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Association between use of the English urgent
referral pathway for suspected cancer and mortality
outcome in cancer patients: cohort study
Henrik Møller, Carolynn Gildea, David Meechan, Greg Rubin,
Thomas Round, Peter Vedsted
Cancer Epidemiology and Population Health, KCL (HM)
Public Health England, Knowledge & Intelligence (CG, DM, HM)
Durham University (GR)
Primary Care and Public Health Sciences, KCL (TR)
Cancer Diagnosis in Primary Care, Aarhus University (HM, PV)
Cancer in the UK
• >1 in 2 people in the UK with develop cancer (Ahmad 2015)
• >300,000 patients are diagnosed and >150,000 die every
year from cancer in the UK (CRUK)
• Late diagnosis is a major contributing factor to relatively
poorer cancer survival rates in the UK (Richards 2009)
• >10,000 premature cancer deaths per year could be
avoided if survival rates matched the best in Europe (AbdelRahman 2007)
• Nearly 1 in 4 patients diagnosed via an emergency
admission route with poorer 1 year survival (Elliss Brookes
2012)
ICBP: 1 year relative survival
90
Coleman et al, Lancet 2011
45
AUS
CAN
SWE
NOR
DEN
SWE
UK
AUS
85
CAN
40
SWE
AUS
CAN
80
NOR
NOR
35
DEN
DEN
75
UK
UK
30
25
70
20
65
1995-99
2000-02
1995-99
2005-07
Colorectal Cancer 1yr RS
2000-02
2005-07
Lung Cancer 1yr RS
100
80
SWE
98
NOR
75
CAN
AUS
CAN
AUS
96
70
DEN
NOR
DEN
94
UK
65
UK
60
92
55
90
1995-99
Breast
CancerCAN
1yr RS
AUS
2000-02
SWE
2005-07
NOR
DEN
UK
50
1995-99
AUS
CANRS
Ovarian Cancer
1yr
2000-02
NOR
DEN
2005-07
UK
Delays in Symptomatic Cancer Diagnosis
Model of Total Patient Delay (Walter 2012)
Cancer: National Awareness and Early
Diagnosis Initiative (NAEDI)
(Hiom 2015)
Primary Care and Cancer
• Most of those with cancer present with symptoms, and
most of these presentations are to primary care (Rubin 2011)
• Suspecting a diagnosis of cancer in general practice is not
straightforward: average full time GP 7-8 new cancer
cases/year (Richards 2009)
• Low predictive value of even “red flag” symptoms eg PPV
rectal bleeding 2.4% (Jones 2007)
• Many patients have multiple GP visits prior to referral
especially those with cancers of greater diagnostic difficulty
(Lyratzopoulos 2014)
Primary Care and Cancer
Three or more general practitioner consultations before hospital referral
(Lyratzopoulos 2012)
Referral for suspected cancer
• Referral guidelines for suspected cancer, DoH 2000
• Referral guidelines for suspected cancer, NICE 2005
”Urgent referral” (Two week wait/2ww)
• The patient is seen by a specialist within 14 days, and
• The patient is treated within 62 days from referral or within
31 days from the decision to treat
• Updated NICE referral guidance due for publication May
2015
Change in diagnostic intervals 2001/02 – 2007/08
(Neal 2013)
The “waiting time paradox” (Torring 2011)
Urgent Referrals 2009-2014
Use of the urgent referral pathway and
mortality outcome in cancer patients
Variation
in a care
process
?
Variation in a
relevant
outcome
10,000
0
5,000
Frequency
15,000
Histogram of referral ratio
0
1
2
Referral ratio
ratio
Referral
3
4
20,000
0
10,000
Frequency
30,000
40,000
Histogram of conversion rate
0
.2
.4
.6
PPV rate
Conversion
.8
1
10,000
0
5,000
Frequency
15,000
Histogram of detection rate
0
.2
.4
.6
Sensitivity
Detection
rate
.8
1
Strategy of analysis
Mortality of
urgently referred
cancer patients
?
=
Mortality of
other cancer
patients
Strategy of analysis
Mortality of
urgently referred
cancer patients
Mortality of
cancer patients
from GP
practices with
high use of
urgent referral
?
=
Mortality of
other cancer
patients
?
