Patient non-attendance at urgent referral appointments for suspected cancer and its links to cancer diagnosis and one year mortality: A cohort study of patients referred on the Two Week Wait pathway

BackgroundThe ‘Two Week Wait’ policy aims to ensure patients with suspected cancer are seen within two weeks of referral. However, patient non-attendance can result in this target being missed. This study aimed to identify predictors of non-attendance; and analyse the relationship between attendance and outcomes including cancer diagnosis and early mortality.MethodsA cohort study of 109,433 adults registered at 105 general practices, referred to a cancer centre within a large NHS hospital trust (April 2009 to December 2016) on the ‘Two Week Wait’ pathway.Results5673 (5.2%) patients did not attend. Non-attendance was largely predicted by patient factors (younger and older age, male gender, greater deprivation, suspected cancer site, earlier year of referral, greater distance to the hospital) over practice factors (greater deprivation, lower Quality and Outcomes Framework score, lower cancer conversion rate, lower cancer detection rate). 10,360 (9.6%) patients were diagnosed with cancer within six months of referral (9.8% attending patients, 5.6% non-attending patients). Among these patients, 2029 (19.6%) died within 12 months of diagnosis: early mortality risk was 31.3% in non-attenders and 19.2% in attending patients.ConclusionsNon-attendance at urgent referral appointments for suspected cancer involves a minority of patients but happens in predictable groups. Cancer diagnosis was less likely in non-attending patients but these patients had worse early mortality outcomes than attending patients. The study findings have implications for cancer services and policy.     

Use of Structured Templates to Improve Completeness of Endocrinology Referrals

ObjectiveEndocrinology referrals frequently lack important clinical information, which may increase the risk of inefficiency and adverse outcomes. This quality improvement project aimed to improve the completeness of new referrals by utilizing structured referral templates for common endocrine conditions at a large Veterans Health Administration medical center. Our target was of at least a 30% improvement in referral completeness for each condition after the intervention.MethodsElectronic structured referral templates were designed utilizing existing resources and input from primary care providers and endocrinologists. Essential elements were identified and included in the templates. We conducted a retrospective chart review to compare referrals for 125 patients referred between January 1, 2021 and September 1, 2021 (preintervention) and 125 patients referred between October 1, 2021 and September 30, 2022 (postintervention). Each referral was rated using a scoring system derived from the criteria in the data abstraction tool formulated by the investigators.ResultsOn average, preintervention referrals included 52% of the essential elements and postintervention referrals included 93%. Improvements in referral scores for each condition all met the prespecified 30% improvement target. The greatest improvement was for the element “type of visit preference.” A separate analysis excluding that element showed an average improvement from 64% of essential elements preintervention to 92% postintervention.ConclusionStructured referral templates, designed with the input of primary care providers and endocrinologists and embedded into an electronic referral system, can improve the availability of essential information and increase the quality of referrals. Future work should examine the effect of structured referral templates on efficiency, specialist experience, patient experience of care, and clinical outcomes.     

Patterns and predictors of referral to the specialized chronic lymphocytic leukemia clinic in Manitoba,Canada

BackgroundBetter CLL patient survival has been reported for specialized CLL clinics/hematologists (compared to other CLL patients). It is possible that improved survival is driven by a better prognosis of referred patients.MethodsWe used logistic regression to calculate the odds ratios (ORs) and 95 % confidence intervals 95 %CIs) of the association between patient characteristics and CLL referral of all persons diagnosed in 2005–2016 with a pathologically-confirmed CLL or SLL.ResultsTwo-thirds of 1293 patients were referred to the CLL clinic. Referred patients were younger (16 % vs 44 % were 80 +) and in better health (47 % vs 56 % with a chronic diseases) than non-referred patients. Referral increased over time: in 2005–2010, about 60 % of patients were referred; in 2011–2016, this increased to 76 %. Gender did not affect referral (the OR for females is 1.0, 95 %CI 0.8–1.2), but age played a major role; CLL patients diagnosed at age 80 + were less likely to be referred than patients diagnosed < 60, 0.2 (0.1–0.3).ConclusionBecause referral to Manitoba’s specialized CLL clinic is associated with age and the patient’s overall health before referral, one should be careful in interpreting differences in outcomes between CLL patients based on referral status alone.     

