Impact of a continuing medical education meeting on the use and timing of urgent cancer referrals among general practitioners - a before-after study

Abstract

Background: Detection of cancer in general practice is challenging because symptoms are diverse. Even so-called alarm symptoms have low positive predictive values of cancer. Nevertheless, appropriate referral is crucial. As 85% of cancer patients initiate their cancer diagnostic pathway in general practice, a Continuing Medical Education meeting (CME-M) in early cancer diagnosis was launched in Denmark in 2012. We aimed to investigate the effect of the CME-M on the primary care interval, patient contacts with general practice and use of urgent cancer referrals.

Methods: A before-after study was conducted in the Central Denmark Region included 396 general practices, which were assigned to one of eight geographical clusters. Practices were invited to participate in the CME-M with three-week intervals between clusters. Based on register data, we calculated urgent referral rates and patient contacts with general practice before referral. Information about primary care intervals was collected by requesting general practitioners to complete a one-page form for each urgent referral during an 8-month period around the time of the CME-Ms. CME-M practices were compared with non-participating reference practices by analysing before-after differences.

Results: Forty percent of all practices participated in the CME-M. There was a statistically significant reduction in the number of total contacts with general practice from urgently referred patients in the month preceding the referral and an increase in the proportion of patients who waited 14 days or more in general practice from the reported date of symptom presentation to the referral date from before to after the CME-M in the CME-M group compared to the reference group.

Conclusions: We found a reduced number of total patient contacts with general practice within the month preceding an urgent referral and an increase in the reported primary care intervals of urgently referred patients in the CME-M group. The trend towards higher urgent referral rates and longer primary care intervals may suggest raised awareness of unspecific cancer symptoms, which could cause the GP to register an earlier date of first symptom presentation. The standardised CME-M may contribute to optimising the timing and the use of urgent cancer referral.

Trial registration: NCT02069470 on ClinicalTrials.gov. Retrospectively registered, 1/29/2014.

Keywords: Behavioural change; Continuing medical education meeting; Denmark; Diagnosis; Early detection of cancer; General practice; Primary care interval; Referral rate; Use of health care.

Figures

Fig. 1

Time periods used for classifying patient populations. The cluster-specific time period used for identifying urgently referred patients in the primary care referral database (light boxes = time before CME-M; dark boxes = time after CME-M). The method at the top was applied for evaluating CME-M effect on referral rates and patient contacts with general practice. The method at the bottom was used for evaluating CME-M effect on primary care intervals