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Research

Impact of travel time and rurality on presentation and outcomes of symptomatic colorectal cancer: a cross-sectional cohort study in primary care

Peninah Murage, Peter Murchie, Max Bachmann, Michael Crawford and Andy Jones
British Journal of General Practice 2017; 67 (660): e460-e466. DOI: https://doi.org/10.3399/bjgp17X691349
Peninah Murage
Faculty of Medicine and Health Sciences, Norwich Medical School, University of East Anglia, Norwich.
Roles: PhD candidate
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Peter Murchie
Division of Applied Health Sciences, University of Aberdeen, Aberdeen.
Roles: Clinical senior lecturer
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Max Bachmann
Faculty of Medicine and Health Sciences, Norwich Medical School, University of East Anglia, Norwich.
Roles: Professor of health services research
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Michael Crawford
Airedale NHS Foundation Trust, Medical Oncology, Keighley, West Yorkshire.
Roles: Clinical lead for research
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Andy Jones
Faculty of Medicine and Health Sciences, Norwich Medical School, University of East Anglia, Norwich.
Roles: Professor of public health
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    Figure 1.

    Differences in association between rural and urban areas, with and without interaction terms. 1a–4a show differences in association between rural and urban areas (from Table 2, models 1d–4d). The lines show modelled association between travel time and alarm symptoms (1a), emergency admission (2a), Dukes’ stage (3a), and 3-year survival (4a). 1b–4b show the difference in the rural versus urban slope, along with 95% CIs. These differences are statistically significant where the CIs do not cross the zero line.

Tables

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    Table 1.

    Sample characteristics and outcome variables

    VariableFrequency, n (%)Mean travel time, minutes
    Sex
    Male521 (56.3)8.8
    Female405 (43.7)7.1
    Age, years
    <59157 (17.0)8.8
    60–69240 (25.9)7.6
    70–79347 (37.5)8.5
    >80182 (19.7)7.1
    Location
    Rural298 (32.2)12.0
    Urban628 (67.8)6.2
    Travel time to GPs, percentile
    25th232 (25)2.8
    50th463 (50)5.5
    75th695 (75)10.3
    99th917 (99)43.8
    Deprivation
    Least deprived Q1191 (20.6)8.6
    Q2191 (20.6)7.8
    Q3171 (18.5)9.1
    Q4188 (20.3)8.1
    Most deprived Q5185 (20.0)6.5
    Comorbidities
    0441 (47.6)7.8
    1–2312 (33.7)8.3
    >3173 (18.7)8.3
    Symptoms
    1–3825 (89.1)7.7
    >4101 (10.9)10.7
    Alarm symptoms373 (40.3)7.9
    Emergency admissions243 (26.2)7.7
    Dukes’ stage CD424 (48.9)a7.9
    • ↵a Information on disease stage was missing in 58 patients.

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    Table 2.

    Association between rurality, travel times to the GP, alarm symptoms, and primary outcomes

    Explanatory variables1) Alarm symptoms OR (95% CI)2) Emergency admission OR (95% CI)3) Dukes’ stages OR (95% CI)4) Death within 3 years HR (95% CI)
    Outcome variables without interaction terms
    a) Travel time to GP0.98 (0.84 to 1.14)0.91 (0.75 to 1.09)0.91 (0.78 to 1.07)0.81a (0.72 to 0.92)
    b) Rural1.08 (0.80 to 1.46)0.83 (0.58 to 1.18)0.99 (0.72 to 1.34)0.71a (0.57 to 0.88)
    c) Alarm symptomsN/A0.36b (0.25 to 0.53)0.85 (0.64 to 1.14)1.15 (0.94 to 1.41)
    Outcome variables with interaction terms fitted
    d) Travel time to GP1.34 (0.98 to 1.82)0.62b (0.39 to 0.97)0.94 (0.68 to 1.29)0.75b (0.59 to 0.96)
    Rural1.62b (1.05 to 2.48)0.61 (0.36 to 1.02)1.11 (0.72 to 1.70)0.69b (0.51 to 0.94)
    Travel time/rurality interaction0.62b (0.43 to 0.90)1.69b (1.02 to 2.79)0.95 (0.65 to 1.38)1.18 (0.88 to 1.57)
    Alarm symptomsN/A0.37a (0.26 to 0.54)0.84 (0.63 to 1.12)1.17 (0.95 to 1.43)
    Age, years1.00 (0.98 to 1.01)1.02b (1.00 to 1.03)0.97a (0.96 to 0.99)1.03a (1.02 to 1.04)
    Female0.95 (0.72 to 1.23)0.89 (0.63 to 1.24)0.76 (0.57 to 1.01)0.74a (0.60 to 0.90)
    Index of deprivation (Carstairs)0.99 (0.94 to 1.04)0.99 (0.93 to 1.05)1.05 (0.99 to 1.11)1.02 (0.99 to 1.06)
    0 comorbidities (Charlson score) (reference)1111
    1–2 comorbidities (Charlson)0.53a (0.39 to 0.71)4.87a (3.27 to 7.26)0.87 (0.63 to 1.19)1.20 (0.95 to 1.50)
    >3 comorbidities (Charlson)0.29a (0.20 to 0.44)7.26a (4.63 to 11.39)1.44 (0.97 to 2.14)2.53a (1.98 to 3.25)
    • ↵a P<0.01.

    • ↵b P<0.05. Travel time is the predictor in ‘a’, rurality is the predictor in ‘b’, and alarm symptoms is the predictor in ‘c’. Travel times are interacted with rurality in ‘d’. All models are adjusted for age, sex, deprivation, and comorbidity. For brevity, the coefficients for the covariates are only shown in the models with the interaction term (d). HR = hazard ratio. N/A = not applicable. OR = odds ratio.

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British Journal of General Practice: 67 (660)
British Journal of General Practice
Vol. 67, Issue 660
July 2017
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Impact of travel time and rurality on presentation and outcomes of symptomatic colorectal cancer: a cross-sectional cohort study in primary care
Peninah Murage, Peter Murchie, Max Bachmann, Michael Crawford, Andy Jones
British Journal of General Practice 2017; 67 (660): e460-e466. DOI: 10.3399/bjgp17X691349

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Impact of travel time and rurality on presentation and outcomes of symptomatic colorectal cancer: a cross-sectional cohort study in primary care
Peninah Murage, Peter Murchie, Max Bachmann, Michael Crawford, Andy Jones
British Journal of General Practice 2017; 67 (660): e460-e466. DOI: 10.3399/bjgp17X691349
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Keywords

  • access
  • cancer symptoms
  • early diagnosis
  • geography
  • primary care
  • rurality

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