Referral for menstrual problems: cross sectional survey of symptoms,reasons for referral,and management

ObjectivesTo describe the menstrual experience of women referred for menstrual problems, in particular menorrhagia (excessive menstrual loss), and to assess associations with reasons for referral given by their general practitioners, the women''s understanding of the reasons for their attendance at the hospital clinics, and clinic outcome.DesignQuestionnaire survey, with partial review of case notes after 8 months.SettingThree hospital gynaecology clinics in Glasgow and Edinburgh.Participants952 women completed the questionnaire, and the first 665 were reviewed.ResultsOnly 38% (95% confidence interval 34% to 41%) of women reported excessive menstrual loss as a severe problem. However 60% (57-63%) gave it as reason for attending a clinic, and 76% (73-79%) of general practitioners gave it as reason for referral. Reason for referral was significantly biased towards bleeding (McNemar odds ratio 4.01, 3.0 to 5.3, P<0.001) and against pain (0.54, 0.4 to 0.7, P<0.001). Dysfunctional uterine bleeding was diagnosed in 37% (31-42%) of the 259 women who gave as reason for attendance something other than bleeding. Women who were economically disadvantaged differed in prevalence of the main diagnoses and were more likely to fail to reattend. Hysterectomy was associated with referral for bleeding (relative risk 4.9, 1.6 to 15.6, P<0.001) but not with the patient stating bleeding as the reason for clinic attendance.ConclusionsIntolerance of the volume of their bleeding is not a key feature among women attending clinics for bleeding problems. Broad menstrual complaint tends to be reframed as excessive bleeding at referral and during management. This may result in women receiving inappropriate care. Conceptualisation and assessment of menorrhagia requires reconsideration.

What is already known on this topic

Excessive menstrual loss (menorrhagia) is one of the commonest reasons for secondary referral of women, but there is no formalised clinical assessment in routine useManagement typically involves potent drugs or invasive surgery, with 60% of women having hysterectomy within 5 yearsMany women referred for menorrhagia have menstrual blood loss that is not excessive

What this study adds

Discordance exists between symptoms and both referral and diagnostic pathways, arising from a disproportionate focus on menstrual bleedingAmong women referred for menorrhagia, volume of bleeding is not a key symptomThis raises concerns about conceptualisation and assessment of menstrual complaint and the appropriateness of healthcare provision     

Effect of delays in primary care referral on survival of women with epithelial ovarian cancer: retrospective audit

ObjectiveTo examine referral pathways from primary care for patients with epithelial ovarian cancer and to identify factors related to survival at 18 months.DesignRetrospective review of patient notes.SettingGeneral practices and receiving hospitals within Mersey region.Subjects135 patients with epithelial ovarian cancer identified from an audit in the Mersey area between 1992 and 1994.Results105 (78%) women first presented to their general practitioner within four weeks of the onset of symptoms. 99 (73%) women were referred to hospital by their general practitioners within four weeks of presentation, and 95 (70%) were seen in hospital within two weeks of referral. Multivariate analysis with survival as the dependent variable identified age (odds ratio 0.96, 95% confidence interval 0.93 to 0.99) cancer stage III or more (0.15, 0.05 to 0.43), and non-specific symptoms (0.36, 0.14 to 0.89) as significant variables.ConclusionMost patients attended their general practitioner within four weeks and were referred within two weeks. No evidence was found that delays in referral or diagnosis adversely affected survival at 18 months. Stage of disease at surgery was the most important adverse factor. An effective screening programme is the most likely method to improve survival.

