Should We Pursue Patients Who Fail to Attend Colorectal Clinics? A 9-Year Study

INTRODUCTION

No uniform protocol exists on how to deal with patients who fail to attend colorectal clinics. Our aim was to identify whether the tendency to ‘failure to attend’ (FTA) in the colorectal clinic was associated with FTA in other clinics and also whether FTA patients have serious pathology.

PATIENTS AND METHODS

This was a retrospective study of a prospectively recorded list of FTA patients, in colorectal urgent or two-week wait clinics from 1996–2004.

RESULTS

A total of 151 patients, who failed to attend their first appointment, were included in the study. Of these, 61 (40.4%) were colorectal referrals, 76 (50.3%) were general surgical referrals, and for 14 (9.3%) case notes were not available. There were 59 FTA episodes in 61 colorectal patients associated with 59 FTA episodes in other clinics (Pearson correlation: r = 0.411; P = 0.01, two-tailed, SPSS v.12). Of 58 colorectal outcomes, five (8.6%) colorectal cancers (CRC) were diagnosed, 23 (39.6%) were persistent non-attendees, 16 (27.5%) had benign colorectal pathology, two (3.4%) benign non-colorectal outcomes and 12 (20.6%) normal outcomes.

CONCLUSIONS

Tendency to FTA is habitual. Care needs to be exercised in the management of FTAs to avoid delayed presentation of colorectal cancer.     

Audit of patient's waiting time to see their family doctor prior to referral to a fast-access breast clinic in the era of a guaranteed 2-week wait

PURPOSE: A prospective study aimed at assessing the effect of introduction of a fast-tract referral system for patients with suspected breast cancer and the quality of GP referrals in Barnsley. METHODS: Between February and April 2001, 70 consecutive patients with symptomatic breast disorders were seen in the fast-access breast clinic. Mean age=46 years (range 18-84). Ten non-urgent referrals seen in the study period were included in the analysis to determine the appropriateness of such referrals. Three screening criteria were used to select high-risk patients and data were recorded prospectively. Patients were classified as urgent, soon or routine based on symptomatology. RESULTS: Of the 70 patients seen, 20 were considered as urgent, 20 as soon and 30 as routine. Forty patients were seen within the '2-week wait' period. Twelve were classified on clinical grounds as malignant. Mean waiting time to see the GP was 2.2 days. Mean waiting time to see the specialist breast surgeon was 6.6 days. CONCLUSION: A fast-track system for suspected breast cancer has led to a significant reduction in the time to diagnosis and initiation of a definitive treatment, with most made within 2 weeks. Fast-track referrals is not appropriate in all cases.     

Reducing surgical outpatient waiting is not the solution to meeting the 2005 colorectal cancer target

OBJECTIVES: The majority of colorectal cancers (CRC) are not diagnosed through the Rapid access route (RAR) and follow-ups (FU) may prolong outpatient-waiting time for new referrals. The aim of this study was to assess the relative contributions of an efficient colorectal clinic and a stringent colonoscopy booking system on the total journey time for CRC. PATIENTS AND METHODS: We reduced the number of follow-up appointments with the introduction of 'Paper clinics'. The composition of the new clinic was determined by the known cancer yield through RAR and non-RAR route. A prospective analysis of clinics and CRC journey times was undertaken from November 2003 for 13 months, with the new outpatient clinic template introduced in December 2003. This coincided with a stringent policy on referral pattern for colonoscopy. RESULTS: In our hospital, only 4% of RAR yield CRC. Seventy-five percent of our CRC are referred through the non-RAR route. Eighty-one percent of follow-ups in a 'paper clinic' were discharged. A flexible template for the outpatient clinics, introduced a corresponding reduction in follow-up and increased urgent and routine slots. There was a progressive drop in the follow-up to new ratio and the waiting times for routine and urgent category decreased from a median of 15.9 and 3.4 weeks to 6.7 and 0.7 weeks, respectively (P < 0.001). Average waiting times for all categories fell from 13.35 weeks in November 2003 to 3.5 weeks in December 2004, while the number of patients waiting less than 4 weeks rose from 46% to 71%. This was associated with reduction in total journey times from 93 days to 62 days (P < 0.05). DNA rates remained unaffected. CONCLUSION: Modifying outpatient clinic composition with 'paper clinics' reduces the waiting time for all referrals to a surgical clinic with a modest effect on CRC clinic waiting time. Reduction in the total waiting time to first treatment (for CRC) is due to reducing the demand on colonoscopy in favour of barium enema. Redirecting the flow of patients towards barium enema is perhaps one way of improving the existing CRC journey time to first treatment, within existing resources. Achieving the 62 day target for cancer journey time will be difficult unless traditional surgical clinic habits are challenged.     

