Primary care referral practice, variability and socio-economic deprivation in colorectal cancer.
OBJECTIVE
The reasons for pre-hospital delay of the diagnosis of cancer are multifactorial, but include a physician-related component. Urgent cancer pathways and direct-to-test approaches have been implemented, but the emergency presentation of colorectal cancer (CRC) remains little changed over recent years. We examined the variability between primary care providers in referral patterns and its effect on outcome.


METHODS
A retrospective analysis was performed of a prospectively maintained database for 2009-2014 in a UK district hospital providing bowel cancer screening and tertiary rectal cancer services.


RESULTS
Of 1145 CRC patients, 937 (81.8%) were diagnosed with a symptomatic cancer; 229/937 (24.4%) initially presented as an emergency. Between 44 primary care providers, emergency presentation varied between 8.3% and 57.1%. Patients of providers with high levels of emergency presentations (HV) had more advanced cancers than those of providers with medium (MV) or low levels (LV) [103/253 (40.7%), 154/461 (33.4%), 65/223 (29.1%); P = 0.025] and a lower 3-year overall survival (50.2%, 57.8%, 65.6%; P = 0.013), but with no difference in case-mix or deprivation levels. In adjusted analysis, this difference remained significant (advanced disease, OR 1.663, P = 0.011; 3-year hazard ratio 1.479, P = 0.010; comparing HV with LV). Conversely, elective suspected cancer referrals were less often used amongst diagnosed cancers [LV 136/223 (61.0%), MV 228/461 (49.5%), HV 114/253 (45.1%), P < 0.001] with limited evidence for a more selective approach in the use of the 2-week rule amongst all 2-week rule referrals [LV 136/2508 (5.4%); MV 228/4239 (5.4%); HV 115/1526 (7.8%); positive cancer diagnosis, P = 0.005].


CONCLUSIONS
Significant variability in emergency presentation of CRC requires local audit and examination of the reasons for delay in diagnosis and targeted measures to improve performance in non-emergency referral pathways.
Department of Colorectal Surgery, North Tees and Hartlepool NHS Foundation Trust, University Hospital of North Tees, Stockton-on-Tees, UK. DWBorowski@AOL.com.|Welwitschia Hospital, Walvis Bay Medipark, Walvis Bay, Namibia. DWBorowski@AOL.com.
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Borowski
Health Information, North Tees and Hartlepool NHS Foundation Trust, University Hospital of North Tees, Stockton-on-Tees, UK.
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Cawkwell
Department of Colorectal Surgery, North Tees and Hartlepool NHS Foundation Trust, University Hospital of North Tees, Stockton-on-Tees, UK.|Department of Surgery, Queens Medical Centre Clifton Boulevard, Nottingham, UK.
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Zaidi
Department of Colorectal Surgery, North Tees and Hartlepool NHS Foundation Trust, University Hospital of North Tees, Stockton-on-Tees, UK.
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Toward
Department of Colorectal Surgery, North Tees and Hartlepool NHS Foundation Trust, University Hospital of North Tees, Stockton-on-Tees, UK.
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Maguire
Department of Colorectal Surgery, North Tees and Hartlepool NHS Foundation Trust, University Hospital of North Tees, Stockton-on-Tees, UK.
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Gill
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015179:Colorectal Neoplasms / Q000175:diagnosis*; D057210:Delayed Diagnosis / Q000706:statistics & numerical data; D055088:Early Detection of Cancer / Q000706:statistics & numerical data*; D004739:England; D005260:Female; D006767:Hospitals, District; D006801:Humans; D008297:Male; D008875:Middle Aged; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011320:Primary Health Care / Q000706:statistics & numerical data*; D011446:Prospective Studies; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D012042:Registries; D012189:Retrospective Studies; D012959:Socioeconomic Factors; D055815:Young Adult
Primary care; care quality; colorectal cancer; emergency; general practice