Study finds lack of guideline-concordant imaging for dyspnea, hemoptysis in PC settings

Key takeaways:

• Women and younger patients were less likely to receive guideline-concordant imaging.
• Those who received guideline-concordant imaging were more likely to receive a lung cancer diagnosis within 12 months.

A significant number of patients in the United Kingdom who presented with dyspnea or hemoptysis did not receive guideline-concordant imaging during primary care visits, according to a recent study.

These “red flag” symptoms suggestive of lung cancer require urgent chest imaging, the researchers explained.

“There is currently limited evidence about how primary care referral guidelines for suspected cancer operate in practice,” Minjoung Monica Koo, PhD, a research associate at the Epidemiology of Cancer Healthcare and Outcomes Group, and colleagues wrote in Thorax. “A recent study found that three-fifths of patients with certain alarm symptoms (not including respiratory symptoms) were not referred in spite of guideline recommendations.”

The researchers, trying to better understand clinical guideline concordance and improve diagnosis procedures, examined a study population of 162,161 patients showing dyspnea and 8,120 patients showing hemoptysis during a primary care visit from April 2012 to March 2017.

Just 13.9% and 49.5% of patients with dyspnea and hemoptysis received guideline-concordant imaging within the recommended 2-week period, respectively.

Koo and colleagues also found that patients with chest screenings within 6 weeks before presentation were less likely to receive imaging for dyspnea (adjusted OR = 0.16; 95% CI, 0.14-0.18) and hemoptysis (aOR = 0.09; 95% CI, 0.06-0.11).

Women and patients aged 30 to 49 years were less likely to receive imaging for both conditions vs. men and those aged 50 to 59 years, respectively, according to the researchers.

Patients with a history of COPD and asthma showing dyspnea also had lower odds of undergoing imaging (aOR = 0.23, 95% CI, 0.23-0.24). Koo and colleagues noted this association was weaker “though similar in direction” in patients presenting with hemoptysis (aOR = 0.88, 95% CI, 0.79-0.97).

The odds of a lung cancer diagnosis within 12 months was higher in patients who received guideline-concordant imaging vs. those who did not while presenting dyspnea (1.1% vs. 0.6%) and hemoptysis (3.6% vs. 2.7%).

“This suggests appropriate clinical decision-making took place for these individuals, though we must acknowledge there are additional patient, doctor and system-level factors contributing to urgent imaging taking place following presentation,” the researchers wrote.

They suggested women and younger were less likely to receive guideline care because of a lower risk for lung cancer compared with men and older patients.

Ultimately, 70% of dyspnea presenters and 43% of hemoptysis presenters later diagnosed with lung cancer did not receive guideline-concordant imaging.

This finding could represent missed opportunities for earlier diagnoses, Koo and colleagues noted.

“Clinical case note review could enhance our understanding of the reasons for guideline discordance and missed opportunities,” they wrote. “Nevertheless, the findings demonstrate the potential for investigation or referral activity captured in electronic health record systems to be used as a diagnostic quality indicator.”