Embedding electronic decision-support tools for suspected cancer in primary care: a qualitative study of GPs' experiences

Aim: The purpose of this evaluation was to obtain views from general practitioners (GPs) who piloted the electronic risk assessment tools (eRATs) for suspected lung or colorectal cancer. We wanted to find out whether GPs were able to integrate these tools into their everyday practice. We were also keen to identify facilitators and barriers to their more widespread use. Background: Cancer remains one of UK’s biggest health problems, in terms of morbidity and mortality. Comparative European data show that five-year survival figures for many cancers are lower in the United Kingdom than in comparable European countries. eRATs are intended to aid recognition of symptoms of lung and colorectal cancers in patients aged 40 years and over. Methods: This was a qualitative study; telephone interviews were conducted with 23 GPs who piloted the eRATs. A systematic qualitative analysis was applied to the data. The normalisation process model was used after data collection. This theory-driven conceptual framework was used to examine the operationalisation of this intervention in Primary Care. Findings: Electronic decision-support tools appear to be useful additions to the resources available to GPs in order to assist them with recognizing potential cancer symptoms. However, the tools need to be refined in order to integrate them into GP practice. The tools raised GPs’ awareness about cancer because of the prompt facility of the software, although this also raised the potential of ‘prompt fatigue’. GPs constantly receive alerts via their clinical system, particularly related to the Quality and Outcomes Framework. The integration of eRATs into routine practice could be engendered by improvement to the training packages that accompany them, and by its delivery via a platform compatible with all GP clinical systems

Does the use of specialist palliative care services modify the effect of socioeconomic status on place of death? A systematic review

© SAGE Publications. Background: Cancer patients in lower socioeconomic groups are significantly less likely to die at home and experience more barriers to access to palliative care. It is unclear whether receiving palliative care may mediate the effect of socioeconomic status on place of death. Aim: This review examines whether and how use of specialist palliative care may modify the effect of socioeconomic status on place of death. Design: A systematic review was conducted. Eligible papers were selected and the quality appraised by two independent reviewers. Data were synthesised using a narrative approach. Data sources: MEDLINE, Embase, CINAHL, PsycINFO and Web of Knowledge were searched (1997-2013). Bibliographies were scanned and experts contacted. Papers were included if they reported the effect of both socioeconomic status and use of specialist palliative care on place of death for adult cancer patients. Results: Nine studies were included. All study subjects had received specialist palliative care. With regard to place of death, socioeconomic status was found to have (1) no effect in seven studies and (2) an effect in one study. Furthermore, one study found that the effect of socioeconomic status on place of death was only significant when patients received standard specialist palliative care. When patients received more intense care adapted to their needs, the effect of socioeconomic status on place of death was no longer seen. Conclusion: There is some evidence to suggest that use of specialist palliative care may modify the effect of socioeconomic status on place of death

Patterns of Care Received by Women With Breast Cancer Living in Affluent and Deprived Areas

Breast cancer occurs less commonly in socio-economically deprived women than in affluent women. Following diagnosis however, deprived women have poorer survival rates from breast cancer. Previous research suggests that their poorer survival is not due to the stage of the cancer at time of presentation. If poorer outcomes are not due to more advanced stage of disease at time of presentation alternative explanations are that the difference may be due to variations in treatment or host response mechanisms or environmental factors. The research described in this thesis explores whether the known poorer survival of deprived women is related to the care they receive for breast cancer from the National Health Service. The process of care is described from presentation through referral, treatment and follow up, and comparison is made between patterns of care received by affluent and deprived women. Patterns of care were described and compared by means of a three phase study: hospital records data collection, general practice records data collection and a postal questionnaire study. The review of case records in hospital and general practice produced data regarding diagnosis, delays, surgical and oncological treatment and follow-up in primary and secondary care. The postal questionnaire to patients provided further information on health status, current anxieties, sources of information about breast cancer, help seeking behaviour and life style changes as a result of a diagnosis with breast cancer. The process of care is investigated for women diagnosed with breast cancer in 1992 and 1993 in the most affluent and deprived areas in Greater Glasgow Health Board. The data presented in this thesis show that women from affluent and deprived areas received similar surgical and oncological care and had the same access to services. Previous studies, which showed no relationship between stage at presentation and deprivation, are challenged by data demonstrating a greater proportion of advanced and metastatic presentations in women from deprived areas compared to women from affluent areas. Evidence from all three phases of data collection (hospital records data collection, general practice records data collection, questionnaire study) point to women from deprived areas experiencing greater physical and psychological co-morbidity than those from affluent areas. Women from deprived areas were admitted to hospital for conditions not related to breast cancer more often than women from affluent areas. Although an increase in consultations with GPs were seen for all women, this increase was greater for deprived women. Deprived women had poorer SF-36 scores indicating greater psychological morbidity several years after diagnosis and reported greater anxiety than affluent women regarding health problems unrelated to breast cancer. Women living in deprived areas also expressed a greater degree of anxiety than women living in affluent areas about financial and family problems. These indications of greater co-morbidity may help to explain the poorer survival of deprived women with breast cancer. This study produces evidence that the National Health Service in Glasgow delivered health care equitably to affluent and deprived women with breast cancer in 1992 and 1993. The presence of other co-existing physical and psychological morbidities in the context of greater social adversity may explain the known poorer survival of deprived women with breast cancer