Two-week rule: Has prioritisation of breast referrals by general practitioners improved?

INTRODUCTION: A 9-month audit, soon after the introduction of the 2-week rule in the UK in 1999, showed that a significant number of breast cancer patients were referred as non-urgent by their GPs, when the goal is that all suspected breast cancer patients should be seen by a hospital specialist urgently within 2 weeks of referral. The aim of this study was to determine whether GP grading of referrals into urgent and non-urgent had improved. METHOD: A retrospective review of GP referrals over 8 months, between September 2003 and April 2004, with regard to their urgency, subsequent diagnosis and the use of proformas (standardised referral formats) was carried out. The results were compared to the 1999 audit. RESULTS: Eighty-two of 1178 patients referred by GP had breast cancer, versus 115 of 1176 patients referred in 1999. Sixty-eight per cent (56/82) of breast cancer patients were referred as urgent, compared to 47% (54/115) in 1999 (P=0.005). A proforma was used in 47% (548/1178) of GP referrals while no proforma was used in 1999. Sixty-five of the 82 cancer patients were referred with a proforma and 85% (55/65) were referred as urgent. CONCLUSION: GP prioritisation of referrals has improved since 1999. With the use of proformas a significant number of patients with cancer were referred urgently.     

The fourteen-day rule and colorectal cancer

OBJECTIVE: To examine the effect of the fourteen-day rule on the colorectal service of a district general hospital. METHODS: Prospective audit of all patients referred by general practitioners to the colorectal service of a district general hospital serving a population of approximately 300,000 people. The main outcome measures were: (i) mean interval in days from referral to first clinic appointment; (ii) first clinic appointment to diagnosis; and (iii) overall interval from referral to diagnosis. RESULTS: There was a change in the referral pattern with greater numbers of 'fourteen-day rule' and urgent referrals than expected (P < 0.001). The mean time interval from referral to diagnosis was reduced (P < 0.01). This was due to a reduction in the wait for a first clinic appointment (P < 0.01). The wait between first appointment and diagnosis was unchanged (P < 0.05). Waiting times for patients referred as 'routine' or whose GPs did not specify a priority also improved. CONCLUSIONS: The 'fourteen-day rule' with respect to colorectal cancer has reduced waiting times for a first appointment to see a specialist. Further improvements will require additional resources to reduce the delay for investigations. The effect on long-term survival remains to be seen.     

Referral prioritization at the specialist breast clinic

Aim: The workload of specialist breast clinics is ever increasing and long waiting time is expected. Clinical guidelines were employed to sort out the priority of consultation. The effectiveness of this system is reviewed. Methods: All referrals seen at the specialist breast clinic from January 2002 to March 2002 were retrospectively studied. The guidelines for allocation to urgent appointment included – (1) urgent referral as determined by referring physician; (2) referral not labelled as urgent but certain ‘high risk’ criteria were present: age more than 50, lump bigger than 3 cm, bloody nipple discharge and physical signs suggestive of malignancy like irregular or fixed breast lump. Routine appointment was given if these criteria were not met. Patients with imaging and cytology results available before specialist consultation were given appointment with reference to the investigation result and excluded from the present analysis. Outcome of the patients in each category was assessed. Results: 165 referrals were analysed and 14 cancers were diagnosed. The mean waiting time for urgent and routine appointments were 2 weeks and 20 weeks, respectively. There were 52 urgent referrals and eight (15.4%) cancers were diagnosed compared to six cancers (5.3%) diagnosed in the 113 non‐urgent referrals. Forty‐two patients among these 113 patients were given urgent appointment due to the presence of high‐risk criteria and as a result, all the six patients with cancers were allocated to urgent appointments. None of the patients given routine appointment had breast cancer diagnosed. Conclusion: It was reassuring that no cancer was diagnosed in patients who had been allocated to routine appointment. In addition to the clinical assessment by the referring physicians, certain ‘high‐risk’ criteria serve as useful guides in assigning the urgency of specialist consultation.     

