Pre-referral Consultations Research Articles

Time intervals and previous primary care consultations in the pathway to emergency cancer diagnosis

BackgroundTime intervals and number of prior consultations in primary care (PC) are recognised metrics of diagnostic timeliness of cancer and are interrelated. However, whether and how the two measures correlate with each other in the emergency diagnostic pathway is unknown. We investigated the association between the number of prereferral consultations and the length of intervals from PC presentation to cancer diagnosis following emergency referral to hospital. MethodsPatients were eligible if they first consulted in PC and were diagnosed with cancer following emergency or nonemergency referral to hospital. We analysed for differences in PC and diagnostic intervals and number of consultations between emergency and nonemergency presenters and determined their associations by cancer type. Differences in presenting symptoms and stage at diagnosis between populations and according to number of consultations were also examined. ResultsThere were 796 emergency and 865 nonemergency presenters with comparable sociodemographic and comorbidity data. Correlation analysis in emergency presenters revealed a strong positive association between number of consultations and intervals for seven of 13 different cancers, including cancers characterised by high proportions of > 3 consultations and long intervals (pancreatic, lung, and colorectal cancer) and vice versa for others (e.g., endometrial, cervical, or oesophageal cancer). Additionally, emergency presenters with > 3 consultations were more likely than those with 1–2 to report nonspecific symptoms (60 vs. 40%, respectively) and to be diagnosed at a later stage. ConclusionSystem level interventions are needed to reduce unnecessary delays in the emergency diagnostic pathway, particularly in cancer patients with multiple prereferral consultations. The findings also suggest opportunities to reduce the proportion of emergency diagnoses by targeting symptomatic individuals pre-presentation.

National Cancer Diagnosis Audits for England 2018 versus 2014: a comparative analysis.

Timely diagnosis of cancer in patients who present with symptoms in primary care is a quality-improvement priority. To examine possible changes to aspects of the diagnostic process, and its timeliness, before and after publication of the National Institute for Health and Care Excellence's (2015) guidance on the referral of suspected cancer in primary care. Comparison of findings from population-based clinical audits of cancer diagnosis in general practices in England for patients diagnosed in 2018 or 2014. GPs in 1878 (2018) and 439 (2014) practices collected primary care information on the diagnostic pathway of cancer patients. Key measures including patient characteristics, place of presentation, number of pre-referral consultations, use of primary care investigations, and referral type were compared between the two audits by descriptive analysis and regression models. Among 64 489 (2018) and 17 042 (2014) records of a new cancer diagnosis, the percentage of patients with same-day referral (denoted by a primary care interval of 0 days) was higher in 2018 (42.7% versus 37.7%) than in 2014, with similar improvements in median diagnostic interval (36 days versus 40 days). Compared with 2014, in 2018: fewer patients had ≥3 pre-referral consultations (18.8% versus 26.2%); use of primary care investigations increased (47.9% versus 45.4%); urgent cancer referrals increased (54.8% versus 51.8%); emergency referrals decreased (13.4% versus 16.5%); and recorded use of safety netting decreased (40.0% versus 44.4%). In the 5-year period, including the year when national guidelines were updated (that is, 2015), there were substantial improvements to the diagnostic process of patients who present to general practice in England with symptoms of a subsequently diagnosed cancer.

Associations between diagnostic time intervals and health-related quality of life, clinical anxiety and depression in adolescents and young adults with cancer: cross-sectional analysis of the BRIGHTLIGHT cohort

BackgroundThe association of diagnostic intervals and outcomes is poorly understood in adolescents and young adults with cancer (AYA). We investigated associations between diagnostic intervals and health-related quality of life (HRQoL), anxiety and depression in a large AYA cohort.MethodsParticipants aged 12–24 completed interviews post-diagnosis, providing data on diagnostic experiences and the patient-reported outcomes (PROs) HRQoL, anxiety and depression. Demographic and cancer information were obtained from clinical and national records. Six diagnostic intervals were considered. Relationships between intervals and PROs were examined using regression models.ResultsEight hundred and thirty participants completed interviews. In adjusted models, across 28 of 30 associations, longer intervals were associated with poorer PROs. Patient intervals (symptom onset to first seeing a GP) of ≥1 month were associated with greater depression (adjusted odds ratio (aOR):1.7, 95% Confidence Interval (CI):1.1–2.5) compared to <1 month. ≥3 pre-referral GP consultations were associated with greater anxiety (aOR:1.6, CI:1.1–2.3) compared to 1–2 consultations. Symptom onset to first oncology appointment intervals of ≥2 months was associated with impaired HRQoL (aOR:1.8, CI:1.2–2.5) compared to <2 months.ConclusionsProlonged diagnostic intervals in AYA are associated with an increased risk of impaired HRQoL, anxiety and depression. Identifying and delivering interventions for this high-risk group is a priority.

