PRIMARY CARE SYSTEM FACTORS AND CLINICAL DECISION-MAKING IN 
PATIENTS THAT COULD HAVE LUNG CANCER: A VIGNETTE STUDY IN 
FIVE BALKAN REGION COUNTRIES
Davorina PETEK1*, Radost ASSENOVA2, Gergana FOREVA3, Svjetlana GAŠPAROVIĆ BABIĆ4,  
Marija PETEK ŠTER1, Nuša PREBIL1, Aida PUIA5, Emmanouil SMYRNAKIS6, Michael HARRIS7,8
1University of Ljubljana, Faculty of Medicine, Department of Family Medicine, Poljanski nasip 58, 1000 Ljubljana, Slovenia
2Department of Urology and General Medicine, Medical Faculty, Medical University of Plovdiv, Bulgaria
3Medical Center BROD, Plovdiv, Bulgaria
4Croatian Health Insurance Fund, Rijeka, Croatia
5Family Medicine Department, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
6Laboratory of Primary Health Care, General Practice and Health Services Research,  
Aristotle University of Thessaloniki, Greece
7College of Medicine & Health, University of Exeter, Exeter, UK
8Institute of Primary Health Care Bern (BIHAM), University of Bern, Switzerland 
Received: Dec 21, 2020
Accepted: Nov 19, 2021
Original scientific article
*Corresponding author: Tel. + 386 1 436 8217; E-mail: davorina.petek@mf.uni-lj.si
10.2478/sjph-2022-0007 Zdr Varst. 2022;61(1):40-47
40
DEJAVNIKI PRIMARNEGA ZDRAVSTVA IN KLINIČNO ODLOČANJE 
PRI BOLNIKIH, KI BI LAHKO IMELI PLJUČNEGA RAKA: RAZISKAVA 
S POMOČJO VINJETE V PETIH DRŽAVAH BALKANSKE REGIJE
© National Institute of Public Health, Slovenia. 
Petek D, Assenova R, Foreva G, Gašparović Babić S, Petek Šter M, Prebil N, Puia A, Smyrnakis E, Harris M. Primary care system factors and clinical decision-making in patients that 
could have lung cancer: a vignette study in five Balkan region countries. Zdr Varst. 2022;61(1):40-47. doi: 10.2478/sjph-2022-0007.
ABSTRACT
Keywords: 
lung cancer, primary 
care, gatekeeping, 
early diagnosis
IZVLEČEK
Ključne besede: 
rak pljuč, primarno 
zdravstvo, sistem 
vratarja, zgodnja 
diagnostika
Introduction: Lung cancer is the leading cause of cancer death, with wide variations in national survival rates. 
This study compares primary care system factors and primary care practitioners’ (PCPs’) clinical decision-making 
for a vignette of a patient that could have lung cancer in five Balkan region countries (Slovenia, Croatia, Bulgaria, 
Greece, Romania).
Methods: PCPs participated in an online questionnaire that asked for demographic data, practice characteristics, 
and information on health system factors. Participants were also asked to make clinical decisions in a vignette of 
a patient with possible lung cancer.
Results: The survey was completed by 475 PCPs. There were significant national differences in PCPs’ direct access 
to investigations, particularly to advanced imaging. PCPs from Bulgaria, Greece, and Romania were more likely 
to organise relevant investigations. The highest specialist referral rates were in Bulgaria and Romania. PCPs in 
Bulgaria were less likely to have access to clinical guidelines, and PCPs from Slovenia and Croatia were more likely 
to have access to a cancer fast-track specialist appointment system. The PCPs’ country had a significant effect on 
their likelihood of investigating or referring the patient.
Conclusions: There are large differences between Balkan region countries in PCPs’ levels of direct access to 
investigations. When faced with a vignette of a patient with the possibility of having lung cancer, their investigation 
and referral rates vary considerably. To reduce diagnostic delay in lung cancer, direct PCP access to advanced 
imaging, availability of relevant clinical guidelines, and fast-track referral systems are needed.
Uvod: Pljučni rak je vodilni vzrok smrti zaradi raka, pri čemer se nacionalne stopnje preživetja zelo razlikujejo. Ta 
študija primerja dejavnike sistema primarnega zdravstvenega varstva (PZV) in klinično odločanje izvajalcev PZV v 
petih državah balkanske regije na primeru vinjete bolnika, ki bi lahko imel pljučnega raka.
Metode: Zdravniki PZV iz petih evropskih držav jugovzhodne regije (Slovenije, Hrvaške, Bolgarije, Grčije in 
Romunije) so izpolnili spletni vprašalnik, ki je zajemal njihove demografske značilnosti, značilnosti ambulante 
in zdravstvenega sistema. Udeleženci so bili pozvani, naj sprejmejo klinične odločitve za v obliki vinjete 
predstavljenega hipotetičnega bolnika, ki bi lahko imel pljučnega raka.
Rezultati: Anketo je izpolnilo 475 oseb. Statistično značilne razlike med državami so bile ugotovljene v 
