Elsevier

Cancer Epidemiology

Volume 65, April 2020, 101698
Cancer Epidemiology

Influences of rurality on action to diagnose cancer by primary care practitioners – Results from a Europe-wide survey in 20 countries

https://doi.org/10.1016/j.canep.2020.101698Get rights and content

Highlights

  • Rural cancer patients have poorer cancer outcomes than urban counterparts.

  • The study reports data from 1779 primary care practitioners from across Europe.

  • European rural primary care practitioners have less direct access to cancer investigations.

  • But European rural practitioners take diagnostic action for potential cancer just as promptly.

  • Service organization is a more likely cause of rural cancer inequality than practitioner behaviour.

Abstract

Background

Rural-dwellers have poorer cancer outcomes than urban counterparts, for reasons which are unclear. At healthcare institution level, poorer access to investigations and different clinical decision-making by rural primary healthcare practitioners (PCPs) could be important.

Aim

To compare access to investigations, attitudes to cancer diagnosis and clinical decision-making between rural and urban PCPs.

Setting

A vignette-based cross-sectional survey of rural and urban PCPs in 20 European countries.

Methods

Data on PCPs’ decision-making and attitudes to cancer diagnosis were based on clinical scenarios. Comparisons were made using tests of proportion, univariable and multivariable binary logistic regression.

Results

Of the 1779 PCPs completing the survey 541 30.4 %) practiced rurally. Rural PCPs had significantly less direct access to all investigative modalities: ultrasound; endoscopy; x-ray and advanced screening (all p < 0.001). Rural PCPs were as likely as urban PCPs to take diagnostic action (investigation and/or referral) at the index consultation in all four clinical vignettes ((OR, 95 % CI) for lung: 0.90, 0.72–1.12; ovarian: 0.95, 0.75–1.19; breast: 0.87, 0.69–1.09; colorectal: 0.98, 0.75–1.30). Rural PCPs were less likely to refer to a specialist at the index consultation for ovarian cancer (OR 0.71 95 % CI 0.51-0.99). Rural PCPs were significantly more likely to report that their patients faced barriers to accessing specialist care, but practitioners did not report greater difficulties making specialist referral than their urban counterparts

Conclusions

European rural PCPs report poorer access to investigations but are at least as likely as urban PCPs to investigate or refer patients that might have cancer at the index consultation.

Introduction

Rural-dwellers have poorer cancer outcomes compared to city-dwellers but underlying mechanisms are poorly understood [1]. Poorer rural cancer outcomes are important socially and economically since 24 % of Europeans live rurally [2]. Evidence for poorer rural cancer outcomes has accumulated over thirty years [3]. A 1990 case-control study found poorer case-survival rates in non-metropolitan South Australians after adjusting for disease stage [4]. In 2000, a Scottish analysis of 63,976 people diagnosed from 1991 to 1995 found that increasing distance from cancer centres was associated with poorer survival for prostate and lung cancer [5]. A Scottish study based on 12,339 people diagnosed with common cancers found lower one-year survival among those living more than 60 min from a cancer centre [6]. More recently, a study of 737,495 people diagnosed with cancer in England between 2006 and 2010 reported that those living more than 30 min from their GP were more likely to have an emergency presentation and less likely to have screen-detected cancer [7]. Studies of a Danish national cohort of 256,662 cancer patients diagnosed between 2005 and 2016 found that increased distance to hospital was associated with longer diagnostic intervals and later stage for harder to diagnose cancers [8,9].

A recent systematic review reported that, of 39 observational studies from seven countries, most showed poorer outcomes for rural patients with cancer [1]. Narrative synthesis of the data suggested that inequities can exist at the levels of: the individual patient (their demographics and behavioural risk factors); healthcare institutions; urban/rural community environments and culture; and at the level of health policy and service organization [1]. At a healthcare institutions level, rural communities could have fewer and less specialised healthcare practitioners, with more limited access to investigations [1].

Most Europeans with potential cancer symptoms present first to a primary care practitioner (PCP) whose decision-making and diagnostic actions will influence the subsequent promptness of cancer diagnosis [10]. It seems plausible that geographical setting could influence PCPs’ diagnostic decision-making when faced with patients who might have cancer. However, we could identify no studies, explicitly comparing attitudes to primary care cancer diagnosis and decision-making intentions between urban and rural PCPs.

The Örenäs Research Group is a is a European group of primary care researchers that studies the primary care factors that relate to cancer survival. A trans-European collaboration that surveyed PCPs in 20 different European countries [11] gathered data from PCPs in rural and urban settings on their access to investigations, attitudes and decision-making around cancer diagnosis in primary care. This gives the opportunity to explore whether these factors differ significantly between rural and urban European PCPs.

Section snippets

Objectives

The objectives of this study were to:

  • 1

    Compare rural and urban PCPs’ direct access to cancer investigations.

  • 2

    Compare likelihood that rural or urban PCPs will arrange investigations or referral at the index consultation for patients with potential cancer symptoms.

  • 3

    Compare attitudes of rural and urban PCPs to factors associated with cancer diagnosis in primary care.

Design and study setting

The study used data from a cross-sectional Örenäs Research Group electronic survey of PCPs in 20 European countries [11]. Development and

Results

The survey was completed by 2086 PCPs from 20 European countries. 1238 59.3 %) practiced in an urban setting, 485 (23.3 %) in a rural setting, 56 (2.7 %) in a remote or island setting, 295 (14.1 %) in a mixed setting, with 12 (0.6 %) missing values. The sample for this analysis described in Table 1 comprised 1779 individuals of whom 541 30.4 %) were considered rural. Rural PCPs were 47.2 % male compared to 34.0 % of urban respondents (p < 0.001) and rural PCPs were significantly more likely to

Main findings

Rural PCPs were more likely to be male and to have been qualified for longer. They were less likely to have had direct access to all investigative modalities. Rural PCPs were just as likely to intend diagnostic action at the index consultation as urban counterparts and were as likely indicate that they would refer in three of the four clinical vignettes. Rural PCPs perceived easier access to specialist referral and advice and being under less pressure than urban counterparts. Rural PCPs were

Funding

The study on how practicing in a rural setting may impact upon primary care practitioners, access to tests, investigative decisions and attitudes to cancer diagnosis has received no external funding.

Ethical approval

Consent by the participating PCPs was implied by agreeing to take part in the survey.

Ethical approval for the study has been given by the University of Bath Research Ethics Approval Committee for Health (approval date: 24th November 2014; REACH reference number: EP 14/15 66; UK National Health Service ethical approval is not required).

CRediT authorship contribution statement

Peter Murchie: Conceptualization, Methodology, Data curation, Formal analysis, Writing - original draft. Wei Lynn Khor: Formal analysis, Writing - review & editing. Rosalind Adam: Formal analysis, Writing - review & editing. Magdalena Esteva: Conceptualization, Writing - review & editing. Emmanouil Smyrnakis: Conceptualization, Writing - review & editing. Davorina Petek: Conceptualization, Writing - review & editing. Hans Thulesius: Conceptualization, Writing - review & editing. Peter Vedsted:

Declaration of Competing Interest

PM, WK, RA, ME, ES, DP, HT, PV, DM and MH have no competing interests to declare.

References (24)

  • P. Murage et al.

    Geographical access to GPs and modes of cancer diagnosis in England: a cross-sectional study

    Fam. Pract.

    (2019)
  • L.F. Virgilsen et al.

    Cancer diagnostic delays and travel distance to health services: a nationwide cohort study in Denmark

    Cancer Epidemiol.

    (2019)
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