Identifying important health system factors that influence primary care practitioners' referrals for cancer suspicion: a European cross-sectional survey

Abstract

Objectives: Cancer survival and stage of disease at diagnosis and treatment vary widely across Europe. These differences may be partly due to variations in access to investigations and specialists. However, evidence to explain how different national health systems influence primary care practitioners' (PCPs') referral decisions is lacking.This study analyses health system factors potentially influencing PCPs' referral decision-making when consulting with patients who may have cancer, and how these vary between European countries.

Design: Based on a content-validity consensus, a list of 45 items relating to a PCP's decisions to refer patients with potential cancer symptoms for further investigation was reduced to 20 items. An online questionnaire with the 20 items was answered by PCPs on a five-point Likert scale, indicating how much each item affected their own decision-making in patients that could have cancer. An exploratory factor analysis identified the factors underlying PCPs' referral decision-making.

Setting: A primary care study; 25 participating centres in 20 European countries.

Participants: 1830 PCPs completed the survey. The median response rate for participating centres was 20.7%.

Outcome measures: The factors derived from items related to PCPs' referral decision-making. Mean factor scores were produced for each country, allowing comparisons.

Results: Factor analysis identified five underlying factors: PCPs' ability to refer; degree of direct patient access to secondary care; PCPs' perceptions of being under pressure; expectations of PCPs' role; and extent to which PCPs believe that quality comes before cost in their health systems. These accounted for 47.4% of the observed variance between individual responses.

Conclusions: Five healthcare system factors influencing PCPs' referral decision-making in 20 European countries were identified. The factors varied considerably between European countries. Knowledge of these factors could assist development of health service policies to produce better cancer outcomes, and inform future research to compare national cancer diagnostic pathways and outcomes.

Keywords: cancer; consultation and referral; decision making; delivery of health care; general practitioners; primary health care.

Figure 1

Comparison of national scores for factor 1: primary care practitioner’s ability to refer. A higher score indicated lower barriers to specialist referral.

Figure 2

Comparison of national scores for factor 2: degree of direct patient access to secondary care. A higher score was linked with the absence of a general practitioner gate-keeping role, but higher financial and geographical barriers to healthcare for some patients.

Figure 3

Comparison of national scores for factor 3: pressure on primary care practitioners from outside. A higher score was linked with perceptions of higher pressure on the primary care practitioner.

Figure 4

Comparison of national scores for factor 4: expectations of the primary care practitioner’s (PCPs') role. A higher score was associated with higher expectations of PCP-centred care, and the presence of guidelines to support PCP decision-making.

Figure 5

Comparison of national scores for factor 5: quality before cost. A higher score was linked with primary care practitioner perceptions that in their systems high quality care for patients was more important than costs.