OBJECTIVES: to inform the rational deployment of assessor resource in the evaluation of applications to the UK Advisory Committee on Clinical Excellence Awards (ACCEA). SETTING: ACCEA are responsible for a scheme to financially reward senior doctors in England and Wales who are assessed to be working over and above the standard expected of their role. PARTICIPANTS: Anonymised applications of consultants and senior academic GPs for awards were considered by members of 14 regional subcommittees and 2 national assessing committees during the 2014-2015 round of applications. DESIGN: it involved secondary analysis of complete anonymised national data set. PRIMARY AND SECONDARY OUTCOME MEASURES: We analysed scores for each of 1916 applications for a clinical excellence award across 4 levels of award. Scores were provided by members of 16 subcommittees. We assessed the reliability of assessments and described the variance in the assessment of scores. RESULTS: Members of regional subcommittees assessed 1529 new applications and 387 renewal applications. Average scores increased with the level of application being made. On average, applications were assessed by 9.5 assessors. The highest contributions to the variance in individual assessors' assessments of applications were attributable to assessors or to residual variance. The applicant accounted for around a quarter of the variance in scores for new bronze applications, with this proportion decreasing for higher award levels. Reliability in excess of 0.7 can be attained where 4 assessors score bronze applications, with twice as many assessors being required for higher levels of application. CONCLUSIONS: Assessment processes pertaining in the competitive allocation of public funds need to be credible and efficient. The present arrangements for assessing and scoring applications are defensible, depending on the level of reliability judged to be required in the assessment process. Some relatively minor reconfiguration in approaches to scoring might usefully be considered in future rounds of assessment.

AbstractObjectivesTo evaluate the faecal immunochemical test (FIT) for primary care clinicians to triage patients with low-risk symptoms of possible colorectal cancer, and to estimate its diagnostic performance.DesignService delivery evaluation.SettingAll primary and secondary care providers in the South West of England, approximate population 4 million.Participants3890 patients aged ≥50 years presenting in primary care with low-risk symptoms of colorectal cancer, following NICE NG12 and DG30, with a FIT (HM-JACKarc assay) analysed from 01/06/2018 to 31/12/2018.Main outcome measuresDiagnosis of colorectal cancer.Results618 (15.9%) patients tested positive at a threshold of 10μg Hb/g faeces (median 36μg Hb/g faeces (IQR 17 to 149)); 458 (74.1%) of these had an urgent referral to specialist lower gastrointestinal (GI) services within three months. 43 were diagnosed with colorectal cancer within 12 months. 3272 patients tested negative; 324 (9.9%) were referred on an urgent lower GI pathway in secondary care within three months. 8 were diagnosed with colorectal cancer within 12 months. The positive predictive value of FIT for colorectal cancer in the low-risk symptomatic population was 7.0% (95% CI 5.1% to 9.3%) and the negative predictive value was 99.8% (CI 99.5% to 99.9%). Sensitivity was 84.3% (CI 71.4% to 93.0%),and specificity 85.0% (CI 83.8% to 86.1%). The area under the ROC curve was 0.92 (CI 0.86 to 0.96). A threshold of 37μg Hb/g faeces would identify patients with an individual 3% risk of cancer.ConclusionsFIT performs exceptionally well to triage patients with low-risk symptoms of colorectal cancer in primary care. The threshold value of 10μg Hb/g faeces represents a risk of cancer below 3% used in current NICE guidance; however, this lower value may be appropriate to meet the national aspiration of improving cancer diagnostics.

Abstract
. Background
. Electronic clinical decision support tools (eCDS) are increasingly available to assist General Practitioners (GP) with the diagnosis and management of a range of health conditions. It is unclear whether the use of eCDS tools has an impact on GP workload. This scoping review aimed to identify the available evidence on the use of eCDS tools by health professionals in general practice in relation to their impact on workload and workflow.
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. Methods
. A scoping review was carried out using the Arksey and O’Malley methodological framework. The search strategy was developed iteratively, with three main aspects: general practice/primary care contexts, risk assessment/decision support tools, and workload-related factors. Three databases were searched in 2019, and updated in 2021, covering articles published since 2009: Medline (Ovid), HMIC (Ovid) and Web of Science (TR). Double screening was completed by two reviewers, and data extracted from included articles were analysed.
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. Results
. The search resulted in 5,594 references, leading to 95 full articles, referring to 87 studies, after screening. of these, 36 studies were based in the USA, 21 in the UK and 11 in Australia. A further 18 originated from Canada or Europe, with the remaining studies conducted in New Zealand, South Africa and Malaysia. Studies examined the use of eCDS tools and reported some findings related to their impact on workload, including on consultation duration. Most studies were qualitative and exploratory in nature, reporting health professionals’ subjective perceptions of consultation duration as opposed to objectively-measured time spent using tools or consultation durations. Other workload-related findings included impacts on cognitive workload, “workflow” and dialogue with patients, and clinicians’ experience of “alert fatigue”.
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. Conclusions
. The published literature on the impact of eCDS tools in general practice showed that limited efforts have focused on investigating the impact of such tools on workload and workflow. To gain an understanding of this area, further research, including quantitative measurement of consultation durations, would be useful to inform the future design and implementation of eCDS tools.
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Background: This study investigated ethnic differences in diagnostic interval (DI)—the period between initial primary care presentation and diagnosis. Methods: We analysed the primary care-linked data of patients who reported features of seven cancers (breast, lung, prostate, colorectal, oesophagogastric, myeloma, and ovarian) one year before diagnosis. Accelerated failure time (AFT) models investigated the association between DI and ethnicity, adjusting for age, sex, deprivation, and morbidity. Results: of 126,627 eligible participants, 92.1% were White, 1.99% Black, 1.71% Asian, 1.83% Mixed, and 2.36% were of Other ethnic backgrounds. Considering all cancer sites combined, the median (interquartile range) DI was 55 (20–175) days, longest in lung [127, (42–265) days], and shortest in breast cancer [13 (13, 8–18) days]. DI for the Black and Asian groups was 10% (AFT ratio, 95%CI 1.10, 1.05–1.14) and 16% (1.16, 1.10–1.22), respectively, longer than for the White group. Site-specific analyses revealed evidence of longer DI in Asian and Black patients with prostate, colorectal, and oesophagogastric cancer, plus Black patients with breast cancer and myeloma, and the Mixed group with lung cancer compared with White patients. DI was shorter for the Other group with lung, prostate, myeloma, and oesophagogastric cancer than the White group. Conclusion: We found limited and inconsistent evidence of ethnic differences in DI among patients who reported cancer features in primary care before diagnosis. Our findings suggest that inequalities in diagnostic intervals, where present, are unlikely to be the sole explanation for ethnic variations in cancer outcomes.

. Background
. The use of web-based services within primary care (PC) in the National Health Service in England is increasing, with medically underserved populations being less likely to engage with web-based services than other patient groups. Digital facilitation—referring to a range of processes, procedures, and personnel that seek to support patients in the uptake and use of web-based services—may be a way of addressing these challenges. However, the models and impact of digital facilitation currently in use are unclear.
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.
. Objective
. This study aimed to identify, characterize, and differentiate between different approaches to digital facilitation in PC; establish what is known about the effectiveness of different approaches; and understand the enablers of digital facilitation.
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. Methods
. Adopting scoping review methodology, we searched academic databases (PubMed, EMBASE, CINAHL, Web of Science, and Cochrane Library) and gray literature published between 2015 and 2020. We conducted snowball searches of reference lists of included articles and articles identified during screening as relevant to digital facilitation, but which did not meet the inclusion criteria because of article type restrictions. Titles and abstracts were independently screened by 2 reviewers. Data from eligible studies were analyzed using a narrative synthesis approach.
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.
. Results
. A total of 85 publications were included. Most (71/85, 84%) were concerned with digital facilitation approaches targeted at patients (promotion of services, training patients to improve their technical skills, or other guidance and support). Further identified approaches targeted PC staff to help patients (eg, improving staff knowledge of web-based services and enhancing their technical or communication skills). Qualitative evidence suggests that some digital facilitation may be effective in promoting the uptake and use of web-based services by patients (eg, recommendation of web-based services by practice staff and coaching). We found little evidence that providing patients with initial assistance in registering for or accessing web-based services leads to increased long-term use. Few studies have addressed the effects of digital facilitation on health care inequalities. Those that addressed this suggested that providing technical training for patients could be effective, at least in part, in reducing inequalities, although not entirely. Factors affecting the success of digital facilitation include perceptions of the usefulness of the web-based service, trust in the service, patients’ trust in providers, the capacity of PC staff, guidelines or regulations supporting facilitation efforts, and staff buy-in and motivation.
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. Conclusions
. Digital facilitation has the potential to increase the uptake and use of web-based services by PC patients. Understanding the approaches that are most effective and cost-effective, for whom, and under what circumstances requires further research, including rigorous evaluations of longer-term impacts. As efforts continue to increase the use of web-based services in PC in England and elsewhere, we offer an early typology to inform conceptual development and evaluations.
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. Trial Registration
. PROSPERO International Prospective Register of Systematic Reviews CRD42020189019; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=189019
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BACKGROUND: it has been proposed that changes in healthcare use before cancer diagnosis could signal opportunities for quicker detection, but systematic appreciation of such evidence is lacking. We reviewed studies examining pre-diagnostic changes in healthcare utilisation (e.g. rates of GP or hospital consultations, prescriptions or diagnostic tests) among patients subsequently diagnosed with cancer. METHODS: We identified studies through Pubmed searches complemented by expert elicitation. We extracted information on the earliest time point when diagnosis could have been possible for at least some cancers, together with variation in the length of such 'diagnostic windows' by tumour and patient characteristics. RESULTS: Across twenty-eight studies, changes in healthcare use were observable at least six months pre-diagnosis for many common cancers, and potentially even earlier for colorectal cancer, multiple myeloma and brain tumours. Early changes were also identified for brain and colon cancer sub-sites. CONCLUSION: Changing healthcare utilisation patterns before diagnosis indicate that future improvements in diagnostic technologies or services could help to shorten diagnostic intervals for cancer. There is greatest potential for quicker diagnosis for certain cancer types and patient groups, which can inform priorities for the development of decision support tools.

BACKGROUND: UK Asian and Black ethnic groups have poorer outcomes for some cancers and are less likely to report a positive care experience than their White counterparts. This study investigated ethnic differences in the route to diagnosis (RTD) to identify areas in patients' cancer journeys where inequalities lie, and targeted intervention might have optimum impact. METHODS: We analysed data of 243,825 patients with 10 cancers (2006-2016) from the RTD project linked to primary care data. Crude and adjusted proportions of patients diagnosed via six routes (emergency, elective GP referral, two-week wait (2WW), screen-detected, hospital, and Other routes) were calculated by ethnicity. Adjusted odds ratios (including two-way interactions between cancer and age, sex, IMD, and ethnicity) determined cancer-specific differences in RTD by ethnicity. RESULTS: Across the 10 cancers studied, most patients were diagnosed via 2WW (36.4%), elective GP referral (23.2%), emergency (18.2%), hospital routes (10.3%), and screening (8.61%). Patients of Other ethnic group had the highest proportion of diagnosis via the emergency route, followed by White patients. Asian and Black group were more likely to be GP-referred, with the Black and Mixed groups also more likely to follow the 2WW route. However, there were notable cancer-specific differences in the RTD by ethnicity. CONCLUSION: Our findings suggest that, where inequalities exist, the adverse cancer outcomes among Asian and Black patients are unlikely to be arising solely from a poorer diagnostic process.

BACKGROUND: There is uncertainty regarding how pre-existing conditions (morbidities) may influence the primary care investigation and management of individuals subsequently diagnosed with cancer. METHODS: We identified morbidities using information from both primary and secondary care records among 11,716 patients included in the English National Cancer Diagnosis Audit (NCDA) 2014. We examined variation in 5 measures of the diagnostic process (the primary care interval, diagnostic interval, number of pre-referral consultations, use of primary care-led investigations, and referral type) by both primary care- and hospital records-derived measures of morbidity. RESULTS: Morbidity prevalence recorded before cancer diagnosis was almost threefold greater using the primary care (75%) vs secondary care-derived measure (28%). After adjustment, there was limited variation in the primary care interval and the number of pre-referral consultations by either definition of morbidity. Patients with more severe morbidities were less likely to have had a primary care-led investigation before cancer diagnosis compared with those without any morbidity (adjusted odds ratio, OR [95% confidence interval]: 0.72 [0.60-0.86] for Charlson score 3+ vs 0; joint P < 0.001). Patients with multiple primary care-recorded conditions or a Charlson score of 3+ were more likely to have diagnostic intervals exceeding 60 days (aOR: 1.26 [1.10-1.45] and 1.19 [>1.00-1.41], respectively), and more likely to receive an emergency referral (aOR: 1.60 [1.26-2.02] and 1.61 [1.26-2.06], respectively). CONCLUSION: Among cancer cases with up to 2 morbidities, there was no evidence of differences in diagnostic processes and intervals in primary care but higher morbidity burden was associated with longer time to diagnosis and higher likelihood of emergency referral.

BACKGROUND: Steroid use is associated with increased risk of Hodgkin lymphoma (HL). However, allergic symptoms commonly treated with steroids are also presenting features of HL in some patients, thereby introducing protopathic bias in estimates of aetiological associations. It is therefore important to examine steroid prescribing patterns pre-diagnosis to understand timing of associations and when healthcare use increases before cancer diagnosis to inform future epidemiological study design. METHODS: We analysed steroid prescribing in 1232 HL patients and 7392 matched controls using primary care electronic health records (Clinical Practice Research Datalink (CPRD), 1987-2016). Using Poisson regression, we calculated monthly steroid prescribing rates for the 24-months preceding HL diagnosis, identifying the inflection point when they start to increase from baseline in cases, comparing rates with synchronous controls, and stratifying by route-of-administration and allergic disease status. RESULTS: 46 % of HL patients had a steroid prescription in the 24-months preceding diagnosis compared to 26 % of controls (OR 2.55, 95 %CI 2.25-2.89, p 

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.

BackgroundClinical guidelines advise GPs in England which patients warrant an urgent referral for suspected cancer. This study assessed how often GPs follow the guidelines, whether certain patients are less likely to be referred, and how many patients were diagnosed with cancer within 1 year of non-referral.MethodsWe used linked primary care (Clinical Practice Research Datalink), secondary care (Hospital Episode Statistics) and cancer registration data. Patients presenting with haematuria, breast lump, dysphagia, iron-deficiency anaemia, post-menopausal or rectal bleeding for the first time during 2014–2015 were included (for ages where guidelines recommend urgent referral). Logistic regression was used to investigate whether receiving a referral was associated with feature type and patient characteristics. Cancer incidence (based on recorded diagnoses in cancer registry data within 1 year of presentation) was compared between those receiving and those not receiving referrals.Results48 715 patients were included, of which 40% (n=19 670) received an urgent referral within 14 days of presentation, varying by feature from 17% (dysphagia) to 68% (breast lump). Young patients (18–24 vs 55–64 years; adjusted OR 0.20, 95% CI 0.10 to 0.42, p&lt;0.001) and those with comorbidities (4 vs 0 comorbidities; adjusted OR 0.87, 95% CI 0.80 to 0.94, p&lt;0.001) were less likely to receive a referral. Associations between patient characteristics and referrals differed across features: among patients presenting with anaemia, breast lump or haematuria, those with multi-morbidity, and additionally for breast lump, more deprived patients were less likely to receive a referral. of 29 045 patients not receiving a referral, 3.6% (1047) were diagnosed with cancer within 1 year, ranging from 2.8% for rectal bleeding to 9.5% for anaemia.ConclusionsGuideline recommendations for action are not followed for the majority of patients presenting with common possible cancer features. A significant number of these patients developed cancer within 1 year of their consultation, indicating scope for improvement in the diagnostic process.

CA125 is widely used as an initial investigation in women presenting with symptoms of possible ovarian cancer. We sought to develop CA125-based diagnostic prediction models and to explore potential implications of implementing model-based thresholds for further investigation in primary care. This retrospective cohort study used routinely collected primary care and cancer registry data from symptomatic, CA125-tested women in England (2011–2014). A total of 29,962 women were included, of whom 279 were diagnosed with ovarian cancer. Logistic regression was used to develop two models to estimate ovarian cancer probability: Model 1 consisted of age and CA125 level; Model 2 incorporated further risk factors. Model discrimination (AUC) was evaluated using 10-fold cross-validation. The sensitivity and specificity of various model risk thresholds (≥1% to ≥3%) were compared with that of the current CA125 cut-off (≥35 U/mL). Model 1 exhibited excellent discrimination (AUC: 0.94) on cross-validation. The inclusion of additional variables (Model 2) did not improve performance. At a risk threshold of ≥1%, Model 1 exhibited greater sensitivity (86.4% vs. 78.5%) but lower specificity (89.1% vs. 94.5%) than CA125 (≥35 U/mL). Applying the ≥1% model threshold to the cohort in place of the current CA125 cut-off, 1 in every 74 additional women identified had ovarian cancer. Following external validation, Model 1 could be used as part of a ‘risk-based triage’ system in which women at high risk of undiagnosed ovarian cancer are selected for urgent specialist investigation, while women at ‘low risk but not no risk’ are offered non-urgent investigation or interval CA125 re-testing. Such an approach has the potential to expedite ovarian cancer diagnosis, but further research is needed to evaluate the clinical impact and health–economic implications.

BACKGROUND: the faecal immunochemical test (FIT) was introduced to triage patients with low-risk symptoms of possible colorectal cancer in English primary care in 2017, underpinned by little primary care evidence. METHODS: all healthcare providers in the South West of England (population 4 million) participated in this evaluation. 3890 patients aged ≥50 years presenting in primary care with low-risk symptoms of colorectal cancer had a FIT from 01/06/2018 to 31/12/2018. A threshold of 10 μg Hb/g faeces defined a positive test. RESULTS: Six hundred and eighteen (15.9%) patients tested positive; 458 (74.1%) had an urgent referral to specialist lower gastrointestinal (GI) services within three months. Forty-three were diagnosed with colorectal cancer within 12 months. 3272 tested negative; 324 (9.9%) had an urgent referral within three months. Eight were diagnosed with colorectal cancer within 12 months. Positive predictive value was 7.0% (95% CI 5.1-9.3%). Negative predictive value was 99.8% (CI 99.5-99.9%). Sensitivity was 84.3% (CI 71.4-93.0%), specificity 85.0% (CI 83.8-86.1%). The area under the ROC curve was 0.92 (CI 0.86-0.96). A threshold of 37 μg Hb/g faeces would identify patients with an individual 3% risk of cancer. CONCLUSIONS: FIT performs exceptionally well to triage patients with low-risk symptoms of colorectal cancer in primary care; a higher threshold may be appropriate in the wake of the COVID-19 crisis.

BACKGROUND: a standard measure of the cancer diagnostic pathway, diagnostic interval, is the time from "first presentation of cancer" to diagnosis. Cancer presentation may be unclear in patients with multimorbidity or non-specific symptoms, signs or test results ("features"). We propose an alternative, guideline interval, with a more certain start date; namely, when the patient first meets suspected-cancer criteria for investigation or referral. METHODS: This retrospective cohort study used Clinical Practice Research Datalink (CPRD) and English cancer registry data. Participants, aged ≥55 years, had diagnostic codes for oesophagogastric cancers in 1/1/12-31/12/17. Features of oesophagogastric cancer in the year before diagnosis were identified from CPRD codes for dysphagia, haematemesis, upper-abdominal mass or pain, low haemoglobin, reflux, dyspepsia, nausea, vomiting, weight loss or thrombocytosis. Diagnostic interval was the time from first feature to diagnosis; guidance interval, the time from first meeting criteria in NICE suspected-cancer guidance to diagnosis. Multimorbidity burden was quantified using Adjusted Clinical Groups®. Accelerated failure-time models explored associations between multimorbidity burden and length of both diagnostic and guideline interval. RESULTS: There were 3,793 eligible participants (69.0 % male), mean age 74.1 years (SD 10.5). 3,097 (81.7 %) presented with ≥1 feature in the year before diagnosis, and 1,990 (52.5 %) met NICE suspected-cancer criteria. The median for both intervals was 11 days in healthy users, and rose with increasing morbidity burden. At very high multimorbidity burden, diagnostic interval was 5.47 (95%CI 3.25-9.20) times longer and guideline interval was 3.91 (2.63-5.80) times longer than for healthy users. CONCLUSIONS: Guideline interval is proposed as a new measure of the cancer diagnostic pathway. It has a more certain start date than diagnostic interval, and is lengthened less than diagnostic interval in people with a very high multimorbidity burden. Guideline interval has potential for assessing the implementation of suspected-cancer policies.