neposrednem dostopu zdravnikov PZV do preiskav, zlasti zahtevnejših slikovnih preiskav. Zdravniki iz Bolgarije, 
Grčije in Romunije so se v primeru iz vinjete pogosteje odločili za ustrezne preiskave kot zdravniki iz Slovenije in 
Hrvaške. Najvišji stopnji napotitve k specialistu sta bili ugotovljeni v Bolgariji in Romuniji. Najslabša dostopnost 
kliničnih smernic je bila ugotovljena v Bolgariji. Najdostopnejši sistem hitre/prednostne diagnostične obravnave 
oz. napotitve pri sumu na raka je bil ugotovljen v Sloveniji in Hrvaški. Država je bila edini napovedni dejavnik za 
verjetnost napotitve bolnika na preiskave ali specialistično obravnavo v primeru klinične vinjete.
Zaključek: Med sodelujočimi državami balkanske regije obstajajo velike razlike v neposrednem dostopu zdravnikov 
PZV do preiskav. V primeru klinične vinjete bolnika z možnostjo pljučnega raka se stopnje odločanja za preiskave 
in napotitve pomembno razlikujejo po državah. Za zmanjšanje diagnostične zamude pri pljučnem raku je treba 
izboljšati neposredni dostop zdravnikov PZV do naprednih slikovnih preiskav, razpoložljivost ustreznih kliničnih 
smernic in uveljaviti hitre napotitvene sisteme.
10.2478/sjph-2022-0007 Zdr Varst. 2022;61(1):40-47
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1 INTRODUCTION
Cancer survival rates across Europe differ considerably, 
and data from the European Cancer Registry-based Study 
on Survival and Care of Cancer Patients (EUROCARE-5) 
show that the national 1-year relative survival rates 
for all cancer sites vary from 58.2% to 81.1% (1).  While 
1-year relative survival can be affected by differences in 
registration as well as lead-time and overdiagnosis biases 
(2, 3), it is thought to be an indicator of more advanced 
disease at diagnosis  (4, 5). This is associated with 
diagnostic delay, which leads to poorer patient outcomes 
and survival rates (4, 6–8). The more advanced a cancer 
is, the more difficult it is to treat it successfully (9). For 
patients with lung cancer, disease stage at diagnosis is 
associated with survival (10). 
Lung cancer is the most commonly diagnosed cancer 
worldwide (11.6% of all cancers) and the leading cause 
of cancer death (18.4% of all cancer deaths). This is a 
particular problem in countries in the Balkan region (1). 
Out of 23 world regions, Eastern Europe has the second-
highest incidence of age-standardised and region-specific 
incidence for lung cancer in men, southern Europe has 
the fifth-highest (11), while age-standardised mortality 
rates for lung cancer in men in both regions are above the 
global average (171 and 132 respectively, compared with 
the world average of 123). The 5-year age-standardised 
net survival rate for lung cancer in 2010-2014 in the Balkan 
region countries included in this study is low, at 14.8% for 
Slovenia, 10.0% for Croatia, 7.7% for Bulgaria, and 11.1% 
for Romania (Cluj) (12). However, apparent differences in 
national cancer relative survival may reflect differences in 
calculation methodology (13). There are no data for lung 
cancer survival rates in Greece.
There are national variations in public awareness of cancer 
symptoms, as well as in the funding and organisation of 
health-care systems, which might affect the timeliness of 
cancer diagnosis in primary care (14). Screening is also 
increasingly important, with evidence that volume CT 
screening of those at high risk significantly lowers lung 
cancer mortality (15, 16). 
The aims of this study were, in five Balkan region 
countries, to explore whether PCPs have direct access to 
relevant investigations, their clinical decision-making in a 
patient that could have lung cancer, to find out how PCP 
demographics and system factors affect these decisions, 
and to identify how these compare between countries.
2 METHODS
2.1 Design and study setting
The Örenäs Research Group (ÖRG), a European group of 
primary care cancer researchers, performed a twenty-
country European on-line cross-sectional survey of PCPs 
to identify the factors associated with national variations 
in cancer survival. The survey methodology is described 
in detail elsewhere (17). This analysis uses data from the 
Balkan region countries that agreed to participate in the 
study: Bulgaria, Croatia, Greece, Romania, and Slovenia.
2.2 The questionnaire