Audit of referral practice to a fast-access breast clinic before the guaranteed 2-week wait

Currently in the fast-access breast clinic at Eastbourne District General Hospital, the specialist determines the level of urgency of a referral. With the new '2-week wait' imposed by the Government since 1 April 1999, the determination of urgency has transferred to the general practitioner. Therefore, we decided to audit the current situation to see whether the guidelines were adequate for this change of emphasis. A total of 100 consecutive patients referred to the fast-access breast clinic were evaluated to assess the quality of referrals and the effectiveness of the clinic. Only 80% of the referrals adhered to the guidelines; 73% of the referrals were deemed by the specialist to be urgent and seen within the 2-week time period. All patients who were subsequently diagnosed as having breast cancer were seen within 2 weeks. The audit indicates that further specific changes could be made to the guidelines to improve the referral practice.     

A study on the routes of referral for patients with colorectal cancer and its affect on the time to surgery and pathological stage

OBJECTIVE: Firstly, to determine the proportion of colorectal cancer (CRC) patients seen within an established two week rule (TWR) system and to observe other routes of referral for CRC patients. Secondly to determine if referral route affects the interval to, and cancer stage at, definitive treatment. PATIENTS AND METHODS: GP referrals of patients with CRC were divided into direct surgical outpatient referrals (group 1) and indirect referrals to accident and emergency and medical outpatients (group 2). Data were recorded on the time to definitive treatment and the location and stage of tumour. RESULTS: There were 78 patients in group 1. Thirty (20%) patients were referred by their GP under the TWR, 31 (21%) as urgent and 17 (12%) as nonurgent referrals, to surgical outpatients. There were 69 patients in group 2. Forty-two (29%) were referred initially to the accident and emergency department and 27 (18%) to general medical outpatients. Group 1 patients were treated within a median of 70.5 days and group 2 patients within 14 days of referral (P < 0.0005). Group 2 contained tumours of a significantly more advanced pathological stage (P = 0.015) and more proximal colonic cancers (P < 0.005). CONCLUSION: Fifty-three percent of patients with CRC were referred directly to surgical outpatients, 20% under the TWR guidelines. Despite having this system in place direct referrals were slower to treatment but the tumours were still of a less advanced pathological stage. Compliance with the TWR should not be used as a means of assessing a colorectal unit's treatment of CRC.     

Fast-track barium enema: meeting the two-week wait rule for patients with suspected colorectal cancer

OBJECTIVES: To meet the introduction of the two-week wait (TWW) rule for patients with suspected colorectal cancer, a fast-track barium enema (FTBE) service was set up. This study was conducted to evaluate the success of this approach in preparation for meeting the forthcoming targets on waiting times to treatment from referral and diagnosis. METHODS: All patients were offered a double-contrast barium enema within two-weeks, except those with a palpable rectal mass. FTBE were double-reported by specialist gastrointestinal radiologists. Patients with a suspected malignancy were booked for an urgent staging CT and outpatient appointment, whilst the remaining patients were referred back to their general practitioner with a report. Prospective data were collected and two 16-month periods analysed. RESULTS: Three hundred and nine patients had a FTBE over the first 16-month period and 277 (89.6%) were seen within two-weeks. Mean times from initial referral to staging CT and first outpatient appointment were 30.7 and 36.0 days, respectively. Cancer was confirmed histologically in 32 (10.4%) patients. Of 267 patients without a malignancy, 46 (17.2%) were referred back to the colorectal outpatient or endoscopy service within 6-months. The number of referrals increased with time from a mean of 19.3 per month in the first period to 27.8 in the second, but the percentage with a suspected malignancy remained similar at 13.6% and 10.1%, respectively. CONCLUSION: FTBE diagnosed malignancy accurately and facilitated rapid staging. The TWW target was met in almost 90% of patients, whilst the impact on the colorectal outpatient and endoscopy service was minimized.     

Audit of acute pancreatitis management: a tale of two hospitals.