BACKGROUND: Most patients obtain medications from pharmacies by prescription, but rural general practices can dispense medications. The clinical implications of this difference in drug delivery are unknown. This study hypothesised that dispensing status may be associated with better medication adherence. This could impact intermediate clinical outcomes dependent on medication adherence in, for example, hypertension or diabetes. AIM: to investigate whether dispensing status is associated with differences in achievement of Quality and Outcomes Framework (QOF) indicators that rely on medication adherence. DESIGN AND SETTING: Cross-sectional analysis of QOF data for 7392 general practices in England. METHOD: QOF data from 1 April 2016 to 31 March 2017 linked to dispensing status for general practices with list sizes ≥1000 in England were analysed. QOF indicators were categorised according to whether their achievement depended on a record of prescribing only, medication adherence, or neither. Differences were estimated between dispensing and non-dispensing practices using mixed-effects logistic regression, adjusting for practice population age, sex, deprivation, list size, single-handed status, and rurality. RESULTS: Data existed for 7392 practices; 1014 (13.7%) could dispense. Achievement was better in dispensing practices than in non-dispensing practices for seven of nine QOF indicators dependent on adherence, including blood pressure targets. Only one of ten indicators dependent on prescribing but not adherence displayed better achievement; indicators unrelated to prescribing showed a trend towards higher achievement by dispensing practices. CONCLUSION: Dispensing practices may achieve better clinical outcomes than prescribing practices. Further work is required to explore underlying mechanisms for these observations and to directly study medication adherence rates.

Background
The diagnostic assessment of abdominal symptoms in primary care presents a challenge. Evidence is needed about the positive predictive values (PPVs) of abdominal symptoms for different cancers and inflammatory bowel disease (IBD).


Methods and findings
Using data from the Health Improvement Network (THIN) in the United Kingdom (2000–2017), we estimated the PPVs for diagnosis of (i) cancer (overall and for different cancer sites); (ii) IBD; and (iii) either cancer or IBD in the year post-consultation with each of 6 abdominal symptoms: dysphagia (n = 86,193 patients), abdominal bloating/distension (n = 100,856), change in bowel habit (n = 106,715), rectal bleeding (n = 235,094), dyspepsia (n = 517,326), and abdominal pain (n = 890,490). The median age ranged from 54 (abdominal pain) to 63 years (dysphagia and change in bowel habit); the ratio of women/men ranged from 50%:50% (rectal bleeding) to 73%:27% (abdominal bloating/distension). Across all studied symptoms, the risk of diagnosis of cancer and the risk of diagnosis of IBD were of similar magnitude, particularly in women, and younger men. Estimated PPVs were greatest for change in bowel habit in men (4.64% cancer and 2.82% IBD) and for rectal bleeding in women (2.39% cancer and 2.57% IBD) and lowest for dyspepsia (for cancer: 1.41% men and 1.03% women; for IBD: 0.89% men and 1.00% women). Considering PPVs for specific cancers, change in bowel habit and rectal bleeding had the highest PPVs for colon and rectal cancer; dysphagia for esophageal cancer; and abdominal bloating/distension (in women) for ovarian cancer. The highest PPVs of abdominal pain (either sex) and abdominal bloating/distension (men only) were for non-abdominal cancer sites. For the composite outcome of diagnosis of either cancer or IBD, PPVs of rectal bleeding exceeded the National Institute of Health and Care Excellence (NICE)-recommended specialist referral threshold of 3% in all age–sex strata, as did PPVs of abdominal pain, change in bowel habit, and dyspepsia, in those aged 60 years and over. Study limitations include reliance on accuracy and completeness of coding of symptoms and disease outcomes.


Conclusions
Based on evidence from more than 1.9 million patients presenting in primary care, the findings provide estimated PPVs that could be used to guide specialist referral decisions, considering the PPVs of common abdominal symptoms for cancer alongside that for IBD and their composite outcome (cancer or IBD), taking into account the variable PPVs of different abdominal symptoms for different cancers sites. Jointly assessing the risk of cancer or IBD can better support decision-making and prompt diagnosis of both conditions, optimising specialist referrals or investigations, particularly in women.

OBJECTIVE: the objective of this study is to investigate primary care use by men with recent onset of lower urinary tract symptoms (LUTS) to identify differences in presentation and investigation that may explain ethnic inequality in prostate cancer outcomes. METHODS: This is a multi-method study of men presenting LUTS to primary care. Two hundred seventy-four men completed a self-administered questionnaire, and 23 participated in face-to-face interviews. Regression analyses investigated ethnic differences in (a) the period between symptom onset and first primary care presentation (patient interval) and (b) the interval between first primary care presentation and investigation with prostate-specific antigen (PSA) and digital rectal examination (DRE). Interview data were analysed using thematic analysis. RESULTS: Half (144, 53%) reported a solitary first symptom, although multiple first symptoms were also common, particularly in Asian and Black men. There was no difference between ethnicities in patient interval or time from presentation to investigation. However, Asian men were offered less PSA testing (odds ratio 0.39; 95% confidence interval 0.17-0.92; p = 0.03). Qualitative data revealed ethnic differences in general practitioners' offer of DRE and PSA testing and highlighted limitations in doctor-patient communication and safety netting. CONCLUSION: Our study showed only small differences in primary care experiences, insufficient to explain ethnic inequalities in prostate cancer outcomes.

Background: in England, patients who meet National Institute for Health and Care Excellence (NICE) guideline criteria for suspected cancer should receive a specialist assessment within 14 days. We examined how quickly bladder and kidney cancer patients who met fast-track referral criteria were actually diagnosed. Methods: We used linked primary care and cancer registration data on bladder and kidney cancer patients who met fast-track referral criteria and examined the time from their first presentation with alarm features to diagnosis. Using logistic regression we examined factors most likely to be associated with non-timely diagnosis (defined as intervals exceeding 90 days), adjusting for age, sex and cancer type, positing that such occurrences represent missed opportunity for timely referral, possibly due to sub-optimal guideline adherence. Results: 28%, 42% and 31% of all urological cancer patients reported no, one or two or more relevant symptoms respectively in the year before diagnosis. of the 2105 patients with alarm features warranting fast-track assessment, 1373 (65%) presented with unexplained haematuria, 382 (18%) with recurrent urinary tract infections (UTIs), 303 (14%) with visible haematuria, and 45 (2%) with an abdominal mass. 27% overall, and 24%, 45%, 18% and 27% of each group respectively, had a non-timely diagnosis. Presentation with recurrent UTI was associated with longest median diagnostic interval (median 83 days, IQR 43–151) and visible haematuria with the shortest (median 50 days, IQR 30–79). After adjustment, presentation with recurrent UTIs, being in the youngest or oldest age group, female sex, and diagnosis of kidney and upper tract urothelial cancer, were associated with greater odds of non-timely diagnosis. Conclusion: More than a quarter of patients presenting with fast-track referral features did not achieve a timely diagnosis, suggesting inadequate guideline adherence for some patients. The findings highlight a substantial number of opportunities for expediting the diagnosis of patients with bladder or kidney cancers.

Background: Stage at diagnosis strongly predicts cancer survival and understanding related inequalities could guide interventions. Methods: We analysed incident cases diagnosed with 10 solid tumours included in the UK government target of 75% of patients diagnosed in TNM stage I/II by 2028. We examined socio-demographic differences in diagnosis at stage III/IV vs. I/II. Multiple imputation was used for missing stage at diagnosis (9% of tumours). Results: of the 202,001 cases, 57% were diagnosed in stage I/II (an absolute 18% ‘gap’ from the 75% target). The likelihood of diagnosis at stage III/IV increased in older age, though variably by cancer site, being strongest for prostate and endometrial cancer. Increasing level of deprivation was associated with advanced stage at diagnosis for all sites except lung and renal cancer. There were, inconsistent in direction, sex inequalities for four cancers. Eliminating socio-demographic inequalities would translate to 61% of patients with the 10 studied cancers being diagnosed at stage I/II, reducing the gap from target to 14%. Conclusions: Potential elimination of socio-demographic inequalities in stage at diagnosis would make a substantial, though partial, contribution to achieving stage shift targets. Earlier diagnosis strategies should additionally focus on the whole population and not only the high-risk socio-demographic groups.

OBJECTIVE: Younger people, minority ethnic groups, sexual minorities and people of lower socioeconomic status report poorer experiences of primary care. In light of NHS ambitions to reduce unwarranted variations in care, we aimed to investigate whether inequalities in patient experience of primary care changed between 2011 and 2017, using data from the General Practice Patient Survey in England. METHODS: We considered inequalities in relation to age, sex, deprivation, ethnicity, sexual orientation and geographical region across five dimensions of patient experience: overall experience, doctor communication, nurse communication, access and continuity of care. We used linear regression to explore whether the magnitude of inequalities changed between 2011 and 2017, using mixed models to assess changes within practices and models without accounting for practice to assess national trends. RESULTS: We included 5,241,408 responses over 11 survey waves from 2011-2017. There was evidence that inequalities changed over time (p 

OBJECTIVES: to determine stage-specific time-trends in renal cancer incidence. METHODS: We used population-based East Anglia data 1999-2016 (population ∼2 million) on 5,456 primary renal cancer diagnoses, estimating stage-specific annual incidence using Poisson regression, allowing for changing time-trends, and adjusting for sex, age, and socioeconomic deprivation. RESULTS: Renal cancer incidence increased from 9.8-16.4 cases per 100,000 during 1999-2016. Incidence of Stage I, II, and III cases increased over time, most steeply for Stage I, with annual Incidence Rate Ratio [IRR] for Stage I of 1.09 (95 % CI 1.07-1.12) during 1999-2010; and 1.03 (1.00-1.05) during 2011-2016. In contrast, the annual incidence of Stage IV renal cancer decreased during most years, IRR of 0.99 (0.98-1.00) during 2003-2016. CONCLUSION: the findings are consistent with both earlier detection of symptomatic renal cancer and increasing identification of asymptomatic lesions. However, the decreasing incidence of late-stage disease suggests genuine shifts towards earlier diagnosis.

Evidence arising from primary care electronic health records can help to assess the risk of symptomatic-but-as-yet-undiagnosed cancer. Existing evidence and methodological innovations in this field of study hold further promise for improving the diagnostic process and achieving earlier diagnosis in cancer patients.

IMPORTANCE: Evidence regarding the presenting symptoms of cancer in adolescents and young adults can support the development of early diagnosis interventions. OBJECTIVE: to examine common presenting symptoms in adolescents and young adults aged 12 to 24 years who subsequently received a diagnosis of cancer and potential variation in time to help-seeking by presenting symptom. DESIGN, SETTING, AND PARTICIPANTS: This multicenter study is a cross-sectional analysis of the BRIGHTLIGHT cohort study, which was conducted across hospitals in England. Participants included adolescents and young adults aged 12 to 24 years with cancer. Information on 17 prespecified presenting symptoms and the interval between symptom onset and help-seeking (the patient interval) was collected through structured face-to-face interviews and was linked to national cancer registry data. Data analysis was performed from January 2018 to August 2019. EXPOSURES: Self-reported presenting symptoms. MAIN OUTCOMES AND MEASURES: the main outcomes were frequencies of presenting symptoms and associated symptom signatures by cancer group and the proportion of patients with each presenting symptom whose patient interval was longer than 1 month. RESULTS: the study population consisted of 803 adolescents and young adults with valid symptom information (443 male [55%]; 509 [63%] aged 19-24 years; 705 [88%] White). The number of symptoms varied by cancer group: for example, 88 patients with leukemia (86%) presented with 2 or more symptoms, whereas only 9 patients with melanoma (31%) presented with multiple symptoms. In total, 352 unique symptom combinations were reported, with the 10 most frequent combinations accounting for 304 patients (38%). Lump or swelling was reported by more than one-half the patients (419 patients [52%; 95% CI, 49%-56%]). Other common presenting symptoms across all cancers were extreme tiredness (308 patients [38%; 95% CI, 35%-42%]), unexplained pain (281 patients [35%; 95% CI, 32%-38%]), night sweats (192 patients [24%; 95% CI, 21%-27%]), lymphadenopathy (191 patients [24%; 95% CI, 21%-27%]), and weight loss (190 patients [24%; 95% CI, 21%-27%]). The relative frequencies of presenting symptoms also varied by cancer group; some symptoms (such as lump or swelling) were highly prevalent across several cancer groups (seen in >50% of patients with lymphomas, germ cell cancers, carcinomas, bone tumors, and soft-tissue sarcomas). More than 1 in 4 patients (27%) reported a patient interval longer than 1 month; this varied from 6% (1 patient) for fits and seizures to 43% (18 patients) for recurrent infections. CONCLUSIONS AND RELEVANCE: Adolescents and young adults with cancer present with a broad spectrum of symptoms, some of which are shared across cancer types. These findings point to discordant presenting symptom prevalence estimates when information is obtained from patient report vs health records and indicate the need for further symptom epidemiology research in this population.

BACKGROUND: General practices are required to provide online booking to patients in line with policy to digitise access. However, uptake of online booking by patients is currently low and there is little evidence about awareness and use by different patient groups. AIM: to examine variability in awareness and use of online appointment booking in general practice. METHOD: Secondary analysis of two questions from the GP Practice Survey data (2018) asking about awareness and use of online booking of appointments. Multivariable logistic regression was used to examine associations with age, gender, ethnicity, deprivation, the presence of a long-term condition, long-term sickness and being deaf. RESULTS: in total, 43.3% (277 278/647 064) of responders reported being aware of being able to book appointments online, while only 15% (93 671/641 073) reported doing so. There was evidence of variation by all factors considered, with strong deprivation gradients in both awareness and use (for example, most versus least deprived quintile OR for use: 0.63 (95% CI = 0.61 to 0.65). There was a reduction in awareness and use in patients >75 years of age. Patients with long-term conditions were more aware and more likely to use online booking. CONCLUSION: While over 40% of patients know that they can book appointment online, the number that actually do so is far lower. With the constant push for online services within the NHS and the roll out of the NHS app, practices should be aware that not all patient groups will book appointments online and that other routes of access need to be maintained to avoid widening health inequalities.

INTRODUCTION: the use of PROs for assessing the outcomes of emergency hospital admissions requires a means of estimating patients' pre-admission health status. A possible alternative to asking patients to recall how their health was before the incident causing admission is to use estimates derived from matched samples from population surveys. Our aims were to explore the impact of different methods of matching and to compare the results with estimates based on retrospective reporting. METHODS: First, elective hip arthroplasty patients were matched to respondents to the General Practice Patient Survey using age, sex, socio-economic status and number of comorbidities. The impact of restricting matching for locality and specific co-morbidities was explored. Second, the best matching method was applied to emergency admissions for laparotomy and for percutaneous coronary intervention (PCI) after acute myocardial infarction. Data were stratified by patient characteristics. Differences in mean EQ-5D scores between the patients and matched population respondents were tested using t tests. RESULTS: Modifying the most basic form of matching by also taking locality and the specific comorbid conditions into account made no significant difference to the mean EQ-5D score for hip arthroplasty patients. Even using the most detailed matching possible, patients' mean EQ-5D score was significantly different to that of the general population for all three cohorts. The difference was greatest for elective hip arthroplasty (0.22 v 0.64), less so for emergency laparotomy (0.56 v 0.72) and least for PCI (0.79 v 0.71). This reflects hip arthroplasty patients having a long-standing condition characterised by pain and limited mobility, whereas the other two cohorts may have enjoyed reasonable health until an unexpected acute episode led to their emergency admission. CONCLUSION: Routine PRO data acquired from population surveys cannot be used as an accurate alternative to retrospectively reported PROMs by patients during their emergency admission episode.

OBJECTIVE: to examine the concordance between dates of death recorded in UK primary care and national mortality records. METHODS: UK primary care data from the Clinical Practice Research Datalink were linked to Office for National Statistics (ONS) data, for 118 571 patients who died between September 2010 and September 2015. Logistic regression was used to examine factors associated with discrepancy in death dates between data sets. RESULTS: Death dates matched in 76.8% of cases with primary care dates preceding ONS date in 2.9%, and following in 20.3% of cases; 92.2% of cases differed by 4 weeks later than ONS in 1.5% of cases and occurred more frequently with deaths categorised as 'external' (15.8% vs 0.8% for cancer), and in younger patients (15.9% vs 1% for 18-29 and 80-89 years, respectively). General practices with the greatest discrepancies (97.5th percentile) had around 200 times higher odds of recording substantially discordant dates than practices with the lowest discrepancies (2.5th percentile). CONCLUSION: Dates of death in primary care records often disagree with national records and should be treated with caution. There is marked variation between practices, and studies involving young patients, unexplained deaths and where precise date of death is important are particularly vulnerable to these issues.

In the absence of effective ovarian cancer screening programs, most women are diagnosed following the onset of symptoms. Symptom-based tools, including symptom checklists and risk prediction models, have been developed to aid detection. The aim of this systematic review was to identify and compare the diagnostic performance of these tools. We searched MEDLINE, EMBASE and Cochrane CENTRAL, without language restriction, for relevant studies published between 1 January 2000 and 3 March 2020. We identified 1625 unique records and included 16 studies, evaluating 21 distinct tools in a range of settings. Fourteen tools included only symptoms; seven also included risk factors or blood tests. Four tools were externally validated—the Goff Symptom Index (sensitivity: 56.9–83.3%; specificity: 48.3–98.9%), a modified Goff Symptom Index (sensitivity: 71.6%; specificity: 88.5%), the Society of Gynaecologic Oncologists consensus criteria (sensitivity: 65.3–71.5%; specificity: 82.9–93.9%) and the QCancer Ovarian model (10% risk threshold—sensitivity: 64.1%; specificity: 90.1%). Study heterogeneity precluded meta-analysis. Given the moderate accuracy of several tools on external validation, they could be of use in helping to select women for ovarian cancer investigations. However, further research is needed to assess the impact of these tools on the timely detection of ovarian cancer and on patient survival.

BACKGROUND: Surveys collecting patient experience data often contain a large number of items covering a wide range of experiences. Knowing which areas to prioritize for improvements efforts can be difficult. OBJECTIVE: to examine which aspects of care experience are the key drivers of overall satisfaction with cancer care. METHODS: Secondary analysis of the National Cancer Patient Experience Survey. Logistic regression was used to examine the relationship between overall satisfaction and 10 core questions covering aspects of experience applicable to all patients. Supplementary analyses examined a further 16 questions applying only to patients in certain groups or on specific treatment pathways. RESULTS: of 68 340 included patients, 58 697 (86%) rated overall satisfaction highly (8 or more out of 10). The strongest predictors of overall satisfaction across all models were responses to 2 questions on experience of care administration and care coordination (odds ratio [OR] = 2.11, 95% confidence interval [95% CI = 2.05-2.17, P <. 0001; OR = 2.03, 95% CI = 1.97-2.09, P <. 0001, respectively, per 1 standard deviation change). CONCLUSION: Focusing improvement efforts on care administration and coordination has potential to improve overall satisfaction with oncological care across diverse patient groups/care pathways.

BACKGROUND: Early diagnosis interventions such as symptom awareness campaigns increasingly form part of global cancer control strategies. However, these strategies will have little impact in improving cancer outcomes if the targeted symptoms represent advanced stage of disease. Therefore, we aimed to examine associations between common presenting symptoms of cancer and stage at diagnosis. METHODS: in this cross-sectional study, we analysed population-level data from the English National Cancer Diagnosis Audit 2014 for patients aged 25 years and older with one of 12 types of solid tumours (bladder, breast, colon, endometrial, laryngeal, lung, melanoma, oral or oropharyngeal, ovarian, prostate, rectal, and renal cancer). We considered 20 common presenting symptoms and examined their associations with stage at diagnosis (TNM stage IV vs stage I-III) using logistic regression. For each symptom, we estimated these associations when reported as a single presenting symptom and when reported together with other symptoms. FINDINGS: We analysed data for 7997 patients. The proportion of patients diagnosed with stage IV cancer varied substantially by presenting symptom, from 1% (95% CI 1-3; eight of 584 patients) for abnormal mole to 80% (71-87; 84 of 105 patients) for neck lump. Three of the examined symptoms (neck lump, chest pain, and back pain) were consistently associated with increased odds of stage IV cancer, whether reported alone or with other symptoms, whereas the opposite was true for abnormal mole, breast lump, postmenopausal bleeding, and rectal bleeding. For 13 of the 20 symptoms (abnormal mole, breast lump, post-menopausal bleeding, rectal bleeding, lower urinary tract symptoms, haematuria, change in bowel habit, hoarseness, fatigue, abdominal pain, lower abdominal pain, weight loss, and the "any other symptom" category), more than 50% of patients were diagnosed at stages other than stage IV; for 19 of the 20 studied symptoms (all except for neck lump), more than a third of patients were diagnosed at stages other than stage IV. INTERPRETATION: Despite specific presenting symptoms being more strongly associated with advanced stage at diagnosis than others, for most symptoms, large proportions of patients are diagnosed at stages other than stage IV. These findings provide support for early diagnosis interventions targeting common cancer symptoms, countering concerns that they might be simply expediting the detection of advanced stage disease. FUNDING: UK Department of Health's Policy Research Unit in Cancer Awareness, Screening and Early Diagnosis; and Cancer Research UK.