=
Mortality of
cancer patients
from GP
practices with
low use of urgent
referral
Data: England; 2009; 215,284 cancer
patients from 8049 GP practices
r: 0.42
Analysis
• Cohort analysis of death rates, adjusted for age,
sex and cancer type
• Cox proportional hazards regression
• Sensitivity analyses
Analysis by tertiles of distributions
Table 1. Hazard ratios for death in relation to referral ratio, conversion rate
and detection rate.
Variable
Referral ratio
Tertile Median Persons Deaths
0.68
1.01
1.39
71773
71768
71743
31136
30417
30067
1.05
1.00
0.97
<0.001
1.04
1.07
0.96
0.99
1
2
3
0.08
0.12
0.17
71811
72101
71372
30206
30672
30742
1.00
1.00
1.01
0.117
0.99
1.02
1.00
1.03
1
2
3
0.33
0.43
0.54
71804
72065
71415
31072
30749
29799
1.04
1.00
0.96
<0.001
1.02
1.06
0.95
0.98
trend p-value
Detection rate
95% CI
1
2
3
trend p-value
Conversion rate
HR
trend p-value
*HR adjusted for age, sex and cancer type
Table 1. Hazard ratios for death in relation to referral ratio, conversion rate
and detection rate.
Variable
Referral ratio
Tertile Median Persons Deaths
0.68
1.01
1.39
71773
71768
71743
31136
30417
30067
1.05
1.00
0.97
<0.001
1.04
1.07
0.96
0.99
1
2
3
0.08
0.12
0.17
71811
72101
71372
30206
30672
30742
1.00
1.00
1.01
0.117
0.99
1.02
1.00
1.03
1
2
3
0.33
0.43
0.54
71804
72065
71415
31072
30749
29799
1.04
1.00
0.96
<0.001
1.02
1.06
0.95
0.98
trend p-value
Detection rate
95% CI
1
2
3
trend p-value
Conversion rate
HR
trend p-value
*HR adjusted for age, sex and cancer type
Analysis by deciles of distributions
ratioby
fordecile
death,of
byreferral
decile ofratio.
referral ratio distribution
A. Hazard ratio Hazard
for death,
1.05
Hazard ratio
1.00
0.95
0.90
0.85
1
2
3
4
5
6
Decile
7
8
9
10
for death,
by decile ofrate.
PPV distribution
B. Hazard ratio for Hazard
death, ratio
by decile
of conversion
1.10
Hazard ratio
1.05
1.00
0.95
0.90
1
2
3
4
5
6
Decile
7
8
9
10
Hazard
ratio
death,
decile of rate.
sensitivity distribution
C. Hazard ratio for
death,
byfor
decile
ofby
detection
1.05
Hazard ratio
1.00
0.95
0.90
0.85
1
2
3
4
5
6
Decile
7
8
9
10
Joint effects of referral ratio, conversion rate and
detection rate
Table 2. Hazard ratios for death in 3-way classification of referral ratio, conversion rate and detection rate tertiles. Numbers of persons and deaths, and hazard ratios for death with 95% confidence intervals. The lower part of the table shows the
three aggregate groups suggested by the analysis.
Referral ratio low
Referral ratio intermediate
Detection rate
low
Conversion rate
low
Conversion rate
intermediate
Conversion rate
high
11347
4906
1.08
11512
5011
1.07
15123
6622
1.06
Detection rate
intermediate
1.12
971
421
1.08
1.03
1.11
4343
1874
1.03
1.03
15538
6898
1.10
1.06
1.04
Hazard ratios adjusted for age, sex and cancer type.