Morbidity and measures of the diagnostic process in primary care for patients subsequently diagnosed with cancer.

BackgroundThere is uncertainty regarding how pre-existing conditions (morbidities) may influence the primary care investigation and management of individuals subsequently diagnosed with cancer.MethodsWe identified morbidities using information from both primary and secondary care records among 11,716 patients included in the English National Cancer Diagnosis Audit (NCDA) 2014. We examined variation in 5 measures of the diagnostic process (the primary care interval, diagnostic interval, number of pre-referral consultations, use of primary care-led investigations, and referral type) by both primary care- and hospital records-derived measures of morbidity.ResultsMorbidity prevalence recorded before cancer diagnosis was almost threefold greater using the primary care (75%) vs secondary care-derived measure (28%). After adjustment, there was limited variation in the primary care interval and the number of pre-referral consultations by either definition of morbidity. Patients with more severe morbidities were less likely to have had a primary care-led investigation before cancer diagnosis compared with those without any morbidity (adjusted odds ratio, OR [95% confidence interval]: 0.72 [0.60–0.86] for Charlson score 3+ vs 0; joint P < 0.001). Patients with multiple primary care-recorded conditions or a Charlson score of 3+ were more likely to have diagnostic intervals exceeding 60 days (aOR: 1.26 [1.10–1.45] and 1.19 [>1.00–1.41], respectively), and more likely to receive an emergency referral (aOR: 1.60 [1.26–2.02] and 1.61 [1.26–2.06], respectively).ConclusionAmong cancer cases with up to 2 morbidities, there was no evidence of differences in diagnostic processes and intervals in primary care but higher morbidity burden was associated with longer time to diagnosis and higher likelihood of emergency referral.

Impact of the Presenting Symptom on Time Intervals and Diagnostic Routes of Patients with Symptomatic Oral Cancer.

Simple SummaryInformation about the relative length of patient stays, primary care, and prereferral intervals (from symptom onset to specialist referral) is very scarce, and how the presenting symptoms influence these intervals and referral routes remains unknown. This study assesses the impact of presenting symptoms on time intervals, number of visits at the primary care level, and referral pattern of patients with symptomatic oral cancer. This approach will allow targets to be identified for future interventions and the optimization of the treatment pathway for symptomatic oral cancer patients.This investigation was aimed at determining the time intervals from the presenting symptoms until the beginning of oral cancer treatment and their relative contribution to the total time, and to assess the impact of the presenting symptom on diagnostic timelines and patient referral routes. A cross-sectional, ambispective study was designed to investigate symptomatic incident cases. The Aarhus statement was used as a conceptual framework. Strategies for minimizing potential recall biases were implemented. A sample of 181 patients was recruited (power: 99.5%; α = 0.05). The patient interval reached 58.2 days (95% CI, 40.3–76.2), which accounted for 74% of the whole prereferral interval and for more than one third of the total time interval. The presenting symptom (trigger for consultation) influenced both the number of primary care consultations and the length of time to diagnosis. General dental practitioners generated longer intervals to diagnosis (p < 0.005) and needed more consultations before referring a patient (RR = 0.76; 95% CI, 0.61–0.93), than general medical practitioners. The current study identifies the patient as the main target for interventions to improve awareness and reinforces the need for increased alertness amongst healthcare professionals about presenting symptoms of oral cancer and to diminish the number of prereferral consultations in order to optimize the primary care interval.

