Testing the two-week rule
In
April 2000, the UK Department of Health issued national guidelines for urgent
referral by a GP of suspected cancer, where suspected was defined as either a
perceived level of risk, or a hunch. This was achieved by something called a
two-week rule for fast-tracking suspected referrals. The two-weeks then became
a target, by which healthcare organisations could be managed.
At
least that is the theory. Bandolier lacks the will to try to determine what
evidence the theory was based upon, but it is interested in how well it works.
Can a national policy like this make a difference, and can it make things
better? Two recent studies suggest that may not be the case.
Lung cancer [1]
This
was a retrospective audit of patient referrals for suspected lung cancer in
Nottingham in the 12 months before and 24 months after the DoH guidelines. It
abstracted route of referral, reasons, symptoms, and eventual diagnosis, as
well as various markers, like time from referral to outpatient visit,
diagnosis, or treatment. It involved 1,044 referrals to respiratory physicians
with suspected diagnosis of lung cancer.
Results
Before
the introduction of the guidelines, almost every case was an urgent referral
(98%). After the introduction, referrals were either under the two-week wait
referral procedures (60%), or were urgent referrals (40%). Figure 1 shows the
number of referrals, and the number of cancers diagnosed. The former increased
substantially, whilst the number of cancers diagnosed did not change, nor did
the stage at which cancers were detected.
Figure 1: Total referrals and total lung cancers diagnosed before and after two week rule
Times
between referral and diagnosis and treatment were either the same, or increased
(worsened), and median times are shown in Table 1.
Table 1: Waiting times before and after two week rule
| Referral To | |||
| first hospital visit | |||
| diagnosis | |||
| treatment | |||
Colorectal cancer [2]
This
systematic review conducted a search for published reports commenting on the
effectiveness of the two-week rule in UK NHS colorectal cancer diagnostic
services. Information was abstracted on the referral route, number of cancers,
and cancer stage.
Results
Eight
articles reported on about 10,000 patients referred by their GP, two
retrospective and six prospective, performed between 2000 and 2003. Of these,
only 24% were referred using the two-week rule procedure (range 17% to 48%),
with another 24% referred as emergency cases, and 52% using other referral
procedures.
Overall,
1,173 colorectal cancers were detected, about 12% of the total referred. Of
patients referred under the two-week rule procedure, the proportion with
colorectal cancer was 10% (range 8% to 14%).
Most
patients were seen by a hospital specialist within the two-week target, and no
studies reported any significant difference in the stage of colorectal cancer
patients referred under the two-week rule, or by other methods.
Comment
Neither
the lung cancer study nor the colorectal cancer review could identify any
improvement in treatment using the two week rule. In both cases almost all
patients were seen within two weeks anyway, whatever the mechanism of referral.
Widespread implementation of guidelines did not increase the number of cancers
detected, nor the stage at which they were detected.
It
would seem that for lung and colorectal cancer, we had a system that
wasn't broke, and intervention didn't fix it. A cynic might think
that one way of hitting targets is to set one up that is already being reached,
and then trumpet it as a success.
As
best Bandolier knows, there was little in the way of pilots, or extensive work
to figure out what was needed to make an already good system better. But an
awful lot of hassle was created and treasure spent for no apparent purpose.
References:
- NR Lewis et al. Under utilisation of the 2-week wait initiative for lung cancer by primary care and its effects on the urgent referral pathway. British Journal of Cancer 2005 93: 905-908.
- K Thorne et al. The effects of the Two-Week rule on NHS colorectal cancer diagnostic services: a systematic literature review. BMC Health Services Research 2006: 43.