Norwich Medical School, Department of Public Health and Primary Care, University of East Anglia, Norwich, UK.
Oncology, Airedale NHS Foundation Trust, West Yorkshire, UK.
Fam Pract. 2019 May 23;36(3):284-290. doi: 10.1093/fampra/cmy077.
Poor geographical access to health services and routes to a cancer diagnosis such as emergency presentations have previously been associated with worse cancer outcomes. However, the extent to which access to GPs determines the route that patients take to obtain a cancer diagnosis is unknown.
We used a linked dataset of cancer registry and hospital records of patients with a cancer diagnosis between 2006 and 2010 across eight different cancer sites. Primary outcomes were defined as 'desirable routes to diagnosis' [screen-detected and 2-week wait (TWW) referrals] and 'less desirable routes' [emergency presentations and death certificate only (DCO)]. All other routes (GP referral, inpatient elective and other outpatient) were specified as the reference category. Geographical access was measured as travel time in minutes from patients to their GP, and multinomial logistic regression was used to estimate relative risk ratios (RRR).
Longer travel was associated with increased risk of diagnosis via emergency and DCO, but decreased risk of diagnosis via screening and TWW. Patients travelling over 30 minutes had the highest risk of a DCO diagnosis, which was statistically significant for breast, colorectal, lung, prostate, stomach and ovarian cancers (compared with patients with travel times ≤10 minutes: RRR 5.89, 7.02, 2.30, 4.75, 10.41; P < 0.01 and 3.51, P < 0.05).
Poor access to GPs may discourage early engagement with health services, decreasing the likelihood of screening uptake and increasing the likelihood of emergency presentations. Extra effort is needed to promote early diagnosis in more distant patients.
以往研究表明，由于地理位置不便导致无法获得医疗服务以及前往癌症诊断的途径（例如急诊就诊）与较差的癌症结局相关。然而，获得全科医生（GP）的途径在多大程度上决定了患者获得癌症诊断的途径尚不清楚。
我们使用了癌症登记处和 2006 年至 2010 年间 8 个不同癌症部位的医院记录的患者的链接数据集。主要结局定义为“理想的诊断途径”[筛查发现和 2 周等待（TWW）转诊]和“不太理想的途径”[急诊就诊和仅死亡证明（DCO）]。所有其他途径（GP 转诊、住院择期和其他门诊）均指定为参考类别。地理位置的可达性通过患者到其 GP 的出行时间（以分钟计）来衡量，使用多项逻辑回归来估计相对风险比（RRR）。
较长的出行时间与通过急诊和 DCO 进行诊断的风险增加相关，但与通过筛查和 TWW 进行诊断的风险降低相关。出行时间超过 30 分钟的患者通过 DCO 进行诊断的风险最高，对于乳腺癌、结直肠癌、肺癌、前列腺癌、胃癌和卵巢癌而言，这种风险显著升高（与出行时间≤10 分钟的患者相比：RRR 5.89、7.02、2.30、4.75、10.41；P<0.01 和 3.51，P<0.05）。
难以获得 GP 可能会阻碍患者尽早与医疗服务机构接触，降低筛查参与率，并增加急诊就诊的可能性。需要付出额外的努力来促进距离较远的患者的早期诊断。
