Title: Innovation in Referral Management: Phototriage for Skin Cancer Referrals Dr Colin Morton Dermatologi
1Innovation in Referral Management Photo-triage
for Skin Cancer ReferralsDr Colin
MortonDermatologistNHS Forth Valley
2Innovation 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?
3Annual Referral Trends Dermatology
www.isdscotland.org
4Models 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..
5Community 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
6Photo-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) -
7Methods
- 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
8Patients 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)
9Pattern of referral wide geographic uptake of
triage
- Photography at 2 GP practices, one in Falkirk,
one in Stirling
Number of referrals
10Results 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)
11Results 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?
12Results 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)
-
13Potential 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
14Increase 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
15Community 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
16Photo-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!
17Progress 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