title: How the probability of presentation to a primary care clinician correlates with cancer survival rates: a European survey using vignettes.
abstract: OBJECTIVE
  European cancer survival rates vary widely. System factors, including whether or not primary care physicians (PCPs) are gatekeepers, may account for some of these differences. This study explores where patients who may have cancer are likely to present for medical care in different European countries, and how probability of presentation to a primary care clinician correlates with cancer survival rates.
  
  
  METHODS
  Seventy-eight PCPs in a range of European countries assessed four vignettes representing patients who might have cancer, and consensus groups agreed how likely those patients were to present to different clinicians in their own countries. These data were compared with national cancer survival rates.
  
  
  METHODS
  A total of 14 countries.
  
  
  METHODS
  Consensus groups of PCPs.
  
  
  METHODS
  Probability of initial presentation to a PCP for four clinical vignettes.
  
  
  RESULTS
  There was no significant correlation between overall national 1-year relative cancer survival rates and the probability of initial presentation to a PCP (r  = -0.16, 95% CI -0.39 to 0.08). Within that there was large variation depending on the type of cancer, with a significantly poorer lung cancer survival in countries where patients were more likely to initially consult a PCP (lung r = -0.57, 95% CI -0.83 to -0.12; ovary: r = -0.13, 95% CI -0.57 to 0.38; breast r = 0.14, 95% CI -0.36 to 0.58; bowel: r = 0.20, 95% CI -0.31 to 0.62).
  
  
  CONCLUSIONS
  There were wide variations in the degree of gatekeeping between countries, with no simple binary model as to whether or not a country has a "PCP-as-gatekeeper" system. While there was case-by-case variation, there was no overall evidence of a link between a higher probability of initial consultation with a PCP and poorer cancer survival. KEY POINTS European cancer survival rates vary widely, and health system factors may account for some of these differences. The data from 14 European countries show a wide variation in the probability of initial presentation to a PCP. The degree to which PCPs act as gatekeepers varies considerably from country to country. There is no overall evidence of a link between a higher probability of initial presentation to a PCP and poorer cancer survival.
authors.affiliation: a Department for Health, University of Bath , Bath , United Kingdom.
authors.forename: Michael
authors.initials: M
authors.lastname: Harris
authors.affiliation: b Berner Institut für Hausarztmedizin, Universität Bern , Bern , Switzerland.
authors.forename: Peter
authors.initials: P
authors.lastname: Frey
authors.affiliation: c Majorca Primary Health Care Department & Instituto de Investigación sanitaria Illes Balears (idISBA) , Palma Mallorca , Spain.
authors.forename: Magdalena
authors.initials: M
authors.lastname: Esteva
authors.affiliation: d Department for Health Education and Health Promotion , Teaching Institute of Public Health of Primorsko-Goranska County, University of Rijeka , Rijeka , Croatia.
authors.forename: Svjetlana
authors.initials: S
authors.lastname: Gašparović Babić
authors.affiliation: e Unitat de Suport a la Recerca, IDIAP Jordi Gol, Direcció d'Atenció Primària Costa de Ponent , Institut Català de la Salut , Cornellà de Llobregat , 08940 , Spain.
authors.forename: Mercè
authors.initials: M
authors.lastname: Marzo-Castillejo
authors.affiliation: f Department of Family Medicine , Faculty of Medicine, University of Ljubljana , Ljubljana , Slovenia.
authors.forename: Davorina
authors.initials: D
authors.lastname: Petek
authors.affiliation: f Department of Family Medicine , Faculty of Medicine, University of Ljubljana , Ljubljana , Slovenia.
authors.forename: Marija
authors.initials: M
authors.lastname: Petek Ster
authors.affiliation: g Department of Clinical Sciences , Lund University , Lund , Sweden.
authors.forename: Hans
authors.initials: H
authors.lastname: Thulesius
mesh_terms: D001291:Attitude of Health Personnel; D001943:Breast Neoplasms / Q000401:mortality; D005060:Europe; D005260:Female; D020793:Gatekeeping; D006801:Humans; D007414:Intestinal Neoplasms / Q000401:mortality; D008175:Lung Neoplasms / Q000401:mortality; D008297:Male; D009369:Neoplasms / Q000401:mortality*; D010051:Ovarian Neoplasms / Q000401:mortality; D058007:Physicians, Primary Care; D010818:Practice Patterns, Physicians'; D011320:Primary Health Care; D011336:Probability; D012017:Referral and Consultation; D011795:Surveys and Questionnaires; D016019:Survival Analysis
keywords: Europe; Health care systems; cancer; decision making; diagnosis; primary health care