0.98
0.98
1.03
Detection rate
high
1.19
340
126
0.87
1.08
1711
699
0.98
1.10
10888
4579
1.00
0.73
0.91
0.96
Detection rate
low
1.03
11627
4961
1.03
1.06
7903
3423
1.02
1.04
1052
528
1.22
Referral ratio high
Detection rate
intermediate
6252
2575
0.98
1.07
0.97
13622
5738
1.06
1.00
8679
3620
0.97
1.12
7594
3152
0.97
13269
5673
1.01
0.98
0.93
1.03
1770
747
1.05
0.99
1.34
0.94
Detection rate
high
0.97
0.93
0.95
Detection rate
low
1.13
11824
4982
1.00
1.02
1253
562
1.07
1.02
163
77
1.18
Detection rate
intermediate
0.96
14338
6002
1.04
0.98
0.98
1.17
8137
3505
0.99
1.47
1270
584
1.10
0.94
Detection rate
high
0.94
13342
5486
1.02
0.96
0.92
0.99
0.95
14941
6240
1.03
0.96
0.93
1.00
1.01
6475
2629
0.92
0.88
0.96
1.19
Referral ratio high
Detection rate
low
11824
4982
1.00
1253
562
1.07
163
77
1.18
Detection rate
intermediate
0.96
14338
6002
1.04
0.98
0.98
1.17
8137
3505
0.99
1.47
1270
584
1.10
0.94
Detection rate
high
0.94
13342
5486
1.02
0.96
0.92
0.99
0.95
14941
6240
1.03
0.96
0.93
1.00
1.01
6475
2629
0.92
0.88
0.96
1.19
Referral ratio high
11824
4982
1.00
1253
562
1.07
163
77
1.18
0.96
14338
6002
0.98
1.04
0.98
1.17
8137
3505
0.99
1.47
1270
584
1.10
0.94
Detection rate
high
Detection rate
intermediate
Detection rate
low
0.94
13342
5486
0.96
1.02
0.92
0.99
0.95
14941
6240
0.96
1.03
0.93
1.00
1.01
6475
2629
0.92
0.88
0.96
1.19
Table 2. Hazard ratios for death in 3-way classification of referral ratio, conversion rate and detection rate tertiles. Numbers of persons and deaths, and hazard ratios for death with 95% confidence intervals. The lower part of the table shows the
three aggregate groups suggested by the analysis.
Referral ratio low
Referral ratio intermediate
Detection rate
low
Conversion rate
low
Conversion rate
intermediate
Conversion rate
high
11347
4906
1.08
11512
5011
1.07
15123
6622
1.06
Detection rate
intermediate
1.12
971
421
1.08
1.03
1.11
4343
1874
1.03
1.03
15538
6898
1.10
1.06
1.04
Hazard ratios adjusted for age, sex and cancer type.
0.98
0.98
1.03
Detection rate
high
1.19
340
126
0.87
1.08
1711
699
0.98
1.10
10888
4579
1.00
0.73
0.91
0.96
Detection rate
low
1.03
11627
4961
1.03
1.06
7903
3423
1.02
1.04
1052
528
1.22
Referral ratio high
Detection rate
intermediate
6252
2575
0.98
1.07
0.97
13622
5738
1.06
1.00
8679
3620
0.97
1.12
7594
3152
0.97
13269
5673
1.01
0.98
0.93
1.03
1770
747
1.05
0.99
1.34
0.94
Detection rate
high
0.97
0.93
0.95
Detection rate
low
1.13
11824
4982
1.00
1.02
1253
562
1.07
1.02
163
77
1.18
Detection rate
intermediate
0.96
14338
6002
1.04
0.98
0.98
1.17
8137
3505
0.99
1.47
1270
584
1.10
0.94
Detection rate
high
0.94
13342
5486
1.02
0.96
0.92
0.99
0.95
14941
6240
1.03
0.96
0.93
1.00
1.01
6475
2629
0.92
0.88
0.96
1.19
Referral ratio low
Detection rate
low
Conversion rate
low
Conversion rate
intermediate
Conversion rate
high
11347
4906
1.08
11512
5011
1.07
15123
6622
1.06
Detection rate
intermediate
1.12
971
421
1.08
1.03
1.11
4343
1874
1.03
1.03
15538
6898
1.10
1.06
1.04
0.98
0.98
1.03
Detection rate
high
1.19
340
126
0.87
0.73
1.03
1.08
1711
699
0.98
0.91
1.06
1.10
10888
4579
1.00
0.96
1.04
Referral ratio low
Detection rate
low
Conversion rate
low
Conversion rate
intermediate
Conversion rate
high
11347
4906
1.08
11512
5011
1.07
15123
6622
1.06
Detection rate
intermediate
1.12
971
421
1.08
1.03
1.11
4343
1874
1.03
1.03
15538
6898
1.10
1.06
1.04
0.98
0.98
1.03
Detection rate
high
1.19
340
126
0.87
0.73
1.03
1.08
1711
699
0.98
0.91
1.06
1.10
10888
4579
1.00
0.96
1.04
Table 2. Hazard ratios for death in 3-way classification of referral ratio, conversion rate and detection rate tertiles. Numbers of persons and deaths, and hazard ratios for death with 95% confidence intervals. The lower part of the table shows the
three aggregate groups suggested by the analysis.
