Abstract Background Melanoma is the 5th commonest cancer in the UK and survivors require frequent and thorough skin checks. During the Achieving Self-directed Integrated Cancer Aftercare (ASICA) ...trial, melanoma survivors used an app to submit images of concerning lesions for assessment by a dermatology nurse. In the past, online courses have been used to train non-specialist primary care practitioners (PCPs) in this skill. Objectives This study aimed to determine whether an online course could increase knowledge, confidence, and attitudes towards skin image triage in PCPs in the Grampian area. Methods Preliminary discussions were held with PCPs to determine the need for an online course. The course was designed at the University of Aberdeen and included an introduction to the skin, case studies and quizzes on a variety of skin conditions based on melanoma survivors’ submissions via the ASICA app. Two pre- and post-course questionnaires were administered to all participants to (1) assess knowledge gained and (2) assess any improvements in confidence and attitudes towards triaging skin lesions that could be indicative of skin cancer. All PCPs in the Grampian area were invited to participate with almost 70 medical practices contacted. Results were analysed using a paired sample T-test. Results The course was advertised to all GP practices in the Grampian area and 38 PCPs completed all its stages. Undertaking the course improved all PCPs’ confidence and attitudes towards triaging ( p < 0.001). It also improved knowledge in all non-GP PCPs ( p = 0.01). Most participants found the course useful; thought it was at the right level of difficulty, right format and thought the design was good. Conclusions Our online course in triaging skin lesions submitted digitally to PCPs was able to improve knowledge, confidence, and attitudes towards triaging. The course was acceptable in its design and was deemed useful and applicable to practice. Further research should investigate the effect the course has on secondary care referral numbers.
Modern demands and challenges among healthcare professionals can be particularly stressful and resilience is increasingly necessary to maintain an effective, adaptable, and sustainable workforce. ...However, definitions of, and associations with, resilience have not been examined within the primary care context.
To examine definitions and measures of resilience, identify characteristics and components, and synthesise current evidence about resilience in primary healthcare professionals.
A systematic review was undertaken to identify studies relating to the primary care setting.
Ovid(®), Embase(®), CINAHL, PsycINFO, and Scopus databases were searched in December 2014. Text selections and data extraction were conducted by paired reviewers working independently. Data were extracted on health professional resilience definitions and associated factors.
Thirteen studies met the inclusion criteria: eight were quantitative, four qualitative, and one was an intervention study. Resilience, although multifaceted, was commonly defined as involving positive adaptation to adversity. Interactions were identified between personal growth and accomplishment in resilient physicians. Resilience, high persistence, high self-directedness, and low avoidance of challenges were strongly correlated; resilience had significant associations with traits supporting high function levels associated with demanding health professional roles. Current resilience measures do not allow for these different aspects in the primary care context.
Health professional resilience is multifaceted, combining discrete personal traits alongside personal, social, and workplace features. A measure for health professional resilience should be developed and validated that may be used in future quantitative research to measure the effect of an intervention to promote it.
1. Context: Melanoma is common and incidence increasing. Guidelines recommend monthly Total-Skin-Self-Examination (TSSE) performed by melanoma survivors to detect recurrent and new primary melanoma. ...TSSE is underperformed despite evidence of benefit. 2. Objective: To compare a self-directed digital intervention (intervention group) with treatment as usual (control group) in patients treated for a first stage 0-IIC primary cutaneous melanoma within the preceding 60 months. 3. Study design: Randomized clinical trial. 4. Setting: Two UK NHS hospitals (Aberdeen Royal Infirmary, Grampian and Addenbrookes, Cambridge 5. Population studied: Adults (aged >18) diagnosed with a first 0-IIC primary cutaneous melanoma. 6. Intervention: ASICA (Achieving Self-directed Integrated Cancer Aftercare) is a tablet-based digital intervention to prompt and support TSSE in melanoma survivors. The hypothesis tested was that ASICA would increase TSSE practice in those affected by melanoma using it, and compared to controls, without affecting psychological well-being. 7. Outcomes Measures: Melanoma worry (Melanoma Worry Scale, MWS), anxiety and depression (Hospital Anxiety and Depression Scale; HADs), and quality of life (EuroQoL EQ-5D-5L) were collected by postal questionnaire 3, 6 and 12-months following randomisation. 8. Results: 241 recruits randomised (1:1) to ASICA (n=141) or control, n=140). There were no significant differences between groups for melanoma worry at 12 months (mean difference 0-12 95% confidence interval (-0-6, 0-84), p=0-743), at 3 months (0-23 (-0-31, 0- 78) p=0.402) or 6 months (-0-1 (0-7, 0-51) p=0-757). The ASICA group had lower anxiety scores at 12 months (- 0.54 (-1.31, 0.230 p=0.168), at 3 months (-0-13; -0-.79, 0-54; p=0-711) and significantly at 6 months (-1-00 (-1-74, -0-26) p=0-009). Depression scores were similar being lower at 12 months (-0-44 (-1-11, 0-23), p=0.195) and 3 months (-0-24 (-0-84, 0-35)p=0-421) but only significantly lower at 6 months (-0-77 (-1-41, -0-12) p=0-020). The ASICA group had significantly higher quality of life scores at 12 months (0-044; (0-003, 0-085); p=0-036) and 6 months (0-070 (0-032, 0-107) p<0-001) and non- significantly at 3 months 0-024(0-006, 0-054) p=0-112). 9. Conclusions: Using ASICA for 12 months does not increase melanoma worry and can reduce anxiety and depression and improves quality of life. ASICA has the potential to improve well-being of melanoma survivors and enable the benefits of regular TSSE.