Background: Pre-existing chronic conditions (morbidities) influence the diagnosis and management of cancer. The prevalence of specific morbidities in patients diagnosed with common and rarer cancers is inadequately described. Methods: Using data from the English National Cancer Diagnosis Audit 2014, we studied 11 pre-existing morbidities recorded as yes/no items by participating general practitioners based on information included in primary care records. We examined the number and type of morbidities across socio-demographic and cancer site strata, and subsequently estimated observed and age/sex standardised prevalence of each morbidity by cancer. Results: over three-quarters (77 %; 11,429/14,774) of non-screen-detected patients had at least one chronic condition before diagnosis, while nearly half (47 %) had two or more. Hypertension (39 %) and physical disability (2%) were the most and least common conditions. Male, older and more socio-economically deprived patients were more likely to have at least one morbidity (p < 0.001 for all between variable group comparisons). For most morbidities, the standardised prevalence was similar across different cancers with a few exceptions, including respiratory disease prevalence being greatest among lung cancer patients and diabetes prevalence being greatest among liver, pancreatic, and endometrial cancer patients. Conclusions: Most cancer patients have at least one morbidity, while almost one in two have two or more. The findings highlight the need to take certain morbidity- and cancer-site combinations into account when examining associations between morbidity and cancer outcomes.

OBJECTIVE: This study aimed to develop a risk prediction model identifying general practices at risk of workforce supply-demand imbalance. DESIGN: This is a secondary analysis of routine data on general practice workforce, patient experience and registered populations (2012 to 2016), combined with a census of general practitioners' (GPs') career intentions (2016). SETTING/PARTICIPANTS: a hybrid approach was used to develop a model to predict workforce supply-demand imbalance based on practice factors using historical data (2012-2016) on all general practices in England (with over 1000 registered patients n=6398). The model was applied to current data (2016) to explore future risk for practices in South West England (n=368). PRIMARY OUTCOME MEASURE: the primary outcome was a practice being in a state of workforce supply-demand imbalance operationally defined as being in the lowest third nationally of access scores according to the General Practice Patient Survey and the highest third nationally according to list size per full-time equivalent GP (weighted to the demographic distribution of registered patients and adjusted for deprivation). RESULTS: Based on historical data, the predictive model had fair to good discriminatory ability to predict which practices faced supply-demand imbalance (area under receiver operating characteristic curve=0.755). Predictions using current data suggested that, on average, practices at highest risk of future supply-demand imbalance are currently characterised by having larger patient lists, employing more nurses, serving more deprived and younger populations, and having considerably worse patient experience ratings when compared with other practices. Incorporating findings from a survey of GP's career intentions made little difference to predictions of future supply-demand risk status when compared with expected future workforce projections based only on routinely available data on GPs' gender and age. CONCLUSIONS: it is possible to make reasonable predictions of an individual general practice's future risk of undersupply of GP workforce with respect to its patient population. However, the predictions are inherently limited by the data available.

. Background
. The increasing difficulty experienced by general practices in meeting patient demand is leading to new approaches being tried, including greater use of telephone consulting.
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. Objectives
. To evaluate a ‘telephone first’ approach, in which all patients requesting a general practitioner (GP) appointment are asked to speak to a GP on the telephone first.
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. Methods
. The study used a controlled before-and-after (time-series) approach using national reference data sets; it also incorporated economic and qualitative elements. There was a comparison between 146 practices using the ‘telephone first’ approach and control practices in England with regard to GP Patient Survey scores and secondary care utilisation (Hospital Episode Statistics). A practice manager survey was used in the ‘telephone first’ practices. There was an analysis of practice data and the patient surveys conducted in 20 practices using the ‘telephone first’ approach. Interviews were conducted with 43 patients and 49 primary care staff. The study also included an analysis of costs.
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. Results
. Following the introduction of the ‘telephone first’ approach, the average number of face-to-face consultations in practices decreased by 38% [95% confidence interval (CI) 29% to 45%; p &lt; 0.0001], whereas there was a 12-fold increase in telephone consultations (95% CI 6.3-fold to 22.9-fold; p &lt; 0.0001). The average durations of consultations decreased, which, when combined with the increased number of consultations, we estimate led to an overall increase of 8% in the mean time spent consulting by GPs, although there was a large amount of uncertainty (95% CI –1% to 17%; p = 0.0883). These average workload figures mask wide variation between practices, with some practices experiencing a substantial reduction in workload. Comparing ‘telephone first’ practices with control practices in England in terms of scores in the national GP Patient Survey, there was an improvement of 20 percentage points in responses to the survey question on length of time to get to see or speak to a doctor or nurse. Other responses were slightly negative. The introduction of the ‘telephone first’ approach was followed by a small (2%) increase in hospital admissions; there was no initial change in accident and emergency (A&amp;E) department attendance, but there was a subsequent small (2%) decrease in the rate of increase in A&amp;E attendances. We found no evidence that the ‘telephone first’ approach would produce net reductions in secondary care costs. Patients and staff expressed a wide range of both positive and negative views in interviews.
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. Conclusions
. The ‘telephone first’ approach shows that many problems in general practice can be dealt with on the telephone. However, the approach does not suit all patients and is not a panacea for meeting demand for care, and it is unlikely to reduce secondary care costs. Future research could include identifying how telephone consulting best meets the needs of different patient groups and practices in varying circumstances and how resources can be tailored to predictable patterns of demand.
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. Limitations
. We acknowledge a number of limitations to our approach. We did not conduct a systematic review of the literature, data collected from clinical administrative records were not originally designed for research purposes and for one element of the study we had no control data. In the economic analysis, we relied on practice managers’ perceptions of staff changes attributed to the ‘telephone first’ approach. In our qualitative work and patient survey, we have some evidence that the practices that participated in that element of the study had a more positive patient experience than those that did not.
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. Funding
. The National Institute for Health Research Health Services and Delivery Research programme.
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BACKGROUND: Diagnosis of cancer through emergency presentation is associated with poorer prognosis. While reductions in emergency presentations have been described, whether known sociodemographic inequalities are changing is uncertain. METHODS: We analysed 'Routes to Diagnosis' data on patients aged ≥25 years diagnosed in England during 2006-2013 with any of 33 common or rarer cancers. Using binary logistic regression we determined time-trends in diagnosis through emergency presentation by age, deprivation and cancer site. RESULTS: Overall adjusted proportions of emergency presentations decreased during the study period (2006: 23%, 2013: 20%). Substantial baseline (2006) inequalities in emergency presentation risk by age and deprivation remained largely unchanged. There was evidence (p

BACKGROUND: Large variation in measures of diagnostic activity has been described previously between English general practices, but related predictors remain understudied. OBJECTIVE: to examine associations between general practice population and characteristics, with the use of urgent referrals for suspected cancer, and use of endoscopy. METHODS: Cross-sectional observational study of English general practices. We examined practice-level use (/1000 patients/year) of urgent referrals for suspected cancer, gastroscopy, flexible sigmoidoscopy and colonoscopy. We used mixed-effects Poisson regression to examine associations with the sociodemographic profile of practice populations and other practice attributes, including the average age, sex and country of qualification of practice doctors. RESULTS: the sociodemographic characteristics of registered patients explained much of the between-practice variance in use of urgent referrals (32%) and endoscopic investigations (18-25%), all being higher in practices with older and more socioeconomically deprived patients. Practice-level attributes explained a substantial amount of between-practice variance in urgent referral (19%) but little of the variance in endoscopy (3%-4%). Adjusted urgent referral rates were higher in training practices and those with younger GPs. Practices with mean doctor ages of 41 and 57 years (at the 10th/90th centiles of the national distribution) would have urgent referral rates of 24.1 and 19.1/1000 registered patients, P < 0.001. CONCLUSION: Most between-practice variation in use of urgent referrals and endoscopies seems to reflect health need. Some practice characteristics, such as the mean age of GPs, are associated with appreciable variation in use of urgent referrals, though these associations do not seem strong enough to justify targeted interventions.

BACKGROUND: Diagnosis of cancer as an emergency is associated with poor outcomes but has a complex aetiology. Examining determinants and time trends in diagnostic routes can help to appreciate the critical role of general practice over time in diagnostic pathways for patients with cancer. AIM: to examine sociodemographic, cancer site, and temporal associations with type of presentation among patients with cancer diagnosed as emergencies. DESIGN AND SETTING: Analysis of Routes to Diagnosis data, 2006-2015, for patients with cancer in England. METHOD: the authors estimated adjusted proportions of emergency presentation after emergency GP referral (GP-EP) or presentation to accident and emergency (AE-EP), by patient sex, age, deprivation group, and year of diagnosis using multivariable regression. RESULTS: Among 554 621 patients presenting as emergencies, 24% (n = 130 372) presented as GP-EP, 62% as AE-EP (n = 346 192), and 14% (n = 78 057) through Other-EP sub-routes. Patients presenting as emergencies were more likely to have been GP-referred if they lived in less deprived areas or were subsequently diagnosed with pancreatic, gallbladder, or ovarian cancer, or acute leukaemia. During the study period the proportion and number of GP-EPs nearly halved (31%, n = 17 364, in 2006; 17%, n = 9155 in 2015), while that of AE-EP increased (55%, n = 31 049 to 68%, n = 36 868). CONCLUSION: Patients presenting as emergencies with cancers characterised by symptoms/signs tolerable by patients but appropriately alarming to doctors (for example, pancreatic cancer manifesting as painless jaundice) are over-represented among cases whose emergency presentation involved GP referral. Reductions in diagnoses of cancer through an emergency presentation likely reflect both the continually increasing use of 2-week-wait GP referrals during the study period and reductions in emergency GP referrals.

Background: Whether diagnostic route (e.g. emergency presentation) is associated with cancer care experience independently of tumour stage is unknown. Methods: We analysed data on 18 590 patients with breast, prostate, colon, lung, and rectal cancers who responded to the 2014 English Cancer Patient Experience Survey, linked to cancer registration data on diagnostic route and tumour stage at diagnosis. We estimated odds ratios (OR) of reporting a negative experience of overall cancer care by tumour stage and diagnostic route (crude and adjusted for patient characteristic and cancer site variables) and examined their interactions with cancer site. Results: After adjustment, the likelihood of reporting a negative experience was highest for emergency presenters and lowest for screening-detected patients with breast, colon, and rectal cancers (OR versus two-week-wait 1.51, 95% confidence interval [CI] 1.24–1.83; 0.88, 95% CI 0.75–1.03, respectively). Patients with the most advanced stage were more likely to report a negative experience (OR stage IV versus I 1.37, 95% CI 1.15–1.62) with little confounding between stage and route, and no evidence for cancer-stage or cancer-route interactions. Conclusions: Though the extent of disease is strongly associated with ratings of overall cancer care, diagnostic route (particularly emergency presentation or screening detection) exerts important independent effects.

Background: Novel diagnostic triage and testing strategies to support early detection of cancer could improve clinical outcomes. Most apparently promising diagnostic tests ultimately fail because of inadequate performance in real-world, low prevalence populations such as primary care or general community populations. They should therefore be systematically evaluated before implementation to determine whether they lead to earlier detection, are cost-effective, and improve patient safety and quality of care, while minimising over-investigation and over-diagnosis. Methods: We performed a systematic scoping review of frameworks for the evaluation of tests and diagnostic approaches. Results: We identified 16 frameworks: none addressed the entire continuum from test development to impact on diagnosis and patient outcomes in the intended population, nor the way in which tests may be used for triage purposes as part of a wider diagnostic strategy. Informed by these findings, we developed a new framework, the 'CanTest Framework', which proposes five iterative research phases forming a clear translational pathway from new test development to health system implementation and evaluation. Conclusion: This framework is suitable for testing in low prevalence populations, where tests are often applied for triage testing and incorporated into a wider diagnostic strategy. It has relevance for a wide range of stakeholders including patients, policymakers, purchasers, healthcare providers and industry.

When the degree of variation between healthcare organisations or geographical regions is quantified, there is often a failure to account for the role of chance, which can lead to an overestimation of the true variation. Mixed-effects models account for the role of chance and estimate the true/underlying variation between organisations or regions. In this paper, we explore how a random intercept model can be applied to rate or proportion indicators and how to interpret the estimated variance parameter.

OBJECTIVES: to estimate the impact on hospital utilisation and costs of a multi-faceted primary care intervention for older people identified as being at risk of avoidable hospitalisation. DESIGN: Observational study: controlled time series analysis and estimation of costs and cost consequences of the Programme. General practitioner (GP)'s practice level data were analysed from 2009 to 2016 (intervention operated from 2012 to 2016). Mixed-effect Poisson regression models of hospital utilisation included comparisons with control practices and background trends in addition to within-practice comparisons. Cost estimation used standard tariff values. SETTING: 94 practices in Southwark and Lambeth and 263 control practices from other parts of England. MAIN OUTCOME MEASURES: Hospital utilisation: emergency department attendance, emergency admissions, emergency admissions for ambulatory sensitive conditions, outpatient attendance, elective admission and length of stay. RESULTS: By the fourth year of the Programme, there were reductions in accident and emergency (A&E) attendance (rate ratio 0.944, 95% CI 0.913 to 0.976), outpatient attendances (rate ratio 0.938, 95% CI 0.902 to 0.975) and elective admissions (rate ratio 0.921, 95% CI 0.908 to 0.935) but there was no evidence of reduced emergency admissions. The costs of the Programme were £149 per resident aged 65 and above but savings in hospital costs were only £86 per resident aged 65 and above, equivalent to a net increase in health service expenditure of £64 per resident though the Programme was nearly cost neutral if set-up costs were excluded. Holistic assessments carried out by GPs and consequent Integrated Care Management (ICM) plans were associated with increases in elective activity and costs; £126 increase in outpatient attendance and £936 in elective admission costs per holistic assessment carried out, and £576 increase in outpatient and £5858 in elective admission costs per patient receiving ICM. CONCLUSIONS: the Older People's Programme was not cost saving. Some aspects of the Programme were associated with increased costs of elective care, possibly through the identification of unmet need.

BackgroundUK general practice faces a workforce crisis, with general practitioner (GP) shortages, organisational change, substantial pressures across the whole health-care system and an ageing population with increasingly complex health needs. GPs require lengthy training, so retaining the existing workforce is urgent and important.Objectives(1) to identify the key policies and strategies that might (i) facilitate the retention of experienced GPs in direct patient care or (ii) support the return of GPs following a career break. (2) to consider the feasibility of potentially implementing those policies and strategies.DesignThis was a comprehensive, mixed-methods study.SettingThis study took place in primary care in England.ParticipantsGeneral practitioners registered in south-west England were surveyed. Interviews were with purposively selected GPs and primary care stakeholders. A RAND/UCLA Appropriateness Method (RAM) panel comprised GP partners and GPs working in national stakeholder organisations. Stakeholder consultations included representatives from regional and national groups.Main outcome measuresSystematic review – factors affecting GPs’ decisions to quit and to take career breaks. Survey – proportion of GPs likely to quit, to take career breaks or to reduce hours spent in patient care within 5 years of being surveyed. Interviews – themes relating to GPs’ decision-making. RAM – a set of policies and strategies to support retention, assessed as ‘appropriate’ and ‘feasible’. Predictive risk modelling – predictive model to identify practices in south-west England at risk of workforce undersupply within 5 years. Stakeholder consultation – comments and key actions regarding implementing emergent policies and strategies from the research.ResultsPast research identified four job-related ‘push’ factors associated with leaving general practice: (1) workload, (2) job dissatisfaction, (3) work-related stress and (4) work–life balance. The survey, returned by 2248 out of 3370 GPs (67%) in the south-west of England, identified a high likelihood of quitting (37%), taking a career break (36%) or reducing hours (57%) within 5 years. Interviews highlighted three drivers of leaving general practice: (1) professional identity and value of the GP role, (2) fear and risk associated with service delivery and (3) career choices. The RAM panel deemed 24 out of 54 retention policies and strategies to be ‘appropriate’, with most also considered ‘feasible’, including identification of and targeted support for practices ‘at risk’ of workforce undersupply and the provision of formal career options for GPs wishing to undertake portfolio roles. Practices at highest risk of workforce undersupply within 5 years are those that have larger patient list sizes, employ more nurses, serve more deprived and younger populations, or have poor patient experience ratings. Actions for national organisations with an interest in workforce planning were identified. These included collection of data on the current scope of GPs’ portfolio roles, and the need for formal career pathways for key primary care professionals, such as practice managers.LimitationsThe survey, qualitative research and modelling were conducted in one UK region. The research took place within a rapidly changing policy environment, providing a challenge in informing emergent policy and practice.ConclusionsThis research identifies the basis for current concerns regarding UK GP workforce capacity, drawing on experiences in south-west England. Policies and strategies identified by expert stakeholders after considering these findings are likely to be of relevance in addressing GP retention in the UK. Collaborative, multidisciplinary research partnerships should investigate the effects of rolling out some of the policies and strategies described in this report.Study registrationThis study is registered as PROSPERO CRD42016033876 and UKCRN ID number 20700.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Background: Diagnosis of cancer through an emergency presentation is associated with worse clinical and patient experience outcomes. The proportion of patients with cancer who are diagnosed through emergency presentations has consequently been introduced as a routine cancer surveillance measure in England. Welcome reductions in this metric have been reported over more than a decade but whether reductions reflect true changes in how patients are diagnosed rather than the changing case-mix of incident cohorts in unknown. Methods: We analysed ‘Routes to Diagnosis’ data on cancer patients (2006–2015) and used logistic regression modelling to determine the contribution of changes in four case-mix variables (sex, age, deprivation, cancer site) to time-trends in emergency presentations. Results: Between 2006 and 2015 there was an absolute 4.7 percentage point reduction in emergency presentations (23.8%–19.2%). Changing distributions of the four case-mix variables explained 19.0% of this reduction, leaving 81.0% unexplained. Changes in cancer site case-mix alone explained 16.0% of the total reduction. Conclusion: Changes in case-mix (particularly that of cancer sites) account for about a fifth of the overall reduction in emergency presentations. This would support the use of adjustment/standardisation of reported statistics to support their interpretation and help appreciate the influence of case-mix, particularly regarding cancer sites with changing incidence. However, most of the reduction in emergency presentations remains unaccounted for, and likely reflects genuine changes during the study period in how patients were being diagnosed.

OBJECTIVES: to assess the degree to which variations in publicly reported hospital scores arising from the English Cancer Patient Experience Survey (CPES) are subject to chance. DESIGN: Secondary analysis of publically reported data. SETTING: English National Health Service hospitals. PARTICIPANTS: 72 756 patients who were recently treated for cancer in one of 146 hospitals and responded to the 2016 English CPES. MAIN OUTCOME MEASURES: Spearman-Brown reliability of hospital scores on 51 evaluative questions regarding cancer care. RESULTS: Hospitals varied in respondent sample size with a median hospital sample size of 419 responses (range 31-1972). There were some hospitals with generally highly reliable scores across most questions, whereas other hospitals had generally unreliable scores (the median reliability of question scores within individual hospitals varied between 0.11 and 0.86). Similarly, there were some questions with generally high reliability across most hospitals, whereas other questions had generally low reliability. of the 7377 individual hospital scores publically reported (146 hospitals by 51 questions, minus 69 suppressed scores), only 34% reached a reliability of 0.7, the minimum generally considered to be useful. In order for 80% of the individual hospital scores to reach a reliability of 0.7, some hospitals would require a fourfold increase in number of respondents; although in a few other hospitals sample sizes could be reduced. CONCLUSIONS: the English Patient Experience Survey represents a globally unique source for understanding experience of a patient with cancer; but in its present form, it is not reliable for high stakes comparisons of the performance of different hospitals. Revised sampling strategies and survey questions could help increase the reliability of hospital scores, and thus make the survey fit for use in performance comparisons.

BACKGROUND: statistics comparing the stage at diagnosis of geographically defined populations of cancer patients are increasingly used in public reporting to monitor geographical inequalities but may be confounded by patient case mix. We explore the impact of case-mix adjustment on a publicly reported measure of early stage at diagnosis in England. METHODS: We analyzed data used for publicly reported statistics about the stage of patients diagnosed with 1 of 11 solid tumours in 2015 in England, including information on cancer site (bladder, breast, colon, rectum, kidney, lung, melanoma, non-Hodgkin lymphoma, ovarian, prostate, endometrial), age, gender, income deprivation and population-based commissioning organization. We investigated how cancer site and other patient characteristics influence organizational comparisons and attainment of early-stage targets (≥60% of all cases diagnosed in TNM stages I-II). RESULTS: Adjusting for patient case mix reduced between-organization variance by more than 50%, resulting in appreciable discordance in organizational ranks (Kendall's tau = 0.53), with 18% (37/207) of organizations being reclassified as meeting/failing the early-stage target due to case mix. CONCLUSION: Summary statistics on stage of cancer diagnosis for geographical populations currently used as public health surveillance tools to monitor organizational inequalities need to account for patient sociodemographic characteristics and cancer site case mix.

