Cancer Diagnostic Pathway Audit Report North of England Cancer Network

Cancer Diagnostic Pathway Audit Report

North of England Cancer Network

Title North of England Cancer Diagnostic Pathway Audit Report

Reference Final Report National GP Audit NECN

Version Release 2 Final V04

Date 22/11/10

Author Parry Lothian Consultancy

Change History

6/10/10 – V01 For initial discussions with GP Cancer Leads

4/11/10 – V02 Final Draft for comments to GP Cancer Leads

12/11/10 – V03 Final Report for submission to client

22/11/2010 – V04 Final Report Release 2 - following client discussion

North of England Cancer Network Cancer Diagnostic Pathway Audit 2

ContentsContents

1. Introduction2. Context and Background3. Methodology

• The Approach• Practice Participation• The Participating Practices• Practice Locations and Population• Tools, Parameters and Timelines

4. The Audit Process5. Findings

• Overview• Key Factors• Base Information• Attendances• Referral Detail and Processes• Diagnosis• Possible Avoidable Delays

6. Practice Learning and Actions 7. Recommendations8. Acknowledgements


IntroductionIntroduction


IntroductionIntroduction

This report describes the process and outcomes from the North of England Cancer Networks’ participation in the National GP Cancer Audit. This is the third element of work

progressed under the umbrella of National Awareness and Early Diagnosis Initiative (NAEDI).

The report highlights the specific findings, the issues raised and the local actions taken to improve specific elements of the care pathway both at practice level and within interfaces

with secondary care.

It makes recommendations on the transference of learning, local communication and further work that will require action.

Initial presentation in Primary Care

Reducing the time delay and waste in the patient journey to support earlier cancer diagnosis

Diagnosis

The second project on NAEDI The third project on NAEDI – the subject of this report

Cancer in Primary Care - the initial NAEDI work

5North of England Cancer Network Cancer Diagnostic Pathway Audit

Context and BackgroundContext and Background


Context and BackgroundContext and Background

Cancer in Primary Care -

the initial NAEDI work

The second project on

NAEDI

As part of the NAEDI to promote timely diagnosis of cancer, a national significant event audit of cancer diagnosis in primary care was commissioned and reported in 2009. This audit in the north east of England was carried out by a collaboration between Durham, Glasgow and Dundee Universities. This primary care audit study was specifically to gain insight into the events that surround the diagnostic process for two groups in cancer (lung cancer and cancer affecting teenagers and young adults). The study demonstrated appropriate recognition and referral for both cancer groups. Where recognition had taken longer there were often reasonable explanations – for lung cancer these related to chest x-rays reported as normal, patient choice factors or presentations complicated by co-morbidity. There was also system and practitioner issues and the use of guidelines highlighted in the findings. The full report can be found on www.cancernorth.nhs.uk

From the initial study above a further project was initiated by NHS County Durham and Darlington . This project was to work more closely with primary care to identify, analyse and find solutions to issues that prevented quick diagnosis as identified in the significant event audit (SEA).As NHS North East were already well advanced in their application of the Virginia Mason Production System the proposal suggested that this vehicle was used to carry out this ‘new ‘work building on from and using the initial findings for lung cancer.This proposal was supported by the National Cancer Action Team and was extended across the Cancer Network to include NHS South of Tyne and Wear. Funding from the National Cancer Action was made available and planning began in November 2009. The initial report on this work was completed in April 2010.Durham University, School of Medicine and Health has evaluated the Virginia Mason Production System as it is applied to the primary care work. This study will be available later in 2010.


Context and Background continuedContext and Background continued

The third project on NAEDI – the subject of this

report

The North of England Cancer Network are now building upon the previous NAEDI work by participating in the National GP Audit developed by the Royal College of General Practitioners and the National Cancer Action Team. An audit tool supports this work and is called the Diagnostic Pathway Template.

