Family Practice Vol. 16, No. 1, 66-70
© Oxford University Press 1999
Strategies to improve cancer screening in general practice: are guidelines the answer?
Needs Assessment & Health Outcomes Unit, Central Sydney Area Health Service, Locked bag 8, Newtown NSW 2042, Australia.
Young JM and Ward JE. Strategies to improve cancer screening in general practice: are guidelines the answer? Family Practice 1999; 16: 66–70.
Received 2 July 1998; Accepted 7 October 1998.
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Abstract |
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Background. GPs are ideally placed to recommend appropriate cancer screening for their patients. However, opportunities to discuss screening are often missed and screening procedures are not always recommended in accordance with national policy. The development of clinical practice guidelines represents one strategy for improving cancer screening in general practice.
Objective. We aimed to ascertain Australian GPs' ratings of current clinical practice guidelines and their views of the likely usefulness of 18 strategies to improve cancer screening in general practice.
Method. A self-administered questionnaire was mailed to a national random sample of 1271 GPs in May 1996. Responders rated the usefulness of each of eight clinical practice guidelines current at the time of the survey. They then rated the usefulness of each of 18 strategies for support of cancer screening.
Results. We received 855 completed questionnaires (a 67% response rate). There was greatest support for guidelines already available on breast and cervical cancer. The most popular strategy to improve cancer screening was seminars with experts in preventive care, rated as ‘very useful’ by 658 (77%), followed by NHMRC guidelines (597, 70%) and pamphlets for patients (587, 69%). There was less support for more innovative strategies including assessment and feedback (35%), case finding by nurse practitioners (11%) and academic detailing (10%).
Conclusion. Responders indicated that strategies involving passive dissemination of information would be most useful for improving cancer screening in general practice. Identification of an effective combination of acceptable initiatives is needed.
Keywords. Family practice, guidelines, mass screening..
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Introduction |
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Evidence-based population screening programs have the potential to reduce significantly the burden of illness from cancer in Australia.1 GPs are uniquely placed to facilitate appropriate cancer screening by virtue of their contact with a large proportion of the population,2 credibility as providers of health information3 and effectiveness in encouraging patients to participate in screening programmes.4–6 However, Australian research suggests that GPs often miss opportunities to discuss screening with patients7,8 and do not always recommend screening in accordance with national guidelines.9–12
In 1991, an expert group identified the establishment of preventive care guidelines for Australia as the foremost strategy required to overcome barriers to preventive care in general practice.13 Other strategies recommended by this group included the development of medical record systems to facilitate preventive care and community-based teaching by prestigious, credible experts. Since then, there has been a proliferation of clinical practice guidelines in Australia.14 However, despite reporting strong support for evidence-based clinical practice guidelines, less than half of 286 Australian GPs responding to a national survey in 1995 believed their practice had changed as a result of a guideline.15 In response, we conducted this study to ascertain the usefulness to date of previous guidelines in cancer screening and the likely usefulness of 18 strategies to improve this crucial component of general practice.
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Methods |
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GP sample and survey administration
A national random sample of 1500 GPs was supplied by the (then) Commonwealth Department of Human Services and Health. Of these, 229 were considered ineligible (deceased, no longer working in general practice or unable to be contacted). As described fully elsewhere,16 a covering letter, questionnaire and reply-paid envelope were mailed in May 1996, using standardized response-aiding strategies to follow up non-responders.
Questionnaire content
As part of a 20-page questionnaire about cancer screening, responders were asked to rate the usefulness of each of eight clinical practice guidelines for general practice using a five-point scale (‘very useful’, ‘somewhat useful’, ‘a little useful’, ‘not useful’ and ‘not aware/can't remember’).
In a separate section, 18 strategies to support optimal cancer screening were listed in five groups as follows:
- Continuing education strategies: seminars with credible experts who have specialized in preventive medicine; a national conference on cancer screening; Practice Assessment Activity17 involving assessment and feedback on preventive care; distance-learning modules attracting Continuing Medical Education points;17 practical training in skills to identify patients at risk and encourage screening; audiotapes about cancer prevention; videotapes about cancer prevention; interactive computer program (n = 8).
- Guidelines development and implementation: guidelines developed by the National Health and Medical Research Council (NHMRC) about cancer screening; guidelines developed by the Royal Australian College of General Practitioners (RACGP) about cancer screening; GP Division (local professional association) meeting to adapt guidelines to local conditions (n = 3).
- Innovative organizational initiatives: nurse practitioners qualified to identify and screen patients in the practice; visits to the practice by trained staff from a health service who could work with the GP on a one-to-one basis; a computerized register of all patients in the practice in order to recall patients overdue for cancer screening tests (n = 3).
- Financial incentives: Better Practice Payments (remuneration from the Commonwealth to practices satisfying specific ‘quality’ criteria) linked to preventive care; payment of Medicare fee-for-service rebate to the practitioner each time a patient was screened according to recognized guidelines (n = 2).
- Patient-based approaches: pamphlets for patients about effective and ineffective cancer screening tests; patient-held record or card to remind patients about recommended screening and to record test results (n = 2).
