Removing hospital-based triage from suspected colorectal cancer pathways: the impact and learning from a primary care-led electronic straight-to-test pathway

2020 ◽  
pp. bmjqs-2019-009975
Author(s):  
Philippa Orchard ◽  
Nitin Arvind ◽  
Alison Wint ◽  
James Kynaston ◽  
Ann Lyons ◽  
...  
Keyword(s):  
Colorectal Cancer ◽  
Primary Care ◽  
Dramatic Improvement ◽  
Hospital System ◽  
Cancer Data ◽  
Cancer Pathways ◽  
Referral Criteria ◽  
Nice Guidance ◽  
Referral Form ◽  
The Impact

BackgroundThe 2-week wait referral pathway for suspected colorectal cancer was introduced in England to improve time from referral from a general practitioner (GP) to diagnosis and treatment. Patients are required to be seen by a hospital clinician within 2 weeks if their symptoms meet the criteria set by the National Institute for Health and Care Excellence (NICE) and to start cancer treatment within 62 days. To achieve this, many hospitals have introduced a straight-to-test (STT) strategy requiring hospital-based triage of referrals. We describe the impact and learning from a new pathway which has removed triage and moved the process of requesting tests from hospital to GPs in primary care.MethodAn electronic STT pathway was introduced allowing GPs to book tests supported by a decision aid based on NICE guidance eliminating the need for a standard referral form or triage process. The hospital identified referrals as being on a cancer pathway and dealt with all ongoing management. Routinely collected cancer data were used to identify time to cancer diagnosis compared with national dataResults11357 patients were referred via the new pathway over 3 years. Time from referral to diagnosis reduced from 39 to 21 days and led to a dramatic improvement in patients starting treatment within 62 days. Challenges included adapting to a change in referral criteria and developing a robust hospital system to monitor the pathway.ConclusionWe have changed the way patients with suspected colorectal cancer are managed within the National Health Service by giving GPs the ability to order tests electronically within a monitored cancer pathway halving time from referral to diagnosis

scholarly journals Quantifying and mitigating the impact of the COVID-19 pandemic on outcomes in colorectal cancer

2020 ◽  
Author(s):  
Amit Sud ◽  
Michael Jones ◽  
John Broggio ◽  
Stephen Scott ◽  
Chey Loveday ◽  
...  
Keyword(s):  
Colorectal Cancer ◽  
Primary Care ◽  
Cancer Research ◽  
Age Groups ◽  
Patient Delay ◽  
Rational Approach ◽  
Cancer Pathways ◽  
Specific Stage ◽  
Crc Management ◽  
The Impact

ABSTRACTBackgroundThe COVID-19 pandemic has caused disruption across cancer pathways for diagnosis and treatment. In England, 32% of colorectal cancer (CRC) is diagnosed via urgent symptomatic referral from primary care, the “2-week-wait” (2WW) pathway. Access to routine endoscopy is likely to be a critical bottleneck causing delays in CRC management due to chronic limitation in capacity, acute competition for physician time, and safety concerns.MethodsWe used age-specific, stage-specific 10 year CRC survival for England 2007–2017 and 2WW CRC cases volumes. We used per-day hazard ratios of CRC survival generated from observational studies of CRC diagnosis-to-treatment interval to model the effect of different durations of per-patient delay. We utilised data from a large London observational study of faecal immunochemical testing (FIT) in symptomatic patients to model FIT-triage to mitigate delay to colonoscopy.FindingsModest delays result in significant reduction in survival from CRC with a 4-month delay resulting across age groups in ≥20% reduction in survival in Stage 3 disease and in total over a year, 1,419 attributable deaths across the 11,266 CRC patients diagnosed via the 2WW pathway. FIT triage of >10 ug Hb/g would salvage 1,292/1,419 of the attributable deaths and reduce colonoscopy requirements by >80%. Diagnostic colonoscopy offers net survival in all age groups, providing nosocomial COVID-19 infection rates are kept low (<2·5%).InterpretationTo avoid significant numbers of avoidable deaths from CRC, normal diagnostic and surgical throughput must be maintained. An accrued backlog of cases will present to primary care following release of lockdown, supranormal endoscopy capacity will be required to manage this without undue delays. FIT-triage of symptomatic cases provides a rational approach by which to avoid patient delay and mitigate pressure on capacity in endoscopy. This would also reduce exposure to nosocomial COVID-19 infection, relevant in particular to older patient groups.FundingBreast Cancer Now, Cancer Research UK, Bobby Moore Fund for Cancer Research, National Institute for Health Research (NIHR).

scholarly journals Development, validation and effectiveness of diagnostic prediction tools for colorectal cancer in primary care: a systematic review