Diagnostic timeliness in adolescents and young adults with cancer: Cross-sectional findings from the BRIGHTLIGHT cohort

BackgroundAdolescents and young adults (AYA) with cancer are thought to experience prolonged diagnostic intervals but robust evidence quantifying such associations is lacking.AimTo examine diagnostic timeliness in a cohort of young people, identifying sociodemographic factors and cancer sites associated with variation in timeliness.MethodWe analysed data from 830 patients with cancer aged 12–24 who completed BRIGHTLIGHT face-to-face interviews, for variation in the patient interval (time from symptom onset to first healthcare presentation); the number of pre-referral GP consultations; and the total interval (time from symptom onset to diagnosis). We present descriptive statistics of these outcomes by patient characteristics and cancer site and multivariable regression models for adjusted estimates of associations.ResultsAmong participants, 27% experienced a patient interval of &gt;1 month and 35% of those consulting a GP had 3 or more (3+) pre-referral consultations. The median total interval was 62 days. We hereafter highlight significant associations (&lt;0.05). Females were more likely to have 3+ consultations and longer total intervals compared with males. Patients with lymphoma or bone tumours were most likely to have 3+ pre-referral consultations and those with melanoma least likely. Females and patients with bone tumours had the longest median total intervals and those with leukaemia the shortest.ConclusionThese data benchmark diagnostic timeliness for young people with cancer and identify subgroups at higher risk of prolonged diagnostic journeys. Further work is now required to prioritise and stratify early diagnosis initiatives for these subgroups.FundingNational Institute for Health Research (RP-PG-1209-10013); Teenage Cancer Trust; Cancer Research UK (A18180).

Diagnostic profile characteristics of cancer patients with frequent consultations in primary care before diagnosis: a case-control study

Many patients with common cancers are late diagnosed. Identify consultation profiles and clinical features in patients with the seven most common cancers, who had consulted a general practitioner (GP) frequently before their cancer diagnosis. A case-control study was conducted in Region Västra Götaland, Sweden. A total of 2570 patients, diagnosed in 2011 with prostate, breast, colorectal, lung, gynaecological and skin cancers including malignant melanoma, and 9424 controls were selected from the Swedish Cancer Register and a regional health care database. Diagnostic codes [International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10)] from primary care for patients with ≥4 GP consultations registered in the year before cancer diagnosis were collected. Likelihood ratios (LRs) were calculated for variables associated with the different cancers. Fifty-six percent of the patients had consulted a GP four or more times in the year before cancer diagnosis. Alarm symptoms or signs represented 60% of the codes with the highest LR, but only 40% of the 10 most prevalent codes. Breast lump had the highest LR, 11.9 [95% confidence interval (CI) 8.0-17.8]; abnormalities of plasma proteins had an LR of 5.0 (95% CI 3.0-8.2) and abnormal serum enzyme levels had an LR of 4.6 (95% CI 3.6-5.9). Early clinical features associated with cancer had been registered already at the first two GP consultations. One out of six clinical features associated with cancer were presented by cancer patients with four or more pre-referral consultations already at the two first consultations. These early clinical features that were focal and had benign characteristics might have been missed diagnostic opportunities.

Diagnostic timeliness in adolescents and young adults with cancer: a cross-sectional analysis of the BRIGHTLIGHT cohort

