Are We Missing Something? The Skin Lesions Not Seen in Teledermatology (Preprint)

BACKGROUND The suspected skin cancer electronic referral pathway was introduced in 2017. It requires general practitioners to add regional, close-up, and dermoscopic images to a lesion-specific referral template for a teledermatologist to review and advise on management. The virtual lesion clinic is a nurse-led clinic used since 2010 to obtain high-quality images for teledermoscopy assessment. A limitation of both services is the absence of a full-body examination. OBJECTIVE This study aims to evaluate the number of skin cancers missed during teledermatology assessment. METHODS This is a retrospective review of skin lesion referrals to dermatology. Suspected skin cancer referrals made in the latter half of 2020 were compared with referrals to the virtual lesion clinic during a similar time period in 2016. RESULTS The study included 481 patients with 548 lesions in the 2020 suspected skin cancer cohort that were matched for age, sex, and ethnicity to 400 patients with 682 lesions in the 2016 virtual lesion clinic cohort. A total of 41 patients underwent subsequent specialist review in the suspected skin cancer cohort compared to 91 in the virtual lesion clinic cohort. A total of 20% of the suspected skin cancer cohort and 24% of the virtual lesion clinic cohort were found to have at least one additional lesion of concern. The majority of these were keratinocytic skin cancers; there were 2 and 0 additional melanomas or melanoma-in-situ, respectively. The virtual lesion clinic nurses identified additional lesions for imaging in 78 of 400 (20%) patients assessed in the virtual lesion clinic. The teledermatologist determined (author AO) that 73% of these additional lesions were malignant. Of the 548 lesions, 10 (2%) in the suspected skin cancer group were rereferred, none of which had a change in diagnosis. Out of 682 lesions, 16 (2%) in the virtual lesion clinic cohort were rereferred, 6 (1%) of which had a change in diagnosis. CONCLUSIONS Patients diagnosed with skin cancer often have multiple lesions of concern. Single-lesion teledermoscopy diagnoses have high concordance with in-person evaluation and histology; however, we have shown that in-person examination may reveal other suspicious lesions. The importance of a full-body skin examination should be emphasized to the referrer.

Patient Chief Complaint and Otolaryngology Referral Rationale: Discordance and Opportunities for Quality Improvement

Objective: As medical systems focus on patient satisfaction as an important care outcome, specialty clinics are tasked with continued improvement of patients’ experience. When patient expectations for a consultation differ from that of the specialty provider, dissatisfaction with the experience can occur. One source of differing expectations is discordance between the patient’s chief complaint and the clinical rationale for the consultation as requested by the referring provider. We sought to better understand when this discordance occurs, as well as factors contributing to this disorientation of patient and provider expectations in a safety net otolaryngology practice. Methods: A retrospective observational study was performed and records were examined from new patient consultations. Patient questionnaires, including self-reported chief concerns, were compared with the electronic referral documentation. A difference between the patient’s Chief Complaint (CC) and Referral Reason (RR) was defined as CC-RR Discordance. Medical records, pre-consultation patient communication, and scheduling data were also reviewed to evaluate contributing factors. Results: Of the 1155 consultations examined, 952 were included in the analysis. A CC-RR Discordance was found in 175 (18.4%) of new-patient encounters, including 117 (12.3%) that were unable to articulate a CC (unsure of the reason for the appointment), and 58 (6.1%) that stated a CC that was different than the RR. The rate of CC-RR Discordance was higher in patients with female sex ( P < .05), older age ( P < .001), and longer time intervals between referral and appointment ( P < .05). Lack of communication with the patient (instructions or referral notification) by the referring provider was not associated with CC-RR Discordance. Conclusions: Discordance between patient CC and the rationale for a consultation is common in this safety-net otolaryngology practice and may be an important source of patient dissatisfaction. Future opportunities for quality improvement include pre-consultation communication between the specialist and the patient and reducing time intervals between referral and appointment.