Specialist-led cancer follow-up is becoming increasingly expensive and is failing to meet many survivors' needs. Alternative models informed by survivors' preferences are urgently needed. It is ...unknown if follow-up preferences differ by cancer type. We conducted the first study to assess British cancer survivors' follow-up preferences, and the first anywhere to compare the preferences of survivors from different cancers.
A discrete choice experiment questionnaire was mailed to 1201 adults in Northeast Scotland surviving melanoma, breast, prostate or colorectal cancer. Preferences and trade-offs for attributes of cancer follow-up were explored, overall and by cancer site.
668 (56.6%) recipients (132 melanoma, 213 breast, 158 prostate, 165 colorectal) responded. Cancer survivors had a strong preference to see a consultant during a face-to-face appointment when receiving cancer follow-up. However, cancer survivors appeared willing to accept follow-up from specialist nurses, registrars or GPs provided that they are compensated by increased continuity of care, dietary advice and one-to-one counselling. Longer appointments were also valued. Telephone and web-based follow-up and group counselling, were not considered desirable. Survivors of colorectal cancer and melanoma would see any alternative provider for greater continuity, whereas breast cancer survivors wished to see a registrar or specialist nurse, and prostate cancer survivors, a general practitioner.
Cancer survivors may accept non-consultant follow-up if compensated with changes elsewhere. Care continuity was sufficient compensation for most cancers. Given practicalities, costs and the potential to develop continuous care, specialist nurse-led cancer follow-up may be attractive.
Evidence has shown for over 20 years that patients residing in rural areas face poorer outcomes for cancer. The inequalities in survival that rural cancer patients face are observed throughout the ...developed world, yet this issue remains under-examined and unexplained. There is evidence to suggest that rural patients are more likely to be diagnosed as a result of an emergency presentation and that rural patients may take longer to seek help for symptoms. However, research to date has been predominantly epidemiological, providing us with an understanding of what is occurring in these populations, yet failing to explain why. In this paper we outline the problems inherent in current research approaches to rural cancer inequalities, namely how 'cancer symptoms' are conceived of and examined, and the propensity towards a reductionist approach to rural environments and populations, which fails to account for their heterogeneity. We advocate for a revised rural cancer inequalities research agenda, built upon in-depth, community-based examinations of rural patients' experiences across the cancer pathway, which takes into account both the micro and macro factors which exert influence on these experiences, in order to develop meaningful interventions to improve cancer outcomes for rural populations.
To investigate how individuals diagnosed with cancer use out-of-hours (OOH) medical services, describe the behavioural determinants of OOH service use and explore whether there are differences ...between urban and rural dwellers.
A cross-sectional questionnaire study conducted in Northeast Scotland.
The questionnaire was sent to 2549 individuals diagnosed with cancer in the preceding 12 months identified through the National Health Service Grampian Cancer Care Pathway database. 490 individuals returned the questionnaire (19.2% response rate), 61.8% were urban and 34.9% were rural.
Outcomes were differences in frequency of medical service use and attitudes towards OOH services between urban and rural participants. Patient experience (qualitative data) was compared.