The aim of this audit is

•To identify any delays in patient pathways•To identify any potential groups of patients or tumour types which are particularly vulnerable to delay•To use the findings to plan interventions to improve early diagnosis across the North of England Cancer Network•To ensure that the findings inform the commissioning intentions for each PCT•To inform and supply information to the National Database

Overall the aim is to build on current good practice and inform service improvements thereby ensuring that individuals with symptoms suspicious of cancer are referred appropriately and early.


MethodologyMethodology


Phase 2 – Planning and Recruiting Phase 3 – Date Collection and Cleansing

Phase 4 – Data Analysis and ReportingPhase 1- Project Initiation

Audit by North of England Cancer Network and Network Primary Care Group.

Aims and objectives of the audit agreed.

Audit parameters agreed.

External Consultant support agreed and recruited.

Timelines and GP practice responsibilities agreed

Scope of practice participants agreed.

Remuneration for practices agreed.

Project Group and Activity Plan developed.

Briefing Pack and Practice agreement developed.

GP Cancer Leads identify and recruited practices

Each participating practice was given from June to October 2010 to complete the audit template.

The records were validated and the data cleansed and amendments agreed with each practice audit lead.

Each practice was given a further month to produce a report of their findings and any action taken.

The data was analysed and the main findings agreed with the GP Cancer Leads.

Guidance supplied by Professor Greg Rubin, Wolfson Institute, University of Durham

The report developed and signed off in November 2010.

Terms of Reference for Project Group.

Audit parameters and timelines.

Project Plan

Briefing pack for participating practices and GP Cancer Leads

Completed , consolidated and validated audit template

A practice report from each participating practice

Data analysis

Final Report

Methodology – The ApproachMethodology – The Approach


Methodology – Practice ParticipationMethodology – Practice Participation

The Practices

GP Practice remuneration

GP Practice roles and responsibilities

GP Practice participation

24 GP Practices were recruited from across the five localities in the NECN . There was no systematic recruitment based on agreed criteria. Practices were approached based on the knowledge they would cooperate, they would find the capacity to participate and would meet the timelines.

The Practices were asked to identify a lead for the practice who would coordinate the completion of the audit and ensure the timelines were met. Each Practice also agreed to conduct a practice meeting/learning event to discuss the audit, identify key areas for improvement and produce an action plan for implementation. This report was shared with the Cancer Network and formed part of the audit process.

Each practice was to receive £500 + £30 per patient record audited, completed and validated. Payment was made retrospectively upon completion of the template with validated records and the production of their practice report template.

Participating Practices varied in size from small < 1000 registered list size to large > 20,000 registered list size. There was a mixture of both rural and urban practices .


Methodology – The Participating PracticesMethodology – The Participating Practices

Participating PracticesDr Cloak and Partners Sunderland

Springwell Medical Group,Sunderland

Glenpark Medical Centre,Gateshead

Bridges Medical PracticeGateshead

Coquet Medical Group, MorpethNorthumberland

Biddlestone Health Group,Newcastle upon Tyne

Lane End SurgeryNewcastle upon Tyne

Harbottle SurgeryNorthumberland

Branch End Surgery, StocksfieldNorthumberland

The Linthorpe SurgeryMiddlesbrough

Havelock Grange PracticeHartlepool

Tennant Street PracticeStockton

Yarm Medical PracticeYarm

Blackhall and Peterlee PracticePeterlee

Jupiter House PracticePeterlee

Station View Health CentreBishop AucklandCo Durham

Murton Medical GroupMurton, SeahamCo Durham

Consett Medical Centre , ConsettCo Durham

Waterloo House SurgeryMillom, Cumbria

Flatt Walks Health CentreWhitehavenCumbria

West Street Practice, AspatriaCumbria

Brunswick House Medical GroupCarlisleCumbria

- - -


Methodology – Practice Locations and PopulationMethodology – Practice Locations and Population

Dotted Eyes © Crown copyright and/or database right 2008. All rights reserved. Licence number 100019918

