What explains variations between GP practices in endoscopy activity and urgent referral for suspected cancer? What can we learn from measures of patient experience?

Appropriately suspecting the diagnosis of cancer in primary care is important, but it is also hard. In this work, we looked into some of the factors that that may (or may not) influence decisions about referrals and endoscopic investigations.

In our paper just published in the BJGP (British Journal of General Practice), we looked at how patient-reported measures of access and continuity of care, and the listening skills of the doctor, may be linked to variation between different general practices in diagnostic activity for suspected cancer. We particularly examined general practice variation in the use of endoscopies and urgent referrals because previous research showed that it may influence the subsequent prognosis of patients.

We found that general practices where patients reported it was easier to see their preferred doctor also had lower rates of endoscopies and urgent referrals. On the contrary, practices that scored higher in doctor communication skills had higher rates of diagnostic activity. Helpfulness of receptionists and ability to book appointments, along with nurse communication skills, did not appear to be associated with diagnostic activity.

Continuity of care is usually regarded as a sign of better quality primary care. However, our study shows that continuity of care may influence decisions about the use of investigations and referrals in a way that leads to lower levels of activity. Although we were not able to test this hypothesis directly, the results may suggest that greater familiarity with the patient may lead the doctor to attribute new symptoms to pre-existing conditions.

We believe there may be three different mechanisms through which we believe doctor communication may be associated with use of investigations and referrals. Firstly, doctors with good communication skills may be able to elicit additional information from their patients about their symptoms. Secondly, such doctors may be more susceptible to patient demand for investigations or referrals. Finally, patients may have a tendency to ‘reward’ practices with higher communication ratings if their doctors investigate or refer more easily.

We should highlight that, although other evidence indicates that lower use of urgent referrals for suspected cancer and endoscopies could lead to poorer outcomes, higher rates will increase resource use, and can disadvantage some patients who may be investigated but found not to have cancer.  Although the 2015 National Institute for Health and Care Excellence guidelines for suspected cancer implicitly suggest that higher rates of urgent referrals would be beneficial, we cannot determine the optimal level of use urgent referrals and endoscopies through studies such as ours, which, however, suggest potential mechanisms that lead to variation in their use.

Photo credit: Dr Jon Ferdinand at the Primary Care Unit, University of Cambridge

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  • The Cambridge Centre for Health Services Research (CCHSR) is a thriving collaboration between the University of Cambridge and RAND Europe. We aim to inform health policy and practice by conducting research and evaluation studies of organisation and delivery of healthcare, including safety, effectiveness, efficiency and patient experience.