Referral ratio low
Referral ratio intermediate
Detection rate
low
Conversion rate
low
Conversion rate
intermediate
Conversion rate
high
11347
4906
1.08
11512
5011
1.07
15123
6622
1.06
Detection rate
intermediate
1.12
971
421
1.08
1.03
1.11
4343
1874
1.03
1.03
15538
6898
1.10
1.06
1.04
Hazard ratios adjusted for age, sex and cancer type.
0.98
0.98
1.03
Detection rate
high
1.19
340
126
0.87
1.08
1711
699
0.98
1.10
10888
4579
1.00
0.73
0.91
0.96
Detection rate
low
1.03
11627
4961
1.03
1.06
7903
3423
1.02
1.04
1052
528
1.22
Referral ratio high
Detection rate
intermediate
6252
2575
0.98
1.07
0.97
13622
5738
1.06
1.00
8679
3620
0.97
1.12
7594
3152
0.97
13269
5673
1.01
0.98
0.93
1.03
1770
747
1.05
0.99
1.34
0.94
Detection rate
high
0.97
0.93
0.95
Detection rate
low
1.13
11824
4982
1.00
1.02
1253
562
1.07
1.02
163
77
1.18
Detection rate
intermediate
0.96
14338
6002
1.04
0.98
0.98
1.17
8137
3505
0.99
1.47
1270
584
1.10
0.94
Detection rate
high
0.94
13342
5486
1.02
0.96
0.92
0.99
0.95
14941
6240
1.03
0.96
0.93
1.00
1.01
6475
2629
0.92
0.88
0.96
1.19
A. Overall analysis (215,284 patients; 91,620 deaths)
Group*
1 High
2
3 Low
p-trend
Patients
34,758
121,692
58,834
%
16
57
27
Deaths
14,355
51,533
25,732
HR
0.95
1.00
1.07
<0.001
95% CI
0.94
0.97
1.05
1.08
*Group 1: High referral ratio and high detection rate.
Group 2: All other combinations than group 1 and group 3.
Group 3: Low referral ratio and low or intermediate detection rate.
Hazard ratios adjusted for age, sex and cancer type.
B. Restricted to colorectal cancer
Group
1 High
2
3 Low
p-trend
Patients
3,865
13,982
6,789
%
16
57
28
Deaths
1,670
6,247
3,073
HR
0.96
1.00
1.03
0.032
95% CI
0.91
1.02
0.98
1.07
Deaths
3,107
11,173
5,656
HR
0.96
1.00
1.04
<0.001
95% CI
0.92
1.00
1.01
1.08
Deaths
997
3,366
1,678
HR
1.07
1.00
1.09
0.247
95% CI
1.00
1.15
1.03
1.16
Deaths
984
3,362
1,703
HR
0.95
1.00
1.08
0.001
95% CI
0.88
1.02
1.02
1.15
C. Restricted to lung cancer
Group
1 High
2
3 Low
p-trend
Patients
3,596
12,792
6,398
%
16
56
28
D. Restricted to female breast cancer
Group
1 High
2
3 Low
p-trend
Patients
5,108
19,236
9,225
%
15
57
27
E. Restricted to prostate cancer
Group
1 High
2
3 Low
p-trend
Patients
4,325
14,259
7,071
%
17
56
28
L. Not adjusted for type of cancer
Group Patients
1 High
34,758
2
121,692
3 Low
58,834
p-trend
%
16
57
27
Deaths
14,355
51,533
25,732
HR
0.96
1.00
1.07
<0.001
95% CI
0.94
0.97
1.05
1.08
J. Also adjusted for the patient's socioeconomic status**
Group Patients
1
34,758
2
121,692
3
58,834
p-trend
%
16
57
27
Deaths
14,355
51,533
25,732
HR
0.95
1.00
1.06
<0.001
**From J: Most vs. least deprived quintile:
HR: 1.35 (1.32-1.37); p-trend over quintiles <0.001
95% CI
0.94
0.97
1.05
1.08
Underlying mechanisms?
High use
of urgent
referral
Low mortality;
(High survival)
Underlying mechanisms?
High use
of urgent
referral
Short delay;
Earlier stage;
Treatment options
Low mortality;
(High survival)
Underlying mechanisms?
High use
of urgent
referral
GP’s
awareness
of cancer ?
Short delay;
Earlier stage;
Treatment options
Low mortality;
(High survival)
Underlying mechanisms?
