Stage-specific risk of colon and rectal cancer in patients presenting with rectal bleeding or change in bowel habit in primary care: A population-based cohort study

INTRODUCTION: Rectal bleeding and change in bowel habit are red-flag symptoms for colon and rectal cancer but how they relate to advanced stage disease is not adequately understood. METHODS: We analysed primary care electronic health records data on patients aged 30-99 years. Using logistic regression, we first examined the risk of colon and rectal cancer within 12 months in patients presenting with change in bowel habit and rectal bleeding, and then the risk of advanced stage at diagnosis within cancer cases. We combined the results to estimate risk of advanced stage colon and rectal cancers at diagnosis. RESULTS: For both symptoms and sexes, risk of cancer (overall and by stage) increased with increasing age. We illustrate the findings for persons at the highest age-specific observed risk (typically aged around 80). In men, change in bowel habit (CIBH) and rectal bleeding were associated with different risk of advanced stage colon and rectal cancers (e.g., for colon, CIBH = 2.7% (95% CI 2.2-3.1) and rectal bleeding = 1.7% (95% CI 1.4-2.0)), but without evidence of risk difference between the two symptoms for non-advanced disease. The opposite pattern was apparent in women, with both symptoms associated with similar risk of advanced disease, but different risk of non-advanced colon and rectal cancers (e.g., for colon, CIBH = 1.0% (95% CI 0.8-1.3) and rectal bleeding = 1.3% (95% CI 1.1-1.6)). DISCUSSION: Change in bowel habit and rectal bleeding have different age-specific associations with advanced stage disease, which vary by sex. A substantial proportion of cases is diagnosed at non-advanced stage, supporting the need for prompt diagnostic assessment of patients who present with those symptoms, taking into account the age-specific nature of risks

Response rates to patient surveys

BACKGROUND: Patient surveys typically have variable response rates between organizations, leading to concerns that such differences may affect the validity of performance comparisons. OBJECTIVE: To explore the size and likely sources of associations between hospital-level survey response rates and patient experience. RESEARCH DESIGN, SUBJECTS, AND MEASURES: Cross-sectional mail survey including 60 patient experience items sent to 101,771 cancer survivors recently treated by 158 English NHS hospitals. Age, sex, race/ethnicity, socioeconomic status, clinical diagnosis, hospital type, and region were available for respondents and nonrespondents. RESULTS: The overall response rate was 67% (range, 39% to 77% between hospitals). Hospitals with higher response rates had higher scores for all items (Spearman correlation range, 0.03-0.44), particularly questions regarding hospital-level administrative processes, for example, procedure cancellations or medical note availability.From multivariable analysis, associations between individual patient experience and hospital-level response rates were statistically significant (P<0.05) for 53/59 analyzed questions, decreasing to 37/59 after adjusting for case-mix, and 25/59 after further adjusting for hospital-level characteristics.Predicting responses of nonrespondents, and re-estimating hypothetical hospital scores assuming a 100% response rate, we found that currently low performing hospitals would have attained even lower scores. Overall nationwide attainment would have decreased slightly to that currently observed. CONCLUSIONS: Higher response rate hospitals have more positive experience scores, and this is only partly explained by patient case-mix. High response rates may be a marker of efficient hospital administration, and higher quality that should not, therefore, be adjusted away in public reporting. Although nonresponse may result in slightly overestimating overall national levels of performance, it does not appear to meaningfully bias comparisons of case-mix-adjusted hospital results.GL is supported by a Cancer Research UK Clinician Scientist Fellowship (A18180).This is the final version of the article. It first appeared from Wolters Kluwer via http://dx.doi.org/10.1097/MLR.000000000000045

Beyond the ecological fallacy: potential problems when studying healthcare organisations.