BACKGROUND: Lower use of endoscopies and urgent referrals for suspected cancer has been linked to poorer outcomes for patients with cancer; it is important to examine potential predictors of variable use. AIM: to examine the associations between general practice measures of patient experience and practice use of endoscopies or urgent referrals for suspected cancer. DESIGN AND SETTING: Cross-sectional ecological analysis in English general practices. METHOD: Data were taken from the GP Patient Survey and the Cancer Services Public Health Profiles. After adjustment for practice population characteristics, practice-level associations were examined between the use of endoscopy and urgent referrals for suspected cancer, and the ability to book an appointment (used as proxy for ease of access), the ability to see a preferred doctor (used as proxy for relational continuity), and doctor/nurse communication skills. RESULTS: Taking into account practice scores for the ability to book an appointment, practices rated higher for the proxy measure of relational continuity used urgent referrals and endoscopies less often (for example, 30% lower urgent referral and 15% lower gastroscopy rates between practices in the 90th/10th centiles, respectively). In contrast, practices rated higher for doctor communication skills used urgent referrals and endoscopies more often (for example, 26% higher urgent referral and 17% higher gastroscopy rates between practices in the 90th/10th centiles, respectively). Patients with cancer in practices that were rated higher for doctor communication skills were less likely to be diagnosed as emergencies (1.7% lower between practices in the 90th than in the 10th centile). CONCLUSION: Practices where patients rated doctor communication highly were more likely to investigate and refer patients urgently but, in contrast, practices where patients could see their preferred doctor more readily were less likely to do so. This article discusses the possible implications of these findings for clinical practice.

OBJECTIVE: to examine how different pathways to diagnosis of colorectal cancer may be associated with the experience of subsequent care. DESIGN: Patient survey linked to information on diagnostic route.English patients with colorectal cancer (analysis sample n=6837) who responded to a patient survey soon after their hospital treatment. MAIN OUTCOME MEASURES: Odds Ratios and adjusted proportions of negative evaluation of key aspects of care for colorectal cancer, including the experience of shared decision-making about treatment, specialist nursing and care coordination, by diagnostic route (ie, screening detection, emergency presentation, urgent and elective general practitioner referral). RESULTS: for 14 of 18 questions, there was evidence (p≤0.02) for variation in patient experience by diagnostic route, with 6-31 percentage point differences between routes in adjusted proportions of negative experience. Emergency presenters were more likely to report a negative experience for most questions, including those about adequacy of information about their diagnosis and sufficient explanation before operations. Screen-detected patients were least likely to report negative experiences except for support from primary care. Patients diagnosed through elective primary care referrals were most likely to report worse experience for questions for which overall variation by route was generally small. CONCLUSIONS: Screening-detected patients tend to report the best and emergency presenters the worst experience of subsequent care. Improvement efforts can target care integration for screening-detected patients and provision of information about the diagnosis and treatment of emergency presenters.

BACKGROUND: Continual improvements in diagnostic processes are needed to minimise the proportion of patients with cancer who experience diagnostic delays. Clinical audit is a means of achieving this. AIM: to characterise key aspects of the diagnostic process for cancer and to generate baseline measures for future re-audit. DESIGN AND SETTING: Clinical audit of cancer diagnosis in general practices in England. METHOD: Information on patient and tumour characteristics held in the English National Cancer Registry was supplemented by information from GPs in participating practices. Data items included diagnostic timepoints, patient characteristics, and clinical management. RESULTS: Data were collected on 17 042 patients with a new diagnosis of cancer during 2014 from 439 practices. Participating practices were similar to non-participating ones, particularly regarding population age, urban/rural location, and practice-based patient experience measures. The median diagnostic interval for all patients was 40 days (interquartile range [IQR] 15-86 days). Most patients were referred promptly (median primary care interval 5 days [IQR 0-27 days]). Where GPs deemed diagnostic delays to have occurred (22% of cases), patient, clinician, or system factors were responsible in 26%, 28%, and 34% of instances, respectively. Safety netting was recorded for 44% of patients. At least one primary care-led investigation was carried out for 45% of patients. Most patients (76%) had at least one existing comorbid condition; 21% had three or more. CONCLUSION: the findings identify avenues for quality improvement activity and provide a baseline for future audit of the impact of 2015 National Institute for Health and Care Excellence guidance on management and referral of suspected cancer.

Background the percentage of cancer patients diagnosed at an early stage is reported publicly for geographically-defined populations corresponding to healthcare commissioning organisations in England, and linked to pay-for-performance targets. Given that stage is incompletely recorded, we investigated the extent to which this indicator reflects underlying organisational differences rather than differences in stage completeness and chance variation. Methods We used population-based data on patients diagnosed with one of ten cancer sites in 2013 (bladder, breast, colorectal, endometrial, lung, ovarian, prostate, renal, NHL, and melanoma). We assessed the degree of bias in CCG (Clinical Commissioning Group) indicators introduced by missing-is-late and complete-case specifications compared with an imputed ‘gold standard’. We estimated the Spearman-Brown (organisation-level) reliability of the complete-case specification. We assessed probable misclassification rates against current pay-for-performance targets. Results Under the missing-is-late approach, bias in estimated CCG percentage of tumours diagnosed at an early stage ranged from −2 to −30 percentage points, while bias under the complete-case approach ranged from −2 to +7 percentage points. Using an annual reporting period, indicators based on the least biased complete-case approach would have poor reliability, misclassifying 27/209 (13%) CCGs against a pay-for-performance target in current use; only half (53%) of CCGs apparently exceeding the target would be correctly classified in terms of their underlying performance. Conclusions Current public reporting schemes for cancer stage at diagnosis in England should use a complete-case specification (i.e. the number of staged cases forming the denominator) and be based on three-year reporting periods. Early stage indicators for the studied geographies should not be used in pay-for-performance schemes.

Patient evaluations of physician communication are widely used, but we know little about how these relate to professionally agreed norms of communication quality. We report an investigation into the association between patient assessments of communication quality and an observer-rated measure of communication competence. Consent was obtained to video record consultations with Family Practitioners in England, following which patients rated the physician's communication skills. A sample of consultation videos was subsequently evaluated by trained clinical raters using an instrument derived from the Calgary-Cambridge guide to the medical interview. Consultations scored highly for communication by clinical raters were also scored highly by patients. However, when clinical raters judged communication to be of lower quality, patient scores ranged from "poor" to "very good." Some patients may be inhibited from rating poor communication negatively. Patient evaluations can be useful for measuring relative performance of physicians' communication skills, but absolute scores should be interpreted with caution.

The aim of this study was to examine temporal trends in overall and stage-specific incidence of melanoma. Using population-based data on patients diagnosed with melanoma in East Anglia, England, 1996-2015, we estimated age-standardized time trends in annual incidence rates for each stage at diagnosis. Negative binomial regression was used to model trends over time adjusted for sex, age group and deprivation, and to subsequently examine variation in stage-specific trends by sex and age group. The age-standardized incidence increased from 14 to 29 cases/100 000 persons (i.e. 4% annually). Increasing incidence was apparent across all stages but was steepest for stage I [adjusted annual increase: 5%, 95% confidence interval (CI): 5-6%, and more gradual for stage II-IV disease (stage II: 3%, 95% CI: 2-4%; stage III/IV: 2%, 95% CI: 1-3%)]. Stage II-IV increase was apparent in men across age groups and in women aged 50 years or older. Increases in incidence were steeper in those aged 70 years or older, and in men. The findings suggest that both a genuine increase in the incidence of consequential illness and a degree of overdiagnosis may be responsible for the observed increasing incidence trends in melanoma in our population during the study period. They also suggest the potentially lower effectiveness of public health awareness campaigns in men and older people.This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/4.0/.

PURPOSE: to examine how family physicians', patients', and trained clinical raters' assessments of physician-patient communication compare by analysis of individual appointments. METHODS: Analysis of survey data from patients attending face-to-face appointments with 45 family physicians at 13 practices in England. Immediately post-appointment, patients and physicians independently completed a questionnaire including 7 items assessing communication quality. A sample of videotaped appointments was assessed by trained clinical raters, using the same 7 communication items. Patient, physician, and rater communication scores were compared using correlation coefficients. RESULTS: Included were 503 physician-patient pairs; of those, 55 appointments were also evaluated by trained clinical raters. Physicians scored themselves, on average, lower than patients (mean physician score 74.5; mean patient score 94.4); 63.4% (319) of patient-reported scores were the maximum of 100. The mean of rater scores from 55 appointments was 57.3. There was a near-zero correlation coefficient between physician-reported and patient-reported communication scores (0.009, P =. 854), and between physician-reported and trained rater-reported communication scores (-0.006, P =. 69). There was a moderate and statistically significant association, however, between patient and trained-rater scores (0.35, P =. 042). CONCLUSIONS: the lack of correlation between physician scores and those of others indicates that physicians' perceptions of good communication during their appointments may differ from those of external peer raters and patients. Physicians may not be aware of how patients experience their communication practices; peer assessment of communication skills is an important approach in identifying areas for improvement.

BACKGROUND: Raising awareness of possible cancer symptoms is important for timely help-seeking; recent campaigns have focused on symptom groups (such as abdominal symptoms) rather than individual alarm symptoms associated with particular cancer sites. The evidence base supporting such initiatives is still emerging however; understanding the frequency and nature of presenting abdominal symptoms among cancer patients could inform the design and evaluation of public health awareness campaigns. METHODS: We examined eight presenting abdominal symptoms (abdominal pain, change in bowel habit, bloating/distension, dyspepsia, rectal bleeding, dysphagia, reflux and nausea/vomiting) among 15 956 patients subsequently diagnosed with cancer in England. We investigated the cancer site case-mix and variation in the patient interval (symptom-onset-to-presentation) by abdominal symptom. RESULTS: Almost a quarter (23%) of cancer patients presented with abdominal symptoms before being diagnosed with one of 27 common and rarer cancers. The patient interval varied substantially by abdominal symptom: median (IQR) intervals ranged from 7 (0-28) days for abdominal pain to 30 (4-73) days for dysphagia. This variation persisted after adjusting for age, sex and ethnicity (P < 0.001). CONCLUSIONS: Abdominal symptoms are common at presentation among cancer patients, while time to presentation varies by symptom. The need for awareness campaigns may be greater for symptoms associated with longer intervals to help-seeking.

OBJECTIVES: Recent public reporting initiatives in England highlight general practice variation in indicators of diagnostic activity related to cancer. We aimed to quantify the size and sources of variation and the reliability of practice-level estimates of such indicators, to better inform how this information is interpreted and used for quality improvement purposes. DESIGN: Ecological cross-sectional study. SETTING: English primary care. PARTICIPANTS: all general practices in England with at least 1000 patients. MAIN OUTCOME MEASURES: Sixteen diagnostic activity indicators from the Cancer Services Public Health Profiles. RESULTS: Mixed-effects logistic and Poisson regression showed that substantial proportions of the observed variance in practice scores reflected chance, variably so for different indicators (between 7% and 85%). However, after accounting for the role of chance, there remained substantial variation between practices (typically up to twofold variation between the 75th and 25th centiles of practice scores, and up to fourfold variation between the 90th and 10th centiles). The age and sex profile of practice populations explained some of this variation, by different amounts across indicators. Generally, the reliability of diagnostic process indicators relating to broader populations of patients most of whom do not have cancer (eg, rate of endoscopic investigations, or urgent referrals for suspected cancer (also known as 'two week wait referrals')) was high (≥0.80) or very high (≥0.90). In contrast, the reliability of diagnostic outcome indicators relating to incident cancer cases (eg, per cent of all cancer cases detected after an emergency presentation) ranged from 0.24 to 0.54, which is well below recommended thresholds (≥0.70). CONCLUSIONS: Use of indicators of diagnostic activity in individual general practices should principally focus on process indicators which have adequate or high reliability and not outcome indicators which are unreliable at practice level.

BACKGROUND: in England, 'fast-track' (also known as 'two-week wait') general practitioner referrals for suspected cancer in symptomatic patients are used to shorten diagnostic intervals and are supported by clinical guidelines. However, the use of the fast-track pathway may vary for different patient groups. METHODS: We examined data from 669 220 patients with 35 cancers diagnosed in 2006-2010 following either fast-track or 'routine' primary-to-secondary care referrals using 'Routes to Diagnosis' data. We estimated the proportion of fast-track referrals by sociodemographic characteristic and cancer site and used logistic regression to estimate respective crude and adjusted odds ratios. We additionally explored whether sociodemographic associations varied by cancer. RESULTS: There were large variations in the odds of fast-track referral by cancer (P

© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted. Objectives to examine patient consultation preferences for seeing or speaking to a general practitioner (GP) or nurse; to estimate associations between patient-reported experiences and the type of consultation patients actually received (phone or face-to-face, GP or nurse). Design Secondary analysis of data from the 2013 to 2014 General Practice Patient Survey. Setting and participants 870 085 patients from 8005 English general practices. Outcomes Patient ratings of communication and 'trust and confidence' with the clinician they saw. Results 77.7% of patients reported wanting to see or speak to a GP, while 14.5% reported asking to see or speak to a nurse the last time they tried to make an appointment (weighted percentages). Being unable to see or speak to the practitioner type of the patients' choice was associated with lower ratings of trust and confidence and patient-rated communication. Smaller differences were found if patients wanted a face-to-face consultation and received a phone consultation instead. The greatest difference was for patients who asked to see a GP and instead spoke to a nurse for whom the adjusted mean difference in confidence and trust compared with those who wanted to see a nurse and did see a nurse was 15.8 points (95% CI -17.6 to -14.0) for confidence and trust in the practitioner and -10.5 points (95% CI -11.7 to -9.3) for net communication score, both on a 0-100 scale. Conclusions Patients' evaluation of their care is worse if they do not receive the type of consultation they expect, especially if they prefer a doctor but are unable to see one. New models of care should consider the potential unintended consequences for patient experience of the widespread introduction of multidisciplinary teams in general practice.

Purpose to address gaps in evidence on the risk of cancer in people from sexual minorities. Patients and Methods We used data from 796,594 population-based English General Practice Patient Survey responders to explore the prevalence of self-reported diagnoses of cancer in the last 5 years among sexual minorities compared with heterosexual women and men. We analyzed data from 249,010 hospital-based English Cancer Patient Experience Survey responders with sexual orientation as a binary outcome, and International Classification of Diseases, Tenth, Revision, diagnosis as covariate-38 different common and rarer cancers, with breast and prostate cancer as baseline categories for women and men, respectively-to examine whether people from sexual minorities are over- or under-represented among different cancer sites. For both analyses, we used logistic regression, stratified by sex and adjusted for age. Results a diagnosis of cancer in the past 5 years was more commonly reported by male General Practice Patient Survey responders who endorsed gay or bisexual orientation compared with heterosexual men (odds ratio [OR], 1.31; 95% CI, 1.15 to 1.49; P <. 001) without evidence of a difference between lesbian or bisexual compared with heterosexual women (OR, 1.14; 95% CI, 0.94 to 1.37; P =. 19). For most common and rarer cancer sites (30 of 33 in women, 28 of 32 in men), the odds of specific cancer site diagnosis among Cancer Patient Experience Survey respondents seemed to be independent of sexual orientation; however, there were notable differences in infection-related (HIV and human papillomavirus [HPV]) cancers. Gay or bisexual men were over-represented among men with Kaposi's sarcoma (OR, 48.2; 95% CI, 22.0 to 105.6), anal (OR, 15.5; 95% CI, 11.0 to 21.9), and penile cancer (OR, 1.8; 95% CI, 0.9 to 3.7). Lesbian or bisexual women were over-represented among women with oropharyngeal cancer (OR, 3.2; 95% CI, 1.7 to 6.0). Conclusion Large-scale evidence indicates that the distribution of cancer sites does not vary substantially by sexual orientation, with the exception of some HPV- and HIV-associated cancers. These findings highlight the importance of HPV vaccination in heterosexual and sexual minority populations.

Many patients with cancer are diagnosed through an emergency presentation, which is associated with inferior clinical and patient-reported outcomes compared with those of patients who are diagnosed electively or through screening. Reducing the proportion of patients with cancer who are diagnosed as emergencies is, therefore, desirable; however, the optimal means of achieving this aim are uncertain owing to the involvement of different tumour, patient and health-care factors, often in combination. Most relevant evidence relates to patients with colorectal or lung cancer in a few economically developed countries, and defines emergency presentations contextually (that is, whether patients presented to emergency health-care services and/or received emergency treatment shortly before their diagnosis) as opposed to clinically (whether patients presented with life-threatening manifestations of their cancer). Consistent inequalities in the risk of emergency presentations by patient characteristics and cancer type have been described, but limited evidence is available on whether, and how, such presentations can be prevented. Evidence on patients' symptoms and health-care use before presentation as an emergency is sparse. In this Review, we describe the extent, causes and implications of a diagnosis of cancer following an emergency presentation, and provide recommendations for public health and health-care interventions, and research efforts aimed at addressing this under-researched aspect of cancer diagnosis.

BACKGROUND: Emergency diagnosis of cancer is common and aetiologically complex. The proportion of emergency presenters who have consulted previously with relevant symptoms is uncertain. AIM: to examine how many patients with cancer, who were diagnosed as emergencies, have had previous primary care consultations with relevant symptoms; and among those, to examine how many had multiple consultations. DESIGN AND SETTING: Secondary analysis of patient survey data from the 2010 English Cancer Patient Experience Survey (CPES), previously linked to population-based data on diagnostic route. METHOD: for emergency presenters with 18 different cancers, associations were examined for two outcomes (prior GP consultation status; and 'three or more consultations' among prior consultees) using logistic regression. RESULTS: Among 4647 emergency presenters, 1349 (29%) reported no prior consultations, being more common in males (32% versus 25% in females, P

Objective To evaluate a "telephone first" approach, in which all patients wanting to see a general practitioner (GP) are asked to speak to a GP on the phone before being given an appointment for a face to face consultation.Design Time series and cross sectional analysis of routine healthcare data, data from national surveys, and primary survey data.Participants 147 general practices adopting the telephone first approach compared with a 10% random sample of other practices in England.Intervention Management support for workload planning and introduction of the telephone first approach provided by two commercial companies.Main outcome measures Number of consultations, total time consulting (59 telephone first practices, no controls). Patient experience (GP Patient Survey, telephone first practices plus controls). Use and costs of secondary care (hospital episode statistics, telephone first practices plus controls). The main analysis was intention to treat, with sensitivity analyses restricted to practices thought to be closely following the companies' protocols.Results After the introduction of the telephone first approach, face to face consultations decreased considerably (adjusted change within practices -38%, 95% confidence interval -45% to -29%; P

BACKGROUND: Melanoma incidence is rising rapidly worldwide among white populations. Defining higher-risk populations using risk prediction models may help targeted screening and early detection approaches. OBJECTIVES: to assess the feasibility of identifying people at higher risk of melanoma using the Williams self-assessed clinical risk estimation model in U.K. primary care. METHODS: We recruited participants from the waiting rooms of 22 general practices covering a total population of > 240 000 in three U.K. regions: Eastern England, North East Scotland and North Wales. Participants completed an electronic questionnaire using tablet computers. The main outcome was the mean melanoma risk score using the Williams melanoma risk model. RESULTS: of 9004 people approached, 7742 (86%) completed the electronic questionnaire. The mean melanoma risk score for the 7566 eligible participants was 17·15 ± 8·51, with small regional differences [lower in England compared with Scotland (P = 0·001) and Wales (P < 0·001), mainly due to greater freckling and childhood sunburn among Scottish and Welsh participants]. After weighting to the age and sex distribution, different potential cut-offs would allow between 4% and 20% of the population to be identified as higher risk, and those groups would contain 30% and 60%, respectively of those likely to develop melanoma. CONCLUSIONS: Collecting data on the melanoma risk profile of the general population in U.K. primary care is both feasible and acceptable for patients in a general practice setting, and provides opportunities for new methods of real-time risk assessment and risk stratified cancer interventions.