BMC Cancer ◽  
2020 ◽  
Vol 20 (1) ◽  
Author(s):  
Bogdan Grigore ◽  
Ruth Lewis ◽  
Jaime Peters ◽  
Sophie Robinson ◽  
Christopher J. Hyde
Keyword(s):  
Colorectal Cancer ◽  
Systematic Review ◽  
Primary Care ◽  
Cost Effectiveness ◽  
Prediction Model ◽  
Prediction Models ◽  
Diagnostic Tools ◽  
Inclusion Criteria ◽  
Impact Studies ◽  
The Impact

Abstract Background Tools based on diagnostic prediction models are available to help general practitioners (GP) diagnose colorectal cancer. It is unclear how well they perform and whether they lead to increased or quicker diagnoses and ultimately impact on patient quality of life and/or survival. The aim of this systematic review is to evaluate the development, validation, effectiveness, and cost-effectiveness, of cancer diagnostic tools for colorectal cancer in primary care. Methods Electronic databases including Medline and Web of Science were searched in May 2017 (updated October 2019). Two reviewers independently screened titles, abstracts and full-texts. Studies were included if they reported the development, validation or accuracy of a prediction model, or assessed the effectiveness or cost-effectiveness of diagnostic tools based on prediction models to aid GP decision-making for symptomatic patients presenting with features potentially indicative of colorectal cancer. Data extraction and risk of bias were completed by one reviewer and checked by a second. A narrative synthesis was conducted. Results Eleven thousand one hundred thirteen records were screened and 23 studies met the inclusion criteria. Twenty-studies reported on the development, validation and/or accuracy of 13 prediction models: eight for colorectal cancer, five for cancer areas/types that include colorectal cancer. The Qcancer models were generally the best performing. Three impact studies met the inclusion criteria. Two (an RCT and a pre-post study) assessed tools based on the RAT prediction model. The third study looked at the impact of GP practices having access to RAT or Qcancer. Although the pre-post study reported a positive impact of the tools on outcomes, the results of the RCT and cross-sectional survey found no evidence that use of, or access to, the tools was associated with better outcomes. No study evaluated cost effectiveness. Conclusions Many prediction models have been developed but none have been fully validated. Evidence demonstrating improved patient outcome of introducing the tools is the main deficiency and is essential given the imperfect classification achieved by all tools. This need is emphasised by the equivocal results of the small number of impact studies done so far.

scholarly journals Anaemia as a risk stratification tool for symptomatic patients referred via the two-week wait pathway for colorectal cancer

2018 ◽  
Vol 100 (5) ◽  
pp. 350-356 ◽  
Author(s):  
S Mashlab ◽  
P Large ◽  
W Laing ◽  
O Ng ◽  
M D’Auria ◽  
...  
Keyword(s):  
Colorectal Cancer ◽  
Fold Increase ◽  
World Health ◽  
Full Blood Count ◽  
Bowel Habit ◽  
Referral Criteria ◽  
Risk Stratification Tool ◽  
Period Data ◽  
Health Organization ◽  
The Impact

Introduction Anaemia is associated with cancer. In 2014 a new form was introduced in our department requesting a haemoglobin (Hb) result on every two-week wait referral for suspected colorectal cancer (CRC). The aim of this study was to review the impact of this intervention. In particular, the significance of any evidence of anaemia (without additional indices) was investigated. Methods A review was conducted of 1,500 consecutive suspected CRC referrals recorded prospectively over a 10-month period. Data on demographics, referral Hb, referral criteria and outcomes were analysed. Anaemia was defined according to World Health Organization criteria (Hb <120g/l for women, Hb <130g/l for men). Results Overall, 1,015 patients were eligible for inclusion in the study. Over a third (38.2%) were documented as anaemic on referral. These patients were three times more likely to be diagnosed with CRC than non-anaemic patients (odds ratio [OR]: 3.22, 95% confidence interval [CI]: 1.87–5.57). Using a more stringent threshold (Hb <100g/l for women and <110g/l for men), they were four times more likely to have CRC (OR: 4.27, 95% CI: 2.35–7.75). Almost a quarter (23.7%) were actually anaemic at the time of referral but not referred with anaemia. In this subgroup, there was a 2.8-fold increase in risk of CRC diagnosis compared with non-anaemic patients (adjusted OR: 2.77, 95% CI: 1.55–4.95). Conclusions Nearly a quarter of patients not referred with iron deficiency anaemia had evidence of anaemia and this was still associated with a higher rate of CRC detection. A full blood count alone might help to risk stratify symptoms such as change in bowel habit in patients on urgent pathways and identify those cases most likely to benefit from invasive investigation.

scholarly journals Impact of the 2015 NICE guidance for urgent assessment of patients with non-visible haematuria

