Understanding implementation and usefulness of electronic clinical decision support (eCDS) for melanoma in English primary care: a qualitative investigation.

BACKGROUND: Timely diagnosis of the serious skin cancer melanoma can improve patient outcomes. Clinical guidelines suggest that GPs use checklists, such as the 7-point checklist (7PCL), to assess pigmented lesions. In 2016, the 7PCL was disseminated by EMIS as an electronic clinical decision support (eCDS) tool. AIM: To understand GP and patient perspectives on the implementation and usefulness of the eCDS. DESIGN & SETTING: Semi-structured interviews with GPs and patients were undertaken. The interviews took place in four general practices in the south east of England following consultations using the eCDS for suspicious pigmented lesions. METHOD: Data were collected from semi-structured face-to-face interviews with GPs and from telephone interviews with patients. They were recorded and transcribed verbatim. The Consolidated Framework for Implementation Research (CFIR) underpinned the analysis using thematic approaches. RESULTS: A total of 14 interviews with GPs and 14 interviews with patients were undertaken. Most GPs reported that, as the eCDS was embedded in the medical record, it was useful, easy to use, time-efficient, and could facilitate patient-GP communication. They were less clear that it could meet policy or patient needs to improve early diagnosis, and some felt that it could lead to unnecessary referrals. Few felt that it had been sufficiently implemented at practice level. More felt confident with their own management of moles, and that the eCDS could be most useful for borderline decision-making. No patients were aware that the eCDS had been used during their consultation. CONCLUSION: Successful implementation of a new tool, such as eCDS for melanoma, requires GPs to perceive its value and understand how it can best be integrated into clinical practice. Disseminating a tool without such explanations is unlikely to promote its adoption into routine practice.NIH

Recognising Colorectal Cancer in Primary Care

This study was supported by the CanTest Collaborative (funded by Cancer Research UK C8640/A23385). No funding or sponsorship was received for the publication of this article.Peer reviewedPublisher PD

Recognising Colorectal Cancer in Primary Care

Abstract: Colorectal cancer (CRC) is the third most common cancer worldwide. Primary care professionals can play an important role in both prevention and early detection of CRC. Most CRCs are attributed to modifiable lifestyle factors, which can be addressed within primary care, and promotion of population-based screening programmes can aid early cancer detection in asymptomatic patients. Primary care professionals have a vital role in clinically assessing patients presenting with symptoms that may indicate cancer, as most patients with CRC first present with symptoms. These assessments are often challenging—many of the symptoms of CRC are non-specific and commonly occur in patients presenting with non-malignant disease. The range of options for investigating symptomatic patients in primary care is rapidly growing. Simple tests, such as faecal immunochemical testing (FIT), are now being used to guide decisions around referral for more invasive tests, such as colonoscopy, while direct access to specialist investigations is also becoming more common. Clinical decision support tools (CDSTs) which calculate cancer risk based on symptomatology, patient characteristics and test results can provide an additional resource to guide decisions on further investigation. This article explores the challenges of CRC prevention and detection from the primary care perspective, discusses current evidence-based approaches for CRC detection used in primary care (with examples from UK guidelines), and highlights emerging research which may likely alter practice in the future

Protocol for the melatools skin self-monitoring trial: a phase II randomised controlled trial of an intervention for primary care patients at higher risk of melanoma.

INTRODUCTION: Melanoma is the fifth most common cancer in the UK. Incidence rates have quadrupled over the last 30 years and continue to rise, especially among younger people. As routine screening of the general population is not currently recommended in the UK, a focus on secondary prevention through early detection and prompt treatment in individuals at increased risk of melanoma could make an important contribution to improve melanoma outcomes. This paper describes the protocol for a phase II, multisite, randomised controlled trial, in the primary care setting, for patients at increased risk of melanoma. A skin self-monitoring (SSM) smartphone 'App' was used to improve symptom appraisal and encourage help seeking in primary care, thereby promoting early presentation with skin changes suspicious of melanoma. METHODS AND ANALYSIS: We aim to recruit 200 participants from general practice waiting rooms in the East of England. Eligible patients are those identified at higher melanoma risk (using a real-time risk assessment tool), without a personal history of melanoma, aged 18 to 75 years. Participants will be invited to a primary care nurse consultation, and randomised to the intervention group (standard written advice on skin cancer detection and sun protection, loading of an SSM 'App' onto the participant's smartphone and instructions on use including self-monitoring reminders) or control group (standard written advice alone). The primary outcomes are consultation rates for changes to a pigmented skin lesion, and the patient interval (time from first noticing a skin change to consultation). Secondary outcomes include patient sun protection behaviours, psychosocial outcomes, and measures of trial feasibility and acceptability. ETHICS AND DISSEMINATION: NHS ethical approval has been obtained from Cambridgeshire and Hertfordshire research ethics committee (REC reference 16/EE/0248). The findings from the MelaTools SSM Trial will be disseminated widely through peer-reviewed publications and scientific conferences. TRIAL REGISTRATION NUMBER: ISCTRN16061621.This work was supported by FMW’s Clinician Scientist award (RG 68235) from the National Institute for Health Research (NIHR). ... The paper also presents independent research funded/supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research & Care (CLAHRC) East of England, at Cambridgeshire and Peterborough NHS Foundation Trust