BACKGROUND: A case note audit of existing practices in the management of acute pancreatitis (AP) at a district general hospital (DGH) and a teaching hospital was undertaken to determine if practices were in accordance with published UK guidelines. METHODS: Casenotes of all adults admitted with AP over a period of one year at the two hospitals were reviewed. RESULTS: Ninety-five patients were treated for AP at the teaching hospital and 52 at the DGH. The age, sex and aetiological distributions at the two hospitals were similar. Fifteen (15.8%) patients at the teaching hospital and eight (15.3%) at the DGH had severe AP. Four patients died at each hospital. Prognostic Glasgow criteria tests (excluding LDH) were completed within 48 hours in 43% patients at the teaching hospital and 48% at the DGH. Five of the twenty-five cholecystectomies at the teaching hospital and 4/18 at the DGH were performed within four weeks after admission with AP. CONCLUSION: Audit of current practice has highlighted deficiencies at many levels compared with current evidence-based guidelines, although this has not resulted in unexpected mortality. It remains to be seen whether new measures to aid compliance with guidelines will result in improvement in morbidity and mortality.     

Audit of elective paediatric clinic referrals from primary care February 2002-September 2006

Our large district general hospital organized additional Waiting List Initiative clinics for paediatric orthopaedic referrals. A prospective audit examined pathology, investigations and disposal, and the implications of Waiting List Initiative clinics, particularly the increased workload for other specialties and disciplines. Variations of normal development were the most common presenting complaints, with the majority discharged following initial consultation. Local protocols, providing guidance to primary care physicians, covered common paediatric orthopaedic problems. We compared these guidelines with the referrals received to establish the referral quality and quantify the extra work generated. Few examples of inappropriate referrals were found, suggesting that referring physicians utilize the guidelines.     

The two-week waiting time standard for cancer: a neurosurgical perspective

The implementation of the two-week wait initiative for cancer referrals in the NHS has had a major impact on outpatient services. A low clinical detection rate among GPs for neurological cancer has resulted in a large number of urgent referrals with a low yield of positive diagnoses. We have devised a strategy for minimizing the impact on outpatient clinics: patients are scanned prior to clinical review and those with normal scans are referred back to the GP without a clinic appointment. Out of 69 referrals of suspected CNS cancer made in 2003, 61 were scanned and six resulted in a positive diagnosis. The equivalent of 10 clinics was saved, and an increased speed of diagnosis and treatment was achieved with no compromise in patient care. Our study illustrates the consequences of the 2-week wait initiative on the neurosurgical service, and proposes an effective and safe solution.     

Urgency of referral and its impact on outcome in patients with colorectal cancer

Aim Primary care referral for patients with bowel symptoms is triaged by general practitioners to urgent or routine based on the clinical suspicion of malignancy. Triage directly influences time to assessment and investigation. This study aimed to establish whether urgency of referral of patients with large bowel malignancy has any effect on management. Method An analysis was undertaken of all patients with colorectal cancer referred by primary care and discussed at the regional colorectal multi‐disciplinary team (MDT) meetings from January 2009 to December 2010. Demographics and tumour data were collated prospectively from MDT records, and operation and investigation reports. Results Of 369 primary case referrals with colorectal cancer, 303 (82.1%) were urgent and 66 (17.9%) routine. Patient characteristics (age, sex, American Society of Anesthesiologists grade) and resection rates were similar in both groups and no significant difference in tumour location was observed. The time from referral to diagnosis was significantly longer in the routine group (mean 73.7 days vs 30.2 days; P = 0.001). Dukes stage was less advanced for the routine referral group, (P = 0.002). Conclusion Urgency of referral decreased the time to diagnosis. This did not influence resection rates. Dukes stage was higher for urgent referrals. Long‐term follow‐up is required to determine any impact on survival.     

'Paper Clinics'- a model for improving delivery of outpatient colorectal services.

