitions to explain variance in emotion was largely theory inconsistent. CONCLUSIONS: Although data support the generic structure of the Transactional Model, they question the model specifics. Larger scale research is needed encompassing a wider range of emotions and using more complex statistical testing. STATEMENT OF CONTRIBUTION: WHAT IS ALREADY KNOWN ON THIS SUBJECT?: • Stress processes are transactional and coping outcome is informed by both cognitive appraisal of the stressor and the individual's emotional response (Lazarus & Folkman, 1984). • Lazarus (1999) made specific hypotheses about which particular stress appraisals would determine which emotional response, but only a small number of these relationships have been robustly investigated. • Previous empirical testing of this theory has been limited by design and statistical limitations. WHAT DOES THIS STUDY ADD?: • This study empirically investigates the cognitive precedents of a much larger range of emotional outcomes than has previously been attempted in the literature. • Support for the model at a general level is established: this study demonstrates that both primary and secondary appraisals, and core-relational themes are important variables in explaining variance in emotional outcome. • The specific hypotheses proposed by Lazarus (1999) are not, however, supported: using data-driven approaches we demonstrate that equally high levels of variance can be explained using entirely different cognitive appraisals than those hypothesized.

The risk of oesophago-gastric cancer in symptomatic patients in primary care: a large case-control study using electronic records.

BACKGROUND: Over 15 000 new oesophago-gastric cancers are diagnosed annually in the United Kingdom, with most being advanced disease. We identified and quantified features of this cancer in primary care. METHODS: Case-control study using electronic primary-care records of the UK patients aged ≥40 years was performed. Cases with primary oesophago-gastric cancer were matched to controls on age, sex and practice. Putative features of cancer were identified in the year before diagnosis. Odds ratios (ORs) were calculated for these features using conditional logistic regression, and positive predictive values (PPVs) were calculated. RESULTS: A total of 7471 cases and 32 877 controls were studied. Sixteen features were independently associated with oesophago-gastric cancer (all P<0.001): dysphagia, OR 139 (95% confidence interval 112-173); reflux, 5.7 (4.8-6.8); abdominal pain, 2.6 (2.3-3.0); epigastric pain, 8.8 (7.0-11.0); dyspepsia, 6 (5.1-7.1); nausea and/or vomiting, 4.9 (4.0-6.0); constipation, 1.5 (1.2-1.7); chest pain, 1.6 (1.4-1.9); weight loss, 8.9 (7.1-11.2); thrombocytosis, 2.4 (2.0-2.9); low haemoglobin, 2.4 (2.1-2.7); low MCV, 5.2 (4.2-6.4); high inflammatory markers, 1.7 (1.4-2.0); raised hepatic enzymes, 1.3 (1.2-1.5); high white cell count, 1.4 (1.2-1.7); and high cholesterol, 0.8 (0.7-0.8). The only PPV >5% in patients ≥55 years was for dysphagia. In patients <55 years, all PPVs were <1%. CONCLUSION: Symptoms of oesophago-gastric cancer reported in secondary care were also important in primary care. The results should inform guidance and commissioning policy for upper GI endoscopy.

Are women ready for the new cervical screening protocol in England? A systematic review and qualitative synthesis of views about human papillomavirus testing.

BACKGROUND: A new protocol for human papillomavirus (HPV) testing within the UK cervical screening programme commenced in April 2011, creating new patient experiences. This is the first review to synthesise a substantial body of international evidence of women's information needs, views and preferences regarding HPV testing. We aimed to inform the development of educational materials to promote informed choice, reduce anxiety and improve disease control. METHODS: We searched 12 bibliographic databases. Two reviewers independently screened papers and assessed study quality; disagreements were resolved by discussion. Results were extracted verbatim and authors' findings treated as primary data. Studies were synthesised collaboratively using framework methods. RESULTS: We synthesised findings from 17 studies. Women had overwhelmingly negative concerns; an HPV diagnosis was daunting, had associated problems of disclosure of a sexually transmitted infection (STI), impacted on relationships and provoked fear of stigmatisation. Nevertheless, many thought HPV testing could be a preferable alternative to repeat cytology. Knowledge was poor; women struggled to interpret limited information in the context of existing knowledge about STIs and cervical cancer. CONCLUSION: Women are likely to be poorly informed, have limited understanding and many unanswered questions. This could increase anxiety and reduce ability to make informed choices, presenting a substantial challenge for those who design and provide information.

The risk of pancreatic cancer in symptomatic patients in primary care: a large case-control study using electronic records.

