Welcome Background to project Progress and findings to date Next - - PowerPoint PPT Presentation

Melanie Ridge, Project Manager Vicki Spencer-Hughes, SpR Public Health

Welcome

Background to project Progress and findings to date Next steps

Overview and rationale

• The A&E Service Evaluation is a priority for London Cancer: earlier

diagnosis, working in partnership with primary care and public health

• It supports the interface between primary and secondary care and

seeks to better understand the reasons why people present via the emergency route and to examine the affect this has on overall health outcomes

• First time that an analysis of patients’ route to diagnosis will be

combined with their own reported behaviour and involvement with the health care system

Methodology

• Identifying all patients in secondary care who have a cancer diagnosed via

emergency presentation (1200 patients).

• Capturing secondary data for root cause analysis (patient demographics,

symptoms, primary and secondary care history, route to diagnosis, site and staging, tests, treatment intent, and date of death if applicable).

• Offering a patient questionnaire (based on the national Cancer Patient Experience

Survey but shorter) to all patients identified in secondary care.

• In-depth patient interviews will be carried out with 40 patients (by Dept. of

Applied Health Research, UCL).

• Contacting patients’ GPs to request information on primary care history

(approximately 960 patients);

• Triangulation of findings to identify reasons for emergency presentation

Progress to 8 May 2013

Patients Identified Expected 1014 Actual 441

Secondary RCA received

Expected 441 Actual 300

Primary Care RCA

Expected 299 Sent out 52

Patient Questionnaires

Expected* 299 Actual 44

Patients for interview

Target 30-40 Agreed 17 Done 5

Preliminary findings - demographics

• To date we have analysed

RCAs on 300 people Age and gender:

• 147 male, 149 female
• Mean age of women 69.9

years and men 66.8 years Ethnicity:

• Predominately White: White

British 42% , White Other 12%,

• British 6%,
• BME c 12%
• 24% not recorded;

10 20 30 40

5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90-94 95 plus

Age group of persons diagnosed via emergency route in A&E audit

Preliminary findings – diagnosis, staging and outcomes

Site of cancer:

• >25% lung, 15% CRC, 12% Upper GI

(HPB) Treatment intent:

• Staging data not well recorded
• Curative 12%, Palliative 56%
• Not recorded 32%

Outcomes:

• 10% had died between emergency

attendance and time data collected – median time to death 16 days (range 3-50 days)

0% 5% 10% 15% 20% 25% 30%

Lung: Colorectal: Upper GI (HPB): (blank) Haematology: Upper GI (OG): CUP Gynaecology: Brain & Spine: Breast: Head & Neck: Renal Skin: Urology: Prostate Other

% of emergency diagnoses by site of cancer – A&E audit v National data

A&E audit National

Sources: A&E audit; NCIN Routes to diagnosis by cancer type for all malignant diagnoses, excluding C44 (non- melanoma skin cancer) and multiples, in England, 2007

Preliminary findings – use of health services

• At least 97% of patients are registered with a GP
• ? Functional relationship
• Primary care history will come from GP data – in progress
• 11 responses – 4 GP suspected cancer, 2 had past history of cancer, 2 changed

GPs after diagnosis

• Secondary care data capture incomplete but on current information:
• Prior to A&E visit leading to diagnosis:
• 22 people (7%) of cohort had been to A&E in previous week
• 46 (15%) in previous month, and 85 (28%) in previous year
• However, not clear that all previous visits related to diagnosis

Questionnaires and interviews

Patient questionnaires

• Based on a questionnaire developed by Amanda Ramirez and Lindsay Forbes at

Kings College London, which was used as a follow-up tool with the 20% of patients who had not previously been to their GP on the National Cancer Patient Experience Survey. This will allow us to do some comparison of the findings with work at a national level

• It is important that we have a sufficient response rate, in order to be able to:
• Make robust comparisons between trusts and in many instances, for all

cancers and between tumour groups within trusts

• Understanding reasons for late presentation from patients perspective
• Current Response rate (15%) much lower than Cancer Patient Experience

Survey 2010/11 (45-68% local)

Question 4 – help seeking

Did any of the following things put you off seeking help sooner?

• I didn’t realise the problem or symptom was serious
• I was too embarrassed
• I was worried about wasting the doctor’s time
• I was too worried about what the doctor would find
• Something else….

Question 4 – help seeking

• responses (n=44)

Did any of the following things put you off seeking help sooner?

• I didn’t realise the problem or symptom was serious – 45%
• I was too embarrassed – 0%
• I was worried about wasting the doctor’s time – 5%
• I was too worried about what the doctor would find – 7%
• Something else…. 43%

Non serious symptoms?

1 month of symptoms before seeking help:

• “Difficulty in breathing and no appetite”
• “Pain in urinating. Pain in lower stomach. Swelling in stomach”
• “severe breathing problems, dry cough for one month and inability to

walk more than a few metres without gasping for breath.” 3 months before seeking help:

• “swelling in right cheek and eye that came up quickly”

6 months before seeking help:

• “abdominal pain and vomiting”

Not sure how long before seeking help

• “Very bad pain in left lower abdomen, present over several weeks but

became unbearable - unable to keep fluids down”

Something else? N= 19

6 people said they were already seeing a health professional for problem 4 people had sought help (unsuccessfully?) Reasons given by people who waited over a year before seeking help:

• “Burying head in the sand, hoping the problem would go away”
• “I really don’t know why I put it off, my mum was treated successfully”
• “I was afraid the doctor would tell me that I had cancer”

Other reasons given:

• “It’s never practical to get an appointment with a GP”
• “It was Christmas and I had visitors”

Question 9 - GP factors

Did any of the following things put you off going to see your GP? N=32

• I didn’t realise the problem or symptom was serious (28%)
• I was too embarrassed (0%)
• I was worried about wasting the doctor’s time (0%)
• I found my GP difficult to talk to (9%)
• It was difficult to make an appointment to see the GP (13%)
• I was too busy to find time to go to see my GP (3%)
• I was too worried about what the doctor would find (3%)
• Something else…. (44%)

Qualitative analysis plan

• We want to understand the patients’ experience of an emergency route to

cancer diagnosis in their own terms

• We will be analysing the interviews using ‘thematic analysis’, in order to

generate themes, which should be representative of what the participants said and meant which are normally supported by narrative description

• We will be considering our data within the framework of the Andersen model of

patient delay, which should help us to combine the quantitative and qualitative results

• We will be paying particular attentions to ‘patient factors’
• We will also be investigating how emergency admission fits into the four stages
• f help-seeking: 1) appraisal; 2) help-seeking; 3) diagnostic; 4) pre-treatment.

Qualitative analysis plan – the Andersen model of patient delay

mm