Concordance with urgent referral guidelines in patients presenting with any of six ‘alarm’ features of possible cancer: a retrospective cohort study using linked primary care records
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  • Published on:
    Better consistency and quality with the use of CDSS (Clinical Decision Support Systems)
    • Dr. Yvette Pyne, Academic GP Trainee University of Bristol - Centre for Academic Primary Care

    The authors of this paper describe GP decision-making as ‘good but not good enough’. Their paper also highlights considerable variation among clinicians with the highest referrers being more than two times more likely to refer patients with red flag symptoms for cancer investigation than the lowest referrers. When we consider this wide disparity among individual doctors, we must look at how we can objectively and consistently reduce this. How can we make the diagnostic process in primary care ‘reliable, not heroic’ [1]?

    Previous papers have considered interventions that can reduce the global burden of diagnostic errors in primary care [2], including the use of information technology tools. Perhaps we can consider that better use of technology such as Clinical Decision Support Systems (CDSS) could improve clinical diagnostics especially in those areas with clear guideline-based practice such as in the decision to refer urgently for suspected cancer [3]. These tools can be used to provide appropriate suggestions for differentials at any point in the clinical consultation or offer ‘alerts’ at the end of the consultation if there are important diagnoses that haven’t been considered [4].

    Uptake of CDSS has been poor [5] and clinician response to these tools when they have been implemented are mixed [6] despite them showing that they increase physician’s diagnostic accuracy [7, 8]. At present, clinical work mostly only uses inconsistently implemented ‘alerts’. Some...

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    Conflict of Interest:
    None declared.
  • Published on:
    Inadequate limitations
    • William P Hart, GP Bodriggy Health Centre, Hayle, Cornwall
    • Other Contributors:
      • Katarzyna Grellier, Oncologist

    We feel that this article and accompanying press release have failed to fully acknowledge some significant limitations of the study. We feel these limitations are important when making the conclusion that following guidelines by earlier referral would be associated with earlier cancer diagnosis.
    1. There is no recognition that the cancer diagnosed in the year following index consultation may not have any association with the index consultation. For example a non-urgent referral for breast lump who developed bladder carcinoma in the following year would be included as someone who could have benefitted from earlier referral.
    2. There is no attempt to acknowledge screening cancer diagnoses. Again these would be included despite them being unrelated to any previous “red flag” symptoms.
    3. Most significantly, there is no acknowledgement that not “following guidelines” is often an important part of shared decision-making that prevents morbidity related to diagnostic processes and treatment. Although the article explains that co-morbidities and age greater than 85 are associated with lower referral rates; it fails to recognise that any delay in cancer diagnosis in this group would often not be considered a “missed opportunity”,. There is sometimes no clinical benefit to the patient of earlier diagnosis. In relation to this It also fails to recognise that many local 2ww guidelines include severe frailty as an exclusion criteria for an urgent or 2w...

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    Conflict of Interest:
    None declared.