British Journal of General Practice最新文献

Background: Evidence is equivocal on whether general practice rates of investigation in symptomatic patients using chest X-ray (CXR) affect outcomes.

Aim: To determine whether there is an association between rates of CXR requested in general practice and lung cancer outcomes.

Design and setting: Observational study using data on English general practices.

Method: Cancer registry data for patients diagnosed with lung cancer in 2014-2018 were linked to data on general practice CXRs from 2013 until 2017. Cancer stage at diagnosis (I/II versus III/IV) and 1-year and 5-year survival rates (conditional on survival to 1 year) post-diagnosis were reported by general practice quintile of CXR rate, with adjustment for population differences (age, smoking, prevalence of chronic obstructive pulmonary disease and heart failure, ethnicity, and deprivation) and by unadjusted category (low, medium, and high).

Results: In total, 192 631 patient records and CXR rates for 7409 practices were obtained. Practices in the highest quintile of CXR rate had fewer cancers diagnosed at stage III/IV compared with those in the lowest quintile (odds ratio [OR] 0.87, 95% confidence interval [CI] = 0.83 to 0.92, P<0.001). The association was weaker for the high unadjusted CXR category (OR 0.94, 95% CI = 0.91 to 0.97). For the highest adjusted quintile, hazard ratios (HRs) for death within 1 year and 5 years were 0.92 (95% CI = 0.90 to 0.95, P<0.001) and 0.95 (95% CI = 0.91 to 0.99, P = 0.023), respectively. For the high unadjusted CXR category, the HR for 1-year survival was 0.98 (95% CI = 0.96 to 0.99, P = 0.004), with no association demonstrated for 5-year survival.

Conclusion: Patients registered at general practices with higher CXR use have a favourable stage distribution and slightly better survival. This supports the use of CXR in promoting earlier diagnosis of symptomatic lung cancer in general practice.

Background: England is short of GPs, and GP consultation rates, consultation duration, and workload are increasing. Electronic clinical decision support tools assist decision making for screening, diagnosis, and risk management. Cancer detection is one area in which tools are designed to support GPs, with some electronic risk assessment tools (eRATs) estimating the risk of current cancer based on symptoms.

Aim: To explore any association between the impact of eRATs and GP workload and workflow during consultations.

Design and setting: Observational sub-study.

Method: Thirteen practices in England participating in a cluster randomised controlled trial of eRATs were recruited to the study. Using mixed-effects regression models, the average duration of consulting sessions and individual consultations in which eRATs were, or were not, activated were compared.

Results: There was no evidence that consulting sessions in which an eRAT was activated were, on average, longer than sessions in which an eRAT had not been activated. However, after adjusting for a range of session and consultation characteristics, individual consultations involving an eRAT were longer, on average, by 3.96 minutes (95% confidence interval = 3.45 to 4.47; P<0.001) when compared with consultations with no eRAT.

Conclusion: There was no evidence to suggest that eRATs should not be used to support GPs in early cancer diagnosis from a workload perspective. Activation of eRATs was not associated with increased workload across a consulting session, despite a small increase in time observed in individual consultations involving eRATs. Ultimately, therefore, it should be definitive findings regarding the clinical effectiveness of eRATs, not the related workload/workflow implications, that determine whether the use of eRATs should be rolled out more widely.

Background: Prostate-specific antigen (PSA) is used in primary care for prostate cancer detection, either for symptomatic assessment or asymptomatic testing following an informed decision.

Aim: To estimate the proportion of patients with prostate cancer who were diagnosed following asymptomatic PSA testing, and the patient and practice factors influencing this route.

Design and setting: The 2018 English National Cancer Diagnosis Audit (NCDA) data were analysed, with linkage to the National Cancer Registration and Analysis Service, practice-level Quality and Outcomes Framework (QOF), and GP Patient Survey (GPPS) data. All 2018 NCDA patients with a diagnosis of prostate cancer were included (n = 9837).

Method: Patients with recorded biomarker testing and no recorded symptoms before diagnosis were classified as having asymptomatic PSA-detected prostate cancer. Patient (age, ethnicity, deprivation, and comorbidities) and practice (geographical location, area deprivation, list size, urgent suspected cancer referral rate, QOF outcomes, and GPPS results) factors were analysed for association with asymptomatic PSA testing using mixed-effects logistic regression models.

Results: In total, 1884 out of 9837 (19.2%) patients with prostate cancer were detected following asymptomatic PSA testing, 982 (52.1%) of whom were aged 50-69 years. Younger age, non-White ethnicity, lower deprivation, and lower comorbidity count were associated with an increased likelihood of diagnosis following asymptomatic PSA testing. There was a 13-fold variation between practices in the odds of detecting prostate cancer through asymptomatic PSA testing, without clear explanatory practice-level factors.

Conclusion: One in five patients with prostate cancer in England are diagnosed after asymptomatic PSA testing in primary care, with large variation in asymptomatic PSA detection between practices.