The effect of the COVID-19 pandemic on urgent referral pathway for suspected cancers

Carola Maria Bigogno; Karishma Mahtani; Brihitejas Patel; Sophie Felicitas Dong

doi:10.7861/fhj.9-2-s3

Introduction

The 2-week-wait referral pathway from primary care was established to ensure urgent specialist assessment of individuals with ‘red-flag’ symptoms. We investigated the impact of the COVID-19 national lockdowns 1 and 3 on the number of urgent referrals, the interval between presentation and referral, and the interval between referral and specialist appointment for patients presenting to Star Lane Medical Centre, Newham, London.

Materials and methods

Population reporting lists were run on EMIS system for patients registered at Star Lane Medical Centre who were coded as ‘fast-track’ or ‘2-week-wait referral’ during January 2020 (baseline, pre-COVID-19), April 2020 and May 2020 (peak 1, lockdown 1), and January 2021 (peak 3, lockdown 3).

Inclusion criteria were: patient was referred for 2-week-wait cancer pathway; patient was over 18 years old; and referral was accepted and an appointment was made by the hospital. Exclusion criteria were: patients were minors (<18 years old); referral was rejected by the hospital; and patient information was incomplete.

The following parameters were recorded for each patient who fulfilled the inclusion and exclusion criteria: type of suspected cancer; date of presentation of ‘red-flag’ symptoms; date of referral by general practitioner; and date of specialist appointment in secondary care.

The primary outcome investigated was the delay in the 2-week-wait referral pathway. Secondary outcomes included the number of 2-week-wait referrals made in primary care and the delay between presentation of ‘red-flag’ symptoms and referral.

Results and discussion

123 patients were referred via the 2-week-wait pathway. Preliminary results demonstrate a considerable decrease in the number of referrals made during peak 1, lockdown 1 compared with pre-COVID-19 (57 referrals in January 2020 vs 15 referrals in April 2020 and 16 referrals in May 2020). The percentage of patients who experienced delays in the 2-week-wait pathway increased from 5.26% in January 2020 to 6.67% in April 2020 and 12.5% in May 2020. This decreased to 5.71% in January 2021. The delay between presentation with ‘red-flag’ symptoms and referral was highest in April 2020, with an average delay of 5.46 days. Similarly, the delays in May 2020 (average delay of 1.5 days) and January 2021 (average delay of 2.89 days) were higher than that of January 2020 (average delay of 0.72 days).

Conclusion and future work

Delays between clinical presentation and referral to the 2-week-wait pathway, and between referral to 2-week-wait pathway and specialist appointment, were noted across the first national lockdown compared with January 2020. These changes may reflect doctor uncertainty concerning referral guidelines, hesitancy towards exposing patients to high-risk environments, and challenges adapting to the online triage system. We are currently in the process of gathering data for all months between January 2020 and January 2021, which were not previously assessed, to have a more complete understanding of the issues. We are also planning to gather data from January 2021 to the present, and from other practices, to assess whether improvements have been made following advice.