Abstract
BackgroundPatients with symptoms of possible colorectal cancer are not always referred for investigation.AimTo ascertain barriers and facilitators to GP referral of patients meeting the National Institute for Health and Care Excellence (NICE) guidelines for urgent referral for suspected colorectal cancer.Design & settingQualitative study in the context of a feasibility study using information technology in GP practices to flag-up patients meeting urgent referral criteria for colorectal cancer.MethodSemi-structured interview with 18 GPs and 12 practice managers, focusing on early detection of colorectal cancer, issues in the use of information technology to identify patients and GP referral of these patients for further investigation were audiotaped, transcribed verbatim, and analysed according to emergent themes.ResultsThere were two main themes: wide variation in willingness to refer and uncertainty about whether to refer; and barriers to referral. Three key messages emerged: there was a desire to avoid over-referral, lack of knowledge of guidelines, and the use of individually-derived decision rules for further investigation or referral of symptoms. Some GPs were unaware that iron deficiency anaemia or persistent diarrhoea are urgent referral criteria. Alternatives to urgent referral included undertaking no investigations, trials of iron therapy, use of faecal occult blood tests (FOBt) and non-urgent referral. In minority ethnic groups (South Asians) anaemia was often accepted as normal.Concerns about over-referral were linked to financial pressures and perceived criticism by healthcare commissioners, and a reluctance to scare patients by discussing suspected cancer.ConclusionGPs’ lack of awareness of referral guidelines and concerns about over-referral are barriers to early diagnosis of colorectal cancer.
Highlights
In the UK, survival after diagnosis of colorectal cancer has been observed to be poorer than in other countries, partly due to diagnosis and treatment at a later stage.[1,2,3,4] For one-quarter of patients in 2007–2008, time between meeting NICE 2005 referral criteria[5] and diagnosis was over 6 months.[6,7] Annual incidence of colorectal cancer is 66 per 100 000 population, so a full-time GP will expect to see only one case per year.[8,9] This relative unfamiliarity, coupled with the many possible symptoms makes it difficult to decide which patients to refer for diagnostic investigation
In the context of Heneghan’s model the current findings suggest that early referral was favoured by following NICE guidelines and by having a clear protocol for referring anaemic patients if their ferritin levels were low
New NICE guidelines encourage GPs to use their judgement when assessing risk of cancer, with much lower threshold levels[27] but these findings suggest this may be ineffective if the GP’s assessment of risk is lower than the actual risk or if the GP is deterred by pressure to reduce spending
Summary
In the UK, survival after diagnosis of colorectal cancer has been observed to be poorer than in other countries, partly due to diagnosis and treatment at a later stage.[1,2,3,4] For one-quarter of patients in 2007–2008, time between meeting NICE 2005 referral criteria[5] and diagnosis was over 6 months.[6,7] Annual incidence of colorectal cancer is 66 per 100 000 population, so a full-time GP will expect to see only one case per year.[8,9] This relative unfamiliarity, coupled with the many possible symptoms makes it difficult to decide which patients to refer for diagnostic investigation. The CREDIBLE study investigated the feasibility of using electronic patient records to flag up patients aged 60–79 years with symptoms meeting NICE urgent referral criteria for investigation of suspected colorectal cancer. These can be thought of as red flag symptoms or warning signs. They include iron deficiency anaemia, persistent diarrhoea, rectal bleeding (NICE 2005 urgent referral criteria for colorectal cancer)[5] or positive FOBt. The previously published quantitative outcomes of the CREDIBLE study[10] found considerable variation in diagnostic and referral action undertaken by GPs for patients flagged up as meeting contemporary NICE urgent referral criteria. This study, which focuses on individual GP-level or GP practice-level barriers to GP referral of patients meeting NICE urgent referral criteria for colorectal cancer, is one of the few to examine barriers to referring patients for suspected colorectal cancer
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