SYDNEY MEDICAL SCHOOL

Beliefs, behaviours and systems in primary care:

NSW findings from the International Cancer

Benchmarking Partnership

Jane Young | University of Sydney

Sydney School of Public Health

Cancer Epidemiology and Cancer Services Research Group

Jane Young, Claire McAulay, Ingrid Stacey, Megan Varlow, David Currow

Background to ICBP

› Evidence of variations in cancer survival between different European

countries

› Example – rectal cancer : 5-year age-standardised relative survival

- Switzerland 61%

- England 52%

- Poland 39%

Sant et al, Eu J Cancer 2009

› ICBP formed to try to answer these questions

› Focus on lung, colorectal, breast and ovarian cancer

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ICBP Module 3 aims

› To explore whether differences in primary care systems might explain

variations in cancer survival between countries

› In NSW, to investigate GPs’:

- beliefs about early diagnosis of cancer and their role in the cancer system

- access to diagnostic tests and specialists in the public and private sectors

- self reported practices for patients presenting with suspicious symptoms

- views of resources that could improve the interface between primary and

specialist care

› To compare responses for urban and rural GPs

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Methods

› Online survey of GPs in

- UK (England, Wales, Northern Ireland)

- Scandinavia (Norway, Sweden, Denmark)

- Canada (British Columbia, Manitoba, Ontario)

- Australia (Victoria and NSW)

› GPs’ behaviours measured using case scenarios

› GPs’ beliefs and systems measured using direct questions

› Additional questions in NSW and Victoria:

- access to services in the public and private sectors

- out-of-pocket expenses for patients

- influences on referral practices

- preferences for resources to improve the interface between primary and specialist care

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NSW sample and recruitment

› Random sample of GPs identified from a commercial list (AMPCo)

› Stratified by urban or regional/rural location based on ARIA+ classification

of practice postcode

› Primer letter, invitation and up to 3 mailed reminders

› GPs were ineligible if:

- not working primarily in clinical general practice

- provided locum services only

- had died, retired, on extended leave

- no longer in NSW

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Response rate

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2500 names selected

1250 metro, 1250 rural

(10% not eligible)

2246 eligible

Embedded RCT of response-aiding

strategies

273 responses (12.2%)

Characteristics of respondents

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Characteristic Rural (N = 140) Urban (N= 133)

n (%) n (%)

Female 61 (44) 62 (47)

Age (years) < 35 14 (10) 13 (10)

35–44 28 (20) 22 (17)

45–54 42 (30) 44 (33)

55–64 52 (37) 39 (29)

≥ 65 4 (3) 15 (11)

GP registrar 10 (7) 8 (6)

Sole practitioner 13 (9) 21 (16)

Part time 44 (31) 54 (41)

Years in general practice

< 3 11 (8) 8 (6)

3–5 18 (13) 10 (8)

6–10 12 (9) 21 (16)

11 + 99 (71) 94 (71)

Beliefs about timely diagnosis

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More timely diagnosis of cancer is important to ensure better outcomes

Agree or Strongly agree

Rural (%) Urban (%)

Colorectal 97 98

Melanoma 96 98

Breast 94 96

Ovarian 89 95

Lung 83 89

Prostate 51 56

Beliefs about role in cancer system

10

Agree or strongly

agree

Rural (%) Urban (%)

I like to wait until I am sure of a diagnosis before referring

to a specialist21 17

I am often unclear about when I should refer to a specialist

when I suspect cancer6 4

Protecting patients from over-investigation is an important

part of my role44 39

Preventing secondary/specialist care cancer services from

being overloaded is an important part of my role44 39

Influences on management decisions

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Agree or strongly agree

Rural (%) Urban (%)

Fear of litigation sometimes influences my decisions to

order investigations38 48

Fear of litigation sometimes influences my decisions to

refer35 43

I sometimes order cancer investigations that I don’t feel

are indicated due to patient pressure36 40

I sometimes refer patients due to patient pressure rather

than clinical indication29 31

Access to specialist advice within 48 hours regarding investigations for suspected cancer