2019 ◽  
Vol 13 (1) ◽  
pp. 56-61 ◽  
Author(s):  
Joseph B John ◽  
Saliya Wijeyaratne ◽  
Mark Speakman
Keyword(s):  
Transitional Cell ◽  
High Rate ◽  
Muscle Invasive Bladder Cancer ◽  
Level Of Evidence ◽  
Referral Criteria ◽  
Nice Guidance ◽  
Diagnosis Rate ◽  
Muscle Invasive ◽  
The Impact ◽  
Low Rate

Objectives: To assess the impact of the 2015 National Institute of Health and Care Excellence (NICE) guidance for referral of non-visible haematuria (NVH) and to compare diagnostic findings in patients referred using 2005 and 2015 guidance. Patients and method: Review of the referral details and diagnostic findings for urgent NVH referrals was assessed over a 27-month period. Referrals continued to be received under 2005 and 2015 NICE guidance during this period, and the diagnostic findings from each pathway were compared. Results: The number of urgent haematuria referrals reduced by 34% over the 27-month period. NVH referrals fell from 144 in the first quarter to 30 in the last quarter. The transitional cell carcinoma (TCC) diagnosis rate was low in patients referred using 2005 and 2015 criteria (1.7 and 1.9% respectively). No muscle-invasive bladder cancer (MIBC) was diagnosed. There was a high rate of benign urological findings. Non-adherence to referral criteria was high in the 2015 pathway (56%). Conclusion: The reduction in NVH referrals following introduction of 2015 NICE guidance could allow resource re-allocation. Low adherence to referral criteria should be investigated. The absence of MIBC and low rate of TCC diagnosis is reassuring and consideration should be given to investigating NVH patients semi-urgently. Level of evidence: 2C

scholarly journals 1542 An Audit of Rates of Lynch Testing in Confirmed Colorectal Cancer Cases

2021 ◽  
Vol 108 (Supplement_6) ◽  
Author(s):  
E Cribb ◽  
F Liccardo ◽  
S Crisford ◽  
N Pawa
Keyword(s):  
Colorectal Cancer ◽  
Lynch Syndrome ◽  
Mismatch Repair ◽  
Service Provision ◽  
Oncological Treatment ◽  
Cancer Services ◽  
Significant Difference ◽  
Nice Guidance ◽  
The Uk ◽  
The Impact

Abstract Introduction 12% of cancers in the UK are colorectal in origin1 with 1-3% secondary to genetic mismatch repair due to Lynch syndrome2, for which the 2017 NICE guidance recommended that patients with colorectal cancer (CRC) be tested3. It increases the risk of developing other cancers such as endometrial, ovarian and small bowel1, changes the oncological treatment offered to CRC patients4,5, and prompts investigation of their relatives for the condition. In this audit we assessed our rates of trust wide Lynch testing. Method Patients with a diagnosis of CRC from 2017-2019 were identified from records held by our cancer services department. Histology results were obtained from an online results portal. Results 345 were included in the analysis, 79% of which were tested for Lynch, with time taken from biopsy to results ranging from 2 to 276 days (average 45). 54% had results within 30 days, 34% between 30 and 90 days and 12% exceeded 90 days. There was no significant difference of Lynch testing rates between each year. The proportion of results returned within 30 days increased by year, with rates of 30% (2017), 55% (2018) and 71% (2019). The median days from biopsy to results also improved, from 39 to 28 and 16 days, respectively. Conclusions Rates and efficiency of our screening for lynch syndrome need improvement to meet the target suggested by NICE. The impact of the recent centralisation our regions pathology department on Lynch testing service provision requires further investigation.

scholarly journals EP.TU.333FIT stratification in the COVID era - Is it safe for rectal bleeding?

2021 ◽  
Vol 108 (Supplement_7) ◽  
Author(s):  
Jaspreet Seehra ◽  
James Bailey ◽  
Caroline Chapman ◽  
Joanne Morling ◽  
David Humes ◽  
...  
Keyword(s):  
Colorectal Cancer ◽  
Primary Care ◽  
Rectal Bleeding ◽  
Digital Rectal Examination ◽  
Final Analysis ◽  
Bowel Habit ◽  
Hospital System ◽  
Testing Protocol ◽  
Low Threshold ◽  
Electronic Hospital