Ecological studies, which consider patient groups rather than individuals, are common in health policy research. The ‘ecological fallacy’ is a well-recognised methodological concern, but in this perspectives paper, we focus on less often appreciated but equally important limitations of such studies. In particular, we consider reliability and power as they apply to ecological studies, and make recommendations to inform the appropriate design and interpretation of these increasingly popular studies.This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. GL is supported by a Cancer Research UK Clinician Scientist Fellowship (A18180). The views expressed in this publication are those of the authors and not necessarily those of any funder or any other organisation or institution.This is the author accepted manuscript. The final version is available from SAGE via http://dx.doi.org/10.1177/014107681561057

Do presenting symptoms, use of pre-diagnostic endoscopy and risk of emergency cancer diagnosis vary by comorbidity burden and type in patients with colorectal cancer?

Background: Cancer patients often have pre-existing comorbidities, which can influence timeliness of cancer diagnosis. We examined symptoms, investigations and emergency presentation (EP) risk among colorectal cancer (CRC) patients by comorbidity status. Methods: Using linked cancer registration, primary care and hospital records of 4836 CRC patients (2011–2015), and multivariate quantile and logistic regression, we examined variations in specialist investigations, diagnostic intervals and EP risk. Results: Among colon cancer patients, 46% had at least one pre-existing hospital-recorded comorbidity, most frequently cardiovascular disease (CVD, 18%). Comorbid versus non-comorbid cancer patients more frequently had records of anaemia (43% vs 38%), less frequently rectal bleeding/change in bowel habit (20% vs 27%), and longer intervals from symptom-to-first relevant test (median 136 vs 74 days). Comorbid patients were less likely investigated with colonoscopy/sigmoidoscopy, independently of symptoms (adjusted OR = 0.7[0.6, 0.9] for Charlson comorbidity score 1–2 and OR = 0.5 [0.4–0.7] for score 3+ versus 0. EP risk increased with comorbidity score 0, 1, 2, 3+: 23%, 35%, 33%, 47%; adjusted OR = 1.8 [1.4, 2.2]; 1.7 [1.3, 2.3]; 3.0 [2.3, 4.0]) and for patients with CVD (adjusted OR = 2.0 [1.5, 2.5]). Conclusions: Comorbid individuals with as-yet-undiagnosed CRC often present with general rather than localising symptoms and are less likely promptly investigated with colonoscopy/sigmoidoscopy. Comorbidity is a risk factor for diagnostic delay and has potential, additionally to symptoms, as risk-stratifier for prioritising patients needing prompt assessment to reduce EP

The underlying structure of the English Cancer Patient Experience Survey: Factor analysis to support survey reporting and design

BACKGROUND: The English Cancer Patient Experience Survey (CPES) is a regularly conducted survey measuring the experience of cancer patients. We studied the survey's underlying structure using factor analysis to identify potential for improvements in reporting or questionnaire design. METHODS: Cancer Patient Experience Survey 2015 respondents (n = 71,186, response rate 66%) were split into two random subgroups. Using exploratory factor analysis (EFA) on the first subgroup, we identified the survey's latent structure. EFA was then applied to 12 sets of items. A first ("core") set was formed by questions that applied to all participants. The subsequent sets contained the "core set" plus questions corresponding to specific care pathways/patient groups. We used confirmatory factor analysis (CFA) on the second data subgroup for cross-validation. RESULTS: The EFA suggested that five latent factors underlie the survey's core questions. Analysis on the remaining 11 care pathway/patient group items also indicated the same five latent factors, although additional factors were present for questions applicable to patients with an overnight stay or those accessing specialist nursing. The five factors models had an excellent fit (comparative fit index = 0.95, root mean square error of approximation = 0.045 for core set of questions). Items loading on each factor generally corresponded to a specific section or subsection of the questionnaire. CFA findings were concordant with the EFA patterns. CONCLUSION: The findings suggest five coherent underlying sub-constructs relating to different aspects of cancer health care. The findings support the construction of evidence-based composite indicators for different domains of experience and provide options for survey re-design

Prevalence of Joint Hypermobility and Patterns of Articular Manifestations in Patients with Inflammatory Bowel Disease

