title: Patients' Experiences of Cancer Diagnosis as a Result of an Emergency Presentation: A Qualitative Study.
abstract: BACKGROUND
  Cancers diagnosed following visits to emergency departments (ED) or emergency admissions (emergency presentations) are associated with poor survival and may result from preventable diagnostic delay. To improve outcomes for these patients, a better understanding is needed about how emergency presentations arise. This study sought to capture patients' experiences of this diagnostic pathway in the English NHS.
  
  
  METHODS
  Eligible patients were identified in a service evaluation of emergency presentations and invited to participate. Interviews, using an open-ended biographical structure, captured participants' experiences of healthcare services before diagnosis and were analysed thematically, informed by the Walter model of Pathways to Treatment and NICE guidance in an iterative process.
  
  
  RESULTS
  Twenty-seven interviews were conducted. Three typologies were identified: A: Rapid investigation and diagnosis, and B: Repeated cycles of healthcare seeking and appraisal without resolution, with two variants where B1 appears consistent with guidance and B2 has evidence that management was not consistent with guidance. Most patients' (23/27) experiences fitted types B1 and B2. Potentially avoidable breakdowns in diagnostic pathways caused delays when patients were conflicted by escalating symptoms and a benign diagnosis given earlier by doctors. ED was sometimes used as a conduit to rapid testing by primary care clinicians, although this pathway was not always successful.
  
  
  CONCLUSIONS
  This study draws on patients' experiences of their diagnosis to provide novel insights into how emergency presentations arise. Through these typologies, we show that the typical experience of patients diagnosed through an emergency presentation diverges significantly from normative pathways even when there is no evidence of serious service failures. Consultations were not a conduit to diagnosis when they inhibited patients' capacity to appraise their own symptoms appropriately and when they resulted in a reluctance to seek further healthcare.
  
  
  CONCLUSIONS
  The findings also point to potentially avoidable breakdowns in the diagnostic process. In particular, to encourage patients to return to the GP if symptoms escalate, a stronger emphasis is needed on diagnostic uncertainty in discussions between patients and doctors in both primary and secondary care. To improve appropriate access to rapid investigations, systems are needed for primary care to communicate directly with secondary care at the time of referral.
authors.affiliation: UCL Department of Applied Health Research, UCL, London, England.
authors.forename: Georgia
authors.initials: G
authors.lastname: Black
authors.affiliation: UCL Department of Applied Health Research, UCL, London, England.
authors.forename: Jessica
authors.initials: J
authors.lastname: Sheringham
authors.affiliation: LKSS Public Health Training Programme & Public Health Service, Lambeth and Southwark Local Authorities, London, England.
authors.forename: Vicki
authors.initials: V
authors.lastname: Spencer-Hughes
authors.affiliation: UCL Partners, London, England.
authors.forename: Melanie
authors.initials: M
authors.lastname: Ridge
authors.affiliation: UCL Partners, London, England.
authors.forename: Mairead
authors.initials: M
authors.lastname: Lyons
authors.affiliation: UCL Partners, London, England.
authors.forename: Charlotte
authors.initials: C
authors.lastname: Williams
authors.affiliation: UCL Department of Applied Health Research, UCL, London, England.
authors.forename: Naomi
authors.initials: N
authors.lastname: Fulop
authors.affiliation: UCL Partners, London, England.
authors.forename: Kathy
authors.initials: K
authors.lastname: Pritchard-Jones
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D057210:Delayed Diagnosis; D004630:Emergencies / Q000523:psychology; D004636:Emergency Service, Hospital; D004739:England; D005260:Female; D006297:Health Services Accessibility; D006760:Hospitalization; D006801:Humans; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000175:diagnosis* / Q000523:psychology*; D010343:Patient Admission; D011320:Primary Health Care; D036301:Qualitative Research; D063127:Secondary Health Care; D055815:Young Adult