BackgroundPrevious systematic reviews have found that nurses and pharmacists can provide equivalent, or higher, quality of care for some tasks performed by GPs in primary care. There is a lack of economic evidence for this substitution.AimTo explore the costs and outcomes of role substitution between GPs and nurses, pharmacists, and allied health professionals in primary care.Design and settingA systematic review of economic evaluations exploring role substitution of allied health professionals in primary care was conducted. Role substitution was defined as ‘the substitution of work that was previously completed by a GP in the past and is now completed by a nurse or allied health professional’.MethodThe following databases were searched: Ovid MEDLINE, CINAHL, Cochrane Library, National Institute for Health and Care Excellence (NICE), and the Centre for Reviews and Dissemination. The review followed guidance from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).ResultsSix economic evaluations were identified. There was some limited evidence that nurse-led care for common minor health problems was cost-effective compared with GP care, and that nurse-led interventions for chronic fatigue syndrome and pharmacy-led services for the medicines management of coronary heart disease and chronic pain were not. In South Korea, community health practitioners delivered primary care services for half the cost of physicians. The review did not identify studies for other allied health professionals such as physiotherapists and occupational therapists.ConclusionThere is limited economic evidence for role substitution in primary care; more economic evaluations are needed.
Background: International variation in cancer outcomes persist. Differences in the accessibility and organisation of cancer patient pathways may influence this. More evidence is needed to understand what extent variations in the structure of primary care referral pathways for cancer investigation contribute to differences in timeliness of diagnoses and cancer outcomes. Aim: To explore the variation in primary care referral pathways for the management of suspected cancer across the International Cancer Benchmarking Partnership countries. Design: Descriptive comparative analysis; mixed methods. Methods: Schematics of primary care referral pathways were developed across 10 ICBP jurisdictions. The Aarhus statement initially informed the development of the schematics, further supplemented with expert insights through consultation of leading experts in primary care and cancer, existing ICBP, focussed review of existing evidence on the management of suspected cancer, published primary care cancer guidelines, and evaluations of referral tools and initiatives within primary care. Results: Referral pathway schematics for 10 ICBP jurisdictions are presented alongside a descriptive comparison of the organisation of primary care management of suspected cancer. Several key areas of variation were identified: inflexibility of referral pathways, lack of a managed route for non-specific symptoms, primary care practitioner decision-making autonomy, direct access to investigations and use of emergency routes. Conclusion: Highlighting differences in referral processes can stimulate further research to better understand the impact of this variation on timeliness of diagnoses and cancer outcomes. Studying these schematics in local contexts may identify opportunities to improve care and facilitate discussions of what may constitute best referral practice.
BackgroundRelatively poor UK cancer outcomes are blamed upon late diagnosis. Despite most cancer patients presenting to their GP with symptoms, diagnostic delay remains a common theme, with many clinical and non-clinical factors responsible. Early diagnosis is key to improving outcomes and survival. This paper reports the multi-method process to design a complex intervention to improve the timely diagnosis of symptomatic cancer.MethodsA review of reviews, survey, discrete choice experiment, qualitative interviews and focus groups, all informed a realist evidence synthesis. This in turn informed the design of a complex intervention, guided by the Behaviour Change Wheel framework using a multi-step process.ResultsKey themes from the realist evidence synthesis included effective safety netting at practitioner and practice system level, increased vigilance and lowering referral thresholds. Qualitative findings explored the tensions, barriers and facilitators affecting suspected cancer referral. The Think Cancer! intervention is an educational and quality improvement workshop directed at the whole primary care team. Bespoke cancer safety netting plans and appointment of cancer champions are key components.ConclusionsThink Cancer! is a novel primary care early cancer diagnosis intervention, requiring evaluation through a cluster randomised control trial.
Background Compared to the rest of Europe, the UK has relatively poor cancer outcomes, with late diagnosis and a slow referral process being major contributors. General practitioners (GPs) are often faced with patients presenting with a multitude of non-specific symptoms that could be cancer. Safety netting can be used to manage diagnostic uncertainty by ensuring patients with vague symptoms are appropriately monitored, which is now even more crucial due to the ongoing COVID-19 pandemic and its major impact on cancer referrals. The ThinkCancer! workshop is an educational behaviour change intervention aimed at the whole general practice team, designed to improve primary care approaches to ensure timely diagnosis of cancer. The workshop will consist of teaching and awareness sessions, the appointment of a Safety Netting Champion and the development of a bespoke Safety Netting Plan and has been adapted so it can be delivered remotely. This study aims to assess the feasibility of the ThinkCancer! intervention for a future definitive randomised controlled trial. Methods The ThinkCancer! study is a randomised, multisite feasibility trial, with an embedded process evaluation and feasibility economic analysis. Twenty-three to 30 general practices will be recruited across Wales, randomised in a ratio of 2:1 of intervention versus control who will follow usual care. The workshop will be delivered by a GP educator and will be adapted iteratively throughout the trial period. Baseline practice characteristics will be collected via questionnaire. We will also collect primary care intervals (PCI), 2-week wait (2WW) referral rates, conversion rates and detection rates at baseline and 6 months post-randomisation. Participant feedback, researcher reflections and economic costings will be collected following each workshop. A process evaluation will assess implementation using an adapted Normalisation Measure Development (NoMAD) questionnaire and qualitative interviews. An economic feasibility analysis will inform a future economic evaluation. Discussion This study will allow us to test and further develop a novel evidenced-based complex intervention aimed at general practice teams to expedite the diagnosis of cancer in primary care. The results from this study will inform the future design of a full-scale definitive phase III trial. Trial registration ClinicalTrials.gov NCT04823559.
BackgroundRelative to the rest of Europe, the UK has relatively poor cancer outcomes, with late diagnosis and a slow referral process being major contributors. General practitioners (GPs) are often faced with patients presenting with a multitude of non-specific symptoms that could be cancer. Safety netting can be used to manage diagnostic uncertainty by ensuring patients with vague symptoms are appropriately monitored, which is now even more crucial due to the ongoing Covid-19 pandemic and its major impact on cancer referrals. The ThinkCancer! Workshop is an educational behaviour change intervention aimed at the whole general practice team, designed to improve primary care approaches to ensure timely diagnosis of cancer. The workshop will consist of teaching and awareness sessions, the appointment of a Safety Netting Champion and the development of a bespoke Safety Netting Plan, and has been adapted so it can be delivered remotely. This study aims to assess the feasibility of the ThinkCancer! Intervention for a future definitive randomised controlled trial.MethodsThe ThinkCancer! study is a randomised, multisite feasibility trial, with an embedded process evaluation and feasibility economic analysis. Twenty-three to 30 general practices will be recruited across Wales, randomised in a ratio of 2:1 of intervention versus control who will follow usual care. The workshop will be delivered by a GP educator and will be adapted iteratively throughout the trial period. Baseline practice characteristics will be collected via questionnaire. We will also collect Primary Care Intervals (PCI), Two Week Wait (2WW) referral rates, conversion rates and detection rates at baseline and six months post-randomisation. Participant feedback, researcher reflections and economic costings will be collected following each workshop. A process evaluation will assess implementation using an adapted Normalisation Measure Development (NoMAD) questionnaire and qualitative interviews. An economic feasibility analysis will inform a future economic evaluation.DiscussionThis study will allow us to test and further develop a novel evidenced-based complex intervention aimed at general practice teams to expedite the diagnosis of cancer in primary care. The results from this study will inform the future design of a full-scale definitive phase III trial.Trial registratiointended registry: clinicaltrials.gov
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