SummaryBackgroundAdolescents and young adults (AYAs) are thought to experience prolonged intervals to cancer diagnosis, but evidence quantifying this hypothesis and identifying high-risk patient subgroups is insufficient. We aimed to investigate diagnostic timeliness in a cohort of AYAs with incident cancers and to identify factors associated with variation in timeliness.MethodsWe did a cross-sectional analysis of the BRIGHTLIGHT cohort, which included AYAs aged 12–24 years recruited within an average of 6 months from new primary cancer diagnosis from 96 National Health Service hospitals across England between July 1, 2012, and April 30, 2015. Participants completed structured, face-to-face interviews to provide information on their diagnostic experience (eg, month and year of symptom onset, number of consultations before referral to specialist care); demographic information was extracted from case report forms and date of diagnosis and cancer type from the national cancer registry. We analysed these data to assess patient interval (time from symptom onset to first presentation to a general practitioner [GP] or emergency department), the number of prereferral GP consultations, and the symptom onset-to-diagnosis interval (time from symptom onset to diagnosis) by patient characteristic and cancer site, and examined associations using multivariable regression models.FindingsOf 1114 participants recruited to the BRIGHTLIGHT cohort, 830 completed a face-to-face interview. Among participants with available information, 204 (27%) of 748 had a patient interval of more than a month and 242 (35%) of 701 consulting a general practitioner had three or more prereferral consultations. The median symptom onset-to-diagnosis interval was 62 days (IQR 29–153). Compared with male AYAs, female AYAs were more likely to have three or more consultations (adjusted odds ratio [OR] 1·6 [95% CI 1·1–2·3], p=0·0093) and longer median symptom onset-to-diagnosis intervals (adjusted median interval longer by 24 days [95% CI 11–37], p=0·0005). Patients with lymphoma or bone tumours (adjusted OR 1·2 [95% CI 0·6–2·1] compared with lymphoma) were most likely to have three or more consultations and those with melanoma least likely (0·2 [0·1–0·7] compared with lymphoma). The adjusted median symptom onset-to-diagnosis intervals were longest in AYAs with bone tumours (51 days [95% CI 29–73] longer than for lymphoma) and shortest in those with leukaemia (33 days [17–49] shorter than for lymphoma).InterpretationThe findings provide a benchmark for diagnostic timeliness in young people with cancer and help to identify subgroups at higher risk of a prolonged diagnostic journey. Further research is needed to understand reasons for these findings and to prioritise and stratify early diagnosis initiatives for AYAs.FundingNational Institute for Health Research, Teenage Cancer Trust, and Cancer Research UK.

Profiling for primary-care presentation, investigation and referral for liver cancers: evidence from a national audit.

The incidence of liver cancer across Europe is increasing. There is a lack of evidence within the current literature on the identification and investigation of liver cancer within primary care. We aimed to profile liver cancer recognition and assessment as well as the timeliness of liver cancer diagnosis from within the primary-care setting in the UK. Data were obtained from the National Audit of Cancer Diagnosis in Primary Care 2009-2010 and analysed. We calculated the patient interval, the primary-care interval and the number of prereferral consultations for liver cancer. We then compared these data with prior data on the respective indicators for other common cancers. The median patient interval was 9 days (interquartile range 0-31 days), and the median primary-care interval for liver cancer was 11 days (interquartile range 0-40 days). Of the 90 patients, 21 (23.3%) had three or more consultations with their general practitioner before specialist referral. For the three metrics (patient interval, primary-care interval and number of prereferral consultations), liver cancer has average or longer intervals when compared with other cancers. The most common symptomatic presentation of liver cancer within the primary-care setting was right upper quadrant pain (11%), followed by decompensated liver failure (9%). Of the patients, 12% were diagnosed with liver cancer on the basis of an incidental finding of an abnormal liver function test. This study provides a detailed and thorough overview of the recognition of liver cancer and the promptness of liver cancer identification in an English context, and should inform strategies for improving the timeliness of diagnosis.

Understanding variation in the timeliness of diagnosis of cancer in symptomatic patients.

301 Background: Diagnosing cancer promptly in symptomatic patients is a priority for healthcare systems worldwide, but little is known about how initiatives can be targeted to patients at greater risk. Methods: UK data on the number of consultations with a family doctor before specialist referral (‘pre-referral consultations’); the time interval from presentation to referral (‘primary care interval’); and stage at diagnosis, were analysed using multivariable regression models. Results: Both patient experience (41,299 patients, 24 cancers) and clinical audit (13,031 patients, 18 cancers) data indicated wide variation in two correlated measures* of the difficulty of suspecting the diagnosis of cancer once the patient had presented to their family doctor. For example, &gt;30% of patients with multiple myeloma, pancreatic and lung cancer experienced three or more pre-referral consultations; in contrast, this was true for &lt;10% of patients with breast cancer and melanoma (p&lt;0.001). Adjusting for diagnostic case-mix, younger and ethnic minority patients, and women, were more likely to experience three or more pre-referral consultations. Data from 88,657 patients (10 cancers) suggested socio-demographic disparities in stage at diagnosis for some only cancers: For patients with melanoma, breast and endometrial cancer, lower socioeconomic status was associated with higher risk of advanced stage at diagnosis and for, these three cancers, the same was true for older age. Conclusions: Different diagnostic intervals vary widely by cancer diagnosis and patient characteristics. Notable disparities in stage at diagnosis are apparent for ‘easy-to-suspect’ cancers (which are associated with minimal delay post-presentation), strongly implicating psychosocial patient factors as the source of these disparities. These findings can help to appropriately target early diagnosis policy initiatives and future research to patients at greater risk of prolonged diagnostic intervals. *Number of pre-referral consultations with a primary care physician and length of primary care interval (Spearman’s r=0.70).

