Innovation in Referral Management: Phototriage for Skin Cancer Referrals Dr Colin Morton Dermatologi - PowerPoint PPT Presentation

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Innovation in Referral Management: Phototriage for Skin Cancer Referrals Dr Colin Morton Dermatologi

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Dermatology, a high volume small' specialty, already subject to system-wide ... 105 urgent dermatology' 126 via cancer box but not photographed due to: GP no' ... – PowerPoint PPT presentation

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Title: Innovation in Referral Management: Phototriage for Skin Cancer Referrals Dr Colin Morton Dermatologi


1
Innovation in Referral Management Photo-triage
for Skin Cancer ReferralsDr Colin
MortonDermatologistNHS Forth Valley
2
Innovation in Referral Management Why?
  • Dermatology, a high volume small specialty,
    already subject to system-wide redesign
    initiatives in Skin Action Scotland 2004-6
  • Increasing demand
  • - limited primary care dermatology experience
  • - changing GP work practices (e.g. less
    cryotherapy)
  • - ? patient expectation
  • - ? incidence of skin cancer
  • Suspected Skin Cancer account for 30-40
    referrals to Dermatology, additional referral
    pathways of lesions to Surgery/Plastics
  • .. can we improve access by innovative
    referral management?

3
Annual Referral Trends Dermatology
www.isdscotland.org
4
Models of photo-triage in Dermatology
  • (Teledermatology service NHS Highland)
  • GP has camera, takes picture and e-mails low
    tech, but picture quality, image security, loss
    of early enthusiasm
  • e.g. Argyll, Tayside
  • Hospital photographer patients attends hospital
    for photo, returning home to be recalled to
    Dermatology service some weeks later hospital
    parking!
  • e.g. Lanarkshire (May C et al. Clin Exptl
    Dermatol 2008 33 736-9) 
  • Community provision of medical photographer in
    Forth Valley..

5
Community Photo-triage for Skin Cancer Referrals
The patient Journey
  • Patients with suspicious skin lesions are advised
    by their GP to contact a hotline to book for
    photograph with a professional medical
    photographer at one of two community centres
    (within 2 weeks)
  • Digital images uploaded and triaged by a
    dermatology consultant
  • Patient then invited to
  • - Direct surgical/photodynamic therapy
    lists - Nurse-led clinic (reassure/cryotherapy)
  • - Consultant diagnostic clinic
  • - Direct referral to another specialty
  • - Community GP special interest clinic
  • No direct discharge back to GP during pilot
    future option

6
Photo-triage for Skin Cancer Referrals Aims
  • 1. Improve rate of delivery of definitive care
    at first visit to specialist
  • 2. Ensure no delay in definitive care by initial
    imaging
  • 3. Increase capacity of service via appropriate
    triage
  • 4. Potential of innovation to speed assessment
    of suspicious lesions
  • 5. Potential to direct certain referrals back to
    primary care
  • 6. Compare relative costs of new with
    conventional model TBC
  • (note lack of clinical staff to recruit, so
    current alternative is WLI)

7
Methods
  • Observational study of conventional vs.
    photo-triage journey
  • No randomisation - hence risk delay from
    photography (up to 2 weeks) could adversely
    lengthen journey for photo-triage group as
    concurrent conventional referrals appointed to
    first available clinics, filling-up these clinics
  • Includes patients referred as urgent skin
    lesion only
  • Data from Jan-Jun 2008

8
Patients referred Jan-Jun 2008 inclusive
  • Conventional
  • n231
  • 105 urgent dermatology 126 via cancer box but
    not photographed due to GP no to photo, unable
    or failed to attend for photo in time
  • Data complete for 188
  • M 95 F 93
  • mean age52 (range 10-95)
  • Photo-triage
  • n411 urgent pigmented lesion referrals -
    referred as suitable for phototriage
  • 321 attended (78 - booking system?)
  • FTA/UTA 66 24 90
  • Data complete for 289
  • M 118 F 172
  • mean age 51yrs (range 4-91)

9
Pattern of referral wide geographic uptake of
triage
  • Photography at 2 GP practices, one in Falkirk,
    one in Stirling

Number of referrals
10
Results 1 Conventional vs. Photo-triage Referral
  • Conventional route all 188 patients appointed to
    consultant clinics
  • Photo-triage destination after attending for
    photo (n289)
  • - Direct surgical list 63 (22)
  • - Nurse-led cryotherapy clinic 43 (15)
  • - Nurse-led clinic to reassure 78 (27)
  • - Consultant diagnostic clinic 82 (28)
  • - Direct referral to another specialty 7
    (2)
  • - Direct photodynamic therapy 9 (3)
  • - Community GP special interest clinic 7
    (2)
  • i.e. Consultant visit saved in 72 (206/289)

11
Results 2 Improve rate of definitive care at
first hospital visit?
  • Conventional (119/188) 63
  • Photo-triage (260/279) 93
  • Was there alteration in practice e.g. to
    greater use of surgery?