BackgroundThere has been an increased focus towards improving quality of care within the NHS in the last 15 years; as part of this, there has been an emphasis on the importance of patient feedback within policy, through National Service Frameworks and the Quality and Outcomes Framework. The development and administration of large-scale national patient surveys to gather representative data on patient experience, such as the national GP Patient Survey in primary care, has been one such initiative. However, it remains unclear how the survey is used by patients and what impact the data may have on practice.ObjectivesOur research aimed to gain insight into how different patients use surveys to record experiences of general practice; how primary care staff respond to feedback; and how to engage primary care staff in responding to feedback.MethodsWe used methods including quantitative survey analyses, focus groups, interviews, an exploratory trial and an experimental vignette study.Results(1)Understanding patient experience data. Patients readily criticised their care when reviewing consultations on video, although they were reluctant to be critical when completing questionnaires. When trained raters judged communication during a consultation to be poor, a substantial proportion of patients rated the doctor as ‘good’ or ‘very good’. Absolute scores on questionnaire surveys should be treated with caution; they may present an overoptimistic view of general practitioner (GP) care. However, relative rankings to identify GPs who are better or poorer at communicating may be acceptable, as long as statistically reliable figures are obtained. Most patients have a particular GP whom they prefer to see; however, up to 40% of people who have such a preference are unable regularly to see the doctor of their choice. Users of out-of-hours care reported worse experiences when the service was run by a commercial provider than when it was run by a not-for profit or NHS provider. (2)Understanding patient experience in minority ethnic groups. Asian respondents to the GP Patient Survey tend to be registered with practices with generally low scores, explaining about half of the difference in the poorer reported experiences of South Asian patients than white British patients. We found no evidence that South Asian patients used response scales differently. When viewing the same consultation in an experimental vignette study, South Asian respondents gave higher scores than white British respondents. This suggests that the low scores given by South Asian respondents in patient experience surveys reflect care that is genuinely worse than that experienced by their white British counterparts. We also found that service users of mixed or Asian ethnicity reported lower scores than white respondents when rating out-of-hours services. (3)Using patient experience data. We found that measuring GP–patient communication at practice level masks variation between how good individual doctors are within a practice. In general practices and in out-of-hours centres, staff were sceptical about the value of patient surveys and their ability to support service reconfiguration and quality improvement. In both settings, surveys were deemed necessary but not sufficient. Staff expressed a preference for free-text comments, as these provided more tangible, actionable data. An exploratory trial of real-time feedback (RTF) found that only 2.5% of consulting patients left feedback using touch screens in the waiting room, although more did so when reminded by staff. The representativeness of responding patients remains to be evaluated. Staff were broadly positive about using RTF, and practices valued the ability to include their own questions. Staff benefited from having a facilitated session and protected time to discuss patient feedback.ConclusionsOur findings demonstrate the importance of patient experience feedback as a means of informing NHS care, and confirm that surveys are a valuable resource for monitoring national trends in quality of care. However, surveys may be insufficient in themselves to fully capture patient feedback, and in practice GPs rarely used the results of surveys for quality improvement. The impact of patient surveys appears to be limited and effort should be invested in making the results of surveys more meaningful to practice staff. There were several limitations of this programme of research. Practice recruitment for our in-hours studies took place in two broad geographical areas, which may not be fully representative of practices nationally. Our focus was on patient experience in primary care; secondary care settings may face different challenges in implementing quality improvement initiatives driven by patient feedback. Recommendations for future research include consideration of alternative feedback methods to better support patients to identify poor care; investigation into the factors driving poorer experiences of communication in South Asian patient groups; further investigation of how best to deliver patient feedback to clinicians to engage them and to foster quality improvement; and further research to support the development and implementation of interventions aiming to improve care when deficiencies in patient experience of care are identified.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.

Objective: to examine concordance between responses to patient experience survey items evaluating doctors' interpersonal skills, and subsequent patient interview accounts of their experiences of care. Design: Mixed methods study integrating data from patient questionnaires completed immediately after a video-recorded face-to-face consultation with a general practitioner (GP) and subsequent interviews with the same patients which included playback of the recording. Setting: 12 general practices in rural, urban and inner city locations in six areas in England. Participants: 50 patients (66% female, aged 19-96 years) consulting face-to-face with 32 participating GPs. Main outcome measures: Positive responses to interpersonal skills items in a postconsultation questionnaire ('good' and 'very good') were compared with experiences reported during subsequent video elicitation interview (categorised as positive, negative or neutral by independent clinical raters) when reviewing that aspect of care. Results: We extracted 230 textual statements from 50 interview transcripts which related to the evaluation of GPs' interpersonal skills. Raters classified 70.9% (n=163) of these statements as positive, 19.6% (n=45) neutral and 9.6% (n=22) negative. Comments made by individual patients during interviews did not always express the same sentiment as their responses to the questionnaire. Where questionnaire responses indicated that interpersonal skills were 'very good', 84.6% of interview statements concerning that item were classified as positive. However, where patients rated interpersonal skills as 'good', only 41.9% of interview statements were classified as positive, and 18.9% as negative. Conclusions: Positive responses on patient experience questionnaires can mask important negative experiences which patients describe in subsequent interviews. The interpretation of absolute patient experience scores in feedback and public reporting should be done with caution, and clinicians should not be complacent following receipt of 'good' feedback. Relative scores are more easily interpretable when used to compare the performance of providers.

OBJECTIVE: Given recent concerns regarding general practitioner (GP) workforce capacity, we aimed to describe GPs' career intentions, especially those which might impact on GP workforce availability over the next 5 years. DESIGN: Census survey, conducted between April and June 2016 using postal and online responses , of all GPs on the National Health Service performers list and eligible to practise in primary care. Two reminders were used as necessary. SETTING: South West England (population 3.5  million), a region with low overall socioeconomic deprivation. PARTICIPANTS: Eligible GPs were 2248 out of 3370 (67 % response rate). MAIN OUTCOME MEASURES: Reported likelihood of permanently leaving or reducing hours spent in direct patient care or of taking a career break within the next 5 years and present morale weighted for non-response. RESULTS: Responders included 217 7 GPs engaged in patient care. of these, 863 (37% weighted, 95%  CI 35 % to 39 %) reported a high likelihood of quitting direct patient care within the next 5 years. Overall, 1535 (70% weighted, 95%  CI 68 % to 72 %) respondents reported a career intention that would negatively impact GP workforce capacity over the next 5 years, through permanently leaving or reducing hours spent in direct patient care, or through taking a career break. GP age was an important predictor of career intentions; sharp increases in the proportion of GPs intending to quit patient care were evident from 52 years. Only 305 (14% weighted, 95%  CI 13 % to 16 %) reported high morale, while 1195 ( 54 % weighted, 95%  CI 52 % to 56 %) reported low morale. Low morale was particularly common among GP partners. Current morale strongly predicted GPs' career intentions; those with very low morale were particularly likely to report intentions to quit patient care or to take a career break. CONCLUSIONS: a substantial majority of GPs in South West England report low morale. Many are considering career intentions which, if implemented, would adversely impact GP workforce capacity within a short time period. STUDY REGISTRATION: NIHR HS&DR - 14/196/02, UKCRN ID 20700.

INTRODUCTION: Most symptomatic women with breast cancer have relatively short diagnostic intervals but a substantial minority experience prolonged journeys to diagnosis. Atypical presentations (with symptoms other than breast lump) may be responsible. METHODS: We examined the presenting symptoms of breast cancer in women using data from a national audit initiative (n=2316). Symptoms were categorised topographically. We investigated variation in the length of the patient interval (time from symptom onset to presentation) and the primary care interval (time from presentation to specialist referral) across symptom groups using descriptive analyses and quantile regression. RESULTS: a total of 56 presenting symptoms were described: breast lump was the most frequent (83%) followed by non-lump breast symptoms, (e.g. nipple abnormalities (7%) and breast pain (6%)); and non-breast symptoms (e.g. back pain (1%) and weight loss (0.3%)). Greater proportions of women with 'non-lump only' and 'both lump and non-lump' symptoms waited 90days or longer before seeking help compared to those with 'breast lump only' (15% and 20% vs. 7% respectively). Quantile regression indicated that the differences in the patient interval persisted after adjusting for age and ethnicity, but there was little variation in primary care interval for the majority of women. CONCLUSIONS: About 1 in 6 women with breast cancer present with a large spectrum of symptoms other than breast lump. Women who present with non-lump breast symptoms tend to delay seeking help. Further emphasis of breast symptoms other than breast lump in symptom awareness campaigns is warranted.

INTRODUCTION: There is uncertainty about the best way to measure emergency department crowding. We have previously developed a consensus-based measure of crowding, the International Crowding Measure in Emergency Departments (ICMED). We aimed to obtain pilot data to evaluate the ability of a shortened form of the ICMED, the sICMED, to predict senior emergency department clinicians’ concerns about crowding and danger compared with a very well-studied measure of emergency department crowding, the National Emergency Department Overcrowding Score (NEDOCS). METHODS: We collected real-time observations of the sICMED and NEDOCS and compared these with clinicians’ perceptions of crowding and danger on a visual analogue scale. Data were collected in four emergency departments in the East of England. Associations were explored using simple regression, random intercept models and models accounting for correlation between adjacent time points. RESULTS: We conducted 82 h of observation in 10 observation sets. Naive modelling suggested strong associations between sICMED and NEDOCS and clinician perceptions of crowding and danger. Further modelling showed that, due to clustering, the association between sICMED and danger persisted, but the association between these two measures and perception of crowding was no longer statistically significant. CONCLUSIONS: Both sICMED and NEDOCS can be collected easily in a variety of English hospitals. Further studies are required but initial results suggest both scores may have potential use for assessing crowding variation at long timescales, but are less sensitive to hour-by-hour variation. Correlation in time is an important methodological consideration which, if ignored, may lead to erroneous conclusions. Future studies should account for such correlation in both design and analysis.

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

OBJECTIVES: Investigate the association between socioeconomic deprivation and completeness of cardiovascular disease (CVD) risk factor recording in primary care, uptake of screening in people with incomplete risk factor recording and with actual CVD risk within the screened subgroup. DESIGN: Cross-sectional study. SETTING: Nine UK general practices. PARTICIPANTS: 7987 people aged 50-74 years with no CVD diagnosis. METHODS: CVD risk was estimated using the Framingham equation from data extracted from primary care electronic health records. Where there was insufficient information to calculate risk, patients were invited to attend a screening assessment. ANALYSIS: Proportion of patients for whom clinical data were sufficiently complete to enable CVD risk to be calculated; proportion of patients invited to screening who attended; proportion of patients who attended screening whose 10-year risk of a cardiovascular event was high (>20%). For each outcome, a set of logistic regression models were run. Crude and adjusted ORs were estimated for person-level deprivation, age, gender and smoking status. We included practice-level deprivation as a continuous variable and practice as a random effect to account for clustering. RESULTS: People who had lower Indices of Multiple Deprivation (IMD) scores (less deprived) had significantly worse routine CVD risk factor recording (adjusted OR 0.97 (0.95 to 1.00) per IMD decile; p=0.042). Screening attendance was poorer in those with more deprivation (adjusted OR 0.89 (0.86 to 0.91) per IMD decile; p20% (OR 1.09 (1.03 to 1.15) per IMD decile; p=0.004). CONCLUSIONS: Our data suggest that those who had the most to gain from screening were least likely to attend, potentially exacerbating existing health inequalities. Future research should focus on tailoring the delivery of CVD screening to ensure engagement of socioeconomically deprived groups.

BACKGROUND: Longer consultations in primary care have been linked with better quality of care and improved health-related outcomes. However, there is little evidence of any potential association between consultation length and patient experience. AIM: to examine the relationship between consultation length and patient-reported communication, trust and confidence in the doctor, and overall satisfaction. DESIGN AND SETTING: Analysis of 440 videorecorded consultations and associated patient experience questionnaires from 13 primary care practices in England. METHOD: Patients attending a face-to-face consultation with participating GPs consented to having their consultations videoed and completed a questionnaire. Consultation length was calculated from the videorecording. Linear regression (adjusting for patient and doctor demographics) was used to investigate associations between patient experience (overall communication, trust and confidence, and overall satisfaction) and consultation length. RESULTS: There was no evidence that consultation length was associated with any of the three measures of patient experience (P >0.3 for all). Adjusted changes on a 0-100 scale per additional minute of consultation were: communication score 0.02 (95% confidence interval [CI] = -0.20 to 0.25), trust and confidence in the doctor 0.07 (95% CI = -0.27 to 0.41), and satisfaction -0.14 (95% CI = -0.46 to 0.18). CONCLUSION: the authors found no association between patient experience measures of communication and consultation length, and patients may sometimes report good experiences from very short consultations. However, longer consultations may be required to achieve clinical effectiveness and patient safety: aspects also important for achieving high quality of care. Future research should continue to study the benefits of longer consultations, particularly for patients with complex multiple conditions.

OBJECTIVE: to investigate the association between student performance in undergraduate objective structured clinical examinations (OSCEs) and the examination schedule to which they were assigned to undertake these examinations. DESIGN: Analysis of routinely collected data. SETTING: One UK medical school. PARTICIPANTS: 2331 OSCEs of 3 different types (obstetrics OSCE, paediatrics OSCE and simulated clinical encounter examination OSCE) between 2009 and 2013. Students were not quarantined between examinations. OUTCOMES: (1) Pass rates by day examination started, (2) pass rates by day station undertaken and (3) mean scores by day examination started. RESULTS: We found no evidence that pass rates differed according to the day on which the examination was started by a candidate in any of the examinations considered (p>0.1 for all). There was evidence (p=0.013) that students were more likely to pass individual stations on the second day of the paediatrics OSCE (OR 1.27, 95% CI 1.05 to 1.54). In the cases of the simulated clinical encounter examination and the obstetrics and gynaecology OSCEs, there was no (p=0.42) or very weak evidence (p=0.099), respectively, of any such variation in the probability of passing individual stations according to the day they were attempted. There was no evidence that mean scores varied by day apart from the paediatric OSCE, where slightly higher scores were achieved on the second day of the examination. CONCLUSIONS: There is little evidence that different examination schedules have a consistent effect on pass rates or mean scores: students starting the examinations later were not consistently more or less likely to pass or score more highly than those starting earlier. The practice of quarantining students to prevent communication with (and subsequent unfair advantage for) subsequent examination cohorts is unlikely to be required.

BACKGROUND: Surveys of the experience of cancer patients are increasingly being introduced in different countries and used in cancer epidemiology research. Sampling processes, post-sampling mortality and survey non-response can influence the representativeness of cancer patient surveys. METHODS: We examined predictors of post-sampling mortality and non-response among patients initially included in the sampling frame of the English Cancer Patient Experience Survey. We also compared the respondents’ diagnostic case-mix to other relevant populations of cancer patients, including incident and prevalent cases. RESULTS: of 109,477 initially sampled cancer patients, 6273 (5.7%) died between sampling and survey mail-out. Older age and diagnosis of brain, lung and pancreatic cancer were associated with higher risk of post-sampling mortality. The overall response rate was 67% (67,713 respondents), being >70% for the most affluent patients and those diagnosed with colon or breast cancer and

BACKGROUND: Some patients with cancer experience multiple pre-diagnostic consultations in primary care, leading to longer time intervals to specialist investigations and diagnosis. Patients with rarer cancers are thought to be at higher risk of such events, but concrete evidence of this is lacking. AIM: to examine the frequency and predictors of repeat consultations with GPs in patients with rarer cancers. DESIGN AND SETTING: Patient-reported data on pre-referral consultations from three English national surveys of patients with cancer (2010, 2013, and 2014), pooled to maximise the sample size of rarer cancers. METHOD: the authors examined the frequency and crude and adjusted odds ratios for ≥3 (versus 1-2) pre-referral consultations by age, sex, ethnicity, level of deprivation, and cancer diagnosis (38 diagnosis groups, including 12 rarer cancers without prior relevant evidence). RESULTS: Among 7838 patients with 12 rarer cancers, crude proportions of patients with ≥3 pre-referral consultations ranged from >30.0% to 60.0% for patients with small intestine, bone sarcoma, liver, gallbladder, cancer of unknown primary, soft-tissue sarcoma, and ureteric cancer. The range was 15.0-30.0% for patients with oropharyngeal, anal, parotid, penile, and oral cancer. The overall proportion of responders with any cancer who had ≥3 consultations was 23.4%. Multivariable logistic regression indicated concordant patterns, with strong evidence for variation between rarer cancers (P

BACKGROUND: Pancreatic cancer is the tenth most common cancer in the UK; however, outcomes are poor, in part due to late diagnosis. We aimed to identify symptoms and other clinical and sociodemographic factors associated with pancreatic cancer diagnosis and diagnostic intervals. METHODS: We did this prospective cohort study at seven hospitals in two regions in England. We recruited participants aged 40 years or older who were referred for suspicion of pancreatic cancer. Data were collected by use of a patient questionnaire and primary care and hospital records. Descriptive and regression analyses were done to examine associations between symptoms and patient factors with the total diagnostic interval (time from onset of the first symptom to the date of diagnosis), comprising patient interval (time from first symptom to first presentation) and health system interval (time from first presentation to diagnosis). FINDINGS: We recruited 391 participants between Jan 1, 2011, and Dec 31, 2014 (24% response rate). 119 (30%) participants were diagnosed with pancreatic cancer (41 [34%] had metastatic disease), 47 (12%) with other cancers, and 225 (58%) with no cancer. 212 (54%) patients had multiple first symptoms whereas 161 (41%) patients had a solitary first symptom. In this referred population, no initial symptoms were reported more frequently by patients with cancer than by those with no cancer. Several subsequent symptoms predicted pancreatic cancer: jaundice (51 [49%] of 105 patients with pancreatic cancer vs 25 [12%] of 211 patients with no cancer; p

BACKGROUND: the objective of this study is to investigate symptoms, clinical factors and socio-demographic factors associated with colorectal cancer (CRC) diagnosis and time to diagnosis. METHODS: Prospective cohort study of participants referred for suspicion of CRC in two English regions. Data were collected using a patient questionnaire, primary care and hospital records. Descriptive and regression analyses examined associations between symptoms and patient factors with total diagnostic interval (TDI), patient interval (PI), health system interval (HSI) and stage. RESULTS: a total of 2677 (22%) participants responded; after exclusions, 2507 remained. Participants were diagnosed with CRC (6.1%, 56% late stage), other cancers (2.0%) or no cancer (91.9%). Half the cohort had a solitary first symptom (1332, 53.1%); multiple first symptoms were common. In this referred population, rectal bleeding was the only initial symptom more frequent among cancer than non-cancer cases (34.2% vs 23.9%, P=0.004). There was no evidence of differences in TDI, PI or HSI for those with cancer vs non-cancer diagnoses (median TDI CRC 124 vs non-cancer 138 days, P=0.142). First symptoms associated with shorter TDIs were rectal bleeding, change in bowel habit, 'feeling different' and fatigue/tiredness. Anxiety, depression and gastro-intestinal co-morbidities were associated with longer HSIs and TDIs. Symptom duration-dependent effects were found for rectal bleeding and change in bowel habit. CONCLUSIONS: Doctors and patients respond less promptly to some symptoms of CRC than others. Healthcare professionals should be vigilant to the possibility of CRC in patients with relevant symptoms and mental health or gastro-intestinal comorbidities.

OBJECTIVES: in many countries, minority ethnic groups report poorer care in patient surveys. This could be because they get worse care or because they respond differently to such surveys. We conducted an experiment to determine whether South Asian people in England rate simulated GP consultations the same or differently from White British people. If these groups rate consultations similarly when viewing identical simulated consultations, it would be more likely that the lower scores reported by minority ethnic groups in real surveys reflect real differences in quality of care. DESIGN: Experimental vignette study. Trained fieldworkers completed computer-assisted personal interviews during which participants rated 3 video recordings of simulated GP-patient consultations, using 5 communication items from the English GP Patient Survey. Consultations were shown in a random order, selected from a pool of 16. SETTING: Geographically confined areas of ∼130 households (output areas) in England, selected using proportional systematic sampling. PARTICIPANTS: 564 White British and 564 Pakistani adults recruited using an in-home face-to-face approach. MAIN OUTCOME MEASURE: Mean differences in communication score (on a scale of 0-100) between White British and Pakistani participants, estimated from linear regression. RESULTS: Pakistani participants, on average, scored consultations 9.8 points higher than White British participants (95% CI 8.0 to 11.7, p

BACKGROUND: Doctor-patient communication is a key driver of overall satisfaction with primary care. Patients from minority ethnic backgrounds consistently report more negative experiences of doctor-patient communication. However, it is currently unknown whether these ethnic differences are concentrated in one gender or in particular age groups. AIM: to determine how reported GP-patient communication varies between patients from different ethnic groups, stratified by age and gender. DESIGN AND SETTING: Analysis of data from the English GP Patient Survey from 2012-2013 and 2013-2014, including 1,599,801 responders. METHOD: a composite score was created for doctor-patient communication from five survey items concerned with interpersonal aspects of care. Mixed-effect linear regression models were used to estimate age- and gender-specific differences between white British patients and patients of the same age and gender from each other ethnic group. RESULTS: There was strong evidence (P

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.

BACKGROUND: There is limited evidence about the impact of specific patterns of multi-morbidity on health-related quality of life (HRQoL) from large samples of adult subjects. METHODS: We used data from the English General Practice Patient Survey 2011-2012. We defined multi-morbidity as the presence of two or more of 12 self-reported conditions or another (unspecified) long-term health problem. We investigated differences in HRQoL (EQ-5D scores) associated with combinations of these conditions after adjusting for age, gender, ethnicity, socio-economic deprivation and the presence of a recent illness or injury. Analyses were based on 831,537 responses from patients aged 18 years or older in 8,254 primary care practices in England. RESULTS: of respondents, 23 % reported two or more chronic conditions (ranging from 7 % of those under 45 years of age to 51 % of those 65 years or older). Multi-morbidity was more common among women, White individuals and respondents from socio-economically deprived areas. Neurological problems, mental health problems, arthritis and long-term back problem were associated with the greatest HRQoL deficits. The presence of three or more conditions was commonly associated with greater reduction in quality of life than that implied by the sum of the differences associated with the individual conditions. The decline in quality of life associated with an additional condition in people with two and three physical conditions was less for older people than for younger people. Multi-morbidity was associated with a substantially worse HRQoL in diabetes than in other long-term conditions. With the exception of neurological conditions, the presence of a comorbid mental health problem had a more adverse effect on HRQoL than any single comorbid physical condition. CONCLUSION: Patients with multi-morbid diabetes, arthritis, neurological, or long-term mental health problems have significantly lower quality of life than other people. People with long-term health conditions require integrated mental and physical healthcare services.