The questionnaire consisted of four sections: 
• PCPs’ demographic data and practice characteristics: 
sex, number of years since graduation, location of 
practice, and number of doctors in practice
• availability of direct PCP access to relevant 
investigations: plain X-ray, contrast X-ray, computerised 
tomography (CT), positron emission tomography CT 
(PET CT) and magnetic resonance imaging (MRI)
• PCPs’ stated clinical actions for a vignette of a patient 
with symptoms that could be due to lung cancer 
• PCPs’ levels of agreement with statements on health 
system factor items that could influence the timeliness 
of cancer diagnoses. In this section, PCPs were asked to 
rate how much they agreed with each item in relation 
to their referral decision-making using a 5-point Likert 
scale.
The vignette described a 62-year-old male smoker with a 
respiratory tract infection, increased sputum production, 
left shoulder pain, a history of chronic obstructive 
pulmonary disease, but no significant findings on physical 
examination. The vignette was designed to have a low 
but significant possibility of lung cancer, with a positive 
predictive value of 3.6% (18) .
The health system factor statements were designed to 
indicate the availability of clinical guidelines giving advice 
on which patients to refer, the availability of a fast-track 
specialist appointment system for patients who may have 
cancer, and the ability of patients to self-refer to specialists 
(an indication of the degree of PCP gatekeeping).
2.3 Participants and recruitment
In each country a lead ÖRG member was asked to recruit at 
least 50 PCPs (physicians working mainly in primary care in 
the community) to the study, by emailing survey invitations 
to PCPs in their areas. In Romania and Slovenia the survey 
was conducted nationwide, and the survey invitation was 
sent through the Association of Family Physicians database. 
In other countries it was conducted in a local healthcare 
district. Consent was implied by agreeing to take part in 
the survey. All data were collected anonymously.
2.4 Statistical analysis
Likert scale responses were converted to numerical scores 
(‘strongly disagree’=1, ‘strongly agree’=5). Descriptive 
statistics were used to report demographic data, practice 
10.2478/sjph-2022-0007 Zdr Varst. 2022;61(1):40-47
42
characteristics, availability of relevant investigations, 
PCPs’ actions, and mean Likert scores for the health 
system factor statements. To compare the Likert scores, 
we fitted an analysis of variance (ANOVA) model to 
investigate whether the differences between countries 
were statistically significant. The chi-square test was used 
to test between-country differences in PCPs’ access to 
investigations, as well as their likelihood of testing and 
referring the patient in the clinical vignette. 
We used a binary logistic regression to test associations 
between whether or not the PCP would (a) investigate 
the patient and (b) refer to a specialist and: PCP sex, 
years since graduation, type of practice, number of 
PCPs in their practice, availability of clinical guidelines, 
availability of a fast-track specialist appointment system, 
ability of patients to self-refer to specialists, availability of 
direct PCP access to relevant investigations, and country. 
In the regression, ‘access to investigations’ is a compound 
variable, with possible access scores ranging from 0 (none 
of the investigations listed above directly available to PCPs) 
to 5 (all five of the listed investigations directly available), 
with 0 as the reference variable. Urban practice had the 
most participants in its group, and so was chosen as the 
reference variables for ‘Type of practice’. For the three 
Likert scale sets of answers and for ‘Country’, we chose 
the first possible option in each answer as the reference 
variable (‘Strongly disagree’ and Bulgaria respectively). 
Tests were 2-tailed, with statistical significance defined as 
P≤0.05. Data were analysed using IBM SPSS v25.
3 RESULTS
A total of 475 Balkan region PCPs completed the 
questionnaire. The response rates and demographics are 
given in Tables 1 and 2 respectively.
Number of respondents
Number invited
Response rate (%)
Sex
Years since 
graduation
Type of practice
Number of PCPs 
in the practice
59
90
65.6
13 (22.0)
44 (74.6)
2 (3.4)
8 (13.6)
11 (18.6)
23 (39.0)
11 (18.6)
5 (8.5)
1 (1.7)
 
