NAEDI Primary care Audit Results 2010 by 76ppp7sb

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									Results of NAEDI Primary
Care Audit 2010
Avon Somerset & Wiltshire Cancer
           Network



  Dr Alison Wint. GP & Associate Medical Director
NAEDI?

   National Awareness and Early Detection
    Initiative.
   Advanced stage at diagnosis is thought to
    account for 50 – 70% avoidable cancer
    deaths.
   Equivalent to 6,000 avoidable cancer
    deaths between 1995-99.
   Or 11,000 compared to the best in Europe.
CRS & National NAEDI Strategy

   Aims to reduce health inequalities and
    improve survival by 2020
   Priority cancers: bladder, breast, bowel,
    cervix, lung & skin.
   Improve staging at diagnosis.
   Raise awareness of early symptoms
   Reduce risk exposure for young people
   Improve Screening performance
   Employ social marketing techniques
The Survival Gap


“If cancer survival in Britain had
  matched the best in Europe,
  1,300 premature cancer deaths
  (within 5yrs of diagnosis) would
  have been avoided each year in
  Britain”

Prof Sir Mike Richards Cancer Tsar
Challenge of cancer diagnosis


                    Cancer
                   300,00/yr
                    8/GP/yr


             Suspicious Symptoms
                  ?number?



            Patients Consulting GPs
                  300million/yr
Diagnostic Pathway
              Diagnostic Delay




Hansen et al Biomed central. BMC Health Ser Res 2008:8.49
NCAT-RCGP Primary care Audit

   Retrospective Audit of new cancer
    diagnoses Aug 2008-Aug 2009.
   Excluding screen detected cancer and BCCs
   Practices asked to under take two
    Significant Event Analyses & hold practice
    team meeting.
   ASW one of several Cancer Networks to
    participate and submitted data for national
    analysis.
   These results represent the local data.
Participation
   56 practices from all 6 PCTs
   Represents 20% of Network (277)
   1,550 new cases of cancer analysed
   75% of practices had >5,000pts
   68% taught medical students
   43% training practices
   35% Urban, 33% semi-rural 10% rural
Incidence & Demographics
                             Age Range of Patients in Audit
                                      N = 1550
                                   Female (47%)     Male (53%)


                 85+

                76-85

                66-75
    Age Range




                56-65

                46-55

                36-45

                26-35

                16-25

                 0-15

                        0   50      100       150        200     250   300
                                      Number of Patients
Ethnicity
                    Reported Ethnic Group (N = 1550)




                                     Not Known

                                                              Indian SubCont
                                           British
                                            White other
                                            Black Caribbean   White Irish

                                            Other
                                                              Mixed other

                                                                Black African
                                                                Chinese
    White British
                                                                Mixed White/Black
                                                                   Caribbean
                                                                Carribean
                                                                Other
Types of cancer diagnosed
                  Distribution of Cancers Within the Audit (N = 1550)

               Sarcoma
               Testicular
                Unknown
            BCN System
         Head and Neck
            Other (NOS)
         Gynaecological
                    Skin
   Upper Gastrointestinal
                    Lung
         Haematological
   Lower Gastrointestinal
                  Breast
               Urological

                            0   50   100   150    200    250   300      350   400
                                            Number of Cases
Stage of cancer at diagnosis by PCT
                   Stage at Diagnosis for Main Cancer Sites by PCT (N = 816 (53%))
                         Distant metastases         Local spread         Organ    Not known


      ASW



  Wiltshire



S Glouces



 Somerset



N Somerset



    Bristol



    Banes


              0%             20%              40%                  60%           80%          100%
Time to presentation by gender
                       Time to Present to GP With Symptom (N =1161)

                                            Female    Male


      Same Day

   Up to 1 Week

  Up to 2 Weeks

   Up to 1 Month

  Up to 3 Months

  Up to 6 Months

    Up to 1 Year

   > than 1 Year

                   0     20     40     60        80      100   120    140   160
                                        Number of Patients
Number of visits to BP before referral

                                      Number of Visits to GP before Referral
                                                   (N = 1550)
                      900
                                  773
                      800
 Number of Patients




                      700
                      600
                      500
                      400                   325
                      300
                      200   137                      126
                      100                                        42       37            47             63
                        0




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                            0



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                                                   Number of Visits




                                                                                        N
Number of GP visits by stage at diagnosis

                           Number of Visits to GP Before Referral by Stage at Diagnosis
                                                    (N = 1550)
                     500
                     450
                                                                             Distant metastases
                     400
                                                                             Local spread
Number of Patients




                     350
                                                                             Not known
                     300
                                                                             Organ
                     250
                     200
                     150
                     100
                      50
                       0
                            0        1        2        3         4       5     > 5 Visits     Not
                                                                                            Specified
                               Median Time (Days) Q1 - Q3
         S




                               10
                                    20
                                         30
                                              40
                                                   50
                                                        60
                                                             70
                                                                  80
                                                                       90




                           0
             ar
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       U
H         nk
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    m              w
       at            n
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        U              l
          pp
                er
     B              G
       ra             I
H          in
 ea           /C
    d             N
       an            S
           d
                                                                                             (N = 1161)




               N
                 ec
                     k
        Lo
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                    G
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                                                                            Time from First Presentation to Referral Sent




                  ca
      Te              l
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                 ul
                    ar
            B
               re
                                                                                                                            Time to referral by cancer type




                 as
                     t
                S
                    ki
                       n
Type of Referral