What is already known on this topic

Epithelial ovarian cancer is the most common gynaecological cancer in the United Kingdom75% of patients present with advanced incurable disease, and five year survival is 30%The Department of Health recommends that everyone suspected of having ovarian cancer should be seen within two weeks of referral by their general practitioner

What this study adds

78% of patients have had symptoms for less than 4 weeks when they present to general practice and are referred to hospital within four weeks of presentation70% of patients are seen in hospital within two weeks of the referralDelay by patients and general practitioners does not affect survival beyond 18 months     

可分流长期护理机构的住院病人筛选方法与实证研究

准确测算大型医院住院患者可下沉至护理机构的数量,为合理推进分级诊疗和基层卫生资源配置提供科学性依据。方法 结合前期研究成果和专家咨询,基于住院天数、病种和转归情况,建立住院病人下沉的筛选方法,并计算可下沉的床日数。结果 样本城市2016年可下沉之护理机构的病人为5 775人次,床日为51.6万。结论 为推进住院病人下沉,建议引入评估机制完善病人转诊规则,针对下沉病人的高发病种,加强基层卫生机构相应的资源配置。同时借助长期护理保险实施,进一步促进护理病人的下沉。     

Referral Patterns for Patients With High-Risk Thyroid Cancer

ObjectiveKnowledge of referral patterns for specialty cancer care is sparse. Information on both the need and reasons for referral of high-risk, well-differentiated thyroid cancer patients should provide a foundation for eliminating obstacles to appropriate patient referrals and improving patient care.MethodsWe surveyed 370 endocrinologists involved in thyroid cancer management. From information in a clinical vignette, respondents were asked to identify the reasons they would need to refer a high-risk patient to a more specialized facility for care. We performed multivariable analysis controlling for hospital and physician characteristics.ResultsThirty-two percent of respondents reported never referring thyroid cancer patients to another facility. Of those that would refer a high-risk patient to another facility, the opportunity for a patient to enter a clinical trial was the most common reason reported (44%), followed by high-dose radioactive iodine (RAI) with or without dosimetry (33%), lateral neck dissection (24%), and external beam radiation (15%). In multivariable analysis, endocrinologists with a higher percentage of their practice devoted to thyroid cancer care were significantly less likely to refer patients to another facility (P = .003).ConclusionsThe majority of endocrinologists treating thyroid cancer patients report referring a high-risk patient to another facility for some or all of their care. Knowledge of the patterns of physician referrals and the likelihood of need for referral are key to understanding discrepancies in referral rates and obstacles in the referral process. (Endocr Pract. 2013;19:638-643)     

Introduction of a new scoring tool to identify clinically stable heart failure patients

IntroductionHeart failure (HF) poses a burden on specialist care, making referral of clinically stable HF patients to primary care a desirable goal. However, a structured approach to guide patient referral is lacking.MethodsThe Maastricht Instability Score—Heart Failure (MIS-HF) questionnaire was developed to objectively stratify the clinical status of HF patients: patients with a low MIS-HF (0–2 points, indicating a stable clinical condition) were considered for treatment in primary care, whereas high scores (> 2 points) indicated the need for specialised care. The MIS-HF was evaluated in 637 consecutive HF patients presenting between 2015 and 2018 at Maastricht University Medical Centre.ResultsOf the 637 patients, 329 (52%) had a low score and 205 of these 329 (62%) patients were referred to primary care. The remaining 124 (38%) patients remained in secondary care. Of the 308 (48%) patients with a high score (> 2 points), 265 (86%) remained in secondary care and 41 (14%) were referred to primary care. The primary composite endpoint (mortality, cardiac hospital admissions) occurred more frequently in patients with a high compared to those with a low MIS-HF after 1 year of follow-up (29.2% vs 10.9%; odds ratio (OR) 3.36, 95% confidence interval (CI) 2.20–5.14). No significant difference in the composite endpoint (9.8% vs 12.9%; OR 0.73, 95% CI 0.36–1.47) was found between patients with a low MIS-HF treated in primary versus secondary care.ConclusionThe MIS-HF questionnaire may improve referral policies, as it helps to identify HF patients that can safely be referred to primary care.Supplementary InformationThe online version of this article (10.1007/s12471-021-01654-8) contains supplementary material, which is available to authorized users.     