Daytime services were used much more frequently than OOH services-83.3% of participants had never contacted an OOH primary care service in the preceding 12 months but 44.2% had used their daytime general practitioner at least four times. There were no significant differences between urban and rural dwellers in the patterns of OOH or daytime service use, the behavioural determinants of service use or the experiences of OOH services. Rural dwellers were significantly less likely to agree that OOH services were close by and more likely to agree that where they lived made it difficult to access these services. Rural dwellers were no more likely to agree or disagree that distance would affect their decision to contact OOH services. Qualitative results highlighted barriers to accessing OOH services exist for all patients but that long travel distances can be offset by service configuration, travel infrastructure and access to a car.
Urban and rural dwellers have similar beliefs, attitudes towards and patterns of OOH service use. In Northeast Scotland, place of residence is unlikely to be the most important factor in influencing decisions about whether to access OOH medical care.
Cancer awareness campaigns aim to increase awareness of the potential seriousness of signs and symptoms of cancer, and encourage their timely presentation to healthcare services. Enhanced ...understanding of the prevalence of symptoms possibly indicative of cancer in different population subgroups, and associated general practitioner (GP) help-seeking behaviour, will help to target cancer awareness campaigns more effectively.
To determine: i) the prevalence of 21 symptoms possibly indicative of breast, colorectal, lung or upper gastrointestinal cancer in the United Kingdom (UK), including six 'red flag' symptoms; ii) whether the prevalence varies among population subgroups; iii) the proportion of symptoms self-reported as presented to GPs; iv) whether GP help-seeking behaviour varies within population subgroups.
Self-completed questionnaire about experience of, and response to, 25 symptoms (including 21 possibly indicative of the four cancers of interest) in the previous month and year; sent to 50,000 adults aged 50 years or more and registered with 21 general practices in Staffordshire, England or across Scotland.
Completed questionnaires were received from 16,778 respondents (corrected response rate 34.2%). Almost half (45.8%) of respondents had experienced at least one symptom possibly indicative of cancer in the last month, and 58.5% in the last year. The prevalence of individual symptoms varied widely (e.g. in the last year between near zero% (vomiting up blood) and 15.0% (tired all the time). Red flag symptoms were uncommon. Female gender, inability to work because of illness, smoking, a history of a specified medical diagnosis, low social support and lower household income were consistently associated with experiencing at least one symptom possibly indicative of cancer in both the last month and year. The proportion of people who had contacted their GP about a symptom experienced in the last month varied between 8.1% (persistent cough) and 39.9% (unexplained weight loss); in the last year between 32.8% (hoarseness) and 85.4% (lump in breast). Nearly half of respondents experiencing at least one red flag symptom in the last year did not contact their GP about it. Females, those aged 80+ years, those unable to work because of illness, ex-smokers and those previously diagnosed with a specified condition were more likely to report a symptom possibly indicative of cancer to their GP; and those on high household income less likely.
Symptoms possibly indicative of cancer are common among adults aged 50+ years in the UK, although they are not evenly distributed. Help-seeking responses to different symptoms also vary. Our results suggest important opportunities to provide more nuanced messaging and targeting of symptom-based cancer awareness campaigns.
ObjectivesTo describe trajectories in melanoma survivors’ adherence to monthly total skin self-examination (TSSE) over 12 months, and to investigate whether adherence trajectories can be predicted ...from demographic, cognitive or emotional factors at baseline.DesignA longitudinal observational study nested within the intervention arm of the ASICA (Achieving Self-Directed Integrated Cancer Aftercare) randomised controlled trial.SettingFollow-up secondary care in Aberdeen and Cambridge UK.Participantsn=104 adults (48 men/56 women; mean age 58.83 years, SD 13.47, range 28–85 years; mean Scottish Index of Multiple Deprivation score 8.03, SD 1.73, range 2–10) who had been treated for stage 0–IIC primary cutaneous melanoma in the preceding 60 months and were actively participating in the intervention arm of the ASICA trial.InterventionsAll participants were using the ASICA intervention—a tablet-based intervention designed to support monthly TSSE.Primary and secondary outcome measuresThe primary outcome was adherence to guideline recommended (monthly) TSSE over 12 months. This was determined from time-stamped TSSE data recorded by the ASICA intervention app.ResultsLatent growth mixture models identified three TSSE adherence trajectories (adherent −41%; drop-off −35%; non-adherent −24%). People who were non-adherent were less likely to intend to perform TSSE as recommended, intending to do it more frequently (OR=0.21, 95% CI 0.06 to 0.81, p=0.023) and were more depressed (OR=1.31, 95% CI 1.06 to 1.61, p=0.011) than people who were adherent. People whose adherence dropped off over time had less well-developed action plans (OR=0.78, 95% CI 0.63 to 0.96, p=0.016) and lower self-efficacy about TSSE (OR=0.92, 95% CI 0.86 to 0.99, p=0.028) than people who were adherent.ConclusionsAdherence to monthly TSSE in people treated for melanoma can be differentiated into adherent, drop-off and non-adherent trajectories. Collecting information about intentions to engage in TSSE, depression, self-efficacy and/or action planning at outset may help to identify those who would benefit from additional intervention.Trial registration numberClinicalTrials.gov Registry (NCT03328247).
