Prognosis of cancer in persons with infrequent consultations in general practice: A population‐based cohort study

Abstract

Cancer survival rates are lower in Denmark than in comparable European countries. This may partly be attributable to subgroups of cancer patients who seek medical attention at late disease stages. It is unknown if differences in usual (i.e. customary) consultation frequency in general practice are associated with cancer prognosis. We aimed to estimate the cancer prognosis of cancer patients stratified by their usual consultation frequency in general practice. We performed a population-based cohort study including 123,943 incident cancer patients aged 50 to 89 years diagnosed in Denmark in 2009 to 2013. We estimated associations between the patient's usual general practitioner (GP) consultation frequency 19 to 36 months before the cancer diagnosis and all-cause mortality by using hazard ratios (HR), estimated by Cox proportional hazards regression. We also estimated the associations between the patient's usual GP consultation frequency and tumour stage, by using logistic regression estimates of odds ratios (ORs). Patients who usually did not see their GP (non-consulters) had higher all-cause mortality [HR = 1.39 (95% CI: 1.33-1.44)] compared to patients who usually saw their GP three to five times during an 18 months period (average consulters). Non-consulters had higher odds of having distant tumour stage [OR = 1.46 (95% CI: 1.38-1.57)] than average consulters. Similar, yet less strong, patterns were seen among patients with low usual GP consultation frequency, yet not statistically significant for all cancer types. In conclusion, the association between usual GP non-consultation and cancer prognosis is a combination of at least two things: a mechanism through more advanced tumour stage and other independent factors.

Characteristics of customary non‐attenders in general practice who are diagnosed with cancer: A cross‐sectional study in Denmark

“…Another major strength was the estimation of the patients' usual consultation frequency. The usual GP consultation rates of the cancer patients in this study were comparable to the usual rates of their sex‐ and age‐matched comparison subjects (Jensen et al, ), and this minimised the risk of misclassification of our main variable of interest.…”

“…The customary non‐attending patients in the present study have previously been shown to have a 40% higher risk of being diagnosed with more advanced disease stage and of dying prematurely when diagnosed with cancer later in life compared to attending patients (Jensen et al, ). Other studies of this population have shown that customary non‐attending patients seek help at the same point in time and to a similar extent as attending patients in the period just before the cancer disease, that is when the cancer disease can influence the patients' healthcare‐seeking behaviour (Jensen et al, ).…”

“…A natural response to the increased mortality in customary non-attenders (Jensen et al, 2017) could be to consider strategies aiming to increase the attendance in primary care (Sheringham, 2017). However, such strategies would also raise some questions.…”

“…It has previously been shown that customary non‐attending patients have a 40% higher risk of being diagnosed with more advanced disease stage and of dying prematurely when diagnosed with cancer compared to regularly consulting patients (Jensen, Vedsted, & Møller, ). In another study, the difference in prognosis could not be contributed to delayed healthcare seeking among customary non‐attending patients, as they started to seek general practice 3–6 months before the cancer diagnosis, just as more regular and frequent attenders do (Jensen, Vedsted, & Møller, ).…”

“…Although low customary use of general practice is associated with worse prognosis (Jensen et al, 2017;Wolinsky et al, 2010), the research on attendance frequency in general practice has so far mostly focused on frequent attenders (Dinkel, Schneider, Schmutzer, Brähler, & Häuser, 2016;Ferrari, Galeazzi, Mackinnon, & Rigatelli, 2008;Gili et al, 2011;Hauswaldt, Hummers-Pradier, & Junius-Walker, 2012;Jørgensen, Andersen, Tjønneland, & Andersen, 2016;Patel et al, 2015;Smits, Brouwer, ter Riet, & Weert, 2009;Vedsted & Olesen, 2005) or no-shows for booked appointments (George & Rubin, 2003). Frequent attenders are more likely to be women, older, socially deprived, and to have more somatic and psychological disorders than average attenders (Dinkel et al, 2016;Ferrari et al, 2008;Gili et al, 2011;Hauswaldt et al, 2012;Jørgensen et al, 2016;Patel et al, 2015;Smits et al, 2009;Vedsted & Olesen, 2005).…”