Influence of a Thiophosphate Linkage on the Duplex Stability - Does Sp Configuration Always Lead to Higher Stability Than Rp?

Abstract

ABSTRACT: In order to design an oligodeoxynucleoside phosphorothioate as an antisense molecule, it is important to establish the structure of the S-oligo with a strong affinity to the target RNA. In these molecules, internucleotide thiophosphate linkages produce diastereomers, the number of which increases in proportion to 2ⁿ (n: number of thiophosphate). To estimate the effect of this linkage on the duplex stability by UV melting curves, oligodeoxynucleotides having a single thiophosphate (referred to Soligo), dGCNsN'CG (s: thiophosphate, N, N′ = A or T), were prepared and their diastereomers isolated by HPLC. As demonstrated previously, the melting temperatures (Tm) for the Sp isomers were higher than those of the Rp when DNA was a target. On the other hand, it was found that for RNA as a target, the Rp isomers of dGCTsTCG and dGCAsTCG had higher stability than the Sp, and that the difference in the Tm values between the diastereomers was smaller than when DNA was a target. With dGCsTsACG, which has two thiophosphates, it was also found that the Tm values decreased with an increase in the number of thiophosphate linkages, and that the difference in Tm between the diastereomers was smaller when RNA was a target. Consequently, in practical clinical applications where RNA is a target, the influence of thiophosphate chirality on the duplex structure is almost negligible and Rp/Sp separation of an S-oligo may be of no major concern.     

A dinosaur ichnocoenosis from the middle jurassic of Yorkshire,UK

An assemblage of dinosaur tracks from the undersurface of a sandstone bed in the Saltwick Formation (Middle Jurassic) of Yorkshire shows a range of morphological types, preservational variants and behavioral styles. The tracks are combinations of transmitted prints and underprints and include three distinct trackways. One trackway was made by an animal walking on exposed damp sand, another was left by an animal swimming diagonally across a current and being swept down current, while the third may have been made by an animal either running or pushing off with its feet as it drifted down current. Environmental conditions that existed during the formation of the trackways varied between crevasse splay floods and exposed damp sand. The morphology of the swimming tracks is sufficiently distinctive to warrant the erection of a new ichnogenus and ichnospecies—Characichnos tridactylus. Previously described material from Kansas, Wyoming and New Mexico can be attributed to this new ichnogenus, while specimens from Germany and Utah are only provisionally referred to it. This indicates a known range from Triassic to Cretaceous.     

Health-related predictors of cancer registry-notified cancer of unknown primary site (CUP)

BackgroundThe relationship between comorbid disease and health service use and risk of cancer of unknown primary site (CUP) is uncertain.MethodsA prospective cohort of 266,724 people aged 45 years and over in New South Wales, Australia. Baseline questionnaire data were linked to cancer registration, health service records 4–27 months prior to diagnosis, and mortality data. We compared individuals with incident registry-notified CUP (n = 327; 90% C80) to two sets of randomly selected controls (3:1): (i) incident metastatic cancer of known primary site (n = 977) and (ii) general cohort population (n = 981). We used conditional logistic regression to estimate adjusted odds ratios (ORs) and 95% confidence intervals (CIs).ResultsIn fully adjusted models incorporating sociodemographic and lifestyle factors, people with cancer registry-notified CUP were more likely to have fair compared with excellent self-rated overall health (OR 1.78, 95% CI 1.01–3.14) and less likely to self-report anxiety (OR 0.48, 95% CI 0.24−0.97) than those registered with metastatic cancer of known primary. Compared to general cohort population controls, people registered with CUP were more likely to have poor rather than excellent self-rated overall health (OR 6.22, 95% CI 1.35–28.6), less likely to self-report anxiety (OR 0.28, 95% CI 0.12−0.63), and more likely to have a history of diabetes (OR 1.89, 95% CI 1.15–3.10) or cancer (OR 1.62, 95% CI 1.03–2.57). Neither tertiary nor community-based health service use independently predicted CUP risk.ConclusionLow self-rated health may be a flag for undiagnosed cancer, and an investigation of its clinical utility in primary care appears warranted.     