OBJECTIVES: The overburdening of colorectal out-patient clinics necessarily leads to delays in time from referral to consultation and subsequent clinic attendance. This study aimed to ascertain the feasibility of 'paper clinic' follow-up rather than all patients receiving a routine follow-up appointment following investigation. A more efficient outpatient follow-up process should reduce unnecessary follow-up, thereby facilitating the speedy investigation and diagnosis of patients through changes in clinic profiles. METHODS: From August 2001 all patients seen in the outpatient clinic of one (part time) Consultant colorectal surgeon, who required investigation, were prospectively recorded on a 'paper clinic' form. These patients were given the necessary test request forms but were not given a further outpatient appointment. The results of the investigations were reviewed, together with the patients' medical records at a formal fortnightly 'paper clinic' session carried out by the Consultant and Nurse Consultant, and a treatment plan derived. Patients then followed one of 5 follow-up pathways and were notified in writing with a copy to their GP. RESULTS: During a 24-month period a total of 897 patients were reviewed using the 'paper clinic' follow-up system. Of these, 285 (31.8%) patients were discharged without further follow-up. In a given 3-month period when the clinic was well established, 152 patients were reviewed, of whom 27% were discharged from follow-up, 17% received SOS appointments, 13% required further investigation (and consequently were returned to 'paper clinic' follow-up), and 7% received Nurse led follow-up. In this 3-month period 64% of patients reviewed by 'paper clinic' follow-up did not return to Surgical Outpatient's and 12% received a Surgical Outpatient appointment for review. CONCLUSION: 'Paper clinic' follow-up is an effective and feasible follow-up alternative, resulting in a major decrease in outpatient follow-up burden. This has allowed the redesign of the outpatient clinic profile allowing for an increase in new urgent slots, and more rapid clinic follow up review of those patients who need it. Re-design and rationalization of existing services can result in considerable service improvement. Expanding clinics should not be considered the only option when faced with capacity and demand issues.     

Nurse-led direct access endoscopy clinics: the future?

BACKGROUND: Many studies have shown that rectal bleeding is a good indicator of underlying colorectal pathology, and that ost of the lesions in patients presenting with rectal bleeding lie in the left side of the colon [1, 5, 9, 12, 23, 26]. The recent acceptance of the nurse-practitioner by the National Health Service may allow the use of nurse-endoscopists to develop throughout the United Kingdom. This study aimed to audit a unique nurse-led direct-access nurse-endoscopy service with regard to its efficacy and cost effectiveness, and to monitor patient satisfaction and direct referrals from the primary health sector. METHODS: A nurse-led open-access flexible sigmoidoscopy (OAFS) service for patients reporting fresh rectal bleeding was established at our center in February 1996. A prospective audit of sigmoidoscopic findings and a retrospective analysis of referral patterns from local general practitioners were conducted. A questionnaire survey of both patient and general practitioner satisfaction also was conducted at the same time. RESULTS: Since February 1996, 706 patients have been referred to our service. Rectal bleeding was by far the most common cause for referral, representing the dominant symptom in 92% of the referrals received. Although 99% of the patients underwent a complete sigmoidoscopic examination, 16% of these examinations were limited because of several factors combined. A cause for bleeding was identified in 91% of the patients, with 24% of them experiencing subsequent significant pathology. Of the patients surveyed, 99% were satisfied with the service provided. The results also show nurse-led OAFS to be a more effective use of financial resources, costing $90 less per patient than general practitioner referrals sent to a consultant for further action. CONCLUSIONS: Rectal bleeding is a good indicator of underlying colorectal disease. Most of the significant lesions presenting with this symptom are found in the left side of the colon. A nurse-led OAFS is safe, effective, and acceptable to patients. It also is more cost effective than a consultant-led service.     

Evolution of the two-week rule pathway – direct access colonoscopy vs outpatient appointments: one year''s experience and patient satisfaction survey