These strategies had been generated from previous local research13,18 and key overseas literature.19,20 Responders were asked to rate the usefulness of each strategy using a four-point scale (‘quite a lot’, ‘a little’, ‘not at all’ and ‘unsure’). The questionnaire ended with standard demographic and professional questions. Copies of the questionnaire are available on request.
Data analysis
Proportions and 95% confidence intervals were calculated. The 18 strategies to support cancer screening were ranked in decreasing order of the proportion responding ‘quite a lot’. The proportions of responders indicating that guidelines from the NHMRC or RACGP would help ‘quite a lot’ were compared using McNemar's test for paired proportions. All analyses were performed using SAS for Windows Version 6.11.21
Ethics
The study was approved by the CSAHS Ethics Review Committee.
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Results |
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From 1271 eligible GPs, we received 855 replies (a 67% response rate). The response rate for females (75%) was significantly higher than that for males (63%) (chi-square = 15.4, 1 d.f., P < 0.001) but did not vary with age, vocational registration status, Fellowship of the RACGP or metropolitan or rural practice location.16
GPs' views about the usefulness of each of eight guidelines for cancer screening are shown in Table 1
. Just over half the responders (52.2%, 95% CI 48.8–55.5%) did not recall the RACGP's ‘Guidelines for preventive activities in general practice’ and only 10.4% (95% CI 8.5–12.6%) rated these guidelines as ‘very useful’. The guidelines recalled by the most responders were those widely distributed by the Commonwealth free of charge and related to female cancer screening (Table 1).
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GPs' ratings of the usefulness of each strategy for improving cancer screening are shown in Table 2
. Seminars with experts in preventive care was the strategy given the highest rating by most responders (77%). Guidelines developed by the NHMRC (70%) ranked second and were identified as ‘quite useful’ by significantly more responders than guidelines developed by the RACGP (61%), ranked seventh (McNemar's chi-square=32.7, df=1, P < 0.001). Overall, pamphlets for patients (69%), payment of Medicare rebate for preventive services (68%) and a computerized patient register (64%) were ranked third, fourth and fifth, respectively. Support from nurse practitioners (11%) and academic detailing (10%) were considered useful by the least responders.
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Discussion |
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Our results give helpful directions to those interested in enhancing cancer screening in general practice. At the time of our survey (1996), well-resourced Commonwealth programs in cervical and mammographic screening appear to have been very effective in distributing guidelines and raising awareness among GPs of their recommendations. The RACGP's own guidelines suffer from limited distribution only to College members, who comprise approximately 48% of all GPs.22 However, recent commercial commitment to distribute a guide about the implementation of preventive strategies (the ‘Green Book’)23 from the RACGP to all general practices may increase future recall. Guidelines are necessary but insufficient to change clinical behaviour.24 The NHMRC's own preventive care guidelines for cancer and cardiovascular disease1 represent the next ‘test case’. Although released in December 1996, they are available only by purchase at $12.95 per guideline.
Seminars with experts in preventive medicine was the most highly rated strategy for support of cancer screening. Although this concept is now 20 years old in Australia,25 there is little evidence that this form of continuing medical education improves clinical skills.26–28 Other strategies considered by responders as likely to be useful included financial incentives, patient resources and a computerized patient register. Yet the evidence to support the widespread introduction of such strategies also remains speculative.
More innovative strategies for which more-convincing evidence of effectiveness exists generated less interest among responders. Local adaptation of guidelines, staff support and academic detailing show considerable promise when evaluated in overseas settings.29 Nonetheless, few studies to evaluate such strategies to promote preventive care have been conducted in fee-for-service, non-academic settings to allow confident generalizeability to the Australian scene. Findings are disappointing. While one randomized trial (n = 264) found that GPs who received academic detailing about a smoking cessation kit were significantly more likely to use ‘intensive intervention’ components of the kit than were GPs who received their materials by courier or mail, the authors concluded that neither the educational facilitator nor the courier approach was cost-effective.18 Similarly, another study showed the rate of cervical screening in a region where all GPs (n = 85) were offered academic detailing did not increase compared with a control region.30 Bonevski randomly allocated GPs (n = 19) involved in a CME program to receive additional computer-generated feedback on clinical performance. Blood pressure and cholesterol screening rates were significantly higher for GPs in the feedback group; however, there was no impact on cancer screening.31
In view of the public health outcomes at stake, interventional research continues to be needed to evaluate strategies for acceptability, effectiveness and cost-effectiveness in achieving behaviour change.13 Our study provides a list of strategies ready for immediate implementation and evaluation.
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Acknowledgments |
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The participation of GPs in our research, without financial incentive, is acknowledged gratefully. We thank Phoebe Holt for contributing to questionnaire design and Tracey Bruce for diligent survey administration. The study was funded by a GPEP seeding grant. JY is supported by an NHMRC Research Scholarship.
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References |
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1 National Health and Medical Research Council. Working party on assessment of preventive activities in the health care system. Guidelines for Preventive Activities in Primary Health Care – Cardiovascular Disease and Cancer. Canberra: AGPS, 1997.
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