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Optimising triage decisions for possible cancer in primary care …

- - - - Incorporates summarised epidemiological data classified by epistomological strength to derive PVs, odds ratios etc. in the form of decision-trees & algorithms to facilitate best diagnostic decisions
        
        Balances harms from under- and over-testing & promotes judicious and equitable use (based on need) of resources in a health system with finite resources
      - EBM originally 'de-emphasised intuition, unsystematic clinical experience, & pathophysiologic rationale as sufficient ground for clinical decision-making' Guyatt et al. 1992. Definition broadened by Sackett in 1996 to include expertise & values
        
        'Over-rationalist' with the inherent & (arguably false) assumption that codefied/analytical knowledge results in more objective decisions & outcomes, avoiding mistakes & biases from relying on own knowledge base
        
        De-values possible contribution of tacit, experiential knowledge, & other factors related to the GP
        
        "we know more than we can tell" (Polyani 1966)
        
        Despite EBM trifecta, GPs encouraged to act predominantly on 'best evidence', reinforced by QOF & pushback from secondary care; in reality they also (consciously or unconsciously) use tacit knowledge, and can be influenced by other provider factors (as well as patient & health-system factors)
        
        Gabbay & Le May (2004) - to make decisions GPs rely on tacit 'mindlines', acquired from brief reading & interactions with colleagues, more than formal/explicit knowledge
        
        the validity of tacit knowledge & other factors as a 'diagnostic tool' are unknown
        
        Non-analytical cognitive processes (system 1)
        
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  - - - GP adherence/use
        
        Variable adherence to guidelines (Baughan et al; Nicholson et al); most GPs would ignore guidelines if concerned about cancer & patients' sx didn't fit criteria, of which 20% would retrofit hx to meet criteria
        
        Equally, patients with red flag symptoms are often not referred by GPs (Kidney et al; CREDIBLE study)
      - Relatively low PPV of symptoms, including alarm symptoms in the context of low cancer incidence (1 full time GP will on average diagnose 8 new cancer cases annually)
      - Fail to support decision-making in the presence of comorbidity which can make it difficult for GPs (& patients) to discern salient features
      - Guidelines principally cover red-flag or alarm symptoms; they don't aid GPs for 50% patients who present with non-specific/vague symptoms
- - - - Knowledge of patients' PMH, risk factors etc.
      - Knowledge or awareness of guidelines/clinical criteria/symptoms
    - - Heuristics, mental shortcuts, biases
        
        First diagnostic impressions associated with subsequent referral decisions (& diagnosis) in patients with vague symptoms of cancer & more likely to reach correct diagnosis of cancer
      - Gut-feeling
        
        'A sense of reassurance or a sense of alarm' - triggered by patients presentation or behaviour with contextual knowledge
        
        GP suspicion of cancer is correlated with more referrals and imaging tests & associated with higher liklihood of cancer diagnosis, PPV 9.8% (Hjertholm et al. 2014)
- - - - Provider factors
        
        Most commonly related to clinicians decisions to request/perform test if occuring in primary care
        
        Multiple consultations before referral/testing particularly for non-specific symptoms
        
        Erroneously sending patients for inappropriate investigations or fail to send them for tests, prolonging the diagnostic pathway
      - Clinical factors/features
        
        Presence/number of comorbidities
        
        Cancer site (pancreatic, colon, rectal & gastric)
        
        Alarm v non-alarm & non-specific symptoms; latter associated with longer diagnostic intervals as difficult for GPs to select most appropriate diagnostic testing pathway
      - Health-system/contextual factors
        
        Investigations conducted in series (whether confined to primary care or referring out); waiting to feedback results of previous test before conducting another