Abstract Objectives The aim of this study was to compare the effectiveness of Direct access colonoscopy (DAC) vs outpatient appointments for two-week rule colorectal cancer referrals and to evaluate the satisfaction of patients referred through these routes. Patients and methods Data were collected prospectively from January 2003 to December 2003 on patients who were referred for DAC or outpatient appointments at the discretion of the referring General practitioner via the Lower GI two-week rule pathway. A postal questionnaire was used to survey patient satisfaction. Results Six hundred and thirty-nine patients were referred via the two-week rule pathway; 188 patients underwent colonoscopy at their initial hospital visit and 19 (10.1%) colorectal cancers were diagnosed; 442 patients had an outpatient appointment and 32 (7.2%) colorectal cancers were identified. There were 7 (1%) inappropriate referrals and 2 patients refused investigations. All outcome parameters measured were reduced for patients referred directly for colonoscopy including time to definitive investigations (Median 9 vs 52 days P < 0.0001), time to histological diagnosis (Median 14 vs 42 days P < 0.0001) and time to treatment (Median 55 vs 75 days P < 0.0483). One hundred and seventy patients were surveyed by the postal questionnaire of whom 127 (75%) responded. Ninety-eight percent of patients were satisfied with the service provided. Four (6.6%) of 60 patients who had undergone direct access colonoscopy expressed a desire to be seen at the outpatient department initially. Conclusions Direct access colonoscopy results in significantly reduced times to histological diagnosis and definitive treatment in patients with colorectal cancer. Patients can be directly admitted for investigations bypassing the outpatient clinic without affecting patient satisfaction.     

The management of women with breast symptoms referred to secondary care clinics in Sheffield: implications for improving local services

Information was collected about 302 women referred for breast symptoms and seen in surgical outpatient or outreach clinics during one month at two hospitals in Sheffield. Three-quarters of the women (n = 244) were referred to specialist breast clinics, 22% (n = 70) were referred to general surgical clinics and 3% (n = 6) were referred to outreach clinics. The ages of the women ranged from 16 to 85 years with a mean and median age of 45 years. Some 200 women (66%) presented with a lump or lumpiness, 42 women (14%) presented with pain, 29 women (10%) had a skin and/or nipple problem, and the remaining 31 women (10%) were concerned about their family history or reported other symptoms. A total of 23 women (8%) were diagnosed as having cancer, 180 (60%) were diagnosed as having benign breast disease, and 99 (33%) were diagnosed as normal. Of the 23 women with cancer, 22 were over 40 years of age; 21 women presented with a lump, one presented with pain, and one presented with metastatic disease. The time required to reach a final clinical diagnosis varied from the same day as the clinic visit to 35 weeks, with a median time of 3 weeks. Surgeons assessed the appropriateness of GPs' referrals for 257 cases and judged that 122 (47%) could have been managed by a GP. The implications of the findings for the organisation of specialist outpatient clinics are discussed, and a categorisation of women as either urgent or routine cases is suggested.     

A single common urgent pathway for all colorectal referrals reduces time to diagnosis and treatment

OBJECTIVE: Guidelines for the urgent referral of patients with suspected colorectal cancer were introduced in 2000. They aimed to facilitate the prompt diagnosis and treatment of patients with symptoms suggestive of malignant disease. Recent assessment of these guidelines has suggested that although they identify 9-14% of patients with colorectal cancer, they may be used inappropriately and may lead to delays in treatment for those patients with cancers whose symptoms do not fit the guidelines. We aimed to assess the effect of introducing a single pathway for all referrals irrespective of indicated urgency. METHOD: All referral letters to a single consultant colorectal surgeon over a 6-month period were coded 'urgent' irrespective of the indicated urgency on the original referral letter. Data was collected prospectively on 47 patients diagnosed with colorectal cancer identified over the trial period. Patient demographics, the mode of presentation, urgency of referral and waiting times were documented. RESULTS: Following the introduction of the common urgent referral pathway, no patient waited longer than 62 days from referral to treatment or 31 days from the decision to treat to first treatment, thus meeting government targets introduced in 2005. CONCLUSION: The introduction of the urgent referral guidelines has accelerated the referral pathway for patients with symptoms suggestive of colorectal cancer, although this is at the expense of the majority of patients who present via conventional pathways. The introduction of a common urgent pathway allows prompt diagnosis and treatment and is of particular benefit for the majority of patients not referred via the 2-week standard. Until a more accurate method of identifying the highest risk patients is implemented, we suggest that all patients are seen on an urgent basis.     

