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Identifying important health system factors that influence primary care practitioners’ referrals for cancer suspicion: a European cross-sectional survey
  1. Michael Harris1,2,
  2. Peter Vedsted3,
  3. Magdalena Esteva4,
  4. Peter Murchie5,
  5. Isabelle Aubin-Auger6,
  6. Joseph Azuri7,
  7. Mette Brekke8,
  8. Krzysztof Buczkowski9,
  9. Nicola Buono10,
  10. Emiliana Costiug11,
  11. Geert-Jan Dinant12,
  12. Gergana Foreva13,
  13. Svjetlana Gašparović Babić14,
  14. Robert Hoffman7,
  15. Eva Jakob15,
  16. Tuomas H Koskela16,
  17. Mercè Marzo-Castillejo17,
  18. Ana Luísa Neves18,19,
  19. Davorina Petek20,
  20. Marija Petek Ster20,
  21. Jolanta Sawicka-Powierza21,
  22. Antonius Schneider22,
  23. Emmanouil Smyrnakis23,
  24. Sven Streit2,
  25. Hans Thulesius24,
  26. Birgitta Weltermann25,
  27. Gordon Taylor1
  1. 1 Department for Health, University of Bath, Bath, UK
  2. 2 Institute of Primary Health Care Bern (BIHAM), University of Bern, Bern, Switzerland
  3. 3 Research Unit for General Practice, Aarhus University, Aarhus, Denmark
  4. 4 Research Unit, Majorca Primary Health Care Department, Balearic Islands Health Research Institute (IdISBa), Palma, Spain
  5. 5 Division of Applied Health Sciences—Academic Primary Care, University of Aberdeen, Aberdeen, UK
  6. 6 Department of General Practice, Université Paris Diderot, Paris, France
  7. 7 Department of Family Medicine, Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
  8. 8 Department of General Practice and General Practice Research Unit, University of Oslo, Oslo, Norway
  9. 9 Department of Family Medicine, Nicolaus Copernicus University, Toruń, Poland
  10. 10 Department of General Practice, National Society of Medical Education in General Practice (SNaMID), Caserta, Italy
  11. 11 Family Medicine Department, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
  12. 12 Department of General Practice, Maastricht University, Maastricht, The Netherlands
  13. 13 Medical Center BROD, Plovdiv, Bulgaria
  14. 14 Odjel Socijalne Medicine, The Teaching Institute of Public Health of Primorsko-goranska County, Rijeka, Croatia
  15. 15 Primary Health Centre, Centro de Saúde Sarria, Sarria, Spain
  16. 16 Department of General Practice, Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
  17. 17 Unitat de Suport a la Recerca, IDIAP Jordi Gol, Institut Catala De La Salut, Barcelona, Spain
  18. 18 Centre for Health Policy, Institute of Global Health Innovation, Imperial College London, London, UK
  19. 19 CINTESIS (Center for Health Technology and Services Research) and MEDCIDS (Department of Community Medicine, Information and Health Decision Sciences), Faculty of Medicine, University of Porto, Porto, Portugal
  20. 20 Department of Family Medicine, University of Ljubljana, Ljubljana, Slovenia
  21. 21 Department of Family Medicine, Medical University of Bialystok, Bialystok, Poland
  22. 22 Institute of General Practice and Health Services Research, Technische Universität München, Munich, Germany
  23. 23 Laboratory of Primary Health Care, General Practice and Health Services Research, Aristotle University of Thessaloniki, Thessaloniki, Greece
  24. 24 Department of Clinical Sciences, Lund University, Malmö, Sweden
  25. 25 Institute for Family Medicine and General Practice, University of Bonn, Bonn, Germany
  1. Correspondence to Professor Michael Harris; michaelharris681{at}


Objectives Cancer survival and stage of disease at diagnosis and treatment vary widely across Europe. These differences may be partly due to variations in access to investigations and specialists. However, evidence to explain how different national health systems influence primary care practitioners’ (PCPs’) referral decisions is lacking.

This study analyses health system factors potentially influencing PCPs’ referral decision-making when consulting with patients who may have cancer, and how these vary between European countries.

Design Based on a content-validity consensus, a list of 45 items relating to a PCP’s decisions to refer patients with potential cancer symptoms for further investigation was reduced to 20 items. An online questionnaire with the 20 items was answered by PCPs on a five-point Likert scale, indicating how much each item affected their own decision-making in patients that could have cancer. An exploratory factor analysis identified the factors underlying PCPs’ referral decision-making.

Setting A primary care study; 25 participating centres in 20 European countries.

Participants 1830 PCPs completed the survey. The median response rate for participating centres was 20.7%.

Outcome measures The factors derived from items related to PCPs’ referral decision-making. Mean factor scores were produced for each country, allowing comparisons.

Results Factor analysis identified five underlying factors: PCPs’ ability to refer; degree of direct patient access to secondary care; PCPs’ perceptions of being under pressure; expectations of PCPs’ role; and extent to which PCPs believe that quality comes before cost in their health systems. These accounted for 47.4% of the observed variance between individual responses.

Conclusions Five healthcare system factors influencing PCPs’ referral decision-making in 20 European countries were identified. The factors varied considerably between European countries. Knowledge of these factors could assist development of health service policies to produce better cancer outcomes, and inform future research to compare national cancer diagnostic pathways and outcomes.

  • delivery of health care
  • primary health care
  • general practitioners
  • cancer
  • decision making
  • consultation and referral

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  • Contributors IA-A, JA, KB, MB, NB, EC, G-JD, ME, GF, SGB, MH, RH, EJ, TK, MM-C, PM, ALN, DP, MPS, JS-P, AS, ES, SS, GT, HT, PV and BW participated in the study design. All authors except GT were involved in the data collection. All authors contributed to the writing and to the review of the manuscript and approved the final version. MH had overall responsibility for the study design, recruitment of local leads, analysis of data and interpretation of results. GT advised on the study design and the statistical analysis.

  • Funding ALN is supported by the National Institute for Health Research (NIHR) Imperial Patient Safety Translation Research Centre, with infrastructure support provided by the NIHR Imperial Biomedical Research Centre (BRC).

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval University of Bath Research Ethics Approval Committee for Health.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement The Örenäs survey data used in this study is available at

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