Objective. The objective is the investigation of Joint Hypermobility (JH) and the Hypermobility Syndrome (HMS) in patients with inflammatory bowel disease (IBD). Methods. We examined 83 patients with IBD and 67 healthy individuals for the presence of JH. Patients were excluded if they were under 18 or over 50 years of age and if they had other conditions which affect joint mobility. The x2 and the Fisher exact test were used appropriately between study groups. Odds ratios (ORs) for the risk of JH and HMS in IBD groups were calculated. Results. A total of 150 individuals (83 IBD patients and 67 healthy controls) participated in the study. 69 IBD patients, 41 with Crohn's Disease (CD) and 28 with ulcerative colitis (UC), were finally eligible. JH was detected in 29 CD patients (70.7%), in 10 UC patients (35.7%), and in 17 healthy control subjects (25.4%). Significant difference was detected on JH in CD patients as compared to UC patients (P = .0063) and controls (P < .0001). The estimated OR for JH was 7.108 (95% CI: 2.98–16.95) in CD and 1.634 (95% CI: 0.63–4.22) in UC patients. HMS was detected in 5 (12.2%) CD and in 1 (3.57%) UC patients. The OR for HMS in CD was 3.75 (95% CI: 0.41–34.007), while 7 (17.1%) CD patients had overlapping symptoms for both HMS and early spondylarthropathy. Conclusions. JH and the HMS are common in CD patients, thus articular manifestations should be carefully interpreted. This implies an involvement of collagen varieties in the pathogenesis of IBD

Estimating the potential survival gains by eliminating socioeconomic and sex inequalities in stage at diagnosis of melanoma

This is the final published version. Available from Springer Nature via the DOI in this record.BACKGROUND: Although inequalities in cancer survival are thought to reflect inequalities in stage at diagnosis, little evidence exists about the size of potential survival gains from eliminating inequalities in stage at diagnosis.METHODS: We used data on patients diagnosed with malignant melanoma in the East of England (2006-2010) to estimate the number of deaths that could be postponed by completely eliminating socioeconomic and sex differences in stage at diagnosis after fitting a flexible parametric excess mortality model.RESULTS: Stage was a strong predictor of survival. There were pronounced socioeconomic and sex inequalities in the proportion of patients diagnosed at stages III-IV (12 and 8% for least deprived men and women and 25 and 18% for most deprived men and women, respectively). For an annual cohort of 1025 incident cases in the East of England, eliminating sex and deprivation differences in stage at diagnosis would postpone approximately 24 deaths to beyond 5 years from diagnosis. Using appropriate weighting, the equivalent estimate for England would be around 215 deaths, representing 11% of all deaths observed within 5 years from diagnosis in this population.CONCLUSIONS: Reducing socioeconomic and sex inequalities in stage at diagnosis would result in substantial reductions in deaths within 5 years of a melanoma diagnosis.Cancer Research UKCancer Research UKNational Institute for Health Research (NIHR

Time trends in service provision and survival outcomes for patients with renal cancer treated by nephrectomy in England 2000-2010.

OBJECTIVE: To describe the temporal trends in nephrectomy practice and outcomes for English patients with renal cell carcinoma (RCC). PATIENTS AND METHODS: Adult RCC nephrectomy patients treated between 2000 and 2010 were identified in the National Cancer Data Repository and Hospital Episode Statistics, and followed-up until date of death or 31 December 2015 (n = 30 763). We estimated the annual frequency for each nephrectomy type, the hospital and surgeon numbers and their case volumes. We analysed short-term surgical outcomes, as well as 1- and 5-year relative survivals. RESULTS: Annual RCC nephrectomy number increased by 66% during the study period. Hospital number decreased by 24%, whilst the median annual hospital volume increased from 10 to 23 (P < 0.01). Surgeon number increased by 27% (P < 0.01), doubling the median consultant number per hospital. The proportion of minimally invasive surgery (MIS) nephrectomies rose from 1% to 46%, whilst the proportion of nephron-sparing surgeries (NSS) increased from 5% to 16%, with 29% of all T1 disease treated with partial nephrectomy in 2010 (P < 0.01). The 30-day mortality rate halved from 2.4% to 1.1% and 90-day mortality decreased from 4.9% to 2.6% (P < 0.01). The 1-year relative survival rate increased from 86.9% to 93.4%, whilst the 5-year relative survival rate rose from 68.2% to 81.2% (P < 0.01). Improvements were most notable in patients aged ≥65 years and those with T3 and T4 disease. CONCLUSIONS: Surgical RCC management has changed considerably with nephrectomy centralisation and increased NSS and MIS. In parallel, we observed significant improvements in short- and long-term survival particularly for elderly patients and those with locally advanced disease

