title: Barriers to the diagnosis and treatment of venous thromboembolism in advanced cancer patients: a qualitative study.
abstract: BACKGROUND
  Venous thromboembolism is common in patients with cancer and the risk increases with advanced disease. Evidence-based treatment is administration of low-molecular-weight heparin daily by subcutaneous injection. Clinical uncertainty exists as to whether treating venous thromboembolism in advanced disease is in the patient's best interests.
  
  
  OBJECTIVE
  To explore the barriers faced by doctors when diagnosing and treating patients with cancer-associated thrombosis.
  
  
  METHODS
  Qualitative, in-depth interview study using framework analysis.
  
  
  METHODS
  Forty-five UK doctors across urban and rural settings, from three specialties, oncology, palliative medicine and general practice, with a mixture of senior and junior staff.
  
  
  RESULTS
  Organisational constraints served to act as barriers to the diagnosis and treatment of this patient group. Issues were identified around access to diagnostic testing. A cancer-associated thrombosis patient having to wait for a scan as an inpatient was sometimes deemed unnecessary. Patient ambulance transport (especially transportation of hospice patients) was often viewed as inflexible and bureaucratic. Low-molecular-weight heparin prescribing had sometimes led to tension between the acute, community and hospice sectors about whose prescribing responsibility this was, with different areas having divergent 'rules' and practices. Finally, the doctors interviewed discussed the role of nurses.
  
  
  CONCLUSIONS
  Multiple logistical barriers are hindering best patient care for people with cancer-associated thrombosis. There is scope for some of these barriers to be reduced to improve service delivery and ultimately patient care. The research team proposes practical recommendations, which could yield direct benefit for patients and the health services.
authors.affiliation: Department of Health Sciences, University of York, York, UK. laura.sheard@york.ac.uk
authors.forename: Laura
authors.initials: L
authors.lastname: Sheard
authors.forename: Hayley
authors.initials: H
authors.lastname: Prout
authors.forename: Dawn
authors.initials: D
authors.lastname: Dowding
authors.forename: Simon
authors.initials: S
authors.lastname: Noble
authors.forename: Ian
authors.initials: I
authors.lastname: Watt
authors.forename: Anthony
authors.initials: A
authors.lastname: Maraveyas
authors.forename: Miriam
authors.initials: M
authors.lastname: Johnson
mesh_terms: D000328:Adult; D003937:Diagnosis, Differential; D005260:Female; D017144:Focus Groups; D006297:Health Services Accessibility / Q000592:standards; D006495:Heparin, Low-Molecular-Weight / Q000008:administration & dosage / Q000627:therapeutic use; D006801:Humans; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000150:complications*; D009934:Organization and Administration / Q000592:standards; D010166:Palliative Care / Q000941:ethics*; D036301:Qualitative Research; D054556:Venous Thromboembolism / Q000175:diagnosis* / Q000188:drug therapy*
chemical_list: D006495:Heparin, Low-Molecular-Weight