Effective Factors in the Establishment and Implementation of Patient Electronic Referral System in the Healthcare System: A Qualitative Study

Background and Purpose: The electronic referral system was established in Iran with the aim of increasing access to care, improving interaction, and efficient use of resources. The purpose of this study was to determine the effective factors in the establishment and implementation of electronic referral system in Iran. Methods: The present study was qualitative with a content analysis approach. In order to collect information, in-depth and semi-structured interviews were used. After interviewing 42 people, the information was saturated. The interviews were transcribed and analyzed, and the main topics were quoted, cited, and coded. The content analysis method was used and all authors participated in the analysis process to avoid bias and agreement. Results: Four main themes and eleven sub-themes were mentioned as effective themes in the implementation of the electronic referral system by the interviewees including resource management (human resource management, financing and equipment, and infrastructure), stewardship (policy-making, inter-sectorial leadership, and intra-sectorial governance), advocacy stakeholders (senior officials and policy-makers related to the program, service providers, community), and social commitment (commitment and accountability of service providers). Conclusions: Successful implementation of electronic referral systems requires the development of an operational plan that correctly identifies the factors affecting the establishment and implementation, as well as the cooperation of all responsible organizations which can help improve the establishment and sustainability of the program. It is suggested that managers and officials active in the field of health services use the results of this study in the establishment and implementation of electronic referral system.

1205 Clinical Audit Demonstrating an Increase in Referrals to The Ophthalmology AMD Clinic at University Hospital Southampton

Aim To demonstrate if the introduction of OCT imaging by a national optician chain across its 740 stores in UK (followed by other chains) would increase in referrals to the wet AMD clinic. Secondly to assess if the direct increase of referrals would have an impact on the clinic workload. Method Retrospective review of all referrals made to the AMD service via optometrists/opticians throughout 2018. Total numbers of referrals that were proven to have nAMD requiring injections Inclusion; direct optician referral or GP referral via an optician. Exclusions: Ophthalmologist, Eye Casualty, other clinics and nAMD not requiring injections. Results Opticians were responsible for 62.88% (566) referrals out of 900 to the AMD service The second half of 2018 showed an increase in referrals (130 more) but with improved quality since the diagnostic accuracy of the optometrists increased from 22.94% to 37.64% The improved diagnostic accuracy of the optometrists was found to be statistically significant (Fisher’s exact test: p &lt; 0.0003) Discussion Increase in patients requiring injections directly increases clinic by initial screen and follow up injections. Medical retina departments faced an increase in false positive referrals. Potentially due to seeing essentially normal findings in a new way (B scan) that are artefacts or misinterpretation of either the image or the normative values Conclusions Upon review and presentation of the audit, NHS will invest in an electronic referral system to aid the clinic. Education and ongoing clinical training are essential to the successful launch of an OCT service in the community.

1091 Assessment of Cauda Equina Syndrome Referrals to The Tertiary Spinal Service for Compliance with National Standards

Introduction Urgent assessment/investigation and appropriate referral of Cauda Equina Syndrome (CES) is important in preventing morbidity and avoiding litigation. A recent GIRFT review outlined a series of guidelines on the management of patients with suspected CES. This audit aimed to assess whether CES referrals to a tertiary spinal service are compliant with GIRFT recommendations and SBNS/BASS guidelines. Method Retrospective review of an electronic referral system at a tertiary spinal centre over 4 months, examining CES referrals from surrounding peripheral hospitals. General Practice referrals were excluded. Data collected included patient demographics, symptoms/examination findings, timing of MRI and outcomes of the referral. Results A total of 48 referrals were included for analysis, mean age was 46.7 and 64% were female. 27% had no ‘red' or ‘yellow' flag signs/symptoms and were inappropriately referred. Majority did not perform pre/post void bladder scans prior to referring. 58% of all referrals were made without an MRI. 22% of those referred within ‘working hours’ were referred without MRI scan. There were significant variations in time taken to perform MRI at the referring hospital; median delay 11.1 hours (3-21hrs). Conclusions SBNS/BASS standards are currently not being met, which may adversely impact patient outcomes. Cost implications of patients being transferred to tertiary spinal centres who are found to have no abnormality, must be balanced against the cost of missed CES. This audit highlights the need for improvement in the quality of referrals through education and training at the referring centres.