22 Practices from across the NECN agreed to participate in this audit

Commissioning Cluster Participating Practice

Cumbria 4

Durham 5

North of Tyne 5

South of Tyne 4

Tees 4

Total Participating Practice Population approximately 207,000

Total NECN Population = > 3 million


Methodology – Tools, Parameters and TimelinesMethodology – Tools, Parameters and Timelines

The Timelines

The Exclusions

The Audit Parameters

The Template

The data fields were developed to:• Determine any relationship between age/gender/ethnicity/communication and access

and the likelihood of urgent referral or diagnosis of cancer• Indicate where health promotion campaigns may encourage earlier attendance• Identify delays in referrals for certain cancers• Identify delays that practice systems may affect onward referral• Identify potential delays in the method or urgency of referral

The Audit, collected data from the period between the 1 April 2009 and the 31 March 2010. Records to be included needed to have demonstrated at least one of the following within the timeframe:• a patient presentation • a patient referral • a specialist appointment

Records of patients diagnosed through screening were excluded as were dyscrasias , pre malignant states and non melanotic carcinoma of the skin

The Audit process started in June 2010 and ran through until the end of October 2010 in which time the Practices were required to submit their completed audit template and their practice meeting /learning event report. Data cleansing, analysis and report development started in September and ran through until Mid November 2010.


The Audit ProcessThe Audit Process


Stage 2 – Data Cleansing and AnalysisStage 3 – Individual Practice learning and report submission

Stage 4 - Report development and sign off

Stage 1- Template completion and Submission

Two practices withdrew from the Audit.

The remaining 22 participating Practices met the timelines for template submission - 30/9/10

There was some support required for a few practices during template completion. This was carried out by email or telephone and mainly concerned the functionality of the spreadsheet template.

Support was supplied by external consultants who were commissioned to project manage the process, analyse the data and produce the report.

The Audit ProcessThe Audit Process

Data cleansing was carried out in two parts:Part 1 where all dates were checked and validated.Part 2 where data was checked for logic, completeness and clarity. Where anomalies and or blanks in data was discovered the Practices where asked to recheck and/or to complete selected data fields.

Data analysis was carried out across the consolidated data set for the whole Network. Individual practice analysis and locality analysis was considered problematic due to the limited amount of records in each cohort and the danger of revealing any individual patient record or source.

All practices were asked to consider their audit findings at a Practice meeting and /or learning event.

Each Practice submitted a record of these discussions using a pre prepared template or free text notes or minutes by 31/10/10.

The Practices were required to consider the following for their report:

•Issues from the Audit•Learning from the results•Action taken in the practice

The main themes from these reports were collated and summarised for this report.

An initial draft report was produced for a meeting with the GP Cancer Leads on the 15/10/10.

At this meeting the scope of the analysis was discussed and agreed.

Further development of the report was undertaken and submitted to the Cancer Leads for input on 4/11/10.

The report was finalised on 12 November 2010.


FindingsFindings


Findings - OverviewFindings - Overview


Findings – Key Factors Findings – Key Factors

To qualify as a valid record it was agreed that the following key data items had to be 100% complete:•Age•Gender•Ethnicity•Diagnosis•Stage at Diagnosis•Where the patient first presented•Would rapid access to investigations alter case management•Type of referral

The numbers of records for each cancer site ranged from 2 to 105.

For the purposes of this report analysis at cancer site level has been restricted to the 5 sites with >50 records:•Lung•Colorectal•Prostate•Breast•Bladder

To maintain overall effective analysis this has been carried out at Network level only.


Findings - Base InformationFindings - Base Information

“Top 5 Cancer Sites” – this colour coding, where relevant, has been used within site specific graphs









Is the Patient Housebound?

Lung Colorectal Bladder Breast Prostate

NO 81 80 40 76 83

YES 15 15 6 8 2

Not Known 9 5 6 3 12

Does the Patient have any communication problems?

