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Variations in GPs' decisions to investigate suspected lung cancer: a factorial experiment using multimedia vignettes
  1. Jessica Sheringham1,
  2. Rachel Sequeira1,
  3. Jonathan Myles2,
  4. William Hamilton3,
  5. Joe McDonnell4,
  6. Judith Offman2,
  7. Stephen Duffy2,
  8. Rosalind Raine1
  1. 1Department of Applied Health Research, UCL, London, UK
  2. 2Queen Mary University of London, Centre for Cancer Prevention, London, UK
  3. 3University of Exeter, Peninsula College of Medicine and Dentistry, Exeter, UK
  4. 4Department of Public Health, London Borough of Waltham Forest, London, UK
  1. Correspondence to Dr Jessica, Sheringham, Department of Applied Health Research, UCL, 1-19 Torrington Place, London WC1E 7HB, UK; j.sheringham{at}


Introduction Lung cancer survival is low and comparatively poor in the UK. Patients with symptoms suggestive of lung cancer commonly consult primary care, but it is unclear how general practitioners (GPs) distinguish which patients require further investigation. This study examined how patients' clinical and sociodemographic characteristics influence GPs' decisions to initiate lung cancer investigations.

Methods A factorial experiment was conducted among a national sample of 227 English GPs using vignettes presented as simulated consultations. A multimedia-interactive website simulated key features of consultations using actors (‘patients’). GP participants made management decisions online for six ‘patients’, whose sociodemographic characteristics systematically varied across three levels of cancer risk. In low-risk vignettes, investigation (ie, chest X-ray ordered, computerised tomography scan or respiratory consultant referral) was not indicated; in medium-risk vignettes, investigation could be appropriate; in high-risk vignettes, investigation was definitely indicated. Each ‘patient’ had two lung cancer-related symptoms: one volunteered and another elicited if GPs asked. Variations in investigation likelihood were examined using multilevel logistic regression.

Results GPs decided to investigate lung cancer in 74% (1000/1348) of vignettes. Investigation likelihood did not increase with cancer risk. Investigations were more likely when GPs requested information on symptoms that ‘patients’ had but did not volunteer (adjusted OR (AOR)=3.18; 95% CI 2.27 to 4.70). However, GPs omitted to seek this information in 42% (570/1348) of cases. GPs were less likely to investigate older than younger ‘patients’ (AOR=0.52; 95% CI 0.39 to 0.7) and black ‘patients’ than white (AOR=0.68; 95% CI 0.48 to 0.95).

Conclusions GPs were not more likely to investigate ‘patients’ with high-risk than low-risk cancer symptoms. Furthermore, they did not investigate everyone with the same symptoms equally. Insufficient data gathering could be responsible for missed opportunities in diagnosis.

  • Diagnostic errors
  • General practice
  • Primary care
  • Simulation
  • Health services research

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