Background Gallstone disease is a common gastrointestinal disorder in industrialised societies. The prevalence of gallstones in the adult population is estimated to be approximately 10–15%, and ...around 80% remain asymptomatic. At present, cholecystectomy is the default option for people with symptomatic gallstone disease. Objectives To assess the clinical and cost-effectiveness of observation/conservative management compared with laparoscopic cholecystectomy for preventing recurrent symptoms and complications in adults presenting with uncomplicated symptomatic gallstones in secondary care. Design Parallel group, multicentre patient randomised superiority pragmatic trial with up to 24 months follow-up and embedded qualitative research. Within-trial cost–utility and 10-year Markov model analyses. Development of a core outcome set for uncomplicated symptomatic gallstone disease. Setting Secondary care elective settings. Participants Adults with symptomatic uncomplicated gallstone disease referred to a secondary care setting were considered for inclusion. Interventions Participants were randomised 1: 1 at clinic to receive either laparoscopic cholecystectomy or observation/conservative management. Main outcome measures The primary outcome was quality of life measured by area under the curve over 18 months using the Short Form-36 bodily pain domain. Secondary outcomes included the Otago gallstones’ condition-specific questionnaire, Short Form-36 domains (excluding bodily pain), area under the curve over 24 months for Short Form-36 bodily pain domain, persistent symptoms, complications and need for further treatment. No outcomes were blinded to allocation. Results Between August 2016 and November 2019, 434 participants were randomised (217 in each group) from 20 United Kingdom centres. By 24 months, 64 (29.5%) in the observation/conservative management group and 153 (70.5%) in the laparoscopic cholecystectomy group had received surgery, median time to surgery of 9.0 months (interquartile range, 5.6–15.0) and 4.7 months (interquartile range 2.6–7.9), respectively. At 18 months, the mean Short Form-36 norm-based bodily pain score was 49.4 (standard deviation 11.7) in the observation/conservative management group and 50.4 (standard deviation 11.6) in the laparoscopic cholecystectomy group. The mean area under the curve over 18 months was 46.8 for both groups with no difference: mean difference –0.0, 95% confidence interval (–1.7 to 1.7); p -value 0.996; n = 203 observation/conservative, n = 205 cholecystectomy. There was no evidence of differences in quality of life, complications or need for further treatment at up to 24 months follow-up. Condition-specific quality of life at 24 months favoured cholecystectomy: mean difference 9.0, 95% confidence interval (4.1 to 14.0), p < 0.001 with a similar pattern for the persistent symptoms score. Within-trial cost–utility analysis found observation/conservative management over 24 months was less costly than cholecystectomy (mean difference –£1033). A non-significant quality-adjusted life-year difference of –0.019 favouring cholecystectomy resulted in an incremental cost-effectiveness ratio of £55,235. The Markov model continued to favour observation/conservative management, but some scenarios reversed the findings due to uncertainties in longer-term quality of life. The core outcome set included 11 critically important outcomes from both patients and healthcare professionals. Conclusions The results suggested that in the short term (up to 24 months) observation/conservative management may be a cost-effective use of National Health Service resources in selected patients, but subsequent surgeries in the randomised groups and differences in quality of life beyond 24 months could reverse this finding. Future research should focus on longer-term follow-up data and identification of the cohort of patients that should be routinely offered surgery. Trial registration This trial is registered as ISRCTN55215960. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 14/192/71) and is published in full in Health Technology Assessment ; Vol. 28, No. 26. See the NIHR Funding and Awards website for further award information.
PDF
