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Primary care system factors and clinical decision-making in patients that could have lung cancer: A vignette study in five balkan region countries

Davorina Petek
Davorina Petek
, 
Radost Assenova
Radost Assenova
, 
Gergana Foreva
Gergana Foreva
, 
Svjetlana Gašparović Babić
Svjetlana Gašparović Babić
, 
Marija Petek Šter
Marija Petek Šter
, 
Nuša Prebil
Nuša Prebil
, 
Aida Puia
Aida Puia
, 
Emmanouil Smyrnakis
Emmanouil Smyrnakis
 y 
Michael Harris
Michael Harris
   | 03 ene 2022
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Article Category: Original scientific article
Publicado en línea: 03 ene 2022
Páginas: 40 - 47
Recibido: 21 dic 2020
Aceptado: 19 nov 2021
DOI: https://doi.org/10.2478/sjph-2022-0007
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© 2022 National Institute of Public Health, Slovenia, published by Sciendo
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License.

Figure 1

National comparisons of PCPs stated clinical actions for vignette of a patient with symptoms that could be due to lung cancer.
National comparisons of PCPs stated clinical actions for vignette of a patient with symptoms that could be due to lung cancer.

Number of participants and response rates in each of the five participating countries.

Bulgaria Croatia Greece Romania Slovenia
Number of respondents 59 67 68 177 104
Number invited 90 292 318 Unknown 352
Response rate (%) 65.6 22.9 21.4 Unknown 29.5

Effects of PCP and practice demographics, system factors, availability of relevant investigations and country on (a) PCPs’ likelihood of scheduling an investigation and (b) likelihood of referral patients to a specialist, for a patient with symptoms that could be due to lung cancer.

Statement a) Effects on PCPs’ likelihood of organising an investigation
 b) Effects on PCPs’ likelihood of referral to a specialist
Exp(B) 95% CI P value Exp(B) 95% CI P value
Sex (Male) 0.912 0.478-1.742 0.781 0.806 0.406-1.599 0.536
Type of practice (Urban) 0.899 0.515
Rural 0.823 0.424-1.596 0.564 1.555 0.802-3.015 0.191
Island 1.312 0.264-6.521 0.740 2.198 0.422-11.459 0.350
Mixed 1.028 0.486-2.174 0.943 1.101 0.470-2.580 0.824
Years since graduation (Less than 10) 0.474 0.975
10 to 19 0.948 0.354-2.541 0.916 1.259 0.438-3.616 0.669
20 to 29 0.697 0.267-1.818 0.461 1.105 0.398-3.063 0.848
30 to 39 1.465 0.505-4.249 0.482 1.212 0.405-3.629 0.732
40 or more 1.117 0.201-6.216 0.900 0.784 0.129-4.776 0.792
‘Common presentations are 0.731 0.662
covered by local or national
guidelines’ (Strongly disagree)
Disagree 2.017 0.490-8.296 0.331 1.000 0.254-3.940 1.000
Neither agree nor disagree 1.572 0.416-5.936 0.504 1.159 0.316-4.246 0.824
Agree 2.162 0.573-8.162 0.255 1.527 0.423-5.517 0.518
Strongly agree 1.548 0.317-7.547 0.589 0.789 0.152-4.105 0.778
‘We have access to a fast-track specialist 0.324 0.318
appointment system’ (Strongly disagree)
Disagree 0.904 0.371-2.202 0.825 0.647 0.266-1.577 0.338
Neither agree nor disagree 1.960 0.655-5.862 0.229 1.015 0.366-2.809 0.978
Agree 0.840 0.329-2.145 0.716 0.833 0.320-2.169 0.708
Strongly agree 1.885 0.465-7.640 0.375 2.130 0.572-7.931 0.259
‘Patients can self-refer to 0.263 0.910
specialists’ (Strongly disagree)
Disagree 1.407 0.755-2.621 0.283 1.150 0.588-2.247 0.683
Neither agree nor disagree 0.941 0.377-2.348 0.896 1.190 0.470-3.013 0.713
Agree 3.676 0.979-13.807 0.054 0.868 0.341-2.212 0.768
Strongly agree 2.059 0.474-8.952 0.335 1.696 0.414-6.955 0.463
Number of relevant investigations 0.376 0.257
available (None)
One 0.250 0.024-2.622 0.248 0.160 0.028-0.907 0.038
Two 0.365 0.043-3.104 0.356 0.358 0.091-1.404 0.141
Three 0.763 0.049-11.952 0.847 0.552 0.065-4.654 0.585
Four 0.552 0.060-5.069 0.599 0.198 0.042-0.929 0.040
Five 0.257 0.027-2.400 0.233 0.251 0.049-1.285 0.097
Country (Bulgaria) <.001 <0.001
Croatia 0.188 0.062-0.572 0.003 0.286 0.098-0.840 0.023
Greece 0.657 0.179-2.414 0.527 0.160 0.042-0.611 0.007
Romania 1.600 0.544-4.705 0.393 3.473 1.544-7.813 0.003
Slovenia 0.210 0.063-0.694 0.011 0.345 0.115-1.033 0.057
Constant 7.205 0.145 1.349 0.781