Dopamine and inhibitory action control: evidence from spontaneous eye blink rates

The inhibitory control of actions has been claimed to rely on dopaminergic pathways. Given that this hypothesis is mainly based on patient and drug studies, some authors have questioned its validity and suggested that beneficial effects of dopaminergic stimulants on response inhibition may be limited to cases of suboptimal inhibitory functioning. We present evidence that, in carefully selected healthy adults, spontaneous eyeblink rate, a marker of central dopaminergic functioning, reliably predicts the efficiency in inhibiting unwanted action tendencies in a stop-signal task. These findings support the assumption of a modulatory role for dopamine in inhibitory action control

Understanding implementation and usefulness of electronic clinical decision support (eCDS) for melanoma in English primary care: a qualitative investigation

Background: Timely diagnosis of the serious skin cancer melanoma can improve patient outcomes. Clinical guidelines suggest that GPs use checklists, such as the 7-point checklist (7PCL), to assess pigmented lesions. In 2016, the 7PCL was disseminated by EMIS as an electronic clinical decision support (eCDS) tool. Aim: To understand GP and patient perspectives on the implementation and usefulness of the eCDS. Design & setting: Semi-structured interviews with GPs and patients were undertaken. The interviews took place in four general practices in the south east of England following consultations using the eCDS for suspicious pigmented lesions. Method: Data were collected from semi-structured face-to-face interviews with GPs and from telephone interviews with patients. They were recorded and transcribed verbatim. The Consolidated Framework for Implementation Research (CFIR) underpinned the analysis using thematic approaches. Results: A total of 14 interviews with GPs and 14 interviews with patients were undertaken. Most GPs reported that, as the eCDS was embedded in the medical record, it was useful, easy to use, time-efficient, and could facilitate patient–GP communication. They were less clear that it could meet policy or patient needs to improve early diagnosis, and some felt that it could lead to unnecessary referrals. Few felt that it had been sufficiently implemented at practice level. More felt confident with their own management of moles, and that the eCDS could be most useful for borderline decision-making. No patients were aware that the eCDS had been used during their consultation. Conclusion: Successful implementation of a new tool, such as eCDS for melanoma, requires GPs to perceive its value and understand how it can best be integrated into clinical practice. Disseminating a tool without such explanations is unlikely to promote its adoption into routine practice

Who are the patients being offered the faecal immunochemical test in routine English general practice, and for what symptoms? A prospective descriptive study.

OBJECTIVES: The faecal immunochemical test (FIT) was introduced to triage patients with lower-risk symptoms of colorectal cancer (CRC) in English primary care in 2018. While there is growing evidence on its utility to triage patients in this setting, evidence is still limited on how official FIT guidance is being used, for which patients and for what symptoms. We aimed to investigate the use of FIT in primary care practice for lower-risk patients who did not immediately meet criteria for urgent referral. DESIGN: A prospective, descriptive study of symptomatic patients offered a FIT in primary care between January and June 2020. SETTING: East of England general practices. PARTICIPANTS: Consenting patients (aged ≥40 years) who were seen by their general practitioners (GPs) with symptoms of possible CRC for whom a FIT was requested. We excluded patients receiving a FIT for asymptomatic screening purposes, or patients deemed by GPs as lacking capacity for informed consent. Data were obtained via patient questionnaire, medical and laboratory records. PRIMARY AND SECONDARY OUTCOME MEASURES: FIT results (10 µg Hb/g faeces defined a positive result); patient sociodemographic and clinical characteristics; patient-reported and GP-recorded symptoms, symptom severity and symptom agreement between patient and GP (% and kappa statistics). RESULTS: Complete data were available for 310 patients, median age 70 (IQR 61-77) years, 53% female and 23% FIT positive. Patients most commonly reported change in bowel habit (69%) and fatigue (57%), while GPs most commonly recorded abdominal pain (25%) and change in bowel habit (24%). Symptom agreement ranged from 44% (fatigue) to 80% (unexplained weight loss). Kappa agreement was universally low across symptoms. CONCLUSION: Almost a quarter of this primary care cohort of symptomatic patients with FIT testing were found to be positive. However, there was low agreement between patient-reported and GP-recorded symptoms. This may impact cancer risk assessment and optimal patient management in primary care