Abstract Aims Faecal Immunochemical Tests (FIT) are increasingly used for stratification of colorectal cancer risk in symptomatic patients. FIT is not currently recommended for use in patients with rectal bleeding, but recent studies have reported its safe use. We report our experiences of FIT in patients presenting with rectal bleeding during the COVID-19 pandemic. Methods Patients referred to NUH NHS Trust with rectal bleeding from 15/04/20-15/08/20 were invited to complete a postal-based FIT (OC-Sensor). Demographics, symptoms, investigations and results were recorded. Outcomes were retrospectively reviewed using an electronic hospital system. Result 344 patients were invited to participate, with 301 (87.5%) returning FITs in accordance with testing protocol. 36 patients declined to be seen, 4 were considered not fit for investigation, and 4 had incomplete records. 257 patients were included in the final analysis with 10 CRC detected (3.9%). Rectal bleeding (257, 100%) was the most common presenting symptom followed by change in bowel habit (133, 51.8%). 10 CRC were diagnosed (3.9%). 2 CRC were detected with FIT &lt;4 µg Hb / g faeces (2/137, 1.5%) and 8 were detected &gt;100 µg Hb / g faeces (8/45, 17.8%). FIT result was significantly associated with CRC diagnosis (p &lt; 0.0001). 4 with CRC had anaemia (4/53, 7.5%), 1 had thrombocytosis (1/12, 8.3%). Conclusions FIT missed 20% of CRC in this patient group with the application of a very low threshold (&lt;4 µg Hb / g faeces). Both cancers missed by FIT were detectable on digital rectal examination, emphasising the importance of this examination in primary care.

scholarly journals The Impact of an Evidence-Based Multi-component Intervention on Colorectal Cancer Screening in Primary Care at a Healthcare System

2021 ◽  
Author(s):  
◽  
Ahnnya Slaughter
Keyword(s):  
Colorectal Cancer ◽  
Primary Care ◽  
Cancer Screening ◽  
Colorectal Cancer Screening ◽  
Healthcare System ◽  
The United States ◽  
The Body ◽  
Average Risk ◽  
Number Of Patients ◽  
The Impact

Practice Problem: Colorectal cancer is the second leading cause of cancer death in the United States; many of the deaths are preventable with early detection. Adherence rates for colorectal cancer screening with fecal immunochemical test kits (FIT) was below the national benchmark at this facility. PICOT: The PICOT question that guided this project was: Among veterans 50 – 75 years old requiring average risk colorectal cancer screening (CRCS) seen in primary care at a veterans affairs healthcare system facility (P), how does the use of a multi-component intervention (I), compared to the usual care (C), affect the number of patients completing CRCS (O) over a period of 12 weeks (T)? Evidence: Review of high-quality studies suggested a multi-component approach, including increasing provider awareness and increasing patient education and outreach, as the most effective approach to increase colorectal screening compliance. Intervention: The multi-component intervention included a standardized CRCS nurse navigation process through standard work which included the teach-back method, patient outreach, and provider feedback. Outcome: There were clinically significant improvements in adherence with returned FIT kits, follow up for abnormal FIT kits, and statistically significant improvements with nursing documentation of patient teaching. The number of patients overdue for CRCS decreased. Conclusion: The multi-component CRCS screening intervention demonstrated significant improvements in the intervention clinics which is consistent with the body of evidence.

The Perspective of Older Men With Depression on Suicide and Its Prevention in Primary Care

Crisis ◽  
2018 ◽  
Vol 39 (5) ◽  
pp. 397-405 ◽  
Author(s):  
Steven Vannoy ◽  
Mijung Park ◽  
Meredith R. Maroney ◽  
Jürgen Unützer ◽  
Ester Carolina Apesoa-Varano ◽  
...  
Keyword(s):  
Primary Care ◽  
Low Socioeconomic Status ◽  
Thematic Analysis ◽  
Older Men ◽  
Primary Care Providers ◽  
Depression Treatment ◽  
Care Providers ◽  
Low Socioeconomic ◽  
Self Image ◽  
The Impact

Abstract. Background: Suicide rates in older men are higher than in the general population, yet their utilization of mental health services is lower. Aims: This study aimed to describe: (a) what primary care providers (PCPs) can do to prevent late-life suicide, and (b) older men's attitudes toward discussing suicide with a PCP. Method: Thematic analysis of interviews focused on depression and suicide with 77 depressed, low-socioeconomic status, older men of Mexican origin, or US-born non-Hispanic whites recruited from primary care. Results: Several themes inhibiting suicide emerged: it is a problematic solution, due to religious prohibition, conflicts with self-image, the impact on others; and, lack of means/capacity. Three approaches to preventing suicide emerged: talking with them about depression, talking about the impact of their suicide on others, and encouraging them to be active. The vast majority, 98%, were open to such conversations. An unexpected theme spontaneously arose: "What prevents men from acting on suicidal thoughts?" Conclusion: Suicide is rarely discussed in primary care encounters in the context of depression treatment. Our study suggests that older men are likely to be open to discussing suicide with their PCP. We have identified several pragmatic approaches to assist clinicians in reducing older men's distress and preventing suicide.

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