High use
of urgent
referral
GP’s
awareness
of cancer ?
Short delay;
Earlier stage;
Treatment options
Low mortality;
(High survival)
M. Also adjusted for GP population age and sex distribution***
Group Patients
1 High
34,758
2
121,692
3 Low
58,834
p-trend
%
16
57
27
Deaths
14,355
51,533
25,732
HR
0.96
1.00
1.06
<0.001
95% CI
0.94
0.98
1.04
1.07
***From M: Effects of GP population characteristics:
HR: 0.88 (0.86-0.90) for highest vs. lowest tertile of median age
Conclusions and implications
• The analysis suggests that urgent referral for suspected
cancer is efficacious.
• The roles of a direct mechanism (via reduced delay) and
indirect mechanisms (via awareness) are not known.
• GP practices with consistent low use of urgent referral may
benefit their cancer patients from using it more often, and
from being more aware of signs of cancer.
r: 0.42
Detection rate
r: 0.42
Referral ratio
Table 2. Hazard ratios for death in 3-way classification of referral ratio, conversion rate and detection rate tertiles. Numbers of persons and deaths, and hazard ratios for death with 95% confidence intervals. The lower part of the table shows the
three aggregate groups suggested by the analysis.
Referral ratio low
Referral ratio intermediate
Detection rate
low
Conversion rate
low
Conversion rate
intermediate
Conversion rate
high
11347
4906
1.08
11512
5011
1.07
15123
6622
1.06
Detection rate
intermediate
1.12
971
421
1.08
1.03
1.11
4343
1874
1.03
1.03
15538
6898
1.10
1.06
1.04
Group 3; 27%
HR: 1.07 (1.05-1.08)
0.98
0.98
1.03
Detection rate
high
1.19
340
126
0.87
1.08
1711
699
0.98
1.10
10888
4579
1.00
0.73
0.91
0.96
Detection rate
low
1.03
11627
4961
1.03
1.06
7903
3423
1.02
1.04
1052
528
1.22
Group 2; 57%
HR: 1.00
Referral ratio high
Detection rate
intermediate
6252
2575
0.98
1.07
0.97
13622
5738
1.06
1.00
8679
3620
0.97
1.12
7594
3152
0.97
13269
5673
1.01
0.98
0.93
1.03
1770
747
1.05
0.99
1.34
0.94
Detection rate
high
0.97
0.93
0.95
Detection rate
low
1.13
11824
4982
1.00
1.02
1253
562
1.07
1.02
163
77
1.18
Detection rate
intermediate
0.96
14338
6002
1.04
0.98
0.98
1.17
8137
3505
0.99
1.47
1270
584
1.10
0.94
Detection rate
high
0.94
13342
5486
1.02
0.96
0.92
0.99
0.95
14941
6240
1.03
0.96
0.93
1.00
1.01
6475
2629
0.92
0.88
0.96
1.19
Group 1; 16%
HR: 0.95 (0.94-0.97)
Hazard ratios adjusted for age, sex and cancer type.
27% of patients:
1.07 (1.05-1.08)
57% of patients
1.00
16% of patients
0.95 (0.94-0.97)
Table 2. Hazard ratios for death in 3-way classification of referral ratio, conversion rate and detection rate tertiles. Numbers of persons and deaths, and hazard ratios for death with 95% confidence intervals. The lower part of the table shows the
three aggregate groups suggested by the analysis.
Referral ratio low
Referral ratio intermediate
Detection rate
low
Conversion rate
low
Conversion rate
intermediate
Conversion rate
high
11347
4906
1.08
11512
5011
1.07
15123
6622
1.06
Detection rate
intermediate
1.12
971
421
1.08
1.03
1.11
4343
1874
1.03
1.03
15538
6898
1.10
1.06
1.04
Hazard ratios adjusted for age, sex and cancer type.