INTRODUCTION: it is believed that some patients are more likely to use out-of-hours primary care services because of difficulties in accessing in-hours care, but substantial evidence about any such association is missing. METHODS: We analysed data from 567,049 respondents to the 2011/2012 English General Practice Patient Survey who reported at least one in-hours primary care consultation in the preceding 6â€
months. of those respondents, 7% also reported using out-of-hours primary care. We used logistic regression to explore associations between use of out-of-hours primary care and five measures of in-hours access (ease of getting through on the telephone, ability to see a preferred general practitioner, ability to get an urgent or routine appointment and convenience of opening hours). We illustrated the potential for reduction in use of out-of-hours primary care in a model where access to in-hours care was made optimal. RESULTS: Worse in-hours access was associated with greater use of out-of-hours primary care for each access factor. In multivariable analysis adjusting for access and patient characteristic variables, worse access was independently associated with increased out-of-hours use for all measures except ease of telephone access. Assuming these associations were causal, we estimated that an 11% relative reduction in use of out-of-hours primary care services in England could be achievable if access to in-hours care were optimal. CONCLUSIONS: This secondary quantitative analysis provides evidence for an association between difficulty in accessing in-hours care and use of out-of-hours primary care services. The findings can motivate the development of interventions to improve in-hour access.

BACKGROUND: Ethnic minorities report poorer evaluations of primary health care compared to White British patients. Emerging evidence suggests that when a doctor and patient share ethnicity and/or language this is associated with more positive reports of patient experience. Whether this is true for adults in English general practices remains to be explored. METHODS: We analysed data from the 2010/2011 English General Practice Patient Survey, which were linked to data from the NHS Choices website to identify languages which were available at the practice. Our analysis was restricted to single-handed practices and included 190,582 patients across 1,068 practices. Including only single-handed practices enabled us to attribute, more accurately, reported patient experience to the languages that were listed as being available. We also carried out sensitivity analyses in multi-doctor practices. We created a composite score on a 0-100 scale from seven survey items assessing doctor-patient communication. Mixed-effect linear regression models were used to examine how differences in reported experience of doctor communication between patients of different self-reported ethnicities varied according to whether a South Asian language concordant with their ethnicity was available in their practice. Models were adjusted for patient characteristics and a random effect for practice. RESULTS: Availability of a concordant language had the largest effect on communication ratings for Bangladeshis and the least for Indian respondents (p < 0.01). Bangladeshi, Pakistani and Indian respondents on average reported poorer communication than White British respondents [-2.9 (95%CI -4.2, -1.6), -1.9 (95%CI -2.6, -1.2) and -1.9 (95%CI -2.5, -1.4), respectively]. However, in practices where a concordant language was offered, the experience reported by Pakistani patients was not substantially worse than that reported by White British patients (-0.2, 95%CI -1.5,+1.0), and in the case of Bangladeshi patients was potentially much better (+4.5, 95%CI -1.0,+10.1). This contrasts with a worse experience reported among Bangladeshi (-3.3, 95%CI -4.6, -2.0) and Pakistani (-2.7, 95%CI -3.6, -1.9) respondents when a concordant language was not offered. CONCLUSIONS: Substantial differences in reported patient experience exist between ethnic groups. Our results suggest that patient experience among Bangladeshis and Pakistanis is improved where the practice offers a language that is concordant with the patient’s ethnicity.

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.

OBJECTIVE: to evaluate two 5-item patient experience scales from the English General Practice (GP) Patient Survey for evidence of differential item functioning (DIF) given prior evidence of substantially worse reported health care experiences for South Asian compared with white British respondents. SETTING: a national survey of English patients' primary care experiences. METHOD: We used classic test and item response theory analysis to examine the possibility of DIF by patient ethnicity (South Asian, white British) after controlling for age, sex, health status, and quality of life in the English GP Patient Survey conducted in 2011/2012. RESULTS: Data were available for 873,051 respondents (818,219 white British/54,832 South Asian from 7795 English practices) who answered items relating to experiences of GP or nurses' care. Internal consistency reliability was high and similar for South Asian and white British patients. White British patients reported better average experiences than South Asians, but there was no evidence of DIF or different item response curves for white British and South Asian respondents, even in sensitivity analyses using matched samples. CONCLUSIONS: all communication items in the English GP Patient Survey showed similar South Asian versus white British differences, with no evidence of DIF. In contrast, differences due to scale use or expectations are typically variable rather than constant across scales. While other possibilities remain, these findings increase the likelihood that the observed negative responses of South Asian patients to this national survey reflect true differences in their experiences of care.

OBJECTIVE: Developing primary care is an important current health policy goal in the U.S. and England. Information on patients’ experience can help to improve the care of people with diabetes. We describe the experiences of people with diabetes in primary care and examine how these experiences vary with increasing comorbidity. RESEARCH DESIGN AND METHODS: Using data from 906,578 responders to the 2012 General Practice Patient Survey (England), including 85,760 with self-reported diabetes, we used logistic regressions controlling for age, sex, ethnicity, and socioeconomic status to analyze patient experience using seven items covering three domains of primary care: access, continuity, and communication. RESULTS: People with diabetes were significantly more likely to report better experience on six out of seven primary care items than people without diabetes after adjusting for age, sex, ethnicity, and socioeconomic status (adjusted differences 0.88-3.20%; odds ratios [ORs] 1.07-1.18; P < 0.001). Those with diabetes and additional comorbid long-term conditions were more likely to report worse experiences, particularly for access to primary care appointments (patients with diabetes alone compared with patients without diabetes: OR 1.22 [95% CI 1.17-1.28] and patients with diabetes plus three or more conditions compared with patients without diabetes: OR 0.87 [95% CI 0.83-0.91]). CONCLUSIONS: People with diabetes in England report primary care experiences that are at least as good as those without diabetes for most domains of care. However, improvements in primary care are needed for diabetes patients with comorbid long-term conditions, including better access to appointments and improved communication.

BACKGROUND: for patients with symptoms of possible cancer who do not fulfil the criteria for urgent referral, initial investigation in primary care has been advocated in the United Kingdom and supported by additional resources. The consequence of this strategy for the timeliness of diagnosis is unknown. METHODS: We analysed data from the English National Audit of Cancer Diagnosis in Primary Care on patients with lung (1494), colorectal (2111), stomach (246), oesophagus (513), pancreas (327), and ovarian (345) cancer relating to the ordering of investigations by the General Practitioner and their nature. Presenting symptoms were categorised according to National Institute for Health and Care Excellence (NICE) guidance on referral for suspected cancer. We used linear regression to estimate the mean difference in primary-care interval by cancer, after adjustment for age, gender, and the symptomatic presentation category. RESULTS: Primary-care investigations were undertaken in 3198/5036 (64%) of cases. The median primary-care interval was 16 days (IQR 5-45) for patients undergoing investigation and 0 days (IQR 0-10) for those not investigated. Among patients whose symptoms mandated urgent referral to secondary care according to NICE guidelines, between 37% (oesophagus) and 75% (pancreas) were first investigated in primary care. In multivariable linear regression analyses stratified by cancer site, adjustment for age, sex, and NICE referral category explained little of the observed prolongation associated with investigation. INTERPRETATION: for six specified cancers, investigation in primary care was associated with later referral for specialist assessment. This effect was independent of the nature of symptoms. Some patients for whom urgent referral is mandated by NICE guidance are nevertheless investigated before referral. Reducing the intervals between test order, test performance, and reporting can help reduce the prolongation of primary-care intervals associated with investigation use. Alternative models of assessment should be considered.

Patient experience is a critical dimension of cancer care quality. Understanding variation in experience among patients with different cancers and characteristics is an important first step for designing targeted improvement interventions. We analysed data from the 2011/2012 English Cancer Patient Experience Survey (n = 69,086) using logistic regression to explore inequalities in care experience across 64 survey questions. We additionally calculated a summary measure of variation in patient experience by cancer, and explored inequalities between patients with cancers treated by the same specialist teams. We found that younger and very old, ethnic minority patients and women consistently reported worse experiences across questions. Patients with small intestine/rarer lower gastrointestinal, multiple myeloma and hepatobiliary cancers were most likely to report negative experiences whereas patients with breast, melanoma and testicular cancer were least likely (top-to-bottom odds ratio = 1.91, P < 0.0001). There were also inequalities in experience among patients with cancers treated by the same specialty for five of nine services (P < 0.0001). Specifically, patients with ovarian, multiple myeloma, anal, hepatobiliary and renal cancer reported notably worse experiences than patients with other gynaecological, haematological, gastrointestinal and urological malignancies respectively. Initiatives to improve cancer patient experience across oncology services may be suitably targeted on patients at higher risk of poorer experience.

Prolonged diagnostic intervals may negatively affect the patient experience of subsequent cancer care, but evidence about this assertion is sparse. We analysed data from 73 462 respondents to two English Cancer Patient Experience Surveys to examine whether patients with three or more (3+) pre-referral consultations were more likely to report negative experiences of subsequent care compared with patients with one or two consultations in respect of 12 a priori selected survey questions. For each of 12 experience items, logistic regression models were used, adjusting for prior consultation category, cancer site, socio-demographic case-mix and response tendency (to capture potential variation in critical response tendencies between individuals). There was strong evidence (P < 0.01 for all) that patients with 3+ pre-referral consultations reported worse care experience for 10/12 questions, with adjusted odds ratios compared with patients with 1-2 consultations ranging from 1.10 (95% confidence intervals 1.03-1.17) to 1.68 (1.60-1.77), or between +1.8% and +10.6% greater percentage reporting a negative experience. Associations were stronger for processes involving primary as opposed to hospital care; and for evaluation than report items. Considering 1, 2, 3-4 and ’5+’ pre-referral consultations separately a ’dose-response’ relationship was apparent. We conclude that there is a negative association between multiple pre-diagnostic consultations with a general practitioner and the experience of subsequent cancer care.

BACKGROUND: Worldwide, the incidence of cutaneous melanoma has been reported to be highest in the summer and lowest in the winter. Northern Irish data suggested seasonal variation for women only, especially those with thinner melanomas, sited on limbs. We interrogated two larger UK cancer registries for temporal differences in melanoma diagnosis and associated patient characteristics. METHODS: Melanomas diagnosed from 2006 to 2010 in the Eastern England and Scottish cancer registries (n=11,611) were analysed by month of diagnosis, patient demographics and melanoma characteristics, using descriptive and multivariate modelling methods. RESULTS: More patients with melanoma were diagnosed in the summer months (June 9.9%, July 9.7%, August 9.8%) than the winter months (December 7.2%, January 7.2%, February 7.1%) and this pattern was consistent in both regions. There was evidence that the seasonal patterns varied by sex (p=0.015), melanoma thickness (p=0.002), body site (p=0.006), and type (superficial spreading melanomas p=0.005). The seasonal variation was greatest for diagnosis of melanomas occurring on the limbs. CONCLUSION: This study has confirmed seasonal variation in melanoma diagnosis in Eastern England and Scotland across almost all population demographics and melanoma characteristics studied, with higher numbers diagnosed in the summer months, particularly on the limbs. Seasonal patterns in skin awareness and related help-seeking are likely to be implicated. Targeted patient interventions to increase sun awareness and encourage year-long skin inspection are warranted.

BACKGROUND: the health and healthcare of sexual minorities have recently been identified as priorities for health research and policy. OBJECTIVE: to compare the health and healthcare experiences of sexual minorities with heterosexual people of the same gender, adjusting for age, race/ethnicity, and socioeconomic status. DESIGN: Multivariate analyses of observational data from the 2009/2010 English General Practice Patient Survey. PARTICIPANTS: the survey was mailed to 5.56 million randomly sampled adults registered with a National Health Service general practice (representing 99 % of England’s adult population). In all, 2,169,718 people responded (39 % response rate), including 27,497 people who described themselves as gay, lesbian, or bisexual. MAIN MEASURES: Two measures of health status (fair/poor overall self-rated health and self-reported presence of a longstanding psychological condition) and four measures of poor patient experiences (no trust or confidence in the doctor, poor/very poor doctor communication, poor/very poor nurse communication, fairly/very dissatisfied with care overall). KEY RESULTS: Sexual minorities were two to three times more likely to report having a longstanding psychological or emotional problem than heterosexual counterparts (age-adjusted for 5.2 % heterosexual, 10.9 % gay, 15.0 % bisexual for men; 6.0 % heterosexual, 12.3 % lesbian and 18.8 % bisexual for women; p < 0.001 for each). Sexual minorities were also more likely to report fair/poor health (adjusted 19.6 % heterosexual, 21.8 % gay, 26.4 % bisexual for men; 20.5 % heterosexual, 24.9 % lesbian and 31.6 % bisexual for women; p < 0.001 for each). Adjusted for sociodemographic characteristics and health status, sexual minorities were about one and one-half times more likely than heterosexual people to report unfavorable experiences with each of four aspects of primary care. Little of the overall disparity reflected concentration of sexual minorities in low-performing practices. CONCLUSIONS: Sexual minorities suffer both poorer health and worse healthcare experiences. Efforts should be made to recognize the needs and improve the experiences of sexual minorities. Examining patient experience disparities by sexual orientation can inform such efforts.

BACKGROUND: Fatalistic beliefs may be implicated in longer help-seeking intervals, and consequently, greater risk of advanced stage at cancer diagnosis. METHODS: We examined associations between fatalism and stage at diagnosis in a population-based cohort of 4,319 U.S. patients with newly diagnosed lung or colorectal cancer participating in the Cancer Care Outcomes and Research Surveillance (CanCORS) study. Fatalistic beliefs were assessed with an established measure. A fatalism score (range, 4-16) was created by summing Likert scale responses to four items. Cancer stage at diagnosis was abstracted from medical records by trained staff. Logistic regression was used to assess the association between fatalism score and advanced stage at diagnosis (IV vs. I-III), adjusting for sociodemographic and clinical characteristics. RESULTS: Overall, 917 (21%) patients had stage IV cancers (lung: 28%, colorectal: 16%). The mean fatalism score was 10.7 (median = 11; interquartile range, 9-12). In adjusted analyses, a higher fatalism score was associated with greater odds of stage IV diagnosis (OR per unit increase in fatalism = 1.05; 95% confidence interval 1.02-1.08; P = 0.003). Patients with the highest fatalism score had an adjusted 8.9% higher frequency of stage IV diagnosis compared with patients with the lowest score (25.4% vs. 16.5%). DISCUSSION: in this large and socioeconomically, geographically, and ethnically diverse population of patients with lung and colorectal cancer, fatalistic beliefs were associated with higher risk of advanced stage at diagnosis. Longitudinal studies are needed to confirm causation. IMPACT: These findings support the value of incorporating information about the curability of early-stage cancers in public education campaigns.

BACKGROUND: Older women with breast cancer have poorer relative survival outcomes, but whether achieving earlier stage at diagnosis would translate to substantial reductions in mortality is uncertain. METHODS: We analysed data on East of England women with breast cancer (2006-2010) aged 70+ years. We estimated survival for different stage-deprivation-age group strata using both the observed and a hypothetical stage distribution (assuming that all women aged 75+ years acquired the stage distribution of those aged 70-74 years). We subsequently estimated deaths that could be postponed beyond 5 years from diagnosis if women aged 75+ years had the hypothetical stage distribution. We projected findings to the English population using appropriate age and socioeconomic group weights. RESULTS: for a typically sized annual cohort in the East of England, 27 deaths in women with breast cancer aged 75+ years can be postponed within 5 years from diagnosis if their stage distribution matched that of the women aged 70-74 years (4.8% of all 566 deaths within 5 years post diagnosis in this population). Under assumptions, we estimate that the respective number for England would be 280 deaths (5.0% of all deaths within 5 years post diagnosis in this population). CONCLUSIONS: the findings support ongoing development of targeted campaigns aimed at encouraging prompt presentation in older women.

BACKGROUND: Appreciating variation in the length of pre- or post-presentation diagnostic intervals can help prioritise early diagnosis interventions with either a community or a primary care focus. METHODS: We analysed data from the first English National Audit of Cancer Diagnosis in Primary Care on 10 953 patients with any of 28 cancers. We calculated summary statistics for the length of the patient and the primary care interval and their ratio, by cancer site. RESULTS: Interval lengths varied greatly by cancer. Laryngeal and oropharyngeal cancers had the longest median patient intervals, whereas renal and bladder cancer had the shortest (34.5 and 30 compared with 3 and 2 days, respectively). Multiple myeloma and gallbladder cancer had the longest median primary care intervals, and melanoma and breast cancer had the shortest (20.5 and 20 compared with 0 and 0 days, respectively). Mean patient intervals were longer than primary care intervals for most (18 of 28) cancers, and notably so (two- to five-fold greater) for 10 cancers (breast, melanoma, testicular, vulval, cervical, endometrial, oropharyngeal, laryngeal, ovarian and thyroid). CONCLUSIONS: the findings support the continuing development and evaluation of public health interventions aimed at shortening patient intervals, particularly for cancers with long patient interval and/or high patient interval over primary care interval ratio.

BACKGROUND: Truancy has been linked to risky sexual behaviours in teenagers. However, no studies in England have examined the association between truancy and teenage pregnancy, and the use of truancy as a marker of teenagers at risk of pregnancy. METHODS: Using logistic regression, we investigated the association between truancy at age 15 and the likelihood of teenage pregnancy by age 19 among 3837 female teenagers who participated in the Longitudinal Study of Young People of England. We calculated the areas under the ROC curves of four models to determine how useful truancy would be as a marker of future teenage pregnancy. RESULTS: Truancy showed a dose-response association with teenage pregnancy after adjusting for ethnicity, educational intentions at age 16, parental socioeconomic status and family composition (’several days at a time’ versus ’none’, odds ratio 3.48 95% confidence interval 1.90-6.36, P < 0.001). Inclusion of risk behaviours improved the accuracy of predictive models only marginally (area under the ROC curve 0.76 full model versus 0.71 sociodemographic characteristics only). CONCLUSIONS: Truancy is independently associated with teenage pregnancy among English adolescent girls. However, the discriminatory powers of models were low, suggesting that interventions addressing the whole population, rather than targeting high-risk individuals, might be more effective in reducing teenage pregnancy rates.

OBJECTIVES: to describe and explain the primary care experiences of people with multiple long-term conditions in England. DESIGN AND METHODS: Using questionnaire data from 906,578 responders to the English 2012 General Practice Patient Survey, we describe the primary care experiences of patients with long-term conditions, including 583,143 patients who reported one or more long-term conditions. We employed mixed effect logistic regressions to analyse data on six items covering three care domains (access, continuity and communication) and a single item on overall primary care experience. We controlled for sociodemographic characteristics, and for general practice using a random effect, and further, controlled for, and explored the importance of, health-related quality of life measured using the EuroQoL (EQ-5D) scale. RESULTS: Most patients with long-term conditions report a positive experience of care at their general practice (after adjusting for sociodemographic characteristics and general practice, range 74.0-93.1% reporting positive experience of care across seven questions) with only modest variation by type of condition. For all three domains of patient experience, an increasing number of comorbid conditions is associated with a reducing percentage of patients reporting a positive experience of care. For example, compared with respondents with no long-term condition, the OR for reporting a positive experience is 0.83 (95% CI 0.80 to 0.87) for respondents with four or more long-term conditions. However, this relationship is no longer observed after adjusting for health-related quality of life (OR (95% CI) single condition=1.23 (1.21 to 1.26); four or more conditions=1.31 (1.25 to 1.37)), with pain making the greatest difference among five quality of life variables included in the analysis. CONCLUSIONS: Patients with multiple long-term conditions more frequently report worse experiences in primary care. However, patient-centred measures of health-related quality of life, especially pain, are more important than the number of conditions in explaining why patients with multiple long-term conditions report worse experiences of care.

Objectives: to investigate initial reliability of the Global Consultation Rating Scale (GCRS: an instrument to assess the effectiveness of communication across an entire doctor-patient consultation, based on the Calgary-Cambridge guide to the medical interview), in simulated patient consultations. Design: Multiple ratings of simulated general practitioner (GP)-patient consultations by trained GP evaluators. Setting: UK primary care. Participants: 21 GPs and six trained GP evaluators. Outcome measures: GCRS score. Methods: 6 GP raters used GCRS to rate randomly assigned video recordings of GP consultations with simulated patients. Each of the 42 consultations was rated separately by four raters. We considered whether a fixed difference between scores had the same meaning at all levels of performance. We then examined the reliability of GCRS using mixed linear regression models. We augmented our regression model to also examine whether there were systematic biases between the scores given by different raters and to look for possible order effects. Results: Assessing the communication quality of individual consultations, GCRS achieved a reliability of 0.73 (95% CI 0.44 to 0.79) for two raters, 0.80 (0.54 to 0.85) for three and 0.85 (0.61 to 0.88) for four. We found an average difference of 1.65 (on a 0-10 scale) in the scores given by the least and most generous raters: adjusting for this evaluator bias increased reliability to 0.78 (0.53 to 0.83) for two raters; 0.85 (0.63 to 0.88) for three and 0.88 (0.69 to 0.91) for four. There were considerable order effects, with later consultations (after 15-20 ratings) receiving, on average, scores more than one point higher on a 0-10 scale. Conclusions: GCRS shows good reliability with three raters assessing each consultation. We are currently developing the scale further by assessing a large sample of real-world consultations.