12
Results 4 Safety of Photo-triage - No delay in
definitive care by addition of imaging to journey
  • Photo-triage
  • RTT 40d (11-105d, median 39d) Includes 7
    patients referred to OMF waiting 75d (40-105)
  • RTT if exclude OMF 39d
  • MM n13 mean wait 36d (25-70d,
    median 36d)
  • SCC n3 mean wait 28d
  • (11-47d, median 25d)
  • BCC n36 mean wait 35d
  • (15-57d, median 35d)
  • All waiting measures reduced by triage
  • Conventional
  • RTT 41d (6-144, median 35d)
  • MM n 6 mean wait 39d
  • (12-85d, median 44d)
  • SCC n 7 mean wait 50d
  • (16-103, median 34d)
  • BCC n 31 mean wait 58d
  • (9-144, median 46d)

13
Potential to accelerate assessment of melanoma?
  • Despite observational design, slight reduction in
    wait 39 to 36 days
  • Referral to photo 15d (10-23d) 13days excl.
    patient induced delays
  • Photo to definitive therapy 21d (6-35d)
  • Triage action 7/13 to direct surgery mean 18d
    (13-29d)
  • 5/13 to PLC then surgery mean 24d
    (6-35d)
  • Can we do better? - uniform referral photo-triage
    process that would allow for prioritisation to
    surgical lists, additional photo sessions to
    reduce waits, refined photo booking system

14
Increase capacity of specialist clinic? Yes!
  • Consultant visit saved in 72 (206/289)
  • Triage of 400 (22 of referrals) has freed-up 34
    consultant clinics p.a. for additional new
    patients
  • Where did these patients go? direct therapy
    saved 13 clinic, nurse-delivered saved 20
    consultant clinics
  • But time taken for triage? - 1 hour per week
    consultant triage time admin nursing
    organisation
  • If scaled-up to include two-thirds of current
    1800 lesions, then gt 100 clinics/year additional
    capacity possible
  • Current gain in setting of consultant vacancies,
    costings to follow

15
Community photo-triage should we all do it?
  • Is enhanced triage required Yes! - High volume
    necessitates referral management, but written
    word insufficient for triage GP diagnostic
    accuracy melanoma 9, SCC 9, BCC 45
  • Is it safe and effective Yes! (risk of melanoma
    delay in volume of conventional referrals greater
    than risk of re-directing referral)
  • Which system is best? need for comparison and
    refinement, different designs for different
    systems?
  • Common software quality standards
  • Demonstrate cost-effectiveness

16
Photo-triage - Conclusions
  • Community photo-triage model confirms safety and
    efficiency with improved definitive care at first
    visit (93 from 63) as well as increased
    consultant clinic capacity
  • Potential of refer-back to GP of obvious
    benign lesions still to be evaluated - ?25 -
    additional capacity to specialist service
  • Next extend to include all suitable referrals
    into Dermatology as well as surgical/ENT/Plastics
    lesions need for funding!

17
Progress a team effort!
  • Steering Group
  • Sandra Auld, SDM, Scottish Centre for Telehealth
  • Paul Baughan, West of Scotland Lead Cancer GP
  • Karen Bonnar, Cancer Services Coordinator, NHSFV
  • Elizabeth-Ann Bowman, Skin Photography
    Coordinator, NHSFV
  • Fiona Downie, Photo-triage project manager, NHSFV
  • John Hunter, Medical Photographer, NHS
    Lanarkshire
  • Colin Morton, Consultant Dermatologist, NHSFV
  • Mary Orzel, Cancer Services manager, NHSFV
  • Dave Simpson, e-health lead, NHSFV
  • Brenda Smith, Dermatology Nurse Consultant, NHSFV
  • John Wells. e-health Officer, NHSFV
  • For more information colin.morton_at_nhs.net
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