Lung Colorectal Bladder Breast Prostate

Dementia 2 1 0 1 1

Learning Difficulties 1 0 0 1 0

Mental Health 2 0 2 0 1

Poor Hearing 2 3 2 0 2

Poor Vision 1 3 1 1 1


Vulnerable Groups

Findings - AttendancesFindings - Attendances

It seems that by far the majority of patients only attend once or twice before being referred to Secondary Care. With regard to the 56 patients with zero attendance the assumption is that these were emergencies or not referred by the practice. However there is insufficient information to arrive at such a conclusion. Of these 56 records, 4 were recorded “Unknown” in terms of the referral type and 25 appear to have been referred by the practice. 9 of the 25 ‘subset’ were referred on the day of attendance, therefore the practices may have recorded these as a zero attendance.

This graph represents 631 records, the remaining 65 records presented insufficient detail on number of attendances to be used in this analysis.


Findings - Attendances Findings - Attendances


Findings - AttendancesFindings - Attendances


Findings - Referral Details and ProcessesFindings - Referral Details and Processes







Reviewing average number of days between attendance and referral needs to be aligned with the number of records e.g. Vulval shows an average of 66.5 days between attendance and referral. However there are only two records, one with 1 day between attendance and referral and the other with 132 days.

Endometrial Melanoma Breast Oesophageal Testicular Gallbladder Mesothelioma Ovarian Colorectal Unknown Primary Thyroid Oropharyngeal Stomach Leukaemia

Average Days 2.7 6.0 7.9 10.5 11.0 15.0 15.6 15.8 16.4 16.8 19.0 19.4 22.2 25.1

No Records 11 21 87 20 2 6 5 14 100 6 3 7 15 15

Min days 0 0 0 0 8 0 0 0 0 1 1 0 0 0

Max days 22 56 170 40 14 40 61 125 176 40 37 73 99 135

Bladder Pancreatic Prostate Other Renal Liver Cervical Sarcoma Lung Laryngeal Myeloma Lymphoma Brain Vulval

Average Days 27.1 27.3 28.6 29.4 29.5 29.8 37.0 40.5 41.2 45.0 49.1 51.7 56.4 66.5

No Records 52 8 97 32 20 5 4 6 105 7 10 26 10 2

Min days 0 0 0 0 0 0 0 0 0 0 5 0 0 1

Max days 303 114 377 246 185 77 138 127 436 197 167 269 472 132



The “2 Week” referral option is by far the most common type of referral with more than 50% of all referrals falling into this group. A similar pattern is seen when selecting the ‘Top 5’ cancer sites . The follow page separates out the ‘Top 5’ cancer sites to illustrate the percentage share of type of referral






Days from Referral to First Seen/Investigated by Specialist

All Records Lung Colorectal Bladder Breast Prostate

0-14 days 431 75 63 25 64 60

15 – 21 days 56 3 11 5 9 6

22 – 28 days 33 3 0 8 3 6

29 – 35 days 27 3 4 1 3 6

36 – 42 days 11 2 2 1 1 0

43 + days 48 5 10 3 0 9

Unknown 90 14 10 9 7 10

696 105 100 52 87 97

Findings - DiagnosisFindings - Diagnosis

In this audit it appears that the majority of cases are diagnosed at organ level. Lung being the exception, where a greater percentage appears to be diagnosed at later stages of the disease


Findings - Possible Avoidable DelaysFindings - Possible Avoidable Delays

With most cancers, the earlier the diagnosis is made, the better the prognosis. One of the aims of the audit was to identify whether there were any avoidable delays in the patient journey.

A wide range of factors possibly affecting the patient journey were reported. For the purposes of this report these have been categorised within the context of “A Health System” modelled below. 67% of records stated that there was no avoidable delays in the patient journey. Of the total 696 records 128 indicated avoidable delays with a further 67 records recording “Unsure”.