Can we do better? A qualitative study in the East of England investigating patient experience and acceptability of using the faecal immunochemical test in primary care

Peer reviewed: TrueAcknowledgements: We thank all the patients who agreed to be interviewed. We thank the North East Essex and Suffolk Pathology Services at the East Suffolk and North Essex NHS Foundation Trust, and the Clinical Biochemistry section of Laboratory Medicine at Norfolk and Norwich University Hospitals NHS Foundation Trust. They have added a study recruitment letter, consent form and prepaid envelope to each FIT kit, distributed these to GP practices and provided data on FIT results. We thank Professor Niek de Wit and Dr Peter Holloway for their support in the earlier stages of the study. We are grateful to Marije van Melle for her work in the early stages of study design. We thank James Brimicombe for data management advice, support and expertise, and Andy Cowan for his help collecting and managing FIT-East study data. We are grateful to the CanTest Patient & Public Involvement (PPI) Panel (special thanks to Margaret Johnson) for reading and commenting on interview transcripts.Objectives: The faecal immunochemical test (FIT) is increasingly used in UK primary care to triage patients presenting with symptoms and at different levels of colorectal cancer risk. Evidence is scarce on patients’ views of using FIT in this context. We aimed to explore patients’ care experience and acceptability of using FIT in primary care. Design: A qualitative semi-structured interview study. Interviews were conducted via Zoom between April and October 2020. Transcribed recordings were analysed using framework analysis. Setting: East of England general practices. Participants: Consenting patients (aged ≥40 years) who presented in primary care with possible symptoms of colorectal cancer, and for whom a FIT was requested, were recruited to the FIT-East study. Participants were purposively sampled for this qualitative substudy based on age, gender and FIT result. Results: 44 participants were interviewed with a mean age 61 years, and 25 (57%) being men: 8 (18%) received a positive FIT result. Three themes and seven subthemes were identified. Participants’ familiarity with similar tests and perceived risk of cancer influenced test experience and acceptability. All participants were happy to do the FIT themselves and to recommend it to others. Most participants reported that the test was straightforward, although some considered it may be a challenge to others. However, test explanation by healthcare professionals was often limited. Furthermore, while some participants received their results quickly, many did not receive them at all with the common assumption that ‘no news is good news’. For those with a negative result and persisting symptoms, there was uncertainty about any next steps. Conclusions: While FIT is acceptable to patients, elements of communication with patients by the healthcare system show potential for improvement. We suggest possible ways to improve the FIT experience, particularly regarding communication about the test and its results

Can we do better? A qualitative study in the East of England investigating patient experience and acceptability of using the faecal immunochemical test in primary care.

OBJECTIVES: The faecal immunochemical test (FIT) is increasingly used in UK primary care to triage patients presenting with symptoms and at different levels of colorectal cancer risk. Evidence is scarce on patients' views of using FIT in this context. We aimed to explore patients' care experience and acceptability of using FIT in primary care. DESIGN: A qualitative semi-structured interview study. Interviews were conducted via Zoom between April and October 2020. Transcribed recordings were analysed using framework analysis. SETTING: East of England general practices. PARTICIPANTS: Consenting patients (aged ≥40 years) who presented in primary care with possible symptoms of colorectal cancer, and for whom a FIT was requested, were recruited to the FIT-East study. Participants were purposively sampled for this qualitative substudy based on age, gender and FIT result. RESULTS: 44 participants were interviewed with a mean age 61 years, and 25 (57%) being men: 8 (18%) received a positive FIT result. Three themes and seven subthemes were identified. Participants' familiarity with similar tests and perceived risk of cancer influenced test experience and acceptability. All participants were happy to do the FIT themselves and to recommend it to others. Most participants reported that the test was straightforward, although some considered it may be a challenge to others. However, test explanation by healthcare professionals was often limited. Furthermore, while some participants received their results quickly, many did not receive them at all with the common assumption that 'no news is good news'. For those with a negative result and persisting symptoms, there was uncertainty about any next steps. CONCLUSIONS: While FIT is acceptable to patients, elements of communication with patients by the healthcare system show potential for improvement. We suggest possible ways to improve the FIT experience, particularly regarding communication about the test and its results