0.98
0.98
1.03
Detection rate
high
1.19
340
126
0.87
1.08
1711
699
0.98
1.10
10888
4579
1.00
0.73
0.91
0.96
Detection rate
low
1.03
11627
4961
1.03
1.06
7903
3423
1.02
1.04
1052
528
1.22
Referral ratio high
Detection rate
intermediate
6252
2575
0.98
1.07
0.97
13622
5738
1.06
1.00
8679
3620
0.97
1.12
7594
3152
0.97
13269
5673
1.01
0.98
0.93
1.03
1770
747
1.05
0.99
1.34
0.94
Detection rate
high
0.97
0.93
0.95
Detection rate
low
1.13
11824
4982
1.00
1.02
1253
562
1.07
1.02
163
77
1.18
Detection rate
intermediate
0.96
14338
6002
1.04
0.98
0.98
1.17
8137
3505
0.99
1.47
1270
584
1.10
0.94
Detection rate
high
0.94
13342
5486
1.02
0.96
0.92
0.99
0.95
14941
6240
1.03
0.96
0.93
1.00
1.01
6475
2629
0.92
0.88
0.96
1.19
Table 2. Hazard ratios for death in 3-way classification of referral ratio, conversion rate and detection rate tertiles. Numbers of persons and deaths, and hazard ratios for death with 95% confidence intervals. The lower part of the table shows the
three aggregate groups suggested by the analysis.
Referral ratio low
Referral ratio intermediate
Detection rate
low
Conversion rate
low
Conversion rate
intermediate
Conversion rate
high
11347
4906
1.08
11512
5011
1.07
15123
6622
1.06
Detection rate
intermediate
1.12
971
421
1.08
1.03
1.11
4343
1874
1.03
1.03
15538
6898
1.10
1.06
1.04
Hazard ratios adjusted for age, sex and cancer type.
0.98
0.98
1.03
Detection rate
high
1.19
340
126
0.87
1.08
1711
699
0.98
1.10
10888
4579
1.00
0.73
0.91
0.96
Detection rate
low
1.03
11627
4961
1.03
1.06
7903
3423
1.02
1.04
1052
528
1.22
Referral ratio high
Detection rate
intermediate
6252
2575
0.98
1.07
0.97
13622
5738
1.06
1.00
8679
3620
0.97
1.12
7594
3152
0.97
13269
5673
1.01
0.98
0.93
1.03
1770
747
1.05
0.99
1.34
0.94
Detection rate
high
0.97
0.93
0.95
Detection rate
low
1.13
11824
4982
1.00
1.02
1253
562
1.07
1.02
163
77
1.18
Detection rate
intermediate
0.96
14338
6002
1.04
0.98
0.98
1.17
8137
3505
0.99
1.47
1270
584
1.10
0.94
Detection rate
high
0.94
13342
5486
1.02
0.96
0.92
0.99
0.95
14941
6240
1.03
0.96
0.93
1.00
1.01
6475
2629
0.92
0.88
0.96
1.19
Table 2. Hazard ratios for death in 3-way classification of referral ratio, conversion rate and detection rate tertiles. Numbers of persons and deaths, and hazard ratios for death with 95% confidence intervals. The lower part of the table shows the
three aggregate groups suggested by the analysis.
Referral ratio low
Referral ratio intermediate
Detection rate
low
Conversion rate
low
Conversion rate
intermediate
Conversion rate
high
11347
4906
1.08
11512
5011
1.07
15123
6622
1.06
Detection rate
intermediate
1.12
971
421
1.08
1.03
1.11
4343
1874
1.03
1.03
15538
6898
1.10
1.06
1.04
Group 3; 27%
HR: 1.07 (1.05-1.08)
Hazard ratios adjusted for age, sex and cancer type.
0.98
0.98
1.03
Detection rate
high
1.19
340
126
0.87
1.08
1711
699
0.98
1.10
10888
4579
1.00
0.73
0.91
0.96
Group 2; 57%
HR: 1.00
Detection rate
low
1.03
11627
4961
1.03
1.06
7903
3423
1.02
1.04
1052
528
1.22
Referral ratio high
Detection rate
intermediate
6252
2575
0.98
1.07
0.97
13622
5738
1.06
1.00
8679
3620
0.97
1.12
7594
3152
0.97
13269
5673
1.01
0.98
0.93
1.03
1770
747
1.05
0.99
1.34
0.94
Detection rate
high
0.97
0.93
0.95
Detection rate
low
1.13
11824
4982
1.00
1.02
1253
562
1.07
1.02
163
77
1.18
Detection rate
intermediate
0.96
14338
6002
1.04
0.98
0.98
1.17
8137
3505
0.99
1.47
1270
584
1.10
0.94
Detection rate
high
0.94
13342
5486
1.02
0.96
0.92
0.99
0.95
14941
6240
1.03
0.96
0.93
1.00
1.01
6475
2629
0.92
0.88
0.96
1.19
Group 1; 16%
HR: 0.95 (0.94-0.97)