Berkman, Lindy

Greenfield, Sheila

Kidney, Elaine

Marshall, Tom

Wood, Sally

English

University of Birmingham Research Portal

  University of BirminghamBarriers to GP referral for early diagnosis ofsuspected colorectal cancerKidney, Elaine; Greenfield, Sheila; Berkman, Lindy; Wood, Sally; Marshall, TomCitation for published version (Harvard):Kidney, E, Greenfield, S, Berkman, L, Wood, S & Marshall, T 2016, 'Barriers to GP referral for early diagnosis ofsuspected colorectal cancer', Paper presented at South West Society for Academic Primary Care AnnualResearch Meeting 2016, Cardiff, 1/03/16 - 2/03/16.Link to publication on Research at Birmingham portalGeneral rightsUnless a licence is specified above, all rights (including copyright and moral rights) in this document are retained by the authors and/or thecopyright holders. The express permission of the copyright holder must be obtained for any use of this material other than for purposespermitted by law.•	Users may freely distribute the URL that is used to identify this publication.•	Users may download and/or print one copy of the publication from the University of Birmingham research portal for the purpose of privatestudy or non-commercial research.•	User may use extracts from the document in line with the concept of ‘fair dealing’ under the Copyright, Designs and Patents Act 1988 (?)•	Users may not further distribute the material nor use it for the purposes of commercial gain.Where a licence is displayed above, please note the terms and conditions of the licence govern your use of this document.When citing, please reference the published version.Take down policyWhile the University of Birmingham exercises care and attention in making items available there are rare occasions when an item has beenuploaded in error or has been deemed to be commercially or otherwise sensitive.If you believe that this is the case for this document, please contact UBIRA@lists.bham.ac.uk providing details and we will remove access tothe work immediately and investigate.Download date: 01. Mar. 2020A red flag is not enough: understanding GP delays in referral for suspected colorectal cancer Elaine Kidney, Research Fellow A ; Sheila Greenfield, Professor of Medical Sociology A; Lindy Berkman, Patient/Public Representative A;  George Dowswell, Research Fellow A Willie Hamilton, Professor of Primary Care Diagnostics B; Sally Wood, General Practitioner A,  Tom Marshall, Professor of Public Health and Primary Care A     A Institute of Applied Health Research, University of Birmingham,  B University of Exeter   1. Whose role is it to make sure GP’s are knowledgeable and confident in following best practice? 2. Avoiding “over-referral”  Might it be the CCG’s role to ensure referrals to rule out cancer are explicitly excluded from measures to reduce overall referrals rates? 3. Which diagnostic strategies should the doctor use?  Analysing self-reported preferences for referral using a previously reported categorisation of strategies,2  we found:  Early referral is • Favoured by following NICE guidelines and by pro-actively referring patients with low haemoglobin and ferritin levels.   • Hindered by reliance on: o Tests of time or treatment,  o Probabilistic reasoning (that symptoms are more likely to be due to some other cause)  o Recognising only patterns of symptoms.   4. Scaring the patient Is support needed to encourage referral specifically for patients perceived as too anxious or psychologically fragile for referral?  5. Areas with high prevalence of anaemia. Should doctors serving populations with high levels of anaemia (e.g.  elderly, or South Asian populations) be targeted for action?     Lack of suspicion of red flag symptoms (particularly anaemia) and reluctance to over-refer are barriers to GP referral and early diagnosis of colorectal cancer.  CCGs should encourage early referral for suspicion of colorectal cancer  Further research may be needed on increasing referrals in disadvantaged or marginalised groups, ethnic minorities and patients perceived as anxious.   1. Kidney E., Berkman L., Macherianakis A., Morton D., Dowswell G., Hamilton W., Ryan R., Awbery H., Greenfield S. & Marshall T. 2015. Preliminary results of a feasibility study of the use of information technology for identification of suspected colorectal cancer in primary care: the CREDIBLE study. Br J Cancer, 112: S70-S76. DOI: 10.1038/bjc.2015.45  2. Heneghan C., Glasziou P., Thompson M., Rose P., Balla J., Lasserson D., Scott C. & Perera R. 2009. Diagnosis in general practice: Diagnostic strategies used in primary care. BMJ 338(7701): 1003-1005. doi:10.1136/bmj.b946   A previously published study (CREDIBLE)1 electronically identified 60-79 year olds meeting NICE urgent referral criteria (red-flag symptoms) for suspected colorectal cancer.  These are: - iron deficiency anaemia - persistent diarrhoea - rectal bleeding or a positive FOBt.  We found many patients with red-flag symptoms were judged by their GPs not to need further investigation.   We report attitudinal and contextual influences on investigation and referral of patients with red-flag symptoms and on report barriers and facilitators to GP referral.    Semi-structured interviews - 18 GPs and 12 practice managers  - From practices participating in the CREDIBLE study  Interviews focussed on  - early detection of colorectal cancer - the use of information technology to identify patients - referral of identified patients    Factors hindering referral by GPs: 1. Lack of Knowledge of Referral Criteria Sometimes not considered urgent referral criteria: • Persistent diarrhoea • Iron deficiency anaemia  Anaemia was often attributed to diet  Anaemia in South Asian groups normalised  2. Individually-derived decision rules for investigation or referral Alternatives to urgent referral for lower GI investigation: • Trial of iron therapy for anaemia in elderly patients • FOBt and not referring if was negative • Delaying until additional symptoms were seen • Non-urgent referral • Only referring if strongly suspicious • Referral for upper GI investigation  3. A Desire to Avoid Over-referral • Financial pressures to reduce referrals • Avoiding criticism by health care commissioners and peers • Reluctance to scare patients by discussing suspected cancer • Particularly patients perceived to be anxious Discussion Methods Results Interpretation References Background 

Barriers to GP referral for early diagnosis of suspected colorectal cancer

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Barriers to GP referral for early diagnosis of suspected colorectal cancer

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