Illness identity as an important component of candidacy: Contrasting experiences of help-seeking and access to care in cancer and heart disease

How and when we use health services or healthcare provision has dominated exploration of and debates around healthcare access. Levels of utilisation are assumed as a proxy for access. Yet, focusing on utilisation conceals an important aspect of the access conundrum: the relationships that patients and potential patients have with the healthcare system and the professionals within those systems. Candidacy has been proposed as an antidote to traditional utilisation models. The Candidacy construct offers the ability to include patient-professional aspects alongside utilisation and thus promotes a deeper understanding of access. Originally applied to healthcare access for vulnerable populations, additional socio-demographic factors, including age and ethnicity, have also been shown to influence the Candidacy process. Here we propose a further extension of the Candidacy construct and illustrate the importance of illness identities when accessing healthcare. Drawing on a secondary data analysis of three data sets of qualitative interviews from colorectal cancer and heart failure patients we found that though similar access issues are apparent pre-diagnosis, diagnosis marks a critical juncture in the experience of access. Cancer patients describe a person-centred responsive healthcare system where their patienthood requires only modest assertion. Cancer speaks for itself. In marked contrast heart failure patients, describe struggling within a seemingly impermeable system to understand their illness, its implications and their own legitimacy as patients. Our work highlights the pressing need for healthcare professionals, systems and policies to promote a person centred approach, which is responsive and timely, regardless of illness category. To achieve this, attitudes regarding the importance or priority afforded to different categories of illness need to be tackled as they directly influence ideas of Candidacy and consequently access and experiences of care

The impact of consent on observational research: a comparison of outcomes from consenters and non consenters to an observational study

Background Public health benefits from research often rely on the use of data from personal medical records. When neither patient consent nor anonymisation is possible, the case for accessing such records for research purposes depends on an assessment of the probabilities of public benefit and individual harm. Methods In the late 1990s, we carried out an observational study which compared the care given to affluent and deprived women with breast cancer. Patient consent was not required at that time for review of medical records, but was obtained later in the process prior to participation in the questionnaire study. We have re-analysed our original results to compare the whole sample with those who later provided consent. Results Two important findings emerged from the re-analysis of our data which if presented initially would have resulted in insufficient and inaccurate reporting. Firstly, the reduced dataset contains no information about women presenting with locally advanced or metastatic cancer and we would have been unable to demonstrate one of our initial key findings: namely a larger number of such women in the deprived group. Secondly, our re-analysis of the consented women shows that significantly more women from deprived areas (51 v 31%, p = 0.018) received radiotherapy compared to women from more affluent areas. Previously published data from the entire sample demonstrated no difference in radiotherapy treatment between the affluent and deprived groups. Conclusion The risk benefit assessment made regarding the use of medical records without consent should include the benefits of obtaining research evidence based on 100% of the population and the possibility of inappropriate or insufficient findings if research is confined to consented populations

Core intended learning outcomes for tackling health inequalities in undergraduate medicine Curriculum development

© 2015 Williamson et al.; licensee BioMed Central. Background: Despite there being a concerted effort in recent years to influence what doctors can do to tackle health inequalities in the UK, there has been limited policy focus on what undergraduate students need to learn at medical school in preparation for this. This project led by members of the Health Inequalities Group of the Royal College of General Practitioners in collaboration with the Institute of Health Equity, University College London sought to fill this gap. Discussion: We conducted a Delphi poll using our teaching and stakeholder networks. We identified 5 areas for learning focusing on key knowledge and skills. These were population concepts, health systems, marginalised patient groups, cultural diversity and ethics. Summary: These intended learning outcomes about health inequalities represent the best available evidence to date for colleagues seeking to develop core undergraduate medical curricula on the topic

Emergency admissions and subsequent inpatient care through an emergency oncology service at a tertiary cancer centre: service users’ experiences and views