UNLABELLED:. AIMS: This study aims to explore differences between crude and case mix-adjusted estimates of hospital performance with respect to the experience of cancer patients. MATERIALS & METHODS: This study analyzed the English 2011/2012 Cancer Patient Experience Survey covering all English National Health Service hospitals providing cancer treatment (n = 160). Logistic regression analysis was used to predict hospital performance for each of the 64 evaluative questions, adjusting for age, gender, ethnic group and cancer diagnosis. The degree of reclassification was explored across three categories (bottom 20%, middle 60% and top 20% of hospitals). RESULTS: There was high concordance between crude and adjusted ranks of hospitals (median Kendall’s τ = 0.84; interquartile range: 0.82-0.88). Across all questions, a median of 5.0% (eight) of hospitals (interquartile range: 3.8-6.4%; six to ten hospitals) moved out of the extreme performance categories after case mix adjustment. CONCLUSION: in this context, patient case mix has only a small impact on measured hospital performance for cancer patient experience.

BACKGROUND: Polypharmacy is often considered suggestive of suboptimal prescribing, and is associated with adverse outcomes. It is particularly common in the context of cardiovascular disease, but it is unclear whether prescribing of multiple cardiovascular medicines, which may be entirely appropriate and consistent with clinical guidance, is associated with adverse outcome. The aim of this study was to assess the relationship between number of prescribed cardiovascular medicines and unplanned non-cardiovascular hospital admissions. METHODS: a retrospective cohort analysis of 180,815 adult patients was conducted using Scottish primary care data linked to hospital discharge data. Patients were followed up for one year for the outcome of unplanned non-cardiovascular hospital admission. The association between number of prescribed cardiovascular medicines and hospitalisation was modelled using logistic regression, adjusting for key confounding factors including cardiovascular and non-cardiovascular morbidity and non-cardiovascular prescribing. RESULTS: 25.4% patients were prescribed ≥1 cardiovascular medicine, and 5.7% were prescribed ≥5. At least one unplanned non-cardiovascular admission was experienced by 4.2% of patients. Admissions were more common in patients receiving multiple cardiovascular medicines (6.4% of patients prescribed 5 or 6 cardiovascular medicines) compared with those prescribed none (3.5%). However, after adjusting for key confounders, cardiovascular prescribing was associated with fewer non-cardiovascular admissions (OR 0.66 for 5 or 6 vs. no cardiovascular medicines, 95% CI 0.57-0.75). CONCLUSIONS: We found no evidence that increasing numbers of cardiovascular medicines were associated with an increased risk of unplanned non-cardiovascular hospitalisation, following adjustment for confounding. Assumptions that polypharmacy is hazardous and represents poor care should be moderated in the context of cardiovascular disease.

OBJECTIVES: Almost a quarter of adults in England report a longstanding condition limiting physical activities. However, recent overseas evidence suggests poorer access to healthcare for disabled people. This study aimed to compare patient-reported access to English primary care for adults with and without physical disability. DESIGN: Secondary analysis of the 2010/11 General Practice Patient Survey (response rate 35.9%) using logistic regression. SETTING AND PARTICIPANTS: 1,780,977 patients, from 8384 English general practices, who provided information on longstanding conditions limiting basic physical activity. 41,389 of these patients reported unmet need to see a doctor in the previous 6 months. OUTCOMES: Difficulty getting to the general practitioner (GP) surgery as a reason for unmet need to see a doctor in the preceding 6 months; difficulty getting into the surgery building. RESULTS: Estimated prevalence of physical disability was 17.2% (95% CI 17.0% to 17.3%). 17.9% (95% CI 17.4% to 18.4%) of patients with an unmet need to see a doctor were estimated to experience this due to difficulty getting to the surgery, and 2.2% (95% CI 2.2% to 2.3%) of all patients registered with a GP were estimated to experience difficulty getting into surgery buildings. Adjusting for gender, age, health status and employment, difficulty getting to the surgery explaining unmet need was more likely for patients with physical disability than for those without. Similarly, difficulty getting into surgery buildings was more likely among physically disabled patients. Both associations were stronger among patients aged 65-84 years. CONCLUSIONS: Adults in England with physical disability experience worse physical access into primary care buildings than those without. Physical disability is also associated with increased unmet healthcare need due to difficulty getting to GP premises, compared with the experience of adults without physical disability. Increasing age further exacerbates these problems. Access to primary care in England for patients with physical disability needs improving.

AIMS: Prescribing multiple medications is associated with various adverse outcomes, and polypharmacy is commonly considered suggestive of poor prescribing. Polypharmacy might thus be associated with unplanned hospitalization. We sought to test this assumption. METHODS: Scottish primary care data for 180 815 adults with long-term clinical conditions and numbers of regular medications were linked to national hospital admissions data for the following year. Using logistic regression (age, gender and deprivation adjusted), we modelled the association of prescribing with unplanned admission for patients with different numbers of long-term conditions. RESULTS: Admissions were more common in patients on multiple medications, but admission risk varied with the number of conditions. For patients with one condition, the odds ratio for unplanned admission for four to six medications was 1.25 (95% confidence interval 1.11-1.42) vs. one to three medications, and 3.42 (95% confidence interval 2.72-4.28) for ≥10 medications vs. one to three medications. However, this effect was greatly reduced for patients with multiple conditions; amongst patients with six or more conditions, those on four to six medications were no more likely to have unplanned admissions than those taking one to three medications (odds ratio 1.00; 95% confidence interval 0.88-1.14), and those taking ≥10 medications had a modestly increased risk of admission (odds ratio 1.50; 95% confidence interval 1.31-1.71). CONCLUSIONS: Unplanned hospitalization is strongly associated with the number of regular medications. However, the effect is reduced in patients with multiple conditions, in whom only the most extreme levels of polypharmacy are associated with increased admissions. Assumptions that polypharmacy is always hazardous and represents poor care should be tempered by clinical assessment of the conditions for which those drugs are being prescribed.

PURPOSE: Polypharmacy-the use of multiple medications by a single patient-is an important issue associated with various adverse clinical outcomes and rising costs. It is also a topic rarely addressed by clinical guidelines. We used routine Scottish health records to address the lack of data on the prevalence of polypharmacy in the broader, adult primary care population, particularly in relation to long-term conditions. METHODS: We conducted a cross-sectional analysis of adult electronic primary healthcare records and used linear regression models to examine the association between the number of medicines prescribed regularly and both multimorbidity and specific clinical conditions, adjusting for age, gender and socioeconomic deprivation. RESULTS: Overall, 16.9 % of the adults assessed were receiving four to nine medications, and 4.6 % were receiving ten or more medications, increasing with age (28.6 and 7.4 %, respectively, in those aged 60-69 years; 51.8 and 18.6 %, respectively, in those aged ≥ 80 years), but relatively unaffected by gender or deprivation. of those patients with two clinical conditions, 20.8 % were receiving four to nine medications, and 1.1 % were receiving ten or more medications; in those patients with six or more comorbidities, these values were 47.7 and 41.7 %, respectively. The number of medications varied considerably between clinical conditions, with cardiovascular conditions associated with the greatest number of additional medications. The accumulation of additional medicines was less with concordant conditions. CONCLUSIONS: Polypharmacy is common in UK primary care. The main factor associated with this is multimorbidity, although considerable variation exists between different conditions. The impact of clinical conditions on the number of medicines is generally less in the presence of co-existing concordant conditions.

OBJECTIVES: to determine the extent to which practice level scores mask variation in individual performance between doctors within a practice. DESIGN: Analysis of postal survey of patients' experience of face-to-face consultations with individual general practitioners in a stratified quota sample of primary care practices. SETTING: Twenty five English general practices, selected to include a range of practice scores on doctor-patient communication items in the English national GP Patient Survey. PARTICIPANTS: 7721 of 15,172 patients (response rate 50.9%) who consulted with 105 general practitioners in 25 practices between October 2011 and June 2013. MAIN OUTCOME MEASURE: Score on doctor-patient communication items from post-consultation surveys of patients for each participating general practitioner. The amount of variance in each of six outcomes that was attributable to the practices, to the doctors, and to the patients and other residual sources of variation was calculated using hierarchical linear models. RESULTS: After control for differences in patients' age, sex, ethnicity, and health status, the proportion of variance in communication scores that was due to differences between doctors (6.4%) was considerably more than that due to practices (1.8%). The findings also suggest that higher performing practices usually contain only higher performing doctors. However, lower performing practices may contain doctors with a wide range of communication scores. CONCLUSIONS: Aggregating patients' ratings of doctors' communication skills at practice level can mask considerable variation in the performance of individual doctors, particularly in lower performing practices. Practice level surveys may be better used to "screen" for concerns about performance that require an individual level survey. Higher scoring practices are unlikely to include lower scoring doctors. However, lower scoring practices require further investigation at the level of the individual doctor to distinguish higher and lower scoring general practitioners.

BACKGROUND: Receiver Operator Characteristic (ROC) curves are being used to identify Minimally Important Change (MIC) thresholds on scales that measure a change in health status. In quasi-continuous patient reported outcome measures, such as those that measure changes in chronic diseases with variable clinical trajectories, sensitivity and specificity are often valued equally. Notwithstanding methodologists agreeing that these should be valued equally, different approaches have been taken to estimating MIC thresholds using ROC curves. AIMS AND OBJECTIVES: We aimed to compare the different approaches used with a new approach, exploring the extent to which the methods choose different thresholds, and considering the effect of differences on conclusions in responder analyses. METHODS: Using graphical methods, hypothetical data, and data from a large randomised controlled trial of manual therapy for low back pain, we compared two existing approaches with a new approach that is based on the addition of the sums of squares of 1-sensitivity and 1-specificity. RESULTS: There can be divergence in the thresholds chosen by different estimators. The cut-point selected by different estimators is dependent on the relationship between the cut-points in ROC space and the different contours described by the estimators. In particular, asymmetry and the number of possible cut-points affects threshold selection. CONCLUSION: Choice of MIC estimator is important. Different methods for choosing cut-points can lead to materially different MIC thresholds and thus affect results of responder analyses and trial conclusions. An estimator based on the smallest sum of squares of 1-sensitivity and 1-specificity is preferable when sensitivity and specificity are valued equally. Unlike other methods currently in use, the cut-point chosen by the sum of squares method always and efficiently chooses the cut-point closest to the top-left corner of ROC space, regardless of the shape of the ROC curve.

Cancer awareness public campaigns aim to shorten the interval between symptom onset and presentation to a doctor (the ’patient interval’). Appreciating variation in promptness of presentation can help to better target awareness campaigns. We explored variation in patient intervals recorded in consultations with general practitioners among 10,297 English patients subsequently diagnosed with one of 18 cancers (bladder, brain, breast, colorectal, endometrial, leukaemia, lung, lymphoma, melanoma, multiple myeloma, oesophageal, oro-pharyngeal, ovarian, pancreatic, prostate, renal, stomach, and unknown primary) using data from of the National Audit of Cancer Diagnosis in Primary Care (2009-2010). Proportions of patients with ’prompt’/’non-prompt’ presentation (0-14 or 15+ days from symptom onset, respectively) were described and respective odds ratios were calculated by multivariable logistic regression. The overall median recorded patient interval was 10 days (IQR 0-38). of all patients, 56% presented promptly. Prompt presentation was more frequent among older or housebound patients (p < 0.001). Prompt presentation was most frequent for bladder and renal cancer (74% and 70%, respectively); and least frequent for oro-pharyngeal and oesophageal cancer (34% and 39%, respectively, p

OBJECTIVE: to explore why patients with cancer treated by London hospitals report worse experiences of care compared with those treated in other English regions. DESIGN: Secondary analysis of the 2011/2012 National Cancer Patient Experience Survey (n=69 086). SETTING AND PARTICIPANTS: Patients with cancer treated by the English National Health Service (NHS) hospitals. MAIN OUTCOME MEASURES: 64 patient experience measures covering all aspects of cancer care (pre-diagnosis to discharge). METHODS: Using mixed effects logistic regression, we explored whether poorer scores in London hospitals could be explained by patient case-mix (age, gender, ethnicity and cancer type). Because patients referred to tertiary centres and/or with complex medical problems may report more critical experiences, we also explored whether the experiences reported in London may reflect higher concentration of teaching hospitals in the capital. Finally, using the data from the (general) Adult Inpatients Survey, we explored whether the extent of poorer experience reported by London patients was similar for respondents to either survey. RESULTS: for 52/64 questions, there was evidence of poorer experience in London, with the percentage of patients reporting a positive experience being lower compared with the rest of England by a median of 3.7% (IQR 2.5-5.4%). After case-mix adjustment there was still evidence for worse experience in London for 45/64 question [corrected]. In addition, adjusting for teaching hospital status made trivial difference to the case-mix-adjusted findings. There was evidence that London versus rest-of-England differences were greater for patients with cancer compared with (general) hospital inpatients for 10 of 16 questions in both the Cancer Patient Experience and the Adult Inpatients Surveys. CONCLUSIONS: Patients with cancer treated by London hospitals report worse care experiences and by and large these differences are not explained by patient case-mix or teaching hospital status. Efforts to improve care in London should aim to meet patient expectations and improve care quality.

BACKGROUND: ACE Inhibitors (ACE-I) and Angiotensin-Receptor Antagonists (ARAs) are commonly prescribed but can cause acute kidney injury (AKI) during intercurrent illness. Rates of hospitalization with AKI are increasing. We aimed to determine whether hospital AKI admission rates are associated with increased ACE-I/ARA prescribing. METHODS AND FINDINGS: English NHS prescribing data for ACE-I/ARA prescriptions were matched at the level of the general practice to numbers of hospital admissions with a primary diagnosis of AKI. Numbers of prescriptions were weighted for the demographic characteristics of general practices by expressing prescribing as rates where the denominator is Age, Sex, and Temporary Resident Originated Prescribing Units (ASTRO-PUs). We performed a mixed-effect Poisson regression to model the number of admissions for AKI occurring in each practice for each of 4 years from 1/4/2007. From 2007/8-2010/11, crude AKI admission rates increased from 0.38 to 0.57 per 1000 patients (51.6% increase), and national annual ACE-I/ARA prescribing rates increased by 0.032 from 0.202 to 0.234 (15.8% increase). There was strong evidence (p

OBJECTIVE: to describe the accuracy of ethnicity coding in contemporary National Health Service (NHS) hospital records compared with the ’gold standard’ of self-reported ethnicity. DESIGN: Secondary analysis of data from a cross-sectional survey (2011). SETTING: all NHS hospitals in England providing cancer treatment. PARTICIPANTS: 58 721 patients with cancer for whom ethnicity information (Office for National Statistics 2001 16-group classification) was available from self-reports (considered to represent the ’gold standard’) and their hospital record. METHODS: We calculated the sensitivity and positive predictive value (PPV) of hospital record ethnicity. Further, we used a logistic regression model to explore independent predictors of discordance between recorded and self-reported ethnicity. RESULTS: Overall, 4.9% (4.7-5.1%) of people had their self-reported ethnic group incorrectly recorded in their hospital records. Recorded White British ethnicity had high sensitivity (97.8% (97.7-98.0%)) and PPV (98.1% (98.0-98.2%)) for self-reported White British ethnicity. Recorded ethnicity information for the 15 other ethnic groups was substantially less accurate with 41.2% (39.7-42.7%) incorrect. Recorded ’Mixed’ ethnicity had low sensitivity (12-31%) and PPVs (12-42%). Recorded ’Indian’, ’Chinese’, ’Black-Caribbean’ and ’Black African’ ethnic groups had intermediate levels of sensitivity (65-80%) and PPV (80-89%, respectively). In multivariable analysis, belonging to an ethnic minority group was the only independent predictor of discordant ethnicity information. There was strong evidence that the degree of discordance of ethnicity information varied substantially between different hospitals (p

BACKGROUND AND OBJECTIVE: Falls are a major cause of morbidity and mortality in the elderly. This study examined the frequency of hospital admission for falls or fractures, and the association with a recent change in the use of cardiovascular and psychotropic medications. METHODS: We conducted a retrospective case-cohort study of 39,813 patients aged >65 years from 40 Scottish general practices. Data on current prescriptions, dates of drug changes (defined as increases in dose or starting new drugs), diagnoses and clinical measurements were extracted from primary care electronic records, linked to national hospital admissions data. Multivariable logistic regression was used to model the association of change in prescribing of cardiovascular or psychotropic medication with admission to hospital for falls or fractures in the following 60 days. RESULTS: a total of 838 patients (2.1 %) were admitted in the 1-year study period. Following adjustment for factors including age, sex, socioeconomic deprivation, co-morbidity and current prescribing, changes in both cardiovascular and psychotropic medications were associated with subsequent admission for falls or fractures (odds ratio [OR] 1.54 [95 % confidence interval (CI) 1.17-2.03] and 1.68 [95 % CI 1.28-2.22], respectively). There was no evidence for a difference in the effect of change in medication for different cardiovascular drug types (p = 0.86), but there was evidence (p = 0.003) for variation in the association between change in different psychotropic medications and admission; the strongest associations were observed for changes in selective serotonin reuptake inhibitor (SSRI) antidepressants (OR 1.99 [95 % CI 1.29-3.08]), non-SSRI/tricyclic antidepressants (OR 4.39 [95 % CI 2.21-8.71]) and combination psychotropic medication (OR 3.05 [95 % CI 1.66-5.63]). CONCLUSIONS: Recent changes in psychotropic and cardiovascular medications are associated with a substantial increase in risk of hospital admission for falls and fractures. Caution should thus be taken when instigating prescribing changes in relation to these medicines, particularly in individuals already considered to be at high risk, such as those with multiple co-morbidities and the oldest old.

Background: Changing family practice (voluntary disenrollment) without changing address may indicate dissatisfaction with care. We investigate the potential to use voluntary disenrollment as a quality indicator for primary care. Methods. Data from the English national GP Patient Survey (2,169,718 respondents), the number of voluntary disenrollments without change of address, data relating to practice characteristics (ethnicity, deprivation, gender of patients, practice size and practice density) and doctor characteristics were obtained for all family practices in England (n = 8450). Poisson regression analyses examined associations between rates of voluntary disenrollment, patient experience, and practice and doctor characteristics. Results: Mean and median rates of annual voluntary disenrollment were 11.2 and 7.3 per 1000 patients respectively. Strongest associations with high rates of disenrollment were low practice scores for doctor-patient communication and confidence and trust in the doctor (rate ratios 4.63 and 4.85). In a fully adjusted model, overall satisfaction encompassed other measures of patient experience (rate ratio 3.46). Patients were more likely to move from small practices (single-handed doctors had 2.75 times the disenrollment rate of practices with 6-9 doctors) and where there were other local practices. After allowing for these, substantial unexplained variation remained in practice rates of voluntary disenrollment. Conclusion: Family practices with low levels of patient satisfaction, especially for doctor patient communication, are more likely to experience high rates of disenrollment. However substantial variation in disenrollment rates remains among practices with similar levels of patient satisfaction, limiting the utility of voluntary disenrollment as a performance indicator for primary care in England. © 2013 Nagraj et al.; licensee BioMed Central Ltd.

Background/objectives: to determine which aspects of primary care matter most to patients, we aim to identify those aspects of patient experience that show the strongest relationship with overall satisfaction and examine the extent to which these relationships vary by socio-demographic and health characteristics. Design/setting: Data from the 2009/10 English General Practice Patient Survey including 2 169 718 respondents registered with 8362 primary care practices. Measures/analyses: Linear mixed-effects regression models (fixed effects adjusting for age, gender, ethnicity, deprivation, self-reported health, self-reported mental health condition and random practice effect) predicting overall satisfaction from six items covering four domains of care: access, helpfulness of receptionists, doctor communication and nurse communication. Additional models using interactions tested whether associations between patient experience and satisfaction varied by socio-demographic group. Results: Doctor communication showed the strongest relationship with overall satisfaction (standardized coefficient 0.48, 95% CI = 0.48, 0.48), followed by the helpfulness of reception staff (standardized coefficient 0.22, 95% CI = 0.22, 0.22). Among six measures of patient experience, obtaining appointments in advance showed the weakest relationship with overall satisfaction (standardized coefficient 0.06, 95% CI = 0.05, 0.06). Interactions showed statistically significant but small variation in the importance of drivers across different patient groups. Conclusions: for all patient groups, communication with the doctor is the most important driver of overall satisfaction with primary care in England, along with the helpfulness of receptionists. In contrast, and despite being a policy priority for government, measures of access, including the ability to obtain appointments, were poorly related to overall satisfaction. © 2013 John Wiley & Sons Ltd.

