Can we do better? A qualitative study in the East of England investigating patient experience and acceptability of using the faecal immunochemical test in primary care.

OBJECTIVES: The faecal immunochemical test (FIT) is increasingly used in UK primary care to triage patients presenting with symptoms and at different levels of colorectal cancer risk. Evidence is scarce on patients' views of using FIT in this context. We aimed to explore patients' care experience and acceptability of using FIT in primary care. DESIGN: A qualitative semi-structured interview study. Interviews were conducted via Zoom between April and October 2020. Transcribed recordings were analysed using framework analysis. SETTING: East of England general practices. PARTICIPANTS: Consenting patients (aged ≥40 years) who presented in primary care with possible symptoms of colorectal cancer, and for whom a FIT was requested, were recruited to the FIT-East study. Participants were purposively sampled for this qualitative substudy based on age, gender and FIT result. RESULTS: 44 participants were interviewed with a mean age 61 years, and 25 (57%) being men: 8 (18%) received a positive FIT result. Three themes and seven subthemes were identified. Participants' familiarity with similar tests and perceived risk of cancer influenced test experience and acceptability. All participants were happy to do the FIT themselves and to recommend it to others. Most participants reported that the test was straightforward, although some considered it may be a challenge to others. However, test explanation by healthcare professionals was often limited. Furthermore, while some participants received their results quickly, many did not receive them at all with the common assumption that 'no news is good news'. For those with a negative result and persisting symptoms, there was uncertainty about any next steps. CONCLUSIONS: While FIT is acceptable to patients, elements of communication with patients by the healthcare system show potential for improvement. We suggest possible ways to improve the FIT experience, particularly regarding communication about the test and its results.

Who are the patients being offered the faecal immunochemical test in routine English general practice, and for what symptoms? A prospective descriptive study.

OBJECTIVES: The faecal immunochemical test (FIT) was introduced to triage patients with lower-risk symptoms of colorectal cancer (CRC) in English primary care in 2018. While there is growing evidence on its utility to triage patients in this setting, evidence is still limited on how official FIT guidance is being used, for which patients and for what symptoms. We aimed to investigate the use of FIT in primary care practice for lower-risk patients who did not immediately meet criteria for urgent referral. DESIGN: A prospective, descriptive study of symptomatic patients offered a FIT in primary care between January and June 2020. SETTING: East of England general practices. PARTICIPANTS: Consenting patients (aged ≥40 years) who were seen by their general practitioners (GPs) with symptoms of possible CRC for whom a FIT was requested. We excluded patients receiving a FIT for asymptomatic screening purposes, or patients deemed by GPs as lacking capacity for informed consent. Data were obtained via patient questionnaire, medical and laboratory records. PRIMARY AND SECONDARY OUTCOME MEASURES: FIT results (10 µg Hb/g faeces defined a positive result); patient sociodemographic and clinical characteristics; patient-reported and GP-recorded symptoms, symptom severity and symptom agreement between patient and GP (% and kappa statistics). RESULTS: Complete data were available for 310 patients, median age 70 (IQR 61-77) years, 53% female and 23% FIT positive. Patients most commonly reported change in bowel habit (69%) and fatigue (57%), while GPs most commonly recorded abdominal pain (25%) and change in bowel habit (24%). Symptom agreement ranged from 44% (fatigue) to 80% (unexplained weight loss). Kappa agreement was universally low across symptoms. CONCLUSION: Almost a quarter of this primary care cohort of symptomatic patients with FIT testing were found to be positive. However, there was low agreement between patient-reported and GP-recorded symptoms. This may impact cancer risk assessment and optimal patient management in primary care.

Recognising Colorectal Cancer in Primary Care.

Colorectal cancer (CRC) is the third most common cancer worldwide. Primary care professionals can play an important role in both prevention and early detection of CRC. Most CRCs are attributed to modifiable lifestyle factors, which can be addressed within primary care, and promotion of population-based screening programmes can aid early cancer detection in asymptomatic patients. Primary care professionals have a vital role in clinically assessing patients presenting with symptoms that may indicate cancer, as most patients with CRC first present with symptoms. These assessments are often challenging-many of the symptoms of CRC are non-specific and commonly occur in patients presenting with non-malignant disease. The range of options for investigating symptomatic patients in primary care is rapidly growing. Simple tests, such as faecal immunochemical testing (FIT), are now being used to guide decisions around referral for more invasive tests, such as colonoscopy, while direct access to specialist investigations is also becoming more common. Clinical decision support tools (CDSTs) which calculate cancer risk based on symptomatology, patient characteristics and test results can provide an additional resource to guide decisions on further investigation. This article explores the challenges of CRC prevention and detection from the primary care perspective, discusses current evidence-based approaches for CRC detection used in primary care (with examples from UK guidelines), and highlights emerging research which may likely alter practice in the future.