Purpose Avoiding unnecessary emergency admissions and managing those that are admitted more effectively is a major concern for both patients and health services. To generate evidence useful for improving services for direct patient benefit, this study explores service users’ views and experiences of emergency admissions and subsequent inpatient care.Methods Participants were recruited during a cancer-related emergency admission from a tertiary cancer centre with an emergency oncology service and emergency department. Semi-structured interviews were conducted with fifteen patients and twelve carers post hospital discharge. Interview transcripts were analyzed using framework analysis.Results Twenty patients experienced 43 emergency admissions over six months. Most admissions (35/43) followed patients presenting acutely or as emergencies with cancer treatment side-effects. Most admissions (35/43) were directly to an oncology ward following specialist advice, review and triage and thus unavoidable. Participants experienced outstanding inpatient care because of: prompt and effective symptom control and stabilization of acute conditions; continuity of cancer care and coordination between acute and long-term treatment; satisfactory professional-patient communication and information sharing; responsive, motivated and competent staff; and less restrictive visiting times. Gaps in care were identified. Conclusions Many emergency admissions are necessary for people with cancer. Future work should focus on: improving easy access to specialist advice and triage, and the process of admission; providing rapid palliation of symptoms and prompt stabilization of acute conditions, and satisfactory inpatient care; closing the circle of care for patients by actively involving primary care and palliative/end-of-life care services to address the complex needs of patients and carers

A systematic review examining reducing unplanned hospital admissions in adults with cancer

Review question:1.What interventions have been tested and have successfully reduced unplanned hospital admissions in adults with cancer?2.What are the factors associated with unplanned hospital admissions in adults with cancer

A qualitative exploration of women's perspectives and acceptability of including new cancer awareness information in all‐clear breast or cervical screening results

Objective: This study explored women's perspectives on the acceptability of including new cancer information with an all-clear breast or cervical screening result letter (using ovarian cancer as a case study). Methods: In 2016, six focus group discussions were conducted with women aged 25–70 years old, eligible for invitation to the NHS breast or cervical screening programme and resident in England. The focus groups lasted 60–90 min and were held in community venues. Data were analysed using thematic analysis. Results: Thirty-eight women aged 25–67 years old participated in the focus groups. Data analysis yielded six descriptive themes: general cancer awareness, taking advantage of a ‘teachable moment’, a double-edge sword, barriers to accepting and using new cancer information, motivators for accepting and using new cancer information and wider strategies to increase cancer awareness in women. Women welcomed the inclusion of new cancer information in all-clear screening results but highlighted pertinent lessons to be considered to maximise the usefulness of the approach. Conclusion: While women perceived this approach as acceptable, it is pertinent to note the potential of the new cancer information to stimulate anxiety and potentially widen inequalities by excluding non-attenders at screening programmes. Specific complementary and tailored approaches are necessary to mitigate these limitations

'Unpacking' pathways to lymphoma and myeloma diagnosis : Do experiences align with the Model of Pathways to Treatment? Findings from a UK qualitative study with patients and relatives

OBJECTIVES: To explore alignment of experiences before lymphoma and myeloma diagnosis with the appraisal, help seeking and diagnostic intervals in the Model of Pathways to Treatment (MPT). DESIGN: A qualitative study using in-depth semistructured interviews with patients and relatives. Interviews were transcribed verbatim, anonymised and analysed using qualitative description. SETTING: A UK population-based haematological malignancy patient cohort. PARTICIPANTS: Fifty-five patients (35 lymphoma, 20 myeloma: diagnosed 2014-2016) and 28 relatives participated, within around a year of the patient's diagnosis. Patients were selected from those in the cohort who had returned a questionnaire about their symptoms and help seeking, and consented to contact for further research. Sampling was purposive, to achieve maximum variation in age, sex and time to diagnosis. RESULTS: Participants described time from symptom onset to diagnosis as ranging from several weeks to years. Pathways largely aligned with MPT components and help seeking could lead to the rapid investigations and identification of abnormalities. However, symptoms could be vague and/or inadvertently interpreted as other conditions, which if perpetuated, could cause diagnostic delay. The latter was associated with chaotic pathways, with activities rarely occurring only once or in a linear sequence. Rather, intermittent or ongoing processes were described, moving forward and backwards through intervals. This is 'unpacked' within five themes: (1) appraisal and reappraisal; (2) patient-initiated self-management/treatment; (3) initial help seeking; (4) re-presentation; and (5) patient-initiated actions, decisions and emotions during re-presentation. Within these themes, various healthcare professionals were consulted, often many times, as symptoms persisted/progressed. Input from family/friends was described as substantial, as was the extent to which information seeking occurred. CONCLUSION: Lymphoma and myeloma pathways align with the MPT, but do not fully capture the repetition and complexity described by participants. Time to diagnosis was often prolonged, despite the best efforts of patients, relatives and healthcare professionals. The impact of National Health Service England's Multi-diagnostic Disciplinary Centres on time to haematological cancer diagnosis remains to be seen