BACKGROUND: Over 8000 new pancreatic cancers are diagnosed annually in the UK; most at an advanced stage, with only 3% 5-year survival. We aimed to identify and quantify the risk of pancreatic cancer for features in primary care. METHODS: A case-control study using electronic primary care records identified and quantified the features of pancreatic cancer. Cases, aged ≥40 in the General Practice Research Database, UK, with primary pancreatic cancer were matched with controls on age, sex and practice. Putative features of pancreatic cancer were identified in the year before diagnosis. Odds ratios (OR) were calculated for features of cancer using conditional logistic regression. Positive predictive values (PPV) were calculated for consulting patients. RESULTS: In all, 3635 cases and 16,459 controls were studied. Nine features were associated with pancreatic cancer (all P<0.001 except for back pain, P=0.004); jaundice, OR 1000 (95% confidence interval (CI) 4,302,500); abdominal pain, 5 (4.4, 5.6); nausea/vomiting, 4.5 (3.5, 5.7); back pain, 1.4 (1.1, 1.7); constipation, 2.2 (1.7, 2.8); diarrhoea, 1.9 (1.5, 2.5); weight loss, 15 (11, 22); malaise, 2.4 (1.6, 3.5); new-onset diabetes 2.1 (1.7, 2.5). Positive predictive values for patients aged ≥60 were <1%, apart from jaundice at 22% (95% CI 14, 52), though several pairs of symptoms had PPVs >1%. CONCLUSION: Most previously reported symptoms of pancreatic cancer were also relevant in primary care. Although predictive values were small - apart from jaundice - they provide a basis for selection of patients for investigation, especially with multiple symptoms.

The Aarhus statement: improving design and reporting of studies on early cancer diagnosis.

Early diagnosis is a key factor in improving the outcomes of cancer patients. A greater understanding of the pre-diagnostic patient pathways is vital yet, at present, research in this field lacks consistent definitions and methods. As a consequence much early diagnosis research is difficult to interpret. A consensus group was formed with the aim of producing guidance and a checklist for early cancer-diagnosis researchers. A consensus conference approach combined with nominal group techniques was used. The work was supported by a systematic review of early diagnosis literature, focussing on existing instruments used to measure time points and intervals in early cancer-diagnosis research. A series of recommendations for definitions and methodological approaches is presented. This is complemented by a checklist that early diagnosis researchers can use when designing and conducting studies in this field. The Aarhus checklist is a resource for early cancer-diagnosis research that should promote greater precision and transparency in both definitions and methods. Further work will examine whether the checklist can be readily adopted by researchers, and feedback on the guidance will be used in future updates.

Do diagnostic delays in cancer matter?

BACKGROUND: The United Kingdom has poorer cancer outcomes than many other countries due partly to delays in diagnosing symptomatic cancer, leading to more advanced stage at diagnosis. Delays can occur at the level of patients, primary care, systems and secondary care. There is considerable potential for interventions to minimise delays and lead to earlier-stage diagnosis. METHODS: Scoping review of the published studies, with a focus on methodological issues. RESULTS: Trial data in this area are lacking and observational studies often show no association or negative ones. This review offers methodological explanations for these counter-intuitive findings. CONCLUSION: While diagnostic delays do matter, their importance is uncertain and must be determined through more sophisticated methods.

Follow-up care for men with prostate cancer and the role of primary care: a systematic review of international guidelines.

The optimal role for primary care in providing follow-up for men with prostate cancer is uncertain. A systematic review of international guidelines was undertaken to help identify key elements of existing models of follow-up care to establish a theoretical basis for evaluating future complex interventions. Many guidelines provide insufficient information to judge the reliability of the recommendations. Although the PSA test remains the cornerstone of follow-up, the diversity of recommendations on the provision of follow-up care reflects the current lack of research evidence on which to base firm conclusions. The review highlights the importance of transparent guideline development procedures and the need for robust primary research to inform future evidence-based models of follow-up care for men with prostate cancer.

General practictioners' management of cancer in England: secondary analysis of data from the National Survey of NHS Patients-Cancer.

Relatively little is understood concerning the exact role of general practice in the cancer patients' pre-diagnostic, and post-diagnostic journey. This paper aims to explore this role using data from the National Survey of NHS Patients-Cancer. Data from 65,192 patients relating to five questions from this survey were analysed in detail with particular relevance to differences between the six cancers [breast, colorectal, lung, ovarian, prostate and non-Hodgkin's lymphoma (NHL)], and socio-demographic variables (age, gender and social class). There were considerable differences between patients with the six cancers, and the role of general practice in the cancer diagnosis, and post-diagnosis management. The vast majority of patients saw their general practitioner (GP) with symptoms prior to being seen in hospital. A significant minority were told their diagnosis by their GP. About half the sample were told to contact their GP post-discharge, and about half did so. Being told to contact the GP post-discharge was strongly associated with actually seeing the GP. Most patients felt that their GP was given enough information about their treatment or condition. In conclusion, this work has quantified the central role of general practice in cancer diagnosis and management in England. There remain considerable resource, educational and research needs to continue to provide high-quality cancer care in primary care.