Effect of a Skin Self-monitoring Smartphone Application on Time to Physician Consultation Among Patients With Possible Melanoma: A Phase 2 Randomized Clinical Trial.

Importance: Melanoma is among the most lethal skin cancers; it has become the fifth most common cancer in the United Kingdom, and incidence rates are rising. Population approaches to reducing incidence have focused on mass media campaigns to promote earlier presentation and potentially improve melanoma outcomes; however, interventions using smartphone applications targeting those with the greatest risk could promote earlier presentation to health care professionals for individuals with new or changing skin lesions. Objective: To study the effect of a commercially available skin self-monitoring (SSM) smartphone application among individuals with increased risk of melanoma on their decision to seek help for changing skin lesions. Design, Setting, and Participants: This phase 2 randomized clinical trial was conducted in 12 family practices in Eastern England between 2016 and 2017. A total of 238 participants, aged 18 to 75 years and with an increased risk of melanoma, were identified using a real-time melanoma risk assessment tool in family practice waiting rooms. Analysis was intention to treat. Participants were observed for 12 months, and data analysis was conducted from January to August 2018. Intervention: The intervention and control groups received a consultation with standard written advice on sun protection and skin cancer detection. The intervention group had an SSM application loaded on their smartphone and received instructions for use and monthly self-monitoring reminders. Main Outcomes and Measures: The coprimary outcomes were skin consultation rates with family practice physicians and patient intervals, measured as the time between noticing a skin change and consulting with a family practice clinician. Follow-up questionnaires were sent at 6 and 12 months, and consultation rates were extracted from family practice records. Secondary outcomes included skin self-examination benefits and barriers, self-efficacy for consulting without delay, perceived melanoma risk, sun protection habits, and potential harms. Results: A total of 238 patients were randomized (median [interquartile range] age, 55 [43-65] years, 131 [55.0%] women, 227 [95.4%] white British; 119 [50.0%] randomized to the intervention group). Overall, 51 participants (21.4%) had consultations regarding skin changes during the 12 months of follow-up, and 157 participants (66.0%) responded to at least 1 follow-up questionnaire. There were no significant differences in skin consultation rates (adjusted risk ratio, 0.96; 95% CI, 0.56 to 1.66; P = .89), measures of SSM (adjusted mean difference, 0.08; 95% CI, -0.83 to 1.00; P = .86), or psychological harm (eg, Melanoma Worry Scale: adjusted mean difference, -0.12; 95% CI, -0.56 to 0.31; P = .58). Conclusions and Relevance: In this study, recruitment, retention, and initial delivery of the intervention were feasible, and this research provided no evidence of harm from the SSM smartphone application. However, no evidence of benefit on skin self-examination or health care consulting was found, and there is no reason at this stage to recommend its implementation in this population at increased risk of melanoma. Trial Registration: isrctn.org Identifier: ISRCTN16061621.

Understanding implementation and usefulness of electronic clinical decision support (eCDS) for melanoma in English primary care: a qualitative investigation.