                           Referral Type (N = 1550)
                         Routine
               Private    12%
                3%

               Other
                1%

   Not referred by
      Practice
         8%

        Not known
           3%

                                                      2 Week
                                                       61%
            Emergency
              12%
Time from referral to investigation

                                     Time Interval from Referral to Specialist Investigation by
                                                          Referral Type
                                                            (N = 1431)

                        70
Median Days (Q1 - Q3)




                        60
                        50
                        40
                        30
                        20
                        10
                         0




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                                                                                               N
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                                                   ed
                                                 rr
                                               fe
                                             re
                                          ot
                                         N
Stage of cancer by time to referral

                                                  Time From Presentation to Referral Sent

                                50
                                45
Median with Quartiles 1 and 3




                                40
                                35
                                30

                                25
                                20
                                15
                                10
                                5
                                0
                                      Distant          Not known     All Cases   Local spread   Organ
                                     metastases
Access to Care for four main tumours

          Access to Secondary Care by Main Tumour Site (N = 816)

   2 Week    Emergency        Not known   Not referred by Practice   Other    Private   Routine


All (Main) Cases


 Prostate (31%)


     Lung (16%)


Colorectal (25%)


   Breast (28%)


                   0%   10%     20%   30%    40%     50%    60%      70%     80%   90%    100%
                                                % of Patients
Avoidable Delays by PCT

                                  Avoidable Delays to Patients' Journey

                                            No (69%)   Yes (17%)   Unknown (13%)

                   100%
                   90%
                   80%
Percent Reported




                   70%
                   60%
                   50%
                   40%
                   30%
                   20%
                   10%
                    0%
                          Banes        Bristol   N Somerset    Somerset    S Glouces   Wiltshire
                            Symptoms and Time to Present to GP (N = 1550)
              Wound healing

                     Anemia

                Weight Loss                                                     0 - 14 days
               Disorientation                                                   15- 90 days
          TATT, weak or faint                                                   > 90 days
               Asymptomatic                                                     Unknown
Indigestion, nausea, vomiting

                 Bowel habit

                       Other

     Breathing/Throat/Cough

       Abdominal Discomfort

  Lab or Image Test Results

               Skin Changes

           Urinary Problems

             Pain/Discomfort

           Bleeding/Bruising

     Lump, mass or swelling

                                0     50       100         150            200          250    300
                                                     Number of Patients
Significant Event Analysis

   A well known tool used in Primary Care

   Non-judgemental analysis of issues
    surrounding an event.

   Secondary analysis undertaken
Significant Event Audit

   127 SEA received
   Explores the complexity of cancer diagnosis
   Raises awareness of the issues at practice
    level.
   Practice protocols amended.
   Can influences local service delivery.
   Leads to sustained change in practice.
              Diagnostic Delay




Hansen et al Biomed central. BMC Health Ser Res 2008:8.49
SEA Patient factors

   Previously existing pathology
   Stoical personalities
   Chaotic lifestyles, alcoholics
   Refusing investigation
   Unusual or vague symptoms
   Young patients
SEA Clinical factors

   Negative physical examination
   Common symptoms e.g. cough,
    constipation, sore throat
   Previously made diagnoses can be
    challenged.
   Negative X-Ray result
   “Vigilant waiting”, “safety netting”
SEA Administrative factors

   Route of referral – use of NICE TWW
    guidelines
   Recording of PMH
   Results? Who gets them, who has
    responsibility of acting on them & telling
    the patient?
   Training of F2 and AiT Doctors
   Community Services
   Pathway of Malignancy of Unknown Primary
Summary: Celebrations

   Patients referred swiftly. Mean time to
    referral 5 days.
   few problems reported on access to
    diagnostics.
   Good use of TWW referrals (61%)
   TWW referrals the fastest route to being
    seen in secondary care.
   SEAs proven to be a powerful learning tool
Summary: Variations in Cancers

   Men more likely to have symptoms for
    more than 3months prior to presenting
   20% of lung cancer patients present at A&E
    cf to 9% of four main cancers
   59% of prostate cancer patients are
    referred via TWW cf 65% four main
    cancers.
   Patients with distant metastases at
    diagnosis have an overall longer pathway.
Summary: Variations between PCTs


   Presentation in Primary Care ASW 86%,
    S.Glos 77%
   Presentation in out-patients ASW 4%,
    BANES 7%
   Time to referral by PCT, Somerset mean 26
    days, Bristol mean 57 days
   Distant metastases four main cancers 18%,
    Bristol 22%
   Reported delay more often for S.Glos &
    Bristol
Recommendations

   Revisit patient pathways particularly for
    lung, but also for Upper & Lower GI

   Disseminate the learning

   Spread the practice

   Review Community Services
Steering Group

A Network wide Steering Group will oversee
  projects arising from audit and ensure
  implantation.

A Formal report will be published including all
  details of the audit results.


            www.aswcs.nhs.uk
    Group Work

   PCT tables

   Introductions

   Select a scribe
     For Discussion & feedback
1.    How will you disseminate the learning
      from the audit & SEAs in your
      organisation?
2.    How will you spread the learning in your
      organisation?
3.    What are your current pathways for lung,
      colorectal, upper GI?
      What changes could be made to improve
      these pathways?
Any Questions

								
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