International variation in adherence to referral guidelines for suspected cancer: a secondary analysis of survey data
British Journal of General Practice
Royal College of General Practitioners
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Under indefinite embargo due to publisher policy. The final version is available from the publisher via the DOI in this record.
BACKGROUND: Variation in cancer survival persists between comparable nations and appears to be due, in part, to primary care practitioners (PCPs) having different thresholds for acting definitively in response to cancer-related symptoms. AIM: To explore whether cancer guidelines, and adherence to them, differ between jurisdictions and impacts on PCPs' propensity to take definitive action on cancer-related symptoms. DESIGN AND SETTING: A secondary analysis of survey data from six countries (10 jurisdictions) participating in the International Cancer Benchmarking Partnership. METHOD: PCPs' responses to five clinical vignettes presenting symptoms and signs of lung (n = 2), colorectal (n = 2), and ovarian cancer (n = 1) were compared with investigation and referral recommendations in cancer guidelines. RESULTS: Nine jurisdictions had guidelines covering the two colorectal vignettes. For the lung vignettes, although eight jurisdictions had guidelines for the first, the second was covered by a Swedish guideline alone. Only the UK and Denmark had an ovarian cancer guideline. Survey responses of 2795 PCPs (crude response rate: 12%) were analysed. Guideline adherence ranged from 20-82%. UK adherence was lower than other jurisdictions for the lung vignette covered by the guidance (47% versus 58%; P <0.01) but similar (45% versus 46%) or higher (67% versus 38%; P <0.01) for the two colorectal vignettes. PCPs took definitive action least often when a guideline recommended a non-definitive action or made no recommendation. UK PCPs adhered to recommendations for definitive action less than their counterparts (P <0.01). There wasno association between jurisdictional guideline adherence and 1-year survival. CONCLUSION: Cancer guideline content is variable between similarly developed nations and poor guideline adherence does not explain differential survival. Guidelines that fail to cover high-risk presentations or that recommend non-definitive action may reduce definitive diagnostic action.
This work was supported by Canadian Partnership Against Cancer; Cancer Care Manitoba; Cancer Care Ontario; Cancer Council Victoria; Cancer Institute New South Wales; Danish Health and Medicines Authority; Danish Cancer Society; Department of Health, England; Department of Health, Victoria; Northern Ireland Cancer Registry; the Public Health Agency, Northern Ireland; Norwegian Directorate of Health; South Wales Cancer Network; Swedish Association for Local Authorities and Regions; Tenovus; British Columbia Cancer Agency; Public Health Wales and the Welsh Government. Brian Nicholson was funded by Cancer Research UK and the National Institute for Health Research (NIHR) School for Primary Care Research. Bethany Shinkins is an NIHR-funded research fellow and Richard Neal receives funding from Public Health Wales and Betsi Cadwaladr University Health Board. The views expressed are those of the author(s) and not necessarily those of the funders.
This is the final version of the article. Available from Royal College of General Practitioners via the DOI in this record.
Vol. 66 (643): e106 -e113
Place of publication