44 (74.6)
5 (8.5)
9 (15.3)
1 (1.7)
32 (54.2)
8 (13.6)
8 (13.6)
1 (1.7)
1 (1.7)
1 (1.7)
7 (11.9)
1 (1.7)
Male
Female
Not given
Less than 10
10 to 19
20 to 29
30 to 39
40 or more
Not given 
Urban
Rural
Mixed
Not given
1
2
3
4-5
6-7
8-9
10 or more
Not given
68
318
21.4
34 (50.0)
34 (50.0)
0 (0.0)
0 (0.0)
38 (55.9)
25 (36.8)
5 (7.4)
0 (0.0)
0 (0.0)
 
20 (29.4)
34 (50.0)
14 (20.6)
0 (0.0)
24 (35.3)
8 (11.8)
3 (4.4)
11 (16.2)
6 (8.8)
1 (1.5)
13 (19.1)
2 (2.9)
67
292
22.9
12 (17.9)
54 (80.6)
1 (1.5)
11 (16.4)
10 (14.9)
22 (32.8)
21 (31.3)
1 (1.5)
2 (3.0)
 
31 (46.3)
23 (34.3)
13 (19.4)
0 (0.0)
33 (49.3)
9 (19.4)
6 (9.0)
6 (9.0)
6 (9.0)
5 (7.5)
2 (3.0)
0 (0.0)
177
Unknown
Unknown
21 (11.9)
154 (87.0)
2 (1.2)
8 (4.5)
42 (23.7)
75 (42.4)
50 (28.2)
0 (0.0)
2 (1.1)
 
108 (61.0)
60 (33.9)
7 (4.0)
2 (1.1)
64 (36.2)
33 (18.6)
17 (9.6)
20 (11.3)
9 (5.1)
5 (2.8)
22 (12.4)
7 (4.0)
104
352
29.5
25 (24.0)
78 (75.0)
1 (1.0)
17 (16.3)
34 (32.7)
32 (30.8)
16 (15.4)
5 (4.8)
0 (0.0)
 
44 (42.3)
31 (29.8)
29 (27.9)
0 (0.0)
7 (6.7)
10 (9.6)
14 (13.5)
10 (9.6)
12 (11.5)
15 (14.4)
36 (34.6)
0 (0.0)
Table 1.
Table 2.
Number of participants and response rates in each of the five participating countries.
Participants’ demographic and practice information for each of the five participating countries.
Bulgaria 
Bulgaria 
n (%)
Greece
Greece
n (%)
Croatia
Croatia
n (%)
Romania
Romania
n (%)
Slovenia
Slovenia
n (%)
10.2478/sjph-2022-0007 Zdr Varst. 2022;61(1):40-47
43
Plain X-ray
CT and/or PET CT and/or MRI
‘Common presentations 
and advice to which to 
refer are covered by local 
or national guidelines’ 
‘We have access to a fast-
track specialist appointment 
system if cancer is suspected’
‘Patients can self-refer to 
specialists, so GPs don’t 
need to act as gatekeepers.’
Statement Mean Likert scores (SD)1
54 (91.5)
7 (11.9)
2.76 (1.01) 
 