1596 A Retrospective Audit Investigating and Identifying Factors Relating to Delays to Theatre Within Neurosurgery at Leeds - A Tertiary Referral Centre

Aim Leeds Neurosurgery receives referrals as a tertiary centre from a cohort covering 3 million people, receiving over 9000 referrals in the last year via its online system, Patientpass. This audit aims to identify factors which leads to delays in surgery, especially in light of the COVID-19 pandemic. Method We looked at 760 patients who were included in the study and used the electronic clinical notes system, PPM+ and also the electronic referral system Patientpass and looked at weekday and date of admission, cranial/spinal admission, diagnosis, age, referring hospital, time taken in theatre, theatre used, intraoperative timings, length of stay and date of discharge. Results The majority of the cases were either vascular or trauma related. 77.2% of surgeries were either same day or within 24 hours. The average length of stay was 17 days. The average time in theatre, 2h11m. The designated acute theatres were used approximately 75% of the time. Conclusions Interestingly, the mean time from admission to theatre was 1.25 days. 225 cases were investigated as a sample randomly selected. It is identified that 30 cases were delayed. 20% were delayed due to imaging requested for surgical management. 6% were due to patients awaiting consultant review. 10% due to awaiting other investigation results (i.e., COVID swab.) There were other identifiable factors such as awaiting ‘hot' theatres, reversing coagulopathies and medically deteriorating patients. We have provisionally identified factors and will re-audit this in the next cycle in order to maximise efficiency.

An eReferral Management & Triage System for minor Oral surgery referrals from primary care dentists: a cost-effectiveness evaluation

Objective Oral surgery referrals from NHS dental practices are rising, increasing the pressures on available hospital resources. We assess if an electronic referral system with consultant or peer (general dental practitioner) led triage of patient referrals from general dental practices can effectively divert patients requiring minor oral surgery into specialist led primary care settings at a reduced cost whilst providing care of the same or enhanced quality. One year of no triage (all referrals treated in secondary care) was followed by one-year of consultant led triage, which in turn was followed by year of peer-led triage. Method A health economic evaluation of all patient referrals from 27 UK dental practices for oral surgery procedures. The follow-up is over a three-year period at hospital dental services in two general hospitals, one dental hospital, and a single specialist oral surgeon based in two primary care practices. The evaluation is a comparison of mean outcomes in the hospitals and in specialist primary care dental services between the study periods (i.e. periods with and without the triage system). The main outcomes of interest are mean NHS cost saving per referral (costs to the NHS and costs to broader society), proportion of diverted referrals, case-mix of referrals and patient reports of the quality of dentistry services received at their referral destination. Results The proportion of referrals diverted to specialist primary care was similar during both periods (45% under consultant-led triage and 43% under GDP-led triage). Statistically significant savings per referral diverted were found (£116.11 under consultant-led triage, £90.25 under GDP-led triage). There were no statistically significant changes in the case-mix of referrals. Cost savings varied according to the coding (and hence tariff) of referred cases by the provider hospitals. Patients reported similarly high levels of satisfaction scores for treatment in specialist primary care and secondary care settings. Conclusions Implementation of electronic referral management in primary care, when combined with triage, led to appropriate diversions to specialist primary care. Although cost savings were realised by referral diversion these savings are dependent on the particular tariff allocation (coding) practices of provider hospitals.

Do eReferral, eWOM, familiarity and cultural distance predict enrollment intention? An application of an artificial intelligence technique

Purpose Little empirical attention has been paid to the effects of electronic word-of-mouth (eWOM), electronic referral (eReferral), familiarity and cultural distance on behavioral outcomes, especially within the context of educational tourism. Based on the social network theory, this paper aims to explore the effects of eReferral, eWOM, familiarity and cultural distance on enrollment intention. Design/methodology/approach Survey data (n = 931) were obtained from educational tourists using a judgmental sampling technique. Linear modeling and artificial intelligence (i.e. artificial neural network [ANN]) techniques were used for training and testing the proposed associations. Findings The results suggest that eReferral, eWOM, familiarity and cultural distance predict intention to enroll both symmetrically (linear modeling) and asymmetrically (ANN). The asymmetric modeling possesses greater predictive validity and relevance. Originality/value This study contributes theoretically and methodologically to the management literature by validating the proposed relationships and deploying contemporary methods such as the ANN. Implications for practice and theory are discussed.