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Logo of bmcmidmBioMed Centralsearchsubmit a manuscriptregisterthis articleBMC Medical Informatics and Decision Making
 
BMC Med Inform Decis Mak. 2012; 12: 75.
Published online Jul 20, 2012. doi:  10.1186/1472-6947-12-75
PMCID: PMC3445826
Diagnosis and management of people with venous thromboembolism and advanced cancer: how do doctors decide? a qualitative study
Miriam J Johnson,corresponding author1,2 Laura Sheard,2 Anthony Maraveyas,2,3 Simon Noble,4 Hayley Prout,4 Ian Watt,1,2 and Dawn Dowding5
1Hull York Medical School, Hertford Building, The University of Hull, Cottingham Road, Hull, HU6 7RX, UK
2Department of Health Sciences, The University of York, York, UK
3Academic Department of Oncology, Queens Centre for Oncology and Haematology, Castle Hill Hospital, Hull, UK
4Department of Primary Care and Public Health, School of Medicine, The University of Cardiff, Cardiff, UK
5School of Healthcare, The University of Leeds, Leeds, UK
corresponding authorCorresponding author.
Miriam J Johnson: miriam.johnson/at/hyms.ac.uk; Laura Sheard: laura.sheard/at/york.ac.uk; Anthony Maraveyas: anthony.maraveyas/at/hey.nhs.uk; Simon Noble: simon.noble/at/wales.nhs.uk; Hayley Prout: ProutH/at/cardiff.ac.uk; Ian Watt: ian.watt/at/york.ac.uk; Dawn Dowding: d.dowding/at/leeds.ac.uk
Received January 5, 2012; Accepted June 30, 2012.
Abstract
Background
The treatment of cancer associated thrombosis (CAT) is well established, with level 1A evidence to support the recommendation of a low molecular weight heparin (LMWH) by daily injection for 3–6 months. However, registry data suggest compliance to clinical guidelines is poor. Clinicians face particular challenges in treating CAT in advanced cancer patients due to shorter life expectancy, increased bleeding risk and concerns that self injection may be too burdensome. For these reasons decision making around the diagnosis and management of CAT in people with advanced cancer, can be complex, and should focus on its likely net benefit for the patient. We explored factors that influence doctors’ decision making in this situation and sought to gain an understanding of the barriers and facilitators to the application of best practice.
Methods
Think aloud exercises using standardised case scenarios, and individual in depth interviews were conducted. All were transcribed. The think aloud exercises were analysed using Protocol Analysis and the interviews using Framework Analysis.
Participants: 46 participants took part in the think aloud exercises and 45 participants were interviewed in depth. Each group included oncologists, palliative physicians and general practitioners and included both senior doctors and those in training.
Setting: Two Strategic Health Authority regions, one in the north of England and one in Wales.
Results
The following key issues arose from the data synthesis: the importance of patient prognosis; the concept of “appropriateness”; “benefits and burdens” of diagnosis and treatment; LMWH or warfarin for treatment and sources of information which changed practice. Although interlinked, they do describe distinct aspects of the factors that influence doctors in their decisions in this area.
Conclusions
The above factors are issues doctors take into account when deciding whether to send a patient to hospital for investigation or to anticoagulate a patient with confirmed or suspected VTE. Many factors interweave and are themselves influenced by and dependent on each other. It is only after all are taken into account that the doctor arrives at the point of referring the patient for investigation. Some factors including logistic and organisational issues appeared to influence whether a patient would be investigated or treated with LMWH for a confirmed VTE. It is important that services are optimised to ensure that these do not hinder the appropriate investigation and management of individual patients.
Keywords: Venous thromboembolism, Cancer, Palliative, Clinical decision making
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