Quality of Cancer-Related Clinical Coding in Primary Care in North Central London: Mixed Methods Quality Improvement Project

Abstract

Background: The North Central London (NCL) Cancer Alliance carried out a quality improvement (QI) project to fill a distinct knowledge gap regarding the quality of clinical coded data in a primary care electronic health care record system across the whole cancer pathway. Objective: This study aims to establish the quality of cancer-related clinical coding in NCL primary care, encompassing both quantitative measures (eg, coding completeness and diversity) and qualitative dimensions such as clinical relevance and workflow alignment. Methods: This was a mixed methods QI project in which we combined an observational dataset review and qualitative data from stakeholder interviews, workshops, and discussions. In the dataset review, we evaluated completeness, diversity, validation, and granularity in cancer clinical coding along the patient cancer pathway, which was split into three domains: (1) patient characteristics and risk factors, (2) cancer screening attendance, and (3) living with cancer. It was conducted in NCL primary care electronic health record systems, covering a population of over 1.4 million adults across 5 boroughs. Results: Cancer-related clinical coding in NCL primary care revealed significant gaps despite high completeness for ethnicity (912,679/1,055,083, 86.5%) and language (898,023/1,307,601, 68.7%). Employment status (29,848/1,229,644, 2.4%) and family history of cancer (183,424/1,236,580, 14.8%) were underrecorded, with wide variation in coding practices. Screening data showed good alignment with national datasets for cervical and bowel screening but fragmented and inconsistent breast screening data due to a lack of standardized codes. Cancer diagnosis coding was incomplete (4604/5260, 87.5% recorded), and treatment and staging data were almost entirely absent, limiting proactive management of long-term consequences. Stakeholder input highlighted inconsistent template use, limited data updates, and insufficient incentives as key barriers to better coding. Conclusions: The QI project has provided a detailed insight into the many dimensions of cancer coding and sheds light on many factors that underpin variation and coding preference. We offer a number of recommendations. The prioritized ones include the need for a cancer clinical coding data framework for primary care supported by appropriate funding and incentivization; improvements in the breast screening pathway and its interface with primary care; improvements in the quality of secondary care information that is sent to primary care; and dissemination of the importance of coding of cancer activity in primary care.