BACKGROUND: Timely diagnosis of the serious skin cancer melanoma can improve patient outcomes. Clinical guidelines suggest that GPs use checklists, such as the 7-point checklist (7PCL), to assess pigmented lesions. In 2016, the 7PCL was disseminated by EMIS as an electronic clinical decision support (eCDS) tool. AIM: To understand GP and patient perspectives on the implementation and usefulness of the eCDS. DESIGN & SETTING: Semi-structured interviews with GPs and patients were undertaken. The interviews took place in four general practices in the south east of England following consultations using the eCDS for suspicious pigmented lesions. METHOD: Data were collected from semi-structured face-to-face interviews with GPs and from telephone interviews with patients. They were recorded and transcribed verbatim. The Consolidated Framework for Implementation Research (CFIR) underpinned the analysis using thematic approaches. RESULTS: A total of 14 interviews with GPs and 14 interviews with patients were undertaken. Most GPs reported that, as the eCDS was embedded in the medical record, it was useful, easy to use, time-efficient, and could facilitate patient-GP communication. They were less clear that it could meet policy or patient needs to improve early diagnosis, and some felt that it could lead to unnecessary referrals. Few felt that it had been sufficiently implemented at practice level. More felt confident with their own management of moles, and that the eCDS could be most useful for borderline decision-making. No patients were aware that the eCDS had been used during their consultation. CONCLUSION: Successful implementation of a new tool, such as eCDS for melanoma, requires GPs to perceive its value and understand how it can best be integrated into clinical practice. Disseminating a tool without such explanations is unlikely to promote its adoption into routine practice.

Mental rotation impairs attention shifting and short-term memory encoding: neurophysiological evidence against the response-selection bottleneck model of dual-task performance.

Dual tasks and their associated delays have often been used to examine the boundaries of processing in the brain. We used the dual-task procedure and recorded event-related potentials (ERPs) to investigate how mental rotation of a first stimulus (S1) influences the shifting of visual-spatial attention to a second stimulus (S2). Visual-spatial attention was monitored by using the N2pc component of the ERP. In addition, we examined the sustained posterior contralateral negativity (SPCN) believed to index the retention of information in visual short-term memory. We found modulations of both the N2pc and the SPCN, suggesting that engaging mechanisms of mental rotation impairs the deployment of visual-spatial attention and delays the passage of a representation of S2 into visual short-term memory. Both results suggest interactions between mental rotation and visual-spatial attention in capacity-limited processing mechanisms indicating that response selection is not pivotal in dual-task delays and all three processes are likely to share a common resource like executive control.

Dopamine and inhibitory action control: evidence from spontaneous eye blink rates.

The inhibitory control of actions has been claimed to rely on dopaminergic pathways. Given that this hypothesis is mainly based on patient and drug studies, some authors have questioned its validity and suggested that beneficial effects of dopaminergic stimulants on response inhibition may be limited to cases of suboptimal inhibitory functioning. We present evidence that, in carefully selected healthy adults, spontaneous eyeblink rate, a marker of central dopaminergic functioning, reliably predicts the efficiency in inhibiting unwanted action tendencies in a stop-signal task. These findings support the assumption of a modulatory role for dopamine in inhibitory action control.

Operation compatibility: a neglected contribution to dual-task costs.

Traditionally, dual-task interference has been attributed to the consequences of task load exceeding capacity limitations. However, the current study demonstrates that in addition to task load, the mutual compatibility of the concurrent processes modulates whether 2 tasks can be performed in parallel. In 2 psychological refractory period experiments, task load and process compatibility were independently varied. In Experiment 1, participants performed 2 mental rotation tasks. Task load (rotation angle) and between-task compatibility in rotation direction were varied. Results suggest more considerable parallel execution of compatible than of incompatible operations, arguing for the need to attribute dual-task interference not only to structural but also to functional capacity limitations. Experiment 2 tested whether functional capacity limitations to dual-task performance can be caused only by demanding processes or whether they are also induced by relatively automatic processes. Results indicate that an irrelevant circular movement of Stimulus 2 interfered more with mental rotation of Stimulus 1 if the rotation directions were opposite than if they were equal. In conclusion, compatibility of concurrent processes constitutes an indispensable element in explaining dual-task performance.

Working memory and the attentional blink: blink size is predicted by individual differences in operation span.

The attentional blink (AB) is often attributed to resource limitations, but the nature of these resources is commonly underspecified. Recent observations rule out access to short-term memory or storage capacity as limiting factors, but operation bottlenecks are still an option. We considered the operation span of working memory (WM) as a possible factor and investigated the relationship between individual WM operation span (as measured by OSPAN), fluid intelligence (as measures by Raven's SPM), and the size of the AB. WM operation span was negatively correlated with the AB, whereas fluid intelligence was associated with higher overall accuracy but not with AB magnitude. These results support the idea that individual processing limitations (with regard to either attentional allocation policies or the speed of global cortical integration processes) play a key role in the AB.