Direct access cancer testing in primary care: a systematic review of use and clinical outcomes.

BACKGROUND: Direct access (DA) testing allows GPs to refer patients for investigation without consulting a specialist. The aim is to reduce waiting time for investigations and unnecessary appointments, enabling treatment to begin without delay. AIM: To establish the proportion of patients diagnosed with cancer and other diseases through DA testing, time to diagnosis, and suitability of DA investigations. DESIGN AND SETTING: Systematic review assessing the effectiveness of GP DA testing in adults. METHOD: MEDLINE, Embase, and the Cochrane Library were searched. Where possible, study data were pooled and analysed quantitatively. Where this was not possible, the data are presented narratively. RESULTS: The authors identified 60 papers that met pre-specified inclusion criteria. Most studies were carried out in the UK and were judged to be of poor quality. The authors found no significant difference in the pooled cancer conversion rate between GP DA referrals and patients who first consulted a specialist for any test, except gastroscopy. There were also no significant differences in the proportions of patients receiving any non-cancer diagnosis. Referrals for testing were deemed appropriate in 66.4% of those coming from GPs, and in 80.9% of those from consultants; this difference was not significant. The time from referral to testing was significantly shorter for patients referred for DA tests. Patient and GP satisfaction with DA testing was consistently high. CONCLUSION: GP DA testing performs as well as, and on some measures better than, consultant triaged testing on measures of disease detection, appropriateness of referrals, interval from referral to testing, and patient and GP satisfaction

Sustaining Primary Care Responses to Intimate Partner Violence

Globally, one in three women will experience intimate partner violence in their lifetime. The impact of violence on health and wellbeing is significant, yet, recognition of the relationship between intimate partner violence and ill-health is poor. Implementing and sustaining effective health care responses to intimate partner violence has proven challenging internationally. New Zealand holds a leading role via the Ministry of Health Violence Intervention Programme. Infrastructure supporting health professionals to respond to intimate partner violence and child abuse and neglect has been implemented across hospitals and selected community settings nationally. However, engagement with the primary care sector has been limited. In this study I explore what affects a sustainable response to intimate partner violence within New Zealand primary care settings. I utilise complexity theory to reconceptualise a sustainable primary care response to intimate partner violence as a complex adaptive system. Concurrently, I analyse the function of health system documents informing intimate partner violence responsiveness and interview primary care professionals on responding to intimate partner violence as a health issue. I apply a complexity-led discourse analysis to each data source to explore how system interactions at policy and practice levels influence intimate partner violence responsiveness. I then thread the data sources together to show how sustainable responses to intimate partner violence are emergent from interactions throughout the health system. This thesis argues the under-utilisation of the primary care sector in reducing intimate partner violence is a profound system gap. My use of complexity theory as an innovative qualitative research methodology calls attention to key system interactions challenging the emergence of intimate partner violence responsiveness in primary care. Similarly, I show how complexity may be harnessed to promote intimate partner violence responsiveness. This thesis shows why we need to think differently about how we work to reduce intimate partner violence. Primary care professionals are willing to address intimate partner violence, the next step is to assist the sector in being able to

Advancing Complexity Theory as a Qualitative Research Methodology

Although complexity theory is increasingly used to explain and understand complex health-system behavior, little is known about utilizing complexity theory to augment qualitative research methods. We advance this field by describing our use of complexity theory as a qualitative research methodology to explore sustainable health-care responses to intimate partner violence. We outline how complexity theory shaped our theoretical perspective, conceptualization of the research problem, and selection of methodology and methods. We show how a research methodology informed by complexity theory can capture new insights into complex problems, advancing the application of complexity theory and qualitative research design

Exploring the complex pathway of the primary health care response to intimate partner violence in New Zealand

Abstract Background Integrating sustainable responses to intimate partner violence in health care is a persistent and complex problem internationally. New Zealand holds a leading role, having established national health system infrastructure for responding to intimate partner violence within hospital and selected community settings. However, resources for, and engagement with, the primary health care sector has been limited. The present study focuses on what affects a sustainable response to intimate partner violence within New Zealand primary health care settings. Methods Utilising complexity theory, we reconceptualised a sustainable primary health care response to intimate partner violence as a complex adaptive system. To explore interactions between agents, we analysed the function(s) of key policy, strategy, guideline and evaluation documents informing intimate partner violence responsiveness in health care. We chronologically threaded these documents together by their function(s) to show how discourse influencing intimate partner violence responsiveness emerges from agent interactions. Results This paper presents a complexity informed implementation narrative of the New Zealand health system response to intimate partner violence across the last two decades, focused on the participation of the primary health care sector. We demonstrate how competing discourses have contributed to system gaps and unintended consequences over time. Our findings consider implications for a sustainable response to intimate partner violence in primary health care and call attention to system interactions that challenge a whole health system approach in New Zealand. Conclusions Use of complexity theory facilitates an innovative perspective of a persistent and complex problem. Given the complexity of the problem and New Zealand’s leadership, sharing the lessons learnt is critical for the international community involved in developing health care system approaches to intimate partner violence