Characteristics of service users and provider organisations associated with experience of out of hours general practitioner care in England: population based cross sectional postal questionnaire survey.

OBJECTIVE: To investigate the experience of users of out of hours general practitioner services in England, UK. DESIGN: Population based cross sectional postal questionnaire survey. SETTING: General Practice Patient Survey 2012-13. MAIN OUTCOME MEASURES: Potential associations between sociodemographic factors (including ethnicity and ability to take time away from work during working hours to attend a healthcare consultation) and provider organisation type (not for profit, NHS, or commercial) and service users' experience of out of hours care (timeliness, confidence and trust in the out of hours clinician, and overall experience of the service), rated on a scale of 0-100. Which sociodemographic/provider characteristics were associated with service users' experience, the extent to which any observed differences could be because of clustering of service users of a particular sociodemographic group within poorer scoring providers, and the extent to which observed differences in experience varied across types of provider. RESULTS: The overall response rate was 35%; 971,232/2,750,000 patients returned surveys. Data from 902,170 individual service users were mapped through their registered practice to one of 86 providers of out of hours GP care with known organisation type. Commercial providers of out of hours GP care were associated with poorer reports of overall experience of care, with a mean difference of -3.13 (95% confidence interval -4.96 to -1.30) compared with not for profit providers. Asian service users reported lower scores for all three experience outcomes than white service users (mean difference for overall experience of care -3.62, -4.36 to -2.89), as did service users who were unable to take time away from work compared with service users who did not work (mean difference for overall experience of care -4.73, -5.29 to -4.17). CONCLUSIONS: Commercial providers of out of hours GP care were associated with poorer experience of care. Targeted interventions aimed at improving experience for patients from ethnic minorities and patients who are unable to take time away from work might be warranted

Patient factors associated with non-attendance at colonoscopy after a positive screening faecal occult blood test

BACKGROUND: Screening participants with abnormal faecal occult blood test results who do not attend further testing are at high risk of colorectal cancer, yet little is known about their reasons for non-attendance. METHODS: We conducted a medical record review of 170 patients from two English Bowel Cancer Screening Programme centres who had abnormal guaiac faecal occult blood test screening tests between November 2011 and April 2013 but did not undergo colonoscopy. Using information from patient records, we coded and categorized reasons for non-attendance. RESULTS: Of the 170 patients, 82 were eligible for review, of whom 66 had at least one recorded reason for lack of colonoscopy follow-up. Reasons fell into seven main categories: (i) other commitments, (ii) unwillingness to have the test, (iii) a feeling that the faecal occult blood test result was a false positive, (iv) another health issue taking priority, (v) failing to complete bowel preparation, (vi) practical barriers (e.g. lack of transport), and (vii) having had or planning colonoscopy elsewhere. The most common single reasons were unwillingness to have a colonoscopy and being away. CONCLUSIONS: We identify a range of apparent reasons for colonoscopy non-attendance after a positive faecal occult blood test screening. Education regarding the interpretation of guaiac faecal occult blood test findings, offer of alternative confirmatory test options, and flexibility in the timing or location of subsequent testing might decrease non-attendance of diagnostic testing following positive faecal occult blood test