Future Health Today and patients at risk of undiagnosed cancer: a pragmatic cluster randomised trial of quality-improvement activities in general practice

Abstract

Background Diagnosing cancer in general practice is complex, given the non-specific nature of many presenting symptoms and the overlap of potential diagnoses. Aim This trial aimed to evaluate the effectiveness of Future Health Today (FHT) — a technology that provides clinical decision support, auditing, and quality-improvement monitoring — on the appropriate follow-up of patients at risk of undiagnosed cancer. Design and setting Pragmatic, cluster randomised trial undertaken in general practices in Victoria and Tasmania, Australia. Method Practices were randomly assigned to receive recommendations for follow-up investigations for cancer (FHT cancer module) or the active control. Algorithms were applied to the electronic medical record, and used demographic information and abnormal test results that are associated with a risk of undiagnosed cancer (that is, anaemia/iron deficiency, thrombocytosis, and raised prostate-specific antigen) to identify patients requiring further investigation and provide recommendations for care. The intervention consisted of the FHT cancer module, a case-based learning series, and ongoing practice support. Using the intention-to-treat approach, the between-arm difference in the proportion of patients with abnormal test results who were followed up according to guidelines was determined at 12 months. Results In total, 7555 patients were identified as at risk of undiagnosed cancer. At 12 months post-randomisation, 76.0% of patients in the intervention arm had received recommended follow-up (21 practices, n = 2820/3709), compared with 70.0% in the control arm (19 practices, n = 2693/3846; estimated between-arm difference = 2.6% [95% confidence interval (CI)] = –2.8% to 7.9%; odds ratio = 1.15 [95% CI = 0.87 to 1.53]; P = 0.332). Conclusion The FHT cancer module intervention did not increase the proportion of patients receiving guideline-concordant care. The proportion of patients receiving recommended follow-up was high, suggesting a possible ceiling effect for the intervention.