Casnet2: Evaluation of electronic safety netting for suspected cancer

The CASNET2 study tests an electronic safety-netting toolkit that provides primary care staff with a way to record safety-netting advice and actions when they think cancer could be causing the patient’s symptoms, and to set reminders to ensure that the patient is followed-up. The study will measure the impact the toolkit has on the outcomes of patients that are safety-netted using the tool, what it is like to use the tool, and whether any improvements can be made.

Safety-netting is very common in primary care and refers to a set of actions that aim to ensure that a patient either reattends promptly if they need to, or is followed-up by one of the primary care team. This is to try to reduce any delays in diagnosing serious diseases like cancer as much as possible and it is used when there is uncertainty in what is causing the patient’s symptoms or how the symptoms might progress. Safety-netting involves both advice given to the patient during their appointment, for example on what concerning symptoms they should look out for, and a range of actions done by the primary care team after the appointment. The safety-netting actions taken on by the primary care team include things like checking a patient was seen at their specialist appointment, that the results of a test have been returned and communicated to the patient, or, if no tests were ordered yet, whether their symptoms have improved or need to be investigated further.

Currently, the way safety-netting is done is through a mix of methods that can include verbal or written advice to the patient, GPs keeping personal diary reminders, notes on the patient’s electronic health record, or reminder systems set up by the practice. This means that safety-netting is often done inconsistently and increases the risk that seriously ill patients will fall through the net. 

The CASNET2 toolkit was provided to primary care practices across England to test. These practices provided data on how GPs used the toolkit when they suspected cancer and what happened to the patients who were safety-netted using the toolkit. This testing phase of the study is now complete and we will compare the outcomes of patients before and after the toolkit was introduced to see if there was any impact on the outcomes of these patients.

We also carried out some interviews with primary care staff. These interviews covered:

-          How safety-netting is done in their practice when there is a suspicion of cancer.

-          How COVID-19 affected the suspicion of cancer in their practice.

-          How they found using the CASNET2 toolkit and how it could be improved (with those who had tested it).

-          What features they would like to see in a safety-netting tool.

Finally we took the features that the primary care staff told us were important for a safety-netting tool to have and presented them to another group of staff who prioritised the features in a Delphi study. A Delphi study involves showing a group of experts a range of options to solve a problem or answer a question and the options are discussed and voted on until agreement is reached on what best or most important options are. We have turned the high priority features into recommendations on what features are important and should be included in any future attempt to design an electronic safety-netting tool.

The CASNET2 toolkit will remain available to GP practices after the study is complete. Changes may be made to it based on our findings to improve the user experience. If we find that the outcomes of patients who were safety-netted using the toolkit were improved, we will use this to make a case for its use.

We have some interim results for the CASNET2 study.  

Lay summary of results 

Background

‘Safety netting’ helps doctors when they are not certain what is causing their patient’s symptoms. It includes giving the patient advice on how they can take care of their own symptoms and when they should see the doctor again. Safety-netting also includes checks for the GP practice staff to make sure that if patients have tests for serious diseases like cancer, they are told their test results and any treatment or extra testing is arranged. The aim of this is to diagnose serious illnesses like cancer as quickly as possible.

In the CASNET2 project, we tested an electronic tool that is built into the computer system used by GPs, which supports the GP surgery to safety-net patients well. We wanted to see if using the tool leads to faster cancer diagnosis.

How we did the research

The CASNET2 project tested an electronic safety-netting tool. This allows staff working at GP surgeries to keep a record of the safety-netting advice given and anything that needs to be done for patients that the GP suspects could have cancer. The tool also sends reminders to the practice staff to follow-up with the patient.

We asked 52 GP surgeries across England to “turn on” the tool and collected data on how it was used. We compared what patients’ journeys to their cancer diagnosis looked like before and after the tool was turned on.

We also interviewed GP surgery staff about how easy and useful the tool was and ran a survey to find out what GP surgery staff think is important for a safety-netting tool. We discussed the results of these with patient representatives.

Results

In the 52 practices, 9,803 patients had a diagnosis of cancer during the time we were doing the research. We looked at two main ways of measuring whether the tool improved cancer diagnosis:

• The time from when the first cancer symptom was recorded in the GP’s notes to the time a patient was referred to a hospital (the time to referral)
• The time from when the first cancer symptom was recorded in the GP’s notes to the time the patient got their diagnosis of cancer (the time to diagnosis)

We compared everyone who was diagnosed with cancer before and after the tool was turned on.  We found that:

• the time to referral was an average of 42 days shorter after the safety-netting tool was turned on
• the time to diagnosis was an average of 25 days shorter after the safety netting tool was turned on

We also compared people diagnosed with cancer after the safety-netting tool was used as part of their care to people who were diagnosed before the tool was turned on.  We found that:

• the time to referral was an average of 53 days shorter in patients who had the tool used as part of their care
• the time to diagnosis was an average of 32 days shorter in patients who had the tool used as part of their care, 

We interviewed 13 GP surgery staff who had used the tool as part of the CASNET2 project.  They said that the tool was useful, and they wanted to carry on using it after the study ended.  The survey found that GP surgery staff wanted safety netting tools that:

• were easy to use
• helped with making decisions
• allowed good communication between different members of staff and patients
• made it easy to see if the tool was making a difference for their patients 

When we talked to patients, they generally agreed with the choices made by GP surgery staff.  However, the patients were disappointed that the GP surgery staff did not want using the tool to be required. The patients felt that if the tool was used routinely, more patients would get the benefits of being referred to hospital and diagnosed more quickly. These benefits wouldn’t vary by GP and surgery.

What this means

Earlier diagnosis of cancer means that treatment can begin more quickly.  Early treatment means that patients have a better chance of having their cancer cured, and can save lives.  It also means that patients and their family have less time worrying about a possible cancer diagnosis.

The tool tested as part of CASNET2 is part of the EMIS electronic patient record system, and so is available to all GP surgeries who use the EMIS software.  We hope our research will encourage GP practices to make sure the tool is turned on in their practice. 

We also hope that the results of our survey, including the comments from patients, will be used when new tools are being designed.

This project was funded by Cancer Research UK and University of Oxford Covid-19 Response Fund 

Afsana Bhuiya (North Central London Cancer Alliance)

Yasemin Hirst (University of Lancaster)

Georgia Black (Queen Mary’s University London)

Sue Duncombe (PPI lead)

North Central London Cancer Alliance

University of Lancaster

Queen Mary’s University London