Social Dancing and Incidence of Falls in Older Adults: A Cluster Randomised Controlled Trial

BackgroundThe prevention of falls among older people is a major public health challenge. Exercises that challenge balance are recognized as an efficacious fall prevention strategy. Given that small-scale trials have indicated that diverse dance styles can improve balance and gait of older adults, two of the strongest risk factors for falls in older people, this study aimed to determine whether social dance is effective in i) reducing the number of falls and ii) improving physical and cognitive fall-related risk factors.ConclusionsSocial dancing did not prevent falls or their associated risk factors among these retirement villages'' residents. Modified dance programmes that contain "training elements" to better approximate structured exercise programs, targeted at low and high-risk participants, warrant investigation.

Trial Registration

The Australian New Zealand Clinical Trials Registry ACTRN12612000889853     

Cancer genetics evaluation: barriers to and improvements for referral

Despite the availability of cancer susceptibility testing, little information exists regarding physicians' selection and referral of eligible patients. This study provides insight into whom, why, and when physicians refer for cancer genetics evaluation, as well as their comfort level within this role. Eighty-two physicians (51 primary care, 15 gynecology, 11 surgery and 5 oncology) completed a survey (response rate: 34%) regarding cancer genetics referral practices. Of these, 59% reported an awareness of the hospital's cancer genetics program. Program awareness was greater among oncologists, surgeons, and gynecologists than among primary care physicians (p < 0.0001). Patients were referred for enhanced risk assessment (88%), improved medical management (85%), and concern for family members (83%). Patient eligibility was based on family cancer history (96%), patient cancer history (83%), and patient request (73%). Patients were not referred mainly due to patient disinterest (54%) or physician concern about either insurance coverage (44%) or insurance discrimination (31%). Primary care physicians were less comfortable with identifying patients for referral (p < 0.001) and with discussing genetics (p < 0.002) than specialists. The largest barriers to referral were lack of program awareness and limited knowledge regarding patient eligibility, improved insurance coverage, and antidiscrimination legislation. Physician-targeted marketing and education may improve the referral process.     

Predictors of cardiac rehabilitation referral,enrolment and completion after acute myocardial infarction: an exploratory study

BackgroundDespite proven clinical benefits, only a minority of patients complete outpatient cardiac rehabilitation (CR) after acute myocardial infarction (AMI). The main purpose of this study was to evaluate to what extent and at which time patients drop out of CR, and to assess which patient-related characteristics can predict dropout.MethodsIn a retrospective cohort study, we selected patients who had been hospitalised with an AMI in our centre in 2015 or 2016. Patients were selected pseudonymously based on reimbursement codes in the electronic health record. We extracted baseline characteristics and data on CR referral, enrolment and completion for each patient. Multivariable logistic regression was used to assess which characteristics predicted referral and dropout.ResultsThe 666 patients included were predominantly male (66%), with a mean age of 69.0 years. Of the 640 eligible patients, 201 (31%) were not referred for CR. Enrolment after referral was 94%. Nonreferral was independently associated with older age, female sex, traveling distance, non-ST-elevation myocardial infarction (NSTEMI; as compared with STEMI), no coronary revascularisation and prior manifestations of coronary artery disease. Of the 414 enrolled patients, 24% did not complete their CR programmes (i.e. dropped out). Older age and worse exercise capacity at baseline were independently associated with dropout. The ability of the multiple regression models to predict nonreferral and noncompletion was good to fair, with an area under the receiver operating characteristic curves of 0.86 and 0.71, respectively.ConclusionThe main reason for not participating in or not completing CR after AMI was nonreferral. To optimise CR utilisation, improvement of referral rates should be prioritised.     

