artigo_16_digital image referral for suspected skin malignancy--a pilot study of 300 patients

8/13/2019 Artigo_16_Digital Image Referral for Suspected Skin Malignancy--A Pilot Study of 300 Patients

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Digital image referral for suspected skin malignancy-A pilot study of 300 patients

A. Tadros*, R. Murdoch, J.H. Stevenson

Department of Plastic Surgery, Ninewells Hospital, Tayside, Dundee DD1 7HY, UK

Received 19 September 2007; accepted 2 February 2008

KEYWORDSElectronic referralsystem;Malignant skin lesion;Reduction outpatientwaiting time

Summary Referral of suspect skin cancers as well as non malignant symptomatic skin lesions

using high quality digital images transferred via a secure electronic referral system (ERS)

potentially offers significant advantages regarding speed of referral, diagnosis and subsequent

treatment over conventional pathways.

However concerns over safety of the diagnostic process have been raised. This prospective

study looks at 300 patients referred by ERS. A comparison of the diagnoses made from digital

images with the diagnoses confirmed on pathology reports for lesions excised is described using

a random selection of patients images and referrals. Intra observer analysis of was also

assessed. A sample group of patients with lesions deemed as benign, not requiring surgeryor other treatment and therefore not seen in secondary care were revisited at a special clinic

to determine the safety of the referral system.In this series of 300 patients the study concludes that digital image referral for skin malig-

nancy and other cutaneous lesions reduced the interval between referral and diagnosis by 81%

and referral to commencement of treatment in suspect lesions by 30%. Diagnostic accuracy in

a random sample of 30 patients was comparable to that reported for patients seen in face toface consultations. High levels of GP and patient satisfaction were recorded. In conclusion dig-

ital image referral for skin malignancy and other cutaneous lesions is a safe and cost effective

referral pathway, significantly reducing the interval between referral diagnosis and onset of

treatment for skin malignancy.

2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by

Elsevier Ltd. All rights reserved.

There is little doubt that applying information technologyto healthcare has the potential to deliver qualitative bene-fits to patient care. Approximately 15% of GP referrals arefor skin conditions, of these 4% need secondary referral.1

It has been shown however that most of the suspected ur-gent skin cancer referrals eventually prove to be benign.2

Effectively this means a delay in true skin malignancyassessment identification rate, as they have to competewith false positive referrals. This delay is compoundedeven further by the unpredictable period of time fromgenerating the referral letter in the primary care centre

* Corresponding author. Tel.: 44 7711810786.E-mail address: [email protected](A. Tadros).

1748-6815/$- seefront matter2008BritishAssociationofPlastic,Reconstructiveand AestheticSurgeons. Publishedby ElsevierLtd.Allrightsreserved.doi:10.1016/j.bjps.2008.02.005

Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, 1048e1053
mailto:[email protected]:[email protected]


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until the point it is seen and vetted by the consultant in thesecondary care setting. Further delays to the patientjourney are encountered in assigning patients to a plasticsurgery clinic until finally an operation date is set if surgeryis needed. Furthermore due to the wide geographicalspread of patients in Tayside, the elderly, who form thehighest percentage of patients with skin malignancy, haveto make often long journeys to hospital to be seen by a spe-

cialist, the consultation often being brief to make a diagno-sis. If any of these steps can be bypassed safely, majorreductions in waiting times for suspected skin malignanciesmaybe achieved. A pilot trial conducted by Singh et al 3 sup-ported the view that malignant skin lesions can be safelydetected using high quality photographic imaging in associ-ation with an accurate referral letter. An electronic referralsystem (ERS) was set up to streamline the skin malignancyreferral process between primary and secondary care.3

The aim was to enable true skin malignancies to be diag-nosed earlier and subsequently treated sooner, as well asto reduce the pressure on outpatient clinics.

Methods

Design and project objectives

A digital image referral service was established where GPsuse the existing