Limits...
Understanding missed opportunities for more timely diagnosis of cancer in symptomatic patients after presentation.

Lyratzopoulos G, Vedsted P, Singh H - Br. J. Cancer (2015)

Bottom Line: Multi-disciplinary research targeting such factors is important to shorten diagnostic intervals post presentation.Insights from the fields of organisational and cognitive psychology, human factors science and informatics can be extremely valuable in this emerging research agenda.We provide a conceptual foundation for the development of future interventions to minimise the occurrence of missed opportunities in cancer diagnosis, enriching current approaches that chiefly focus on clinical decision support or on widening access to investigations.

View Article: PubMed Central - PubMed

Affiliation: 1] Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London WC1E 6BT, UK [2] Department of Public Health and Primary Care, Cambridge Centre for Health Services Research, University of Cambridge, Institute of Public Health, Forvie Site, Robinson Way, Cambridge CB2 0SR, UK.

ABSTRACT
The diagnosis of cancer is a complex, multi-step process. In this paper, we highlight factors involved in missed opportunities to diagnose cancer more promptly in symptomatic patients and discuss responsible mechanisms and potential strategies to shorten intervals from presentation to diagnosis. Missed opportunities are instances in which post-hoc judgement indicates that alternative decisions or actions could have led to more timely diagnosis. They can occur in any of the three phases of the diagnostic process (initial diagnostic assessment; diagnostic test performance and interpretation; and diagnostic follow-up and coordination) and can involve patient, doctor/care team, and health-care system factors, often in combination. In this perspective article, we consider epidemiological 'signals' suggestive of missed opportunities and draw on evidence from retrospective case reviews of cancer patient cohorts to summarise factors that contribute to missed opportunities. Multi-disciplinary research targeting such factors is important to shorten diagnostic intervals post presentation. Insights from the fields of organisational and cognitive psychology, human factors science and informatics can be extremely valuable in this emerging research agenda. We provide a conceptual foundation for the development of future interventions to minimise the occurrence of missed opportunities in cancer diagnosis, enriching current approaches that chiefly focus on clinical decision support or on widening access to investigations.

Show MeSH

Related in: MedlinePlus

Epidemiological evidence suggestive of likely missed opportunities. Incidence rate ratios (IRR) for general practitioner consultations before the diagnosis of cancer compared with age- and sex-matched ‘control' patients (without a diagnosis of cancer). Data from Christensen et al (2012); n (women)=63 362 cancer patients and 633 620 controls; n (men)=63 848 cancer patients and 638 480 controls. Note very narrow 95% confidence intervals that exclude parity (i.e., 1.00); and excess risk spanning a 12-month period, including −6 to −4 months.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
getmorefigures.php?uid=PMC4385981&req=5

fig2: Epidemiological evidence suggestive of likely missed opportunities. Incidence rate ratios (IRR) for general practitioner consultations before the diagnosis of cancer compared with age- and sex-matched ‘control' patients (without a diagnosis of cancer). Data from Christensen et al (2012); n (women)=63 362 cancer patients and 633 620 controls; n (men)=63 848 cancer patients and 638 480 controls. Note very narrow 95% confidence intervals that exclude parity (i.e., 1.00); and excess risk spanning a 12-month period, including −6 to −4 months.

Mentions: Retrospective evaluation of individual cases is not the only source of evidence on missed diagnostic opportunities. In England, work conducted by the (former) National Patient Safety Agency has highlighted factors implicated in diagnostic delays in cancer and recommended ‘routine monitoring of delayed diagnosis' (NPSA, 2010). Although thus far no system that allows such routine monitoring exists, epidemiological evidence from England indicates that about one in five patients seen in general practice and subsequently diagnosed with cancer consults with their general practitioners three or more times for relevant symptoms before a specialist referral is made and that instances of multiple consultations are associated with prolonged primary care intervals (Lyratzopoulos et al, 2012, 2013a). Similarly, evidence from Denmark indicates that the rate of primary care consultations, diagnostic tests and hospital visits among patients subsequently diagnosed with cancer is substantially higher than that of ‘control' patients (without cancer), over a period of several months before diagnosis (Figure 2) (Christensen et al, 2012; Ahrensberg et al, 2013; Hansen et al, 2015). However, epidemiological studies do not provide direct evidence or specific clinical information about the circumstances surrounding such events, and not all instances of these ‘early'/multiple pre-diagnostic consultations would be associated with missed opportunities. For example, multiple consultations may be unavoidable in the presence of vague symptoms and/or when it is judged reasonable to investigate patients before referral (Lyratzopoulos et al 2014). Nonetheless, this type of evidence strongly indicates that missed opportunities may occur in at least some patients with cancer diagnoses and we need to understand more about their origins, both in primary and secondary care and throughout the diagnostic process. Further, epidemiological evidence can help identify cancer sites or socio-demographic characteristics of patients that confer a higher than average risk of delayed diagnosis (Lyratzopoulos et al 2012, 2013a), providing insights into potential responsible mechanisms and targets for further research and improvement initiatives.


Understanding missed opportunities for more timely diagnosis of cancer in symptomatic patients after presentation.

Lyratzopoulos G, Vedsted P, Singh H - Br. J. Cancer (2015)

Epidemiological evidence suggestive of likely missed opportunities. Incidence rate ratios (IRR) for general practitioner consultations before the diagnosis of cancer compared with age- and sex-matched ‘control' patients (without a diagnosis of cancer). Data from Christensen et al (2012); n (women)=63 362 cancer patients and 633 620 controls; n (men)=63 848 cancer patients and 638 480 controls. Note very narrow 95% confidence intervals that exclude parity (i.e., 1.00); and excess risk spanning a 12-month period, including −6 to −4 months.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4385981&req=5

fig2: Epidemiological evidence suggestive of likely missed opportunities. Incidence rate ratios (IRR) for general practitioner consultations before the diagnosis of cancer compared with age- and sex-matched ‘control' patients (without a diagnosis of cancer). Data from Christensen et al (2012); n (women)=63 362 cancer patients and 633 620 controls; n (men)=63 848 cancer patients and 638 480 controls. Note very narrow 95% confidence intervals that exclude parity (i.e., 1.00); and excess risk spanning a 12-month period, including −6 to −4 months.
Mentions: Retrospective evaluation of individual cases is not the only source of evidence on missed diagnostic opportunities. In England, work conducted by the (former) National Patient Safety Agency has highlighted factors implicated in diagnostic delays in cancer and recommended ‘routine monitoring of delayed diagnosis' (NPSA, 2010). Although thus far no system that allows such routine monitoring exists, epidemiological evidence from England indicates that about one in five patients seen in general practice and subsequently diagnosed with cancer consults with their general practitioners three or more times for relevant symptoms before a specialist referral is made and that instances of multiple consultations are associated with prolonged primary care intervals (Lyratzopoulos et al, 2012, 2013a). Similarly, evidence from Denmark indicates that the rate of primary care consultations, diagnostic tests and hospital visits among patients subsequently diagnosed with cancer is substantially higher than that of ‘control' patients (without cancer), over a period of several months before diagnosis (Figure 2) (Christensen et al, 2012; Ahrensberg et al, 2013; Hansen et al, 2015). However, epidemiological studies do not provide direct evidence or specific clinical information about the circumstances surrounding such events, and not all instances of these ‘early'/multiple pre-diagnostic consultations would be associated with missed opportunities. For example, multiple consultations may be unavoidable in the presence of vague symptoms and/or when it is judged reasonable to investigate patients before referral (Lyratzopoulos et al 2014). Nonetheless, this type of evidence strongly indicates that missed opportunities may occur in at least some patients with cancer diagnoses and we need to understand more about their origins, both in primary and secondary care and throughout the diagnostic process. Further, epidemiological evidence can help identify cancer sites or socio-demographic characteristics of patients that confer a higher than average risk of delayed diagnosis (Lyratzopoulos et al 2012, 2013a), providing insights into potential responsible mechanisms and targets for further research and improvement initiatives.

Bottom Line: Multi-disciplinary research targeting such factors is important to shorten diagnostic intervals post presentation.Insights from the fields of organisational and cognitive psychology, human factors science and informatics can be extremely valuable in this emerging research agenda.We provide a conceptual foundation for the development of future interventions to minimise the occurrence of missed opportunities in cancer diagnosis, enriching current approaches that chiefly focus on clinical decision support or on widening access to investigations.

View Article: PubMed Central - PubMed

Affiliation: 1] Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London WC1E 6BT, UK [2] Department of Public Health and Primary Care, Cambridge Centre for Health Services Research, University of Cambridge, Institute of Public Health, Forvie Site, Robinson Way, Cambridge CB2 0SR, UK.

ABSTRACT
The diagnosis of cancer is a complex, multi-step process. In this paper, we highlight factors involved in missed opportunities to diagnose cancer more promptly in symptomatic patients and discuss responsible mechanisms and potential strategies to shorten intervals from presentation to diagnosis. Missed opportunities are instances in which post-hoc judgement indicates that alternative decisions or actions could have led to more timely diagnosis. They can occur in any of the three phases of the diagnostic process (initial diagnostic assessment; diagnostic test performance and interpretation; and diagnostic follow-up and coordination) and can involve patient, doctor/care team, and health-care system factors, often in combination. In this perspective article, we consider epidemiological 'signals' suggestive of missed opportunities and draw on evidence from retrospective case reviews of cancer patient cohorts to summarise factors that contribute to missed opportunities. Multi-disciplinary research targeting such factors is important to shorten diagnostic intervals post presentation. Insights from the fields of organisational and cognitive psychology, human factors science and informatics can be extremely valuable in this emerging research agenda. We provide a conceptual foundation for the development of future interventions to minimise the occurrence of missed opportunities in cancer diagnosis, enriching current approaches that chiefly focus on clinical decision support or on widening access to investigations.

Show MeSH
Related in: MedlinePlus