Objectives: Patients' trust in general practitioners (GPs) is fundamental to effective clinical encounters. Associations between patients' trust and their perceptions of communication within the consultation have been identified, but the influence of patients' demographic characteristics on these associations is unknown. We aimed to investigate the relative contribution of the patient's age, gender and ethnicity in any association between patients' ratings of interpersonal aspects of the consultation and their confidence and trust in the doctor. Design: Secondary analysis of English national GP patient survey data (2009). Setting: Primary Care, England, UK. Participants: Data from year 3 of the GP patient survey: 5 660 217 questionnaires sent to patients aged 18 and over, registered with a GP in England for at least 6 months; overall response rate was 42% after adjustment for sampling design. Outcome measures: We used binary logistic regression analysis to investigate patients' reported confidence and trust in the GP, analysing ratings of 7 interpersonal aspects of the consultation, controlling for patients' sociodemographic characteristics. Further modelling examined moderating effects of age, gender and ethnicity on the relative importance of these 7 predictors. Results: Among 1.5 million respondents (adjusted response rate 42%), the sense of 'being taken seriously' had the strongest association with confidence and trust. The relative importance of the 7 interpersonal aspects of care was similar for men and women. Non-white patients accorded higher priority to being given enough time than did white patients. Involvement in decisions regarding their care was more strongly associated with reports of confidence and trust for older patients than for younger patients. Conclusions: Associations between patients' ratings of interpersonal aspects of care and their confidence and trust in their GP are influenced by patients' demographic characteristics. Taking account of these findings could inform patient-centred service design and delivery and potentially enhance patients' confidence and trust in their doctor.

OBJECTIVES: to explore whether women experience greater delays in the diagnosis of bladder and renal cancer when first presenting to a general practitioner with symptoms caused by those cancers and potential reasons for such gender inequalities. DESIGN: Prospective national audit survey of cancer diagnosis. SETTING: English primary care (2009-2010). PARTICIPANTS: 920 patients with bladder and 398 patients with renal cancer (252 (27%) and 165 (42%), respectively, were women). PRIMARY AND SECONDARY OUTCOME MEASURES: Proportion of patients with three or more pre-referral consultations; number of days from first presentation to referral; proportion of patients who presented with haematuria and proportion of patients investigated in primary care. RESULTS: Women required three or more prereferral consultations more often than men (27% (95% CI 21% to 33%) vs 11% (9% to 14%) for bladder (p

Socioeconomic differences in cancer patient survival exist in many countries and across cancer sites. In our article, we estimated the number of deaths in women with breast cancer that could be avoided within 5 years from diagnosis if it were possible to eliminate socioeconomic differences in stage at diagnosis. We analysed data on East of England women with breast cancer (2006-2010). We estimated survival for different stage-age-deprivation strata using both the observed and a hypothetical stage distribution (assuming all women acquired the stage distribution of the most affluent women). Data were analysed on 20,738 women with complete stage information (92%). Affluent women were less likely to be diagnosed in advanced stage. Relative survival decreased with increasing level of deprivation. Eliminating differences in stage at diagnosis could be expected to nearly eliminate differences in relative survival for women in deprivation groups 3 and 4, but would only approximately halve the difference in relative survival for women in the most deprived group (5). This means, for a typical cohort of women diagnosed in a calendar year with breast cancer, eliminating deprivation differences in stage at diagnosis would prevent ∼40 deaths in the East of England from occurring within 5 years from diagnosis. Using appropriate weighting we estimated the respective number of avoidable deaths for the whole of England to be ∼450. The findings suggest that policies aimed at reducing inequalities in stage at diagnosis between women with breast cancer are important to reduce inequalities in breast cancer survival.

BACKGROUND: Evidence is needed about the promptness of cancer diagnosis and associations between its measures. METHODS: We analysed data from the National Audit of Cancer Diagnosis in Primary Care 2009-10 exploring the association between the interval from first symptomatic presentation to specialist referral (the primary care interval, or ’interval’ hereafter) and the number of pre-referral consultations. RESULTS: Among 13,035 patients with any of 18 different cancers, most (82%) were referred after 1 (58%) or 2 (25%) consultations (median intervals 0 and 15 days, respectively) while 9%, 4% and 5% patients required 3, 4 or 5+ consultations (median intervals 34, 47 and 97 days, respectively) (Spearman’s r=0.70). The association was at least moderate for any cancer (Spearman’s r range: 0.55 (prostate)-0.77 (brain)). Patients with cancers with a higher proportion of three or more pre-referral consultations typically also had longer median intervals (e.g. multiple myeloma) and vice versa (e.g. breast cancer). CONCLUSION: the number of pre-referral consultations has construct validity as a measure of the primary care interval. Developing interventions to reduce the number of pre-referral consultations can help improve the timeliness of cancer diagnosis, and constitutes a priority for early diagnosis initiatives and research.

BACKGROUND: the Egyptian government is considering embarking on a new wave of health sector reform. Although primary care is seen as central to the anticipated reforms, little is known about the current morbidity and utilization patterns in Egyptian publicly funded primary care. We conducted this survey study of patient encounters to describe the demographic characteristics of patients attending publicly-funded primary care practices, the relative frequency of conditions encountered in these practices, and the rates of drug prescription, investigation and referral. METHOD: Cross-sectional survey of twelve primary care practices and 2458 patient consultations. Additional secondary data were collected from five of the twelve practices for preventive services provided at these practices i.e. immunizations, family planning and ante-natal care. RESULTS: 54% of the attendances were for people below the age of twenty, of which 54% were females. In patients above the age of twenty, women accounted for 73% of consultations. Upper respiratory tract infection was the most common reason for encounter, accounting for 24% of the presentations, followed by gastroenteritis (10%), intestinal parasites (5%), and lower respiratory tract infections (5%). Over 97% of patients were prescribed at least one drug, whereas investigation and referral rates were low (15% and 5% respectively). When the analysis was repeated for practices where data on both curative and preventive services were available (5 practices and 2146 consultations), substantial proportions of patients were found to seek care for immunizations (25%), family planning (12%), and ante-natal care (11%). CONCLUSION: Most patients utilizing primary care practices in Egypt seek care for minor and preventive services with relatively few consultations for more serious conditions. There is also a pattern of prescribing drugs to most primary care patients which may reflect over-prescribing by primary care doctors.

UNLABELLED: WHAT’S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: How often orthotopic reconstruction should be used after radical cystectomy is uncertain. Male sex, younger age, affluence, white ethnicity and treatment in specialist hospitals may be associated with more frequent use. More evidence about the level and likely variation in the use of orthotopic surgery is needed to establish whether there are inequalities and unmet need. In England during the study period orthotopic bladder reconstruction was likely to be used in about one in 15 patients treated by radical cystectomy. This is lower than previously reported in US series or European studies. Men and younger patients were more likely to be treated by orthotopic reconstruction, as were more affluent patients and those with less advanced disease. Whether clinical reasons or patient choice can explain some of this variation is unclear. There was no evidence for variation between different English cancer networks. A specific procedure code to allow routine analysis of population-based nationwide data would be invaluable for ongoing monitoring of potential inequalities and unmet need. OBJECTIVE: to examine variation in the use of orthotopic bladder reconstruction. Variability in the use of orthotopic reconstruction may indicate potential for quality improvement. PATIENTS AND METHODS: We analysed data from the British Association of Urological Surgeons Cancer Registry Complex Operations data set and Hospital Episode Statistics, covering the period 2004-2011. Three-level (patient, consultant and cancer network) mixed effect logistic regression models were used to examine sociodemographic and organizational variation in use of orthotopic reconstruction. The primary outcome was the odds ratio for use of orthotopic reconstruction for different patient groups. RESULTS: the final analysis sample included 1756 patients with bladder cancer who were treated by cystectomy by 121 consultants in 17 cancer networks. of these, 120 (6.8%) were treated by orthotopic bladder reconstruction by 49 consultants in 14 cancer networks. In multivariable analysis, use of orthotopic surgery was higher in younger patients (odds ratio [OR] = 0.37 per increasing 10-year age group from 30-39 to ≥70, P ≤ 0.001) and men (OR = 2.31, P = 0.005). There was also some evidence of less frequent use among more deprived patients (OR per decreasing deprivation quintile 1.17, P = 0.037) and those with advanced disease (OR per increase in stage category 0.8, P = 0.037). After accounting for patient- and consultant-level variation, there was very limited variation in the use of orthotopic reconstruction between different cancer networks. CONCLUSIONS: Within the study context, use of orthotopic surgery was relatively rare and variable between patients with different characteristics but not between different cancer networks. The extent by which this variation reflects variation in quality of care or patient choice is uncertain. Examining the dissemination of orthotopic surgery use using nationwide data is advisable.

Purpose Clinical quality and patient experience are both widely used to evaluate the quality of health care, but the relationship between these 2 domains remains uncertain. The aim of this study was to examine this relationship using data from 2 established measures of quality in primary care in England. Methods: Practice-level analyses (N = 7,759 practices in England) were conducted on measures of patient experience from the national General Practice Patient Survey (GPPS), and measures of clinical quality from the national pay-forperformance scheme (Quality and Outcomes Framework). Spearman's rank correlation and multiple linear regression were used on practice-level estimates. Results: Although all the correlations between clinical quality summary scores and patient survey scores are positive, and most are statistically significant, the strength of the associations was weak, with the highest correlation coefficient reaching 0.18, and more than one-half were 0.11 or less. Correlations with clinical quality were highest for patient-reported access scores (telephone access 0.16, availability of urgent appointments 0.15, ability to book ahead 0.18, ability to see preferred doctor 0.17) and overall satisfaction (0.15). Conclusion: Although there are associations between clinical quality and measures of patient experience, the 2 domains of care quality remain predominantly distinct. The strongest correlations are observed between practice clinical quality and practice access, with very low correlations between clinical quality and interpersonal aspects of care. The quality of clinical care and the quality of interpersonal care should be considered separately to give an overall assessment of medical care.

BACKGROUND: Understanding socio-demographic inequalities in stage at diagnosis can inform priorities for cancer control. PATIENTS AND METHODS: We analysed data on the stage at diagnosis of East of England patients diagnosed with any of 10 common cancers, 2006-2010. Stage information was available on 88 657 of 98 942 tumours (89.6%). RESULTS: Substantial socio-demographic inequalities in advanced stage at diagnosis (i.e. stage III/IV) existed for seven cancers, but their magnitude and direction varied greatly by cancer: advanced stage at diagnosis was more likely for older patients with melanoma but less likely for older patients with lung cancer [odds ratios for 75-79 versus 65-69 1.60 (1.38-1.86) and 0.83 (0.77-0.89), respectively]. Deprived patients were more likely to be diagnosed in advanced stage for melanoma, prostate, endometrial and (female) breast cancer: odds ratios (most versus least deprived quintile) from 2.24 (1.66-3.03) for melanoma to 1.31 (1.15-1.49) for breast cancer. In England, elimination of socio-demographic inequalities in stage at diagnosis could decrease the number of patients with cancer diagnosed in advanced stage by ∼5600 annually. CONCLUSIONS: There are substantial socio-demographic inequalities in stage at diagnosis for most cancers. Earlier detection interventions and policies can be targeted on patients at higher risk of advanced stage diagnosis.

BACKGROUND: Acute kidney injury (AKI) is an independent risk factor for mortality and is responsible for a significant burden of healthcare expenditure, so accurate measurement of its incidence is important. Administrative coding data has been used for assessing AKI incidence, and shows an increasing proportion of hospital bed days attributable to AKI. However, the accuracy of coding for AKI and changes in coding over time have not been studied in England. METHODS: We studied a random sample of admissions from 2005 and 2010 where ICD-10 code N17 (acute renal failure) was recorded in the administrative coding data at one acute NHS Foundation Trust in England. Using the medical notes and computerised records we examined the demographic and clinical details of these admissions. RESULTS: Against a 6.3% (95% CI 4.8-7.9%) increase in all non-elective admissions, we found a 64% increase in acute renal failure admissions (95% CI 41%-92%, p < 0.001) in 2010 compared to 2005. Median age was 78 years (IQR 72-87), 11-25% had a relevant pre-admission co-morbidity and 64% (55-73%) were taking drugs known to be associated with AKI. Over both years, 95% (91-99%) of cases examined met the Kidney Disease: Improving Global Outcomes criteria for AKI. CONCLUSIONS: Patients with hospital admissions where AKI has been coded are elderly with multiple co-morbidities. Our results demonstrate a high positive predictive value of coding data for a clinical diagnosis of AKI, with no suggestion of marked changes in coding of AKI between 2005 and 2010.

Background: Multimorbidity, the presence of more than 1 long-term disorder, is associated with increased use of health services, but un - planned admissions to hospital may often be undesirable. Furthermore, socioeconomic de p - rivation and mental health comorbidity may lead to additional unplanned admissions. We examined the association between un planned admission to hospital and physical multi - morbidity, mental health and socioeconomic deprivation. Methods: We conducted a retrospective co - hort study using data from 180 815 patients aged 20 years and older who were registered with 40 general practices in Scotland. Details of 32 physical and 8 mental health morbidities were extracted from the patients’ electronic health records (as of Apr. 1, 2006) and linked to hospital admission data. We then recorded the occurrence of unplanned or potentially preventable unplanned acute (nonpsychiatric) admissions to hospital in the subsequent 12 months. We used logistic regression models, adjusting for age and sex, to determine associations between unplanned or potentially preventable unplanned admissions to hospital and physical multimorbidity, mental health and socioeconomic deprivation. Results: We identified 10 828 (6.0%) patients who had at least 1 unplanned admission to hospital and 2037 (1.1%) patients who had at least 1 potentially preventable unplanned admission to hospital. Both unplanned and potentially preventable unplanned admissions were independently associated with increasing physical multimorbidity (for = 4 v. 0 conditions, odds ratio [OR] 5.87 [95% confidence interval (CI) 5.45-6.32] for unplanned admissions, OR 14.38 [95% CI 11.87-17.43] for potentially preventable unplanned admissions), mental health conditions (for ≥ 1 v. 0 conditions, OR 2.01 [95% CI 1.92-2.09] for unplanned admissions, OR 1.80 [95% CI 1.64- 1.97] for potentially preventable unplanned admissions) and socioeconomic deprivation (for most v. least deprived quintile, OR 1.56 [95% CI 1.43-1.70] for unplanned admissions, OR 1.98 [95% CI 1.63-2.41] for potentially preventable unplanned admissions). Interpretation: Physical multimorbidity was strongly associated with unplanned admission to hospital, including admissions that were potentially preventable. The risk of admission to hospital was exacerbated by the coexistence of mental health conditions and socio - economic deprivation. © 2013 Canadian Medical Association or its licensors.

BACKGROUND: Exploring variation in patients’ experiences of involvement in treatment decision making can identify groups needing extra support, such as additional consultation time, when considering treatment options. METHODS: We analysed data from the 2010 English National Cancer Patient Experience Survey, a national survey of all patients attending hospitals in England for cancer treatment over a 3-month period, to examine how experience of involvement in decisions about treatment varied between patients with 38 different primary cancers using logistic regression. We analysed responses from 41 411 patients to a single question examining patient experience of involvement in treatment decision making. We calculated unadjusted odds ratios of reporting the most positive experience between patients of different sociodemographic and tumour characteristics and explored the effects of adjusting for age, gender, ethnicity, deprivation, cancer type and hospital of treatment. RESULTS: of the 41 441 respondents, 29 776 (72%) reported positive experiences of decision-making involvement. Younger patients reported substantially less positive experiences of involvement in decision making (adjusted OR=0.49 16-24 vs 65-74; P

OBJECTIVES: Data linkage combines information from several clinical data sets. The authors examined whether coding inconsistencies for cardiovascular disease between components of linked data sets result in differences in apparent population characteristics. DESIGN: Retrospective cohort study. SETTING: Routine primary care data from 40 Scottish general practitioner (GP) surgeries linked to national hospital records. PARTICIPANTS: 240 846 patients, aged 20 years or older, registered at a GP surgery. OUTCOMES: Cases of myocardial infarction, ischaemic heart disease and stroke (cerebrovascular disease) were identified from GP and hospital records. Patient characteristics and incidence rates were assessed for all three clinical outcomes, based on GP, hospital, paired GP/hospital (similar diagnoses recorded simultaneously in both data sets) or pooled GP/hospital records (diagnosis recorded in either or both data sets). RESULTS: for all three outcomes, the authors found evidence (p

Background: Interpersonal continuity of care is valued by patients, but there is concern that it has declined in recent years. Aim: to determine how often patients express preference for seeing a particular GP and the extent to which that preference is met. Design of study: Analysis of data from the 2009/2010 English GP Patient Survey. Setting: a stratified random sample of adult patients registered with 8362 general practices in England (response rate 39%, yielding 2 169 718 responses). Method: Weighted estimates were calculated of preference for and success in seeing a particular GP. Multilevel logistic regression was used to identify characteristics associated with these two outcomes. Results: Excluding practices with one GP, 62% of patients expressed a preference for seeing a particular GP. of these patients, 72% were successful in seeing their preferred GP most of the time. Certain patient groups were associated with more preference for and success in seeing a particular GP. These were older patients (preference odds ratio [OR] = 1.7, success OR = 1.8), those with chronic medical conditions (preference OR = 1.9, success OR = 1.3), those with chronic psychological conditions (preference OR = 1.6, success OR = 1.3), and those recently requesting only non-urgent versus urgent appointments (preference OR = 1.4, success OR = 1.6). Patient groups that had more frequent preference but less success in seeing a preferred GP were females (preference OR = 1.5, success OR = 0.9), patients in larger practices (preference OR = 1.3, success OR = 0.5), and those belonging to non-white ethnic groups. Conclusion: the majority of patients value interpersonal continuity, yet a large minority of patients and specific patient groups are not regularly able to see the GP they prefer. ©British Journal of General Practice.

Deprivation is multi-dimensional, and as such can be challenging to quantify. In the UK, each of the four constituent countries measures deprivation using their own distinct index of multiple deprivation (IMD), designed to facilitate targeting of policies within that particular country. Although these four IMD scores are not directly comparable, there are circumstances where comparison across the whole of the UK may be desirable.

Background: Understanding variation in stage at diagnosis can inform interventions to improve the timeliness of diagnosis for patients with different cancers and characteristics. Methods: We analysed population-based data on 17 836 and 13 286 East of England residents diagnosed with (female) breast and lung cancer during 2006-2009, with stage information on 16 460 (92%) and 10 435 (79%) patients, respectively. Odds ratios (ORs) of advanced stage at diagnosis adjusted for patient and tumour characteristics were derived using logistic regression. Results :We present adjusted ORs of diagnosis in stages III/IV compared with diagnosis in stages I/II. For breast cancer, the frequency of advanced stage at diagnosis increased stepwise among old women (ORs: 1.21, 1.46, 1.68 and 1.78 for women aged 70-74, 75-79, 80-84 and ≥85, respectively, compared with those aged 65-69, P

BACKGROUND: Information from patient surveys can help to identify patient groups and cancers with the greatest potential for improvement in the experience and timeliness of cancer diagnosis. We aimed to examine variation in the number of pre-referral consultations with a general practitioner between patients with different cancers and sociodemographic characteristics. METHODS: We analysed data from 41,299 patients with 24 different cancers who took part in the 2010 National Cancer Patient Experience Survey in England. We examined variation in the number of general practitioner consultations with cancer symptoms before hospital referral to diagnose cancer. Logistic regression was used to identify independent predictors of three or more pre-referral consultations, adjusting for cancer type, age, sex, deprivation quintile, and ethnic group. FINDINGS: We identified wide variation between cancer types in the proportion of patients who had visited their general practitioner three or more times before hospital referral (7·4% [625 of 8408] for breast cancer and 10·1% [113 of 1124] for melanoma; 41·3% [193 of 467] for pancreatic cancer and 50·6% [939 of 1854] for multiple myeloma). In multivariable analysis, with patients with rectal cancer as the reference group, those with subsequent diagnosis of multiple myeloma (odds ratio [OR] 3·42, 95% CI 3·01-3·90), pancreatic cancer (2·35, 1·91-2·88), stomach cancer (1·96, 1·65-2·34), and lung cancer (1·68, 1·48-1·90) were more likely to have had three or more pre-referral consultations; conversely patients with subsequent diagnosis of breast cancer (0·19; 0·17-0·22), melanoma (0·34, 0·27-0·43), testicular cancer (0·47, 0·33-0·67), and endometrial cancer (0·59, 0·49-0·71) were more likely to have been referred to hospital after only one or two consultations. The probability of three or more pre-referral consultations was greater in young patients (OR for patients aged 16-24 years vs 65-74 years 2·12, 95% CI 1·63-2·75; p

People with psychological problems face important challenges in obtaining high quality healthcare. We review evidence on the experience of primary care by people with mental health problems, including reasons why their care may be reported as worse than other groups. In the 2009 English GP Patient Survey, 5.7% of 2,163,456 respondents reported that they had a long-standing psychological or emotional condition. In an unadjusted regression model, respondents with long-standing emotional or psychological conditions rated their experiences worse than people without such problems, with scores which were up to 3 percentage points lower on individual survey items. However, after controlling for age, gender, ethnicity, deprivation and self-reported general health, people with long-standing psychological or emotional problems had slightly higher scores on 16 out of the 18 survey items, though with the equivalent of less than 2 percentage points difference for most items. Part of the reason for the difference between the adjusted and unadjusted models was the high prevalence of self-reported ’fair’ or ’poor’ general health among people who reported psychological problems. Overall, the results suggest that people with long-standing psychological and emotional conditions have similar experiences of English primary care compared to the rest of the population.