Markers and measures of timeliness of cancer diagnosis after symptom onset: A conceptual framework and its implications

Adolescents and young adults (AYAs) are thought to experience prolonged intervals to cancer diagnosis, but evidence quantifying this hypothesis and identifying high-risk patient subgroups is insufficient. We aimed to investigate diagnostic timeliness in a cohort of AYAs with incident cancers and to identify factors associated with variation in timeliness.We did a cross-sectional analysis of the BRIGHTLIGHT cohort, which included AYAs aged 12–24 years recruited within an average of 6 months from new primary cancer diagnosis from 96 National Health Service hospitals across England between July 1, 2012, and April 30, 2015. Participants completed structured, face-to-face interviews to provide information on their diagnostic experience (eg, month and year of symptom onset, number of consultations before referral to specialist care); demographic information was extracted from case report forms and date of diagnosis and cancer type from the national cancer registry. We analysed these data to assess patient interval (time from symptom onset to first presentation to a general practitioner [GP] or emergency department), the number of prereferral GP consultations, and the symptom onset-to-diagnosis interval (time from symptom onset to diagnosis) by patient characteristic and cancer site, and examined associations using multivariable regression models.Of 1114 participants recruited to the BRIGHTLIGHT cohort, 830 completed a face-to-face interview. Among participants with available information, 204 (27%) of 748 had a patient interval of more than a month and 242 (35%) of 701 consulting a general practitioner had three or more prereferral consultations. The median symptom onset-to-diagnosis interval was 62 days (IQR 29–153). Compared with male AYAs, female AYAs were more likely to have three or more consultations (adjusted odds ratio [OR] 1·6 [95% CI 1·1–2·3], p=0·0093) and longer median symptom onset-to-diagnosis intervals (adjusted median interval longer by 24 days [95% CI 11–37], p=0·0005). Patients with lymphoma or bone tumours (adjusted OR 1·2 [95% CI 0·6–2·1] compared with lymphoma) were most likely to have three or more consultations and those with melanoma least likely (0·2 [0·1–0·7] compared with lymphoma). The adjusted median symptom onset-to-diagnosis intervals were longest in AYAs with bone tumours (51 days [95% CI 29–73] longer than for lymphoma) and shortest in those with leukaemia (33 days [17–49] shorter than for lymphoma).The findings provide a benchmark for diagnostic timeliness in young people with cancer and help to identify subgroups at higher risk of a prolonged diagnostic journey. Further research is needed to understand reasons for these findings and to prioritise and stratify early diagnosis initiatives for AYAs.National Institute for Health Research, Teenage Cancer Trust, and Cancer Research UK.

Gender inequalities in the promptness of diagnosis of bladder and renal cancer after symptomatic presentation: evidence from secondary analysis of an English primary care audit survey

ObjectivesTo explore whether women experience greater delays in the diagnosis of bladder and renal cancer when first presenting to a general practitioner with symptoms caused by those cancers and potential...

