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BMJ Open. 2018 Sep 5;8(9):e022904. doi: 10.1136/bmjopen-2018-022904.

Identifying important health system factors that influence primary care practitioners' referrals for cancer suspicion: a European cross-sectional survey.

Author information

1
Department for Health, University of Bath, Bath, UK.
2
Institute of Primary Health Care Bern (BIHAM), University of Bern, Bern, Switzerland.
3
Research Unit for General Practice, Aarhus University, Aarhus, Denmark.
4
Research Unit, Majorca Primary Health Care Department, Balearic Islands Health Research Institute (IdISBa), Palma, Spain.
5
Division of Applied Health Sciences-Academic Primary Care, University of Aberdeen, Aberdeen, UK.
6
Department of General Practice, Université Paris Diderot, Paris, France.
7
Department of Family Medicine, Sackler Medical School, Tel Aviv University, Tel Aviv, Israel.
8
Department of General Practice and General Practice Research Unit, University of Oslo, Oslo, Norway.
9
Department of Family Medicine, Nicolaus Copernicus University, Toruń, Poland.
10
Department of General Practice, National Society of Medical Education in General Practice (SNaMID), Caserta, Italy.
11
Family Medicine Department, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.
12
Department of General Practice, Maastricht University, Maastricht, The Netherlands.
13
Medical Center BROD, Plovdiv, Bulgaria.
14
Odjel Socijalne Medicine, The Teaching Institute of Public Health of Primorsko-goranska County, Rijeka, Croatia.
15
Primary Health Centre, Centro de Saúde Sarria, Sarria, Spain.
16
Department of General Practice, Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland.
17
Unitat de Suport a la Recerca, IDIAP Jordi Gol, Institut Catala De La Salut, Barcelona, Spain.
18
Centre for Health Policy, Institute of Global Health Innovation, Imperial College London, London, UK.
19
CINTESIS (Center for Health Technology and Services Research) and MEDCIDS (Department of Community Medicine, Information and Health Decision Sciences), Faculty of Medicine, University of Porto, Porto, Portugal.
20
Department of Family Medicine, University of Ljubljana, Ljubljana, Slovenia.
21
Department of Family Medicine, Medical University of Bialystok, Bialystok, Poland.
22
Institute of General Practice and Health Services Research, Technische Universität München, Munich, Germany.
23
Laboratory of Primary Health Care, General Practice and Health Services Research, Aristotle University of Thessaloniki, Thessaloniki, Greece.
24
Department of Clinical Sciences, Lund University, Malmö, Sweden.
25
Institute for Family Medicine and General Practice, University of Bonn, Bonn, Germany.

Abstract

OBJECTIVES:

Cancer survival and stage of disease at diagnosis and treatment vary widely across Europe. These differences may be partly due to variations in access to investigations and specialists. However, evidence to explain how different national health systems influence primary care practitioners' (PCPs') referral decisions is lacking.This study analyses health system factors potentially influencing PCPs' referral decision-making when consulting with patients who may have cancer, and how these vary between European countries.

DESIGN:

Based on a content-validity consensus, a list of 45 items relating to a PCP's decisions to refer patients with potential cancer symptoms for further investigation was reduced to 20 items. An online questionnaire with the 20 items was answered by PCPs on a five-point Likert scale, indicating how much each item affected their own decision-making in patients that could have cancer. An exploratory factor analysis identified the factors underlying PCPs' referral decision-making.

SETTING:

A primary care study; 25 participating centres in 20 European countries.

PARTICIPANTS:

1830 PCPs completed the survey. The median response rate for participating centres was 20.7%.

OUTCOME MEASURES:

The factors derived from items related to PCPs' referral decision-making. Mean factor scores were produced for each country, allowing comparisons.

RESULTS:

Factor analysis identified five underlying factors: PCPs' ability to refer; degree of direct patient access to secondary care; PCPs' perceptions of being under pressure; expectations of PCPs' role; and extent to which PCPs believe that quality comes before cost in their health systems. These accounted for 47.4% of the observed variance between individual responses.

CONCLUSIONS:

Five healthcare system factors influencing PCPs' referral decision-making in 20 European countries were identified. The factors varied considerably between European countries. Knowledge of these factors could assist development of health service policies to produce better cancer outcomes, and inform future research to compare national cancer diagnostic pathways and outcomes.

KEYWORDS:

cancer; consultation and referral; decision making; delivery of health care; general practitioners; primary health care

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