 
2.71 (1.19) 
 
2.39 (1.04)
66 (97.1)
53 (77.9)
3.59 (1.01) 
 
 
2.45 (1.11) 
 
2.58 (1.30)
64 (95.5)
16 (23.9)
3.22 (0.98) 
 
 
3.22 (1.17) 
 
2.04 (1.02)
149 (84.2)
23 (13.0)
3.37 (1.00) 
 
 
2.58 (1.08) 
 
2.38 (1.15)
90 (86.5)
71 (68.3)
3.73 (0.84) 
 
 
3.22 (1.22) 
 
1.55 (0.85)
<0.006
<0.001
<0.001 
 
 
<0.001 
 
<0.001
Figure 1.
Table 3.
Table 4.
National comparisons of PCPs stated clinical actions 
for vignette of a patient with symptoms that could 
be due to lung cancer.
Number of PCPs who have direct access to relevant imaging for lung cancer.
PCPs’ levels of agreement with statements on health system factors that could influence the timeliness of cancer diagnosis.
1Mean and standard deviation (SD) for the answers on Likert scale: 1=strongly disagree, 2=disagree, 3=neither agree nor disagree, 
4=agree, 5=strongly agree.
Bulgaria 
n (%)
Bulgaria 
Greece
n (%)
Greece
Croatia
n (%)
Croatia
Romania
n (%)
Romania
Slovenia
n (%)
Slovenia
Significance  
(P value)
Significance  
(P value)
3.1 Availability of direct access to investigations
Over 80% of PCPs had direct access to plain X-rays in each 
of the countries, though there was significant between-
country variation. A larger difference, also significant, 
was seen in direct access to advanced imaging, with less 
than a quarter of PCPs in Bulgaria, Croatia and Romania 
having this access (Table 3).
3.2 PCPs’ actions for the clinical vignette
With the exception of PCPs in Greece, over half of PCPs 
would have written a prescription for the patient at the 
index consultation (Figure 1). At least three-quarters of 
PCPs from each country would have scheduled a follow-
up appointment for the patient. There was a significant 
difference in the proportion of doctors who would 
arrange a chest X-ray, tumour marker, or another special 
investigation or imaging: in Bulgaria, Greece, and Romania 
over 80% of PCPs would do this, compared with less than 
60% in Slovenia and Croatia (Χ2=49.39, df=4, P<0.001). The 
largest between-country variation in PCPs’ stated actions 
was for referral to a specialist, ranging from Greece (8.1% 
would refer), through Slovenia (14.9%), Croatia (18.6%), 
and Bulgaria (36.5%) to Romania (65.8%). This difference 
was statistically significant (Χ2=106.9, df=4, P<0.001).
3.3 PCPs’ views on health system factors that influence 
their clinical decision-making
Local or national referral guidelines were least likely 
to be available to Bulgarian PCPs (Table 4). Fast track 
appointment systems for patients who may have cancer 
were more likely to be available in Slovenia and Croatia. 
Slovenian PCPs were least likely to consider that their 
patients could self-refer to a specialist. For each of these 
factors, there were statistically significant differences 
between the national means.
10.2478/sjph-2022-0007 Zdr Varst. 2022;61(1):40-47
44
3.4 Effects of different factors on PCPs’ likelihood of 
investigating or referring in the clinical vignette
Table 5 shows the regression analysis for the association 
between likelihood of investigation and referral to a 
specialist and the independent predictors. Country was 
a significant variable for both of these: Croatian and 
Slovenian PCPs were less likely to schedule an investigation 
or refer patients to a specialist than their Bulgarian, 
Greek, and Romanian colleagues. PCPs in Croatia, Greece, 
and Slovenia had a significantly lower likelihood of referral 
than their Bulgarian counterparts, while Romanian PCPs 
had a significantly increased likelihood. None of the other 
variables had a significant effect.
Sex (Male)
Type of practice (Urban)
Rural
Island
Mixed
Years since graduation (Less than 10)
10 to 19
20 to 29
30 to 39
40 or more
‘Common presentations are 
covered by local or national 
guidelines’ (Strongly disagree)
Disagree
Neither agree nor disagree
Agree
Strongly agree
‘We have access to a fast-track specialist 
appointment system’ (Strongly disagree)
Disagree
Neither agree nor disagree
Agree
Strongly agree
‘Patients can self-refer to 
specialists’ (Strongly disagree)
Disagree
Neither agree nor disagree
Agree
Strongly agree
Number of relevant investigations 
available (None)
One
Two
Three
Four
Five
Statement a) Effects on PCPs’ likelihood of 
organising an investigation
b) Effects on PCPs’ likelihood 
of referral to a specialist
0.912
0.823
1.312
1.028
0.948
0.697
1.465
1.117
 