Measures of promptness of cancer diagnosis in primary care

Sir, In their discussion Lyratzopoulos et al (2003) make the crucial point that they were not able to examine whether prolonged values of either the primary care interval or the number of pre-referral consultations were either justifiable or preventable. We also wish to question the widely held assumption that optimum care necessitates correctly identifying and referring a patient with serious illness (cancer) during the first consultation? This implies that reviewing a patient over time may cause harm as a consequence of delayed referral and subsequent diagnosis. One of the most important diagnostic tasks performed by general practitioners is discriminating between the majority of patients with minor, usually self-limiting illness and the minority with serious disease such as cancer. We have previously argued that the test re-test opportunity afforded by reviewing a patient maximises the gain in certainty in low prevalence settings such as general practice, the time efficiency principle (Irving and Holden, 2013). Arranging a follow-up consultation when presented with a patient with non-specific symptoms that may indicate major pathology frequently provides an opportunity to safely and efficiently reduce the number needed to predict (the number of patients that need to be examined in order to predict a diagnosis of a given cancer in one patient). The authors provide two examples of ‘more challenging cancers without specific symptoms'. One GP can expect to see a new case of each during their whole professional career. Furthermore, the median primary care intervals for these two cancers were 14 and 21 days, respectively. This suggests that GPs may well be performing effectively by picking up these difficult cancers by using the time efficiency principle and further improvement may thus be extremely hard to achieve. Therefore, the opportunities to improve the performance of GPs may be remote. The cost of additional investigation and referral in these circumstances may also far exceed any possible benefit to patients. We therefore consider that the key issue is ‘what is the optimum number of consultations required to safely and efficiently reduce the number needed to predict while keeping delays below biologically plausible limits for individual cancers?' We should be open to the possibility that this may paradoxically be more than one consultation. Indeed, we estimate that optimum range will often be about 1–3 consultations based on the evidence presented in this paper.

Measures of promptness of cancer diagnosis in primary care: secondary analysis of national audit data on patients with 18 common and rarer cancers.

Background:Evidence is needed about the promptness of cancer diagnosis and associations between its measures.Methods:We analysed data from the National Audit of Cancer Diagnosis in Primary Care 2009–10 exploring the association between the interval from first symptomatic presentation to specialist referral (the primary care interval, or ‘interval' hereafter) and the number of pre-referral consultations.Results:Among 13 035 patients with any of 18 different cancers, most (82%) were referred after 1 (58%) or 2 (25%) consultations (median intervals 0 and 15 days, respectively) while 9%, 4% and 5% patients required 3, 4 or 5+ consultations (median intervals 34, 47 and 97 days, respectively) (Spearman's r=0.70). The association was at least moderate for any cancer (Spearman's r range: 0.55 (prostate)−0.77 (brain)). Patients with cancers with a higher proportion of three or more pre-referral consultations typically also had longer median intervals (e.g., multiple myeloma) and vice versa (e.g., breast cancer).Conclusion:The number of pre-referral consultations has construct validity as a measure of the primary care interval. Developing interventions to reduce the number of pre-referral consultations can help improve the timeliness of cancer diagnosis, and constitutes a priority for early diagnosis initiatives and research.

Variation in number of general practitioner consultations before hospital referral for cancer: findings from the 2010 National Cancer Patient Experience Survey in England

Information from patient surveys can help to identify patient groups and cancers with the greatest potential for improvement in the experience and timeliness of cancer diagnosis. We aimed to examine variation in the number of pre-referral consultations with a general practitioner between patients with different cancers and sociodemographic characteristics. We analysed data from 41,299 patients with 24 different cancers who took part in the 2010 National Cancer Patient Experience Survey in England. We examined variation in the number of general practitioner consultations with cancer symptoms before hospital referral to diagnose cancer. Logistic regression was used to identify independent predictors of three or more pre-referral consultations, adjusting for cancer type, age, sex, deprivation quintile, and ethnic group. We identified wide variation between cancer types in the proportion of patients who had visited their general practitioner three or more times before hospital referral (7·4% [625 of 8408] for breast cancer and 10·1% [113 of 1124] for melanoma; 41·3% [193 of 467] for pancreatic cancer and 50·6% [939 of 1854] for multiple myeloma). In multivariable analysis, with patients with rectal cancer as the reference group, those with subsequent diagnosis of multiple myeloma (odds ratio [OR] 3·42, 95% CI 3·01-3·90), pancreatic cancer (2·35, 1·91-2·88), stomach cancer (1·96, 1·65-2·34), and lung cancer (1·68, 1·48-1·90) were more likely to have had three or more pre-referral consultations; conversely patients with subsequent diagnosis of breast cancer (0·19; 0·17-0·22), melanoma (0·34, 0·27-0·43), testicular cancer (0·47, 0·33-0·67), and endometrial cancer (0·59, 0·49-0·71) were more likely to have been referred to hospital after only one or two consultations. The probability of three or more pre-referral consultations was greater in young patients (OR for patients aged 16-24 years vs 65-74 years 2·12, 95% CI 1·63-2·75; p<0·0001), those from ethnic minorities (OR for Asian vs white 1·73, 1·45-2·08; p<0·0001; OR for black vs white 1·83, 1·51-2·23; p<0·0001), and women (OR for women vs men 1·28, 1·21-1·36; p<0·0001). We identified strong evidence of interactions between cancer type and age group and sex (p<0·0001 for both), and between age and ethnicity (p=0·0013). The model including these interactions showed a particularly strong sex effect for bladder cancer (OR for women vs men 2·31, 95% CI 1·98-2·69) and no apparent ethnic group differences in young patients aged 16-24 years, whilst the only cancers without an apparent age gradient were testicular cancer and mesothelioma. Our findings could help to prioritise and stratify early diagnosis initiatives and research, focusing on patients with cancers and sociodemographic characteristics with the largest potential for improvement. None.