Inter general practice variability in use of referral guidelines for colorectal cancer

OBJECTIVE: The Two-Week Wait (TWW) referral system for suspected colorectal cancers has a low yield. To examine this, we assessed the referral pattern of general practices within four primary care trusts and looked at the variability of yield of colorectal cancer amongst all TWW referrals and assessed the reasons for variability. METHOD: A prospectively collected database of all colorectal cancers was examined for new cases diagnosed in the 12 months from April 1st 2004. Patients were cross-referenced via general practitioner (GP) codes to identify the referral origin. Reasons for the variability in referral patterns from each general practice were assessed in relation to TWW referrals, population demographics and through postal questionnaire of GPs. RESULTS: A total of 175 patients diagnosed with colorectal cancer were referred from 49 general practices. Whilst there was a positive correlation between the number of TWW referrals and colorectal cancer per 1000-practice population (P = 0.001; Spearman correlation coefficient r(s=0.447,) two-tailed), there was a big discrepancy between referrals and cancer diagnosed in many general practices. Twenty-six general practices (53%) had no colorectal cancer diagnosed via the TWW route and these practices had significantly lower utilization of the TWW referral pathway. In the postal survey, 22% of GPs were unaware of TWW clinics or colorectal cancer referral guidelines and only 8% of GPs knew the number of referral criteria. CONCLUSION: This study demonstrates wide variability within primary care, in the appropriate use of colorectal cancer referral guidelines. General practices should be targeted for education.     

The Effectiveness of a Rapid-Access Flexible Sigmoidoscopy Clinic in a District Hospital

Historically rapid-access colorectal clinics have had high proportions of nonconforming referrals from primary care physicians, which calls into question the clinics'' efficacy. We aim to determine the effectiveness of our rapid-access flexible sigmoidoscopy clinic, and the adherence to the referral guidelines for suspected bowel cancer by general practitioners. We performed a 3-month retrospective audit to evaluate (1) the proportion of patients seen within 2 weeks, (2) the appropriateness of referrals, (3) the proportion of patients with findings, and (4) the proportion of patients who had further tests. A total of 59 patients (19 male, 40 female; age 35–86 years) were included in the study. All were offered an appointment within 2 weeks. Forty-one cases (82%) were appropriate referrals. Twenty-eight patients (47%) had pathology at sigmoidoscopy. Cancer pick-up rate was 6%. Thirty-seven patients (74%) had further investigations. We determined that our rapid-access clinic for symptomatic patients has high diagnostic accuracy and that access to early investigation is being used appropriately by general practitioners. In the current climate of spending cuts and streamlining services, our study confirms we are meeting targets for delivery of our colorectal service. The majority of referrals under the 2-week rule are appropriate. Rapid access to early investigation is being used appropriately by general practitioners contrasting previous studies with high proportions of nonconforming referrals.Key words: Rapid access, Department of health, Colorectal cancer, Screening, Flexible sigmoidoscopyEfforts to improve diagnostic and treatment services for colorectal cancer (CRC) have been implemented in the National Health Service (NHS) since the early 1990s. The NHS Bowel Cancer Screening Programme focusing on occult fecal tests has been piloted, assessed, and rolled out on a national level.^1,2Recommendations from the Department of Health of a maximum 2-week wait for initial specialist assessment of all urgent general practitioner (GP) referrals with suspected cancer led to the restructuring of colorectal services and the widespread establishment of dedicated rapid-access flexible sigmoidoscopy clinics in hospitals across the United Kingdom.^3,4 Evidence-based reviews for stratifying CRC risk have further contributed to the outline of current referral protocols for patients with high-risk symptoms.⁵Over the past decade, the service has significantly evolved, as a result of considerable work examining its effectiveness and efficiency. Various authors have commented positively on the suitability and safety of the use of flexible sigmoidoscopy in establishing a diagnosis of distal colonic pathologies and excluding carcinoma,^6,7 while others have highlighted the need for flexible sigmoidoscopy in order for a one-stop service to be effective and safe.^8,9Queen Mary''s Hospital (QMH) is a District General Hospital (DGH) situated in Kent and serving a population of approximately 300,000. Since its establishment, the rapid-access flexible sigmoidoscopy clinic averages 250 patients per year. There is a consultant-led dedicated endoscopy session each week. The majority of referrals come through primary care physicians, with some cases directly referred from the Trust''s Emergency Department.This study aimed to determine the efficacy of the rapid-access flexible sigmoidoscopy clinic in meeting the 2-week target from referral to preliminary assessment, including an assessment of the pathologies found, and the adherence to the Department of Health''s referral guidelines for bowel cancer by GPs.