“Health System Model”

Communications Issues

Clinical Decisions and Actions

Patient Decisions and Actions Referral Processes Non SpecificInvestigations and

Reporting

Factors relating to the clinical decisions and actions made in both primary and secondary care

Factors relating to poor or inappropriate communication that could have occurred at any stage within the patient journey

Factors relating to the failure, delay or reporting of investigations including relevance and timeliness

Factors relating to decisions and actions made by the patient

Factors relating to aspects of referral – such as timeliness, appropriateness and the referral protocols themselves

Some comments were too vague or unique to categorise

72 Records

17Records

27 Records

45 Records

36Records

12Records


Findings - Possible Avoidable DelayFindings - Possible Avoidable Delay

The above presents the “Health System Model” categories across all records and shows a summary of comments made regarding possible avoidable delays. In indicating possible delays 195 records stated “Yes” or “Unsure”. It should be noted that some records recorded “No” but still provided comments. All comments have been included in this categorisation. 487 comments have been reflected in this section.






Practice Learnings and ActionsPractice Learnings and Actions


Issues Learning's Actions

Some Practices identified changes to specific process and/or administrative procedures to improve communication. Examples of these include:•Regular forums where suspect cases can be discussed. These discussions would take place prior to referral and help the decision making processes around case management and the referral ;• ‘red flagging’ suspected cancer on Practice systems to ensure all clinicians are aware of potential diagnosis.The majority of Practices highlighted issues that had not been clear to them before the audit . Examples include: •Prostate Cancer protocols required review •Repeat chest x-ray for suspected lung cancer required further thought and action• The 2 week referral criteria did not always fit a patient presentation • 2 week referrals were being seen within the timeline but patients often waited a long time for further investigations •Co morbidity often masked underlying cancer • Negative investigation results delayed diagnosis

By far the most important ‘learning’ the practices described was that they were required to be far more vigilant in their suspicions of cancer even when the clinical presentation did not ‘quite fit’ , the initial investigations were negative and/or the patient had co morbid disease that may mask an underlying cancer. Practices described the potential to establish effective training and development, case review and significant event audit to ensure more effective and informed vigilance.The other ‘learning’ that stood out was that communication within the practice was vital. To address this the following developments were highlighted:• Red flagging systems to identify potential cancer cases• Forums for complex case discussions• Standardisation of patient review systems and operational practices to ensure that investigations are carried out appropriately, consistently and timely. The majority of the practices reported that the audit had been beneficial and some practices planned to repeat the audit in one year.

Practice Learning and ActionsPractice Learning and Actions

All the practices reported some actions to improve the current patient journey in primary care. The following are the key themed actions reported:• Forums for internal discussions• Improving system coding/flagging• Reviewing internal investigative protocols e.g. Prostate• Lowering threshold for investigations e.g. Chest X-rays for smokers; further investigations for anaemia.• Improving teaching about diligence in complex cases • Significant event audit on complex cases• Improve systems to track results• Increase the amount of routine weighing of patients


RecommendationsRecommendations


RecommendationsRecommendations


AcknowledgementsAcknowledgements


AcknowledgementsAcknowledgements

Name Organisation email

Dr Duncan Leith NECN – Cancer Lead and Chair of the Primary Care Group [email protected]

Dr Jonathan Berry NECN GP Cancer Lead [email protected]

Dr Robin Armstrong NECN GP Cancer Lead [email protected]

Dr Henry Choi NECN GP Cancer Lead [email protected]

Dr Joan Bryson NECN GP Cancer Lead [email protected]

Dr Relton Cummings NECN GP Cancer Lead [email protected]

Susan Collins Cancer Services Officer, NHS Cumbria [email protected]

Professor Greg Rubin Wolfson Unit, Durham University [email protected]

Suzanne Thompson NECN Cancer Modernisation Manager [email protected]

Joanne Preston NECN Service Improvement Facilitator [email protected]

Linda Wintersgill Information and Audit Manager NECN [email protected]

All Participating Practices and their staff



Documents

Cancer Diagnostic Pathway Audit Report North of England Cancer Network