Sociodemographic factors and delays in the diagnosis of six cancers: analysis of data from the "National Survey of NHS Patients: Cancer".

This paper aims to explore the relationship between sociodemographic factors and the components of diagnostic delay (total, patient and primary care, referral, secondary care) for these six cancers (breast, colorectal, lung, ovarian, prostate, or non-Hodgkin's lymphoma). Secondary analysis of patient-reported data from the 'National Survey of NHS patients: Cancer' was undertaken (65 192 patients). Data were analysed using univariate analysis and Generalised Linear Modelling. With regard to total delay, the findings from the GLM showed that for colorectal cancer, the significant factors were marital status and age, for lung and ovarian cancer none of the factors were significant, for prostate cancer the only significant factor was social class, for non-Hodgkin's lymphoma the only significant factor was age, and for breast cancer the significant factors were marital status and ethnic group. Where associations between any of the component delays were found, the direction of the association was always in the same direction (female subjects had longer delays than male subjects, younger people had longer delays than older people, single and separated/divorced people had longer delays than married people, lower social class groups had longer delays than higher social class groups, and Black and south Asian people had longer delays than white people). These findings should influence the design of interventions aimed at reducing diagnostic delays with the aim of improving morbidity, mortality, and psychological outcomes through earlier stage diagnosis.

Delays in the diagnosis of six cancers: analysis of data from the National Survey of NHS Patients: Cancer.

The aim of this paper is to describe and compare components of diagnostic delay (patient, primary care, referral, secondary care) for six cancers (breast, colorectal, lung, ovarian, prostate and non-Hodgkin's lymphoma), and to compare delays in patients who saw their GP prior to diagnosis with those who did not. Secondary data analysis of The National Survey of NHS Patients: Cancer was undertaken (65 192 patients). Breast cancer patients experienced the shortest total delays (mean 55.2 days), followed by lung (88.5), ovarian (90.3), non-Hodgkin's lymphoma (102.8), colorectal (125.7) and prostate (148.5). Trends were similar for all components of delay. Compared with patient and primary care delays, referral delays and secondary care delays were much shorter. Patients who saw their GP prior to diagnosis experienced considerably longer total diagnostic delays than those who did not. There were significant differences in all components of delay between the six cancers. Reducing diagnostic delays with the intention of increasing the proportion of early stage cancers may improve cancer survival in the UK, which is poorer than most other European countries. Interventions aimed at reducing patient and primary care delays need to be developed and their effect on diagnostic stage and psychological distress evaluated.

The association between satisfaction with services provided in primary care and outcomes in Type 2 diabetes mellitus.

BACKGROUND: Patient satisfaction is of increasing importance, is taken into account when planning services, and is used by healthcare providers as a measure of healthcare quality. Satisfaction with medical care, including diabetic care, has been associated with various health-related behaviours and outcomes that have a direct bearing on health and illness. The association between satisfaction and health outcomes is poorly understood. AIM: The aim of the study was to determine whether there is an association between satisfaction in patients with Type 2 diabetes and the outcome of their diabetic care, and to determine the contribution of different aspects of satisfaction with the primary care. METHODS: Patients with Type 2 diabetes were identified from two general practices in Leeds. PATIENTS: scores on the General Practice Assessment Survey Questionnaire (GPAS) were correlated with the outcome of care, as measured by HbA1c level collected from patients' medical records. RESULTS: Data from 106 patients were analysed. There was a generally high satisfaction rate for all GPAS domains. The correlation between different GPAS domains and HbA1c level showed significant positive correlations (P < 0.001) for continuity of care, trust and overall satisfaction; and positive correlations (P < 0.01) for access, receptionists, interpersonal care, communication skills, knowledge of patient about the doctor, technical care, and practice nursing. CONCLUSION: The findings from this study demonstrate that there is an association between satisfaction and outcome in diabetes, which goes across all the GPAS domains. This suggests that processes that can act to increase patient satisfaction may be contributing to improved clinical outcomes. More development work is needed in this field to explore and elucidate the complex relationship between satisfaction and clinical outcomes.