12

Agree or strongly agree

Rural (%) Urban (%)

Public system 51 51

Private system 76 89

Specialist referral within 48 hours for patient with suspected cancer

13

Agree or strongly agree

Rural (%) Urban (%)

Public system 36 50

Private system 69 82

Proportion of GPs reporting direct access to GI diagnostic tests (no specialist referral required)

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NSW

rural

NSW

urban

VIC

rural

VIC

urban

Upper GI endoscopy 21 30 53 9

Flexible sigmoidoscopy 14 21 29 43

Colonoscopy 21 31 47 78

Access to colonoscopy

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NSW rural NSW urban VIC rural VIC urban

Public

system

14 23 24 18

Private

system

79 88 84 96

Proportion of GPs reporting average waiting time of 4 weeks or less:

Proportion of GPs receiving colonoscopy results within 1 week:

NSW rural NSW urban VIC rural VIC urban

37 40 67 68

Proportion of GPs who can arrange colonoscopy with no out of pocket expenses

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Rural Urban

Yes, this is easy to organise 25 25

Yes, but with difficulty 51 56

No 19 18

Don’t know 4 2

Proportion of GPs reporting time to specialist appointment within 2 weeks

17

Rural Urban

General surgeon Public

Private

46

85

58

94

Gastroenterologist Public

Private

31

68

52

92

Colorectal surgeon Public

Private

38

69

50

91

Respiratory physician Public

Private

36

66

55

87

Thoracic surgeon Public

Private

29

57

46

84

Gynaecologist Public

Private

46

77

56

90

Gynaecologic oncologist Public

Private

27

52

48

77

GPs’ perceived importance of various factors for

selecting a specialist

Factor Rural Urban

Previous experience referring patients to this specialist 84.3 90.2

Length of wait for appointment 70 68.4

Patient preference 49.3 52.6

Colleague recommendation 52.1 48.9

Specialist's hospital has good reputation for cancer care 32.1 57.9

Specialist is member of MDT 33.6 51.1

Specialists’ relevant cancer caseload 29.3 43.6

Know specialist personally 32.9 38.3

Out of pocket costs for patients 32.9 34.6

Distance patient must travel 33.6 26.3

Specialist's hospital has good published outcomes/low complication

rates for cancer patients

17.1 41.4

Specialist is in directory of cancer specialists 6.4 19.5

Specialist is involved in clinical trials 3.6 11.3

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Perceived usefulness of resources for informing about cancer services and referral pathways

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Factor Percentage responding “very important”

Rural Urban

Discussion with colleagues 82 76

GP meetings or seminars 60 63

Feedback from patients 41 44

Mailed brochures or info from

hospitals/specialists

36 40

GP publications and newsletters 25 41

Directory of specialists/services 26 39

Internet searches 24 29

Cancer Institute NSW CanRefer

website

14 19

Limitations

› Very low response rate

› Participating GPs more positive towards cancer care than non-responders

› Scope of questions limited due to requirements of standardised instrument

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Summary

› GPs expressed strong support for timely diagnosis to improve patient

outcomes for breast, colorectal and melanoma skin cancer, but less for

other cancer types

› Almost half of GPs considered that gatekeeping was an important part of

their role

› There were marked differences in access to diagnostic tests and specialist

services between urban and regional/rural GPs and for patients in the

public and private sectors

› Waiting times were one of the most important factors influencing referral

pathways

› These findings can inform future programs to enhance the interface

between primary and specialist care and provide a baseline to monitor

change

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Acknowledgements

› We thank the GPs who participated in the survey, the ICBP Module 3 team

who developed the core questionnaire and Sigmer UK who developed and

managed the online database

› The study was funded by the Cancer Institute NSW

› JY is supported by Academic Leader in Cancer Epidemiology award

number 08/EPC/1-01 from the Cancer Institute NSW and CM was

employed through this award

› Paper reporting embedded RCT of financial incentives to improve

response rate will be published in Journal of Clinical Epidemiology (in

press)

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