Assessing the Acceptability of Problem-Solving Procedures by School Teams: Preliminary Development of the Pre-Referral Intervention Team Inventory

The responses of 472 educators were used to develop the Pre-Referral Intervention Team Inventory (PRITI), a 24-item Likert scale. Principal axis analyses resulted in a one-dimensional structure with high internal consistency that explained 57% of the total variance. Acceptability of team procedures was strongly and positively correlated with a measure of team members' interaction practices and negatively related to professional stress. These results suggest that (a) pending further analyses and development, the PRITI may prove useful for assessing school staff acceptability perceptions of pre-referral team consultation procedures and (b) team process variables are important predictors of the acceptability of pre-referral team consultation procedures to educators. Directions for future research are proposed.

The Dilemma of Pragmatics:Why Schools Don't Use Quality Team Consultation Practices

Research supports that school districts' prereferral consultation teams adhere less closely to quality consultation procedures and are less effective than those conducted through university research projects (e.g., Bahr, Whitten, Dieker, Kocarek, & Manson, 1999). This study investigated whether this finding might be due to incompatibilities between school settings and recommended team consultation practices. First, self-assessment surveys and case evaluation activities verified that teams in this school district-led project were not fully implementing research-recommended team consultation procedures. Then, focus group discussions verified through follow-up ratings were used to describe why the research-recommended procedures were not followed. Results suggest that school teams consider the recommended team consultation procedures to be unfamiliar, discrepant from existing staff roles, unnecessarily complex, and often inefficient. In too many cases, administrative support for team activities is inconsistent and the teams lack sufficient intervention resources to have an impact on student success. Team recommendations for improving the consultation procedures are discussed.

Evaluating Child Protection Referrals from Southern Education & Library Board Schools

This research project set out to evaluate the experiences of staff in schools within the Southern Education & Library Board when making referrals to Social Services about child protection concerns during 1999/2000. In June 2001 data were gathered from questionnaires and interviews conducted with those who had made referrals. The pre-referral consultation process with the senior social worker was seen as a necessary and important provision in supporting staff when considering a referral. The report concluded that staff believed the process mostly protected the children and young people about whom they had concerns. However, some stated that they did not receive sufficient information and feedback from Social Services about the investigation and ongoing work, which they viewed as necessary in helping them support these young people appropriately during this traumatic and disruptive time.

Prereferral Consultation and Intervention Assistance Teams Revisited: Some New Food for Thought

(1997). Prereferral Consultation and Intervention Assistance Teams Revisited: Some New Food for Thought. Journal of Educational and Psychological Consultation: Vol. 8, No. 1, pp. 93-100.

Considerations for Future Research in the Institutionalization of School-Based Consultation

The purpose of this article is to identify some of the research questions which arise when consultation services are introduced in school systems. Specifically, questions that arise from introducing pre-referral and in-service consultation are discussed. It is emphasized that unique problems are encountered when consultation is implemented system wide. These problems need to be empirically evaluated across each organizational level of school systems. Conclusions are drawn suggesting the need to adopt formal methods for institutionalizing consultation in the schools.