Demographic,social and lifestyle risk factors for cancer registry-notified cancer of unknown primary site (CUP)

BackgroundLittle is known about the risk factors for cancer of unknown primary site (CUP). We examined the demographic, social and lifestyle risk factors for CUP in a prospective cohort of 266,724 people aged 45 years and over in New South Wales, Australia.MethodsBaseline questionnaire data were linked to cancer registration, hospitalisation, emergency department admission, and mortality data. We compared individuals with incident cancer registry-notified CUP (n = 327) to two sets of controls randomly selected (3:1) using incidence density sampling with replacement: (i) incident cancer registry-notified metastatic cancer of known primary site (n = 977) and (ii) general cohort population (n = 981). We used conditional logistic regression to estimate adjusted odds ratios (ORs) and 95% confidence intervals (CIs).ResultsIn a fully adjusted model incorporating self-rated overall health and comorbidity, people diagnosed with CUP were more likely to be older (OR 1.05, 95% CI 1.04–1.07 per year) and more likely to have low educational attainment (OR 1.77, 95% CI 1.24–2.53) than those diagnosed with metastatic cancer of known primary. Similarly, compared to general cohort population controls, people diagnosed with CUP were older (OR 1.10, 95% CI 1.08–1.12 per year), of low educational attainment (OR 1.69, 95% CI 1.08–2.64), and current (OR 3.42, 95% CI 1.81–6.47) or former (OR 1.95, 95% CI 1.33–2.86) smokers.ConclusionThe consistent association with educational attainment suggests low health literacy may play a role in CUP diagnosis. These findings highlight the need to develop strategies to achieve earlier identification of diagnostically challenging malignancies in people with low health literacy.     

Older cancer patients in cancer clinical trials are underrepresented. Systematic literature review of almost 5000 meta- and pooled analyses of phase III randomized trials of survival from breast,prostate and lung cancer

BackgroundOlder people represent increasing proportions of the population with cancer. To understand the representivity of cancer treatments in older people, we performed a systematic literature review using PRISMA guidelines of the age distribution of clinical trial participants for three leading cancer types, namely breast, prostate, and lung.MethodsWe used PubMed to identify articles detailing meta or pooled-analyses of phase III, randomised controlled trials (RCTs) of survival for breast, prostate and lung cancer, published ≤5 years from 2016. We compared the age distribution of participants to that of these cancers for “More developed regions”.Results4993 potential papers were identified, but only three papers on breast cancer, three on lung cancer, and none on prostate cancer presented the age distribution of their participants. Except for one paper of breast cancer, participants ≥70 years in all other papers were underrepresented.ConclusionsWe recommend the age distribution of patients be clearly reported in all clinical trials, as per guidelines. Clinical trials ought to be more representative of the populations most affected by the disease for which treatments are being tested. This should lead to better knowledge of effectiveness of treatments and better translation of trial results to optimal care of older cancer patients.     

Heavy metal contamination and health risks of indoor dust around Xinqiao Mining Area,Tongling, China

Abstract

In this study, the concentrations and health risks of heavy metals (Cu, Pb, Zn, Ni, Co, Cd, and Cr) in indoor dust are investigated in the vicinity of the Xinqiao mining area, Tongling, China. Results indicate that heavy metals except Co were clearly enriched in indoor dust. Especially Cd was extremely enriched, followed by Zn, Cu, and Pb. However, no significant regional differences (p?>?0.05) were found in other elemental contents aside from Cu. Statistical analysis revealed that metal elements except Co were presumed to originate primarily from mining activities. Health risk assessment indicated that the hazard quotients and hazard indices of all studied metal elements were less than 1 and thus posed no potential noncancer health risks to adults and children. Moreover, the cancer risks of Ni, Cr, Cd, and Co were within acceptable ranges, implying no cancer risk to local residents; however, the noncarcinogenic risk of Pb and the carcinogenic risk of Cr and Cd warrant close attention.