PCPs’ levels of agreement with statements on health system factors that could influence the timeliness of cancer diagnosis.

Statement Mean Likert scores (SD)1
 Significance
Bulgaria Croatia Greece Romania Slovenia (P value)
‘Common presentations and advice to which to refer are covered by local or national guidelines’ 2.76 (1.01) 3.22 (0.98) 3.59 (1.01) 3.37 (1.00) 3.73 (0.84) <0.001
‘We have access to a fast- track specialist appointment system if cancer is suspected’ 2.71 (1.19) 3.22 (1.17) 2.45 (1.11) 2.58 (1.08) 3.22 (1.22) <0.001
‘Patients can self-refer to specialists, so GPs don’t need to act as gatekeepers.’ 2.39 (1.04) 2.04 (1.02) 2.58 (1.30) 2.38 (1.15) 1.55 (0.85) <0.001

Participants’ demographic and practice information for each of the five participating countries.

Bulgaria n (%) Croatia n (%) Greece n (%) Romania n (%) Slovenia n (%)
Sex Male 13 (22.0) 12 (17.9) 34 (50.0) 21 (11.9) 25 (24.0)
Female 44 (74.6) 54 (80.6) 34 (50.0) 154 (87.0) 78 (75.0)
Not given 2 (3.4) 1 (1.5) 0 (0.0) 2 (1.2) 1 (1.0)
Years since Less than 10 8 (13.6) 11 (16.4) 0 (0.0) 8 (4.5) 17 (16.3)
graduation 10 to 19 11 (18.6) 10 (14.9) 38 (55.9) 42 (23.7) 34 (32.7)
20 to 29 23 (39.0) 22 (32.8) 25 (36.8) 75 (42.4) 32 (30.8)
30 to 39 11 (18.6) 21 (31.3) 5 (7.4) 50 (28.2) 16 (15.4)
40 or more 5 (8.5) 1 (1.5) 0 (0.0) 0 (0.0) 5 (4.8)
Not given 1 (1.7) 2 (3.0) 0 (0.0) 2 (1.1) 0 (0.0)
Type of practice Urban 44 (74.6) 31 (46.3) 20 (29.4) 108 (61.0) 44 (42.3)
Rural 5 (8.5) 23 (34.3) 34 (50.0) 60 (33.9) 31 (29.8)
Mixed 9 (15.3) 13 (19.4) 14 (20.6) 7 (4.0) 29 (27.9)
Not given 1 (1.7) 0 (0.0) 0 (0.0) 2 (1.1) 0 (0.0)
Number of PCPs 1 32 (54.2) 33 (49.3) 24 (35.3) 64 (36.2) 7 (6.7)
in the practice 2 8 (13.6) 9 (19.4) 8 (11.8) 33 (18.6) 10 (9.6)
3 8 (13.6) 6 (9.0) 3 (4.4) 17 (9.6) 14 (13.5)
4-5 1 (1.7) 6 (9.0) 11 (16.2) 20 (11.3) 10 (9.6)
6-7 1 (1.7) 6 (9.0) 6 (8.8) 9 (5.1) 12 (11.5)
8-9 1 (1.7) 5 (7.5) 1 (1.5) 5 (2.8) 15 (14.4)
10 or more 7 (11.9) 2 (3.0) 13 (19.1) 22 (12.4) 36 (34.6)
Not given 1 (1.7) 0 (0.0) 2 (2.9) 7 (4.0) 0 (0.0)

Number of PCPs who have direct access to relevant imaging for lung cancer.

Bulgaria n (%) Croatia n (%) Greece n (%) Romania n (%) Slovenia n (%) Significance (P value)
Plain X-ray 54 (91.5) 64 (95.5) 66 (97.1) 149 (84.2) 90 (86.5) <0.006
CT and/or PET CT and/or MRI 7 (11.9) 16 (23.9) 53 (77.9) 23 (13.0) 71 (68.3) <0.001
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