This project was funded by the NIHR Health Technology Assessment programme and the Wellcome Trust and will be published in full in Health Technology Assessment; Vol. 18, No. 43. See the NIHR Journals Library website for further project information.

ObjeCtiveTo assess the overall effect of the English urgent referral pathway on cancer survival. Setting general practices in England.DeSign Cohort study. Linked information from the national Cancer Waiting Times database, NHS Exeter database, and National Cancer Register was used to estimate mortality in patients in relation to the propensity of their general practice to use the urgent referral pathway.PartiCiPantS 215 284 patients with cancer, diagnosed or first treated in England in 2009 and followed up to 2013. OutCOme meaSureHazard ratios for death from any cause, as estimated from a Cox proportional hazards regression.reSultS During four years of follow-up, 91 620 deaths occurred, of which 51 606 (56%) occurred within the first year after diagnosis. Two measures of the propensity to use urgent referral, the standardised referral ratio and the detection rate, were associated with reduced mortality. The hazard ratio for the combination of high referral ratio and high detection rate was 0.96 (95% confidence interval 0.94 to 0.99), applying to 16% (n=34 758) of the study population. Patients with cancer who were registered with general practices with the lowest use of urgent referral had an excess mortality (hazard ratio 1.07 (95% confidence interval 1.05 to 1.08); 37% (n=79 416) of the study population). The comparator group for these two hazard ratios was the remaining 47% (n=101 110) of the study population. This result in mortality was consistent for different types of cancer (apart from breast cancer) and with other stratifications of the dataset, and was not sensitive to adjustment for potential confounders and other details of the statistical model. COnCluSiOnSUse of the urgent referral pathway could be efficacious. General practices that consistently have a low propensity to use urgent referrals could consider increasing the use of this pathway to improve the survival of their patients with cancer.

BackgroundDesigners of computerised diagnostic support systems (CDSSs) expect physicians to notice when they need advice and enter into the CDSS all information that they have gathered about the patient. The poor use of CDSSs and the tendency not to follow advice once a leading diagnosis emerges would question this expectation.AimTo determine whether providing GPs with diagnoses to consider before they start testing hypotheses improves accuracy.Design and settingMixed factorial design, where 297 GPs diagnosed nine patient cases, differing in difficulty, in one of three experimental conditions: control, early support, or late support.MethodData were collected over the internet. After reading some initial information about the patient and the reason for encounter, GPs requested further information for diagnosis and management. Those receiving early support were shown a list of possible diagnoses before gathering further information. In late support, GPs first gave a diagnosis and were then shown which other diagnoses they could still not discount.ResultsEarly support significantly improved diagnostic accuracy over control (odds ratio [OR] 1.31; 95% confidence interval [95%CI] = 1.03 to 1.66, P = 0.027), while late support did not (OR 1.10; 95% CI = 0.88 to 1.37). An absolute improvement of 6% with early support was obtained. There was no significant interaction with case difficulty and no effect of GP experience on accuracy. No differences in information search were detected between experimental conditions.ConclusionReminding GPs of diagnoses to consider before they start testing hypotheses can improve diagnostic accuracy irrespective of case difficulty, without lengthening information search.

Objective: Clinically irrelevant but psychologically important factors such as patients' expectations for antibiotics encourage overprescribing. We aimed to (a) provide missing causal evidence of this effect, (b) identify whether the expectations distort the perceived probability of a bacterial infection either in a preor postdecisional distortions pathway, and (c) detect possible moderators of this effect. Method: Family physicians expressed their willingness to prescribe antibiotics (Experiment 1, n 1 ϭ 305) or their decision to prescribe (Experiment 2, n 2 ϭ 131) and assessed the probability of a bacterial infection in hypothetical patients with infections either with low or high expectations for antibiotics. Response order of prescribing/probability was manipulated in Experiment 1. Results: Overall, the expectations for antibiotics increased intention to prescribe (Experiment 1, F(1, 301) ϭ 25.32, p Ͻ .001, p 2 ϭ .08, regardless of the response order; Experiment 2, odds ratio [OR] ϭ 2.31, and OR ϭ 0.75, Vignettes 1 and 2, respectively). Expectations for antibiotics did not change the perceived probability of a bacterial infection (Experiment 1, F(1, 301) ϭ 1.86, p ϭ .173, p 2 ϭ .01, regardless of the response order; Experiment 2, d ϭ Ϫ0.03, and d ϭ ϩ0.25, Vignettes 1 and 2, respectively). Physicians' experience was positively associated with prescribing, but it did not moderate the expectations effect on prescribing. Conclusions: Patients' and their parents' expectations increase antibiotics prescribing, but their effect is localized-it does not leak into the perceived probability of a bacterial infection. Interventions reducing the overprescribing of antibiotics should target also psychological factors.

BackgroundThere is considerable variation between GP practices in England in their use of urgent referral pathways for suspected cancer.AimTo determine the association between practice use of urgent referral and cancer stage at diagnosis and cancer patient mortality, for all cancers and the most common types of cancer (colorectal, lung, breast, and prostate).Design and settingNational cohort study of 1.4 million patients diagnosed with cancer in England between 2011 and 2015.MethodThe cohort was stratified according to quintiles of urgent referral metrics. Cox proportional hazards regression was used to quantify risk of death, and logistic regression to calculate odds of late-stage (III/IV) versus early-stage (I/II) cancers in relation to referral quintiles and cancer type.ResultsCancer patients from the highest referring practices had a lower hazard of death (hazard ratio [HR] = 0.96; 95% confidence interval [CI] = 0.95 to 0.97), with similar patterns for individual cancers: colorectal (HR = 0.95; CI = 0.93 to 0.97); lung (HR = 0.95; CI = 0.94 to 0.97); breast (HR = 0.96; CI = 0.93 to 0.99); and prostate (HR = 0.88; CI = 0.85 to 0.91). Similarly, for cancer patients from these practices, there were lower odds of late-stage diagnosis for individual cancer types, except for colorectal cancer.ConclusionHigher practice use of referrals for suspected cancer is associated with lower mortality for the four most common types of cancer. A significant proportion of the observed mortality reduction is likely due to earlier stage at diagnosis, except for colorectal cancer. This adds to evidence supporting the lowering of referral thresholds and consequent increased use of urgent referral for suspected cancer.