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• Better consistency and quality with the use of CDSS (Clinical Decision Support Systems)
  Dr. Yvette Pyne
  Published on: 19 July 2022
• Inadequate limitations
  William P Hart, Katarzyna Grellier
  Published on: 19 July 2022

• Published on: 19 July 2022

  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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  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’. Sometimes, these alerts can reduce inappropriate prescribing and improve patient health [9] although poorly implemented alerts can add to the doctor’s burden [10]. Only small studies have previously looked at the acceptability of these alerts [11] which highlights an area rich for further action and research to improve patient outcomes.

  Investment in better and more effective technologies in the primary care consulting room has the potential to reduce the disparity between different doctors’ referral rates and provide a more consistent adherence to the cancer referral guidelines potentially increasing our detection rate.

  References

  1 Schiff GD, Bates DW. Can Electronic Clinical Documentation Help Prevent Diagnostic Errors? New England Journal of Medicine 2010;362:1066–9. doi:10.1056/NEJMp0911734

  2 Singh H, Schiff GD, Graber ML, et al. The global burden of diagnostic errors in primary care. BMJ Quality & Safety 2017;26:484–94. doi:10.1136/bmjqs-2016-005401

  3 Graber ML. Reaching 95%: Decision support tools are the surest way to improve diagnosis now. BMJ Quality & Safety Published Online First: October 2021. doi:10.1136/bmjqs-2021-014033

  4 Nurek M, Kostopoulou O, Delaney BC, et al. Reducing diagnostic errors in primary care. A systematic meta-review of computerized diagnostic decision support systems by the LINNEAUS collaboration on patient safety in primary care. European Journal of General Practice 2015;21:8–13. doi:10.3109/13814788.2015.1043123

  5 Cheraghi-Sohi S, Alam R, Hann M, et al. Assessing the utility of a differential diagnostic generator in UK general practice: A feasibility study. Diagnosis 2021;8:91–9. doi:10.1515/dx-2019-0033

  6 Ford E, Edelman N, Somers L, et al. Barriers and facilitators to the adoption of electronic clinical decision support systems: A qualitative interview study with UK general practitioners. BMC Medical Informatics and Decision Making 2021;21. doi:10.1186/s12911-021-01557-z

  7 Kostopoulou O, Rosen A, Round T, et al. Early diagnostic suggestions improve accuracy of GPs: A randomised controlled trial using computer-simulated patients. British Journal of General Practice 2015;65:e49–54. doi:10.3399/bjgp15X683161

  8 Riches N, Panagioti M, Alam R, et al. The Effectiveness of Electronic Differential Diagnoses (DDX) Generators: A Systematic Review and Meta-Analysis. PLOS ONE 2016;11:e0148991. doi:10.1371/journal.pone.0148991

  9 McKibben S, Bush A, Thomas M, et al. An electronic alert to reduce excessive prescribing of short-acting Beta2-agonists for people with asthma in East London: A retrospective case-control study using routine primary care data. In: M-Health/e-health. European Respiratory Society 2020. 1364. doi:10.1183/13993003.congress-2020.1364

  10 Cecil E, Dewa LH, Ma R, et al. General practitioner and nurse practitioner attitudes towards electronic reminders in primary care: A qualitative analysis. BMJ Open 2021;11:e045050. doi:10.1136/bmjopen-2020-045050

  11 Kelsey EA, Njeru JW, Chaudhry R, et al. Understanding User Acceptance of Clinical Decision Support Systems to Promote Increased Cancer Screening Rates in a Primary Care Practice. Journal of Primary Care & Community Health 2020;11:215013272095883. doi:10.1177/2150132720958832

  Conflict of Interest
  None declared

  2.
  Title: “Inadequate limitations”
  Author: William P, Hart, Katarzyna, Grellier
  In response to the published article 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"

  Rapid response:
  Other Contributors:
  October 13, 2021
  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 by following guidelines, 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 two-week wait guidelines include severe frailty as an exclusion criteria for an urgent or two-week wait referral.
  Conflict of Interest
  None declared

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  Conflict of Interest:
  None declared.

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• Published on: 19 July 2022

  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...

  Show More

  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 2ww referral.

  Show Less

  Conflict of Interest:
  None declared.

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