 
2.017
1.572
2.162
1.548
 
0.904
1.960
0.840
1.885
 
1.407
0.941
3.676
2.059
 
0.250
0.365
0.763
0.552
0.257
0.806
1.555
2.198
1.101
1.259
1.105
1.212
0.784
 
 
1.000
1.159
1.527
0.789
 
0.647
1.015
0.833
2.130
 
1.150
1.190
0.868
1.696
 
0.160
0.358
0.552
0.198
0.251
0.781
0.899
0.564
0.740
0.943
0.474
0.916
0.461
0.482
0.900
0.731 
 
0.331
0.504
0.255
0.589
0.324 
0.825
0.229
0.716
0.375
0.263 
0.283
0.896
0.054
0.335
0.376 
0.248
0.356
0.847
0.599
0.233
0.536
0.515
0.191
0.350
0.824
0.975
0.669
0.848
0.732
0.792
0.662 
 
1.000
0.824
0.518
0.778
0.318 
0.338
0.978
0.708
0.259
0.910 
0.683
0.713
0.768
0.463
0.257 
0.038
0.141
0.585
0.040
0.097
0.478-1.742
0.424-1.596
0.264-6.521
0.486-2.174
0.354-2.541
0.267-1.818
0.505-4.249
0.201-6.216
 
 
0.490-8.296
0.416-5.936
0.573-8.162
0.317-7.547
 
0.371-2.202
0.655-5.862
0.329-2.145
0.465-7.640
 
0.755-2.621
0.377-2.348
0.979-13.807
0.474-8.952
 
0.024-2.622
0.043-3.104
0.049-11.952
0.060-5.069
0.027-2.400
0.406-1.599
0.802-3.015
0.422-11.459
0.470-2.580
0.438-3.616
0.398-3.063
0.405-3.629
0.129-4.776
 
 
0.254-3.940
0.316-4.246
0.423-5.517
0.152-4.105
 
0.266-1.577
0.366-2.809
0.320-2.169
0.572-7.931
 
0.588-2.247
0.470-3.013
0.341-2.212
0.414-6.955
 
0.028-0.907
0.091-1.404
0.065-4.654
0.042-0.929
0.049-1.285
Table 5. Effects of PCP and practice demographics, system factors, availability of relevant investigations and country on (a) PCPs’ 
likelihood of scheduling an investigation and (b) likelihood of referral patients to a specialist, for a patient with symptoms 
that could be due to lung cancer.
Exp(B) Exp(B)P value P value95% CI 95% CI
4 DISCUSSION
4.1 Main findings
This study examined key factors that could contribute to 
a primary care delay in the diagnostic process of patients 
with possible lung cancer. We found significant national 
differences between the five Balkan region countries 
in PCPs’ direct access to investigations, particularly for 
advanced imaging. Analysis of the vignette responses 
showed large differences in specialist referral rates, 
with the highest rates in Bulgaria and Romania. PCPs 
from Bulgaria, Greece, and Romania were more likely to 
schedule relevant investigations.  
10.2478/sjph-2022-0007 Zdr Varst. 2022;61(1):40-47
45
Country (Bulgaria)
Croatia
Greece
Romania
Slovenia
Constant
Statement a) Effects on PCPs’ likelihood of 
organising an investigation
b) Effects on PCPs’ likelihood 
of referral to a specialist
0.188
0.657
1.600
0.210
7.205
0.286
0.160
3.473
0.345
1.349
<.001
0.003
0.527
0.393
0.011
0.145
<0.001
0.023
0.007
0.003
0.057
0.781
0.062-0.572
0.179-2.414
0.544-4.705
0.063-0.694
0.098-0.840
0.042-0.611
1.544-7.813
0.115-1.033
Hosmer–Lemeshow test for effects on PCPs’ likelihood of organising an investigation: Χ2=3.95, df=8, P=0.863; for effects on PCPs’ 
likelihood of referral to a specialist: Χ2=9.77, df=8, P=0.281
Exp(B) Exp(B)P value P value95% CI 95% CI
PCPs in Bulgaria were less likely to report having access to 
clinical guidelines than those in the other countries, but 
PCPs from Slovenia and Croatia were more likely to agree 
that a fast-track specialist appointment system for patients 
who may have cancer was available to them. The ability 
of patients to self-refer was lowest in Slovenia, suggesting 
that PCPs have a stronger gate-keeping role there. Of the 
factors that we investigated, a PCPs’ country was the only 
one that had a significant effect on their likelihood of 
investigating or referring in the clinical vignette.
4.2 Comparison with existing literature
While GP gate-keeping is associated with better overall 
health outcomes (19), it has been suggested that it may 
be linked with poorer survival of patients with cancer 
(20), and delays in cancer diagnosis have been found in 
some countries with strong gate-keeping systems (UK, 
Denmark) (4, 21, 22). However, a European study found 
no link between a higher probability of initial consultation 
with a GP and poorer cancer survival rates (23) and, of 
the countries in our study, Slovenia has both the strongest 
reported GP gate-keeping role and the best lung cancer 
5-year survival rate (12). 
Several health systems have, like Slovenia and Croatia in 
our study, developed fast track systems (24–26). While 
it is still unclear whether reducing cancer diagnostic or 
treatment wait times results in improved survival, there is 
evidence that it can result in earlier cancer stage at time 
of treatment for non-small cell lung cancer  (27), and an 
increase in the number of therapeutic options (28). 
Over 80% of PCPs in each of the countries in our study 
reported direct access plain X-ray imaging, similar levels to 
those reported in England (29) and the other International 
Cancer Benchmarking Partnership (ICBP) countries (18). 
The levels of direct access to advanced imaging varied 
considerably in our study. This wide range reflects that 
seen in the ICPC countries, where direct access to MRI 
machines, for example, ranged from 11.0% to 91.6% (18).  
Availability of national guidelines in our study seemed 
inconsistent, with most respondents stating that they 
‘neither agree nor disagree’ that common presentations 
and advice to refer are covered by these. This indecision 
may be because of barriers to their use: 75% of GPs in a 
Canadian study indicated active use of cancer guidelines, 
but they reported barriers that included not being aware 
of them, being too busy, and user unfriendliness of the 
website (30). 
We found that the two countries (Bulgaria and Romania) 
with the lowest levels of direct access to advanced 
imaging and low levels of access to fast-track specialist 
appointment systems had also the highest levels of 
referral to a specialist in the clinical vignette. Our data 
do not provide an explanation for this result. It may be 
that higher levels of referral indicate that this option 
is relatively quick and easy in these countries, so there 
is less need for PCPs to have direct access to advanced 
imaging or fast-track systems. We also believe that GPs 
are aware of the importance of early diagnosis in the 
event of suspected cancer and that they adapt their 
action to the characteristics of the system. However, the 
availability of a fast-track system can be important in 
early cancer detection, with evidence that it accelerates 
the diagnostic work-up process and clinical pathway (31). 
A higher referral rate to secondary care in the two weeks 
after first consultation, using a fast-track system was 
associated with earlier detection of lung cancer (32).
While we found no association between PCP demographics 
or practice characteristics with the decision to investigate 
or refer, in another study female doctors were associated 
with a longer system delay, and GPs that provided more 
services tended to have shorter system delays (33). 
4.3 Strengths and limitations of the study
This is the first study that compares the factors underlying 
PCPs’ referral decision-making in patients that might have 
lung cancer in Balkan region countries. The data come 
from a survey that was carefully developed and piloted by 
PCPs, based on their clinical experience, and it includes 
the views of PCPs who are not usually involved in research 
(17). The sample was diverse, with participants varying in 
10.2478/sjph-2022-0007 Zdr Varst. 2022;61(1):40-47
46
terms of years of clinical practice, sex, and site and size 
of practice.
While low survey response rates are common in primary 
care and are known to vary between countries, the response 
rates in our study were comparable to those of a recent 
ICBP survey, in which response rates varied from 5.5% to 
45.6%. We have no data on non-responders, as the survey 
was anonymous. However, the respondent anonymity might 
have reduced the risk of social desirability bias.
Participants in this study were recruited by an on-line 
questionnaire, and they may not be representative of 
their populations. Although we asked participants about 
access to relevant investigations, we did not ask them for 
data on waiting times for these: longer waiting times for 
tests have been reported be associated with delays in 
diagnosis (34). 
Vignette design is frequently used to study how individual’s 
thoughts, decisions and behaviour are affected by 
factors that are difficult to study in real situations (35). 
While vignettes may not be typical of patients seen by 
participant PCPs in their everyday practice, and there 
have been concerns about the validity of such research 
(35), as clinical decision-making is a complex cognitive 
process. Despite this potential limitation, well-designed 
vignette studies can be highly generalisable to ‘real-life’ 
behaviour (36). 
4.4 Implications for practice
Prompt testing and rapid referral to a specialist are 
important for the early detection of cancer. Although it 
has low sensitivity, a chest X-ray is still the most important 
first-line investigation (37,38) and its use has been found 
to result in earlier cancer detection (39). More recently, 
direct access to low dose CT (LDCT) by GPs has also been 
proposed as a way of improving early lung cancer diagnosis 
rates (40), and this suggests that levels of direct access 
to advanced imaging need to be improved in the study’s 
participating countries.
While clinical guidelines do not ensure good clinical 
practice (41), guidelines may speed up the diagnostic 
process (42), and well-designed cancer referral guidelines 
need to be easily accessible in the participating countries. 
5 CONCLUSIONS
The five Balkan region countries that participated in this 
study show large differences between their PCPs’ levels of 
direct access to investigations. When their PCPs are faced 
with a vignette of a patient with a small but significant 
possibility of having lung cancer, their investigation and 
referral rates vary considerably. Research is needed 
to find out whether these findings are reflected in real-
life clinical decision-making. To reduce diagnostic delay 
in lung cancer, levels of direct PCP access to advanced 
imaging, availability of relevant clinical guidelines, and 
fast-track referral systems must be improved. 
ACKNOWLEDGEMENTS
The authors are grateful to all the PCPs who piloted the 
questionnaire and completed the survey. They also thank 
Professor Gordon Taylor, Professor of Medical Statistics of 
the University of Exeter, United Kingdom, for his expert 
help with the data analysis.
CONFLICTS OF INTEREST
None declared.
FUNDING
The study was partly supported by the European General 
Practice Research Network (EGPRN).
ETHICAL APPROVAL 
113/08/14 was received from the National Medical Ethics 
Committee Republic of Slovenia on December 8th, 2014. 
Other countries’ study leads either achieved local ethical 
approval or gave statements that formal ethical approval 
was not needed in their jurisdictions. 
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