Cancer survival and primary care cancer management: Knowledge from the New Zealand study of International Cancer Benchmarking Partnership Project Module 3

Abstract

Background Cancer survival differs between countries that have similar healthcare systems and comparable wealth. Early diagnosis and treatment are important for cancer survival; and primary care leads suspected cancer cases to specialist services but in variable ways. Variations in primary care cancer management are hypothesized to be a possible cause of disparities in cancer survival in the study countries. Aims 1. To determine reasons for observed disparities in cancer survival by examining variations in the primary care diagnosis and management of suspected cancer 2. To explore potential barriers in primary care in New Zealand for investigations and referrals for the diagnosis of cancer, including direct access to cancer investigations and specialist review 3. To contribute New Zealand data to an international study (International Cancer Benchmarking Partnership, ICBP) and allow comparisons of the New Zealand data to international findings Methods The New Zealand study was a vignette-based online survey, linked to similar surveys carried out in 11 other jurisdictions contributing to the ICBP Module 3. Participants were recruited by nation-wide sampling from vocationally registered GPs, general registrant doctors working in primary care, and GP registrars (GPEP Years 1, 2 or 3). Three sampling methods were used: snowball sampling starting with study ‘champions’ to promote the study; publicity using ePulse and general practice newsletters, and talks in GP conferences. The survey has three major components: (1) demographic information from GPs and practices; (2) reported direct access to tests and specialist services in public and private systems and waiting time for tests and specialist review; (3) clinical vignettes on patient management. The study used lung, colorectal, ovarian cancer vignettes and each GP answered two vignettes, randomly chosen by the system. The same vignettes and survey instrument were used in all international partners in the ICBP study. The vignettes presented evidence-based symptoms tested in primary care setting. Vignettes have three evolving phases with worsening clinical symptoms in next phase. Outcomes recorded were: definitive actions and non-definitive actions. Results There were 234 completed responses, analysed separately as two groups according to training status: 192 fully trained GPs for international comparisons and 42 GP trainees. Direct access to tests or waiting time for tests was different between public and private systems in New Zealand. Differences in waiting time (public versus private) for all types of investigative tests were significant (P<0.05). Differences were not seen in proportion of GPs taking definitive actions between fully trained GPs and GP trainees. The New Zealand data is compatible with the results of the international study, showing statistically significant associations between cancer survival and proportion of GPs taking definitive actions in the jurisdiction. The association was not seen between characteristics of the participants and definitive actions taking. Conclusions Variations are present in primary care access to tests or waiting times for tests between public and private systems in New Zealand and overall difference is significant internationally. The finding possibly influences management of cancer in primary care and its variations across the ICBP countries. International study confirmed that primary care management has an impact on cancer survival rates at 1 and 5 year and its variations are related to survival differences. The effects of health system factors such as access to diagnostic tests or waiting time on general practice variations require further investigations.