How the probability of presentation to a primary care clinician correlates with cancer survival rates: a European survey using vignettes

Abstract

ObjectiveEuropean cancer survival rates vary widely. System factors, including whether or not primary care physicians (PCPs) are gatekeepers, may account for some of these differences. This study explores where patients who may have cancer are likely to present for medical care in different European countries, and how probability of presentation to a primary care clinician correlates with cancer survival rates.DesignSeventy-eight PCPs in a range of European countries assessed four vignettes representing patients who might have cancer, and consensus groups agreed how likely those patients were to present to different clinicians in their own countries. These data were compared with national cancer survival rates.SettingA total of 14 countries.SubjectsConsensus groups of PCPs.Main outcome measuresProbability of initial presentation to a PCP for four clinical vignettes.ResultsThere was no significant correlation between overall national 1-year relative cancer survival rates and the probability of initial presentation to a PCP (r = −0.16, 95% CI −0.39 to 0.08). Within that there was large variation depending on the type of cancer, with a significantly poorer lung cancer survival in countries where patients were more likely to initially consult a PCP (lung r = −0.57, 95% CI −0.83 to −0.12; ovary: r = −0.13, 95% CI −0.57 to 0.38; breast r = 0.14, 95% CI −0.36 to 0.58; bowel: r = 0.20, 95% CI −0.31 to 0.62).ConclusionsThere were wide variations in the degree of gatekeeping between countries, with no simple binary model as to whether or not a country has a “PCP-as-gatekeeper” system. While there was case-by-case variation, there was no overall evidence of a link between a higher probability of initial consultation with a PCP and poorer cancer survival.Key pointsEuropean cancer survival rates vary widely, and health system factors may account for some of these differences.The data from 14 European countries show a wide variation in the probability of initial presentation to a PCP.The degree to which PCPs act as gatekeepers varies considerably from country to country.There is no overall evidence of a link between a higher probability of initial presentation to a PCP and poorer cancer survival.

Impact of GP gatekeeping on quality of care, and health outcomes, use, and expenditure: a systematic review

“…40,41 This suggests that, at least in the UK, delayed diagnosis of cancer is not caused solely by gatekeeping, but by other healthcare system factors, patient behaviour, and healthcare provider factors. 15,[42][43][44][45][46] Implications for policy and research Caution should be exercised in interpreting these findings to the policy context. Policymakers eager to reduce costs and use may conclude that reduction in specialist healthcare use and expenditure makes gatekeeping a favourable system.…”

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

“… 21 However, there are wide variations in the degree of gatekeeping between countries, with no simple binary model as to whether or not a country has a ‘GP-as-gatekeeper’ system, and a European study found no link between a higher probability of initial consultation with a GP and poorer cancer survival. 22 …”

Primary care practitioners’ diagnostic action when the patient may have cancer: an exploratory vignette study in 20 European countries

“… 59 However, there are important variations in the level of gatekeeping between countries, with no simple binary model as to whether or not a country has a ‘GP-as-gatekeeper’ system, and a European study found no association between cancer survival and a probability of presentation to a GP. 36 …”

“…More information about this process is given elsewhere. 36 No changes to the demographic questions were made. One of the vignettes No changes to the questions were made following this second pilot.…”