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Concordance with primary care referral guidelines for breast lumps in Singapore: A retrospective cohort study
A H Ong1, S C C van der Lubbe2, A Szücs3
1Division of Family Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Family Medicine and Singapore Primary Care Cancer Network (SPRiNT), National University Health System, Singapore; National University Polyclinics, National University Health System, Singapore.
Objectives:
Timely referral from primary care is pivotal for early diagnosis. The National University Health System (NUHS) introduced referral guidelines for suspected cancer in January 2022 but the concordance with them is unknown. Using breast lumps as an exemplar, we assessed guideline concordance, defined operationally as adherence to NUHS guideline recommendations regarding: (1) whether a referral was made, and (2) whether it was timely (within four weeks). We further examined patient- and consultation-factors associated with non-referral and non-timely referral.
Study Design:
Retrospective cohort study METHODS: We analysed female patients presenting with breast lumps to public polyclinics in Western Singapore between August 2022 and November 2024. Two primary outcomes were assessed for guideline concordance: (1) specialist referral occurrence, and (2) referral timeliness. Multivariable logistic regression analyses examined the associations between socio-demographic and consultation factors, and referral occurrence and timeliness.
Results:
We included 2513 patients, with 2160 (86·0%) referred overall, and 1760 (70·0%) referred within 4 weeks. Predictors of non-referral when it would have been supported by the guidelines included patients of Indian ethnicity (OR 1·78; 95% CI:1·21-2·61, p = 0·013 versus Chinese ethnicity) and being seen during a chronic disease consultation (OR 1·52, 95%CI: 1·00-2·29 p = 0·048; versus acute consultation). Predictors of delays in referral included being seen in a chronic disease consultation (OR 1·65, 95% CI:1·05-2·59, p = 0·030), and younger age (OR 4·94, 95%CI: 2·86-8·52, p < 0·001; 20-29 years versus 60-69 years).
Conclusion:
We found variations in the likelihood and timeliness of guideline-concordant referrals for breast lumps in Singapore primary care. Our findings suggest a need for the development of targeted educational interventions to reduce inequalities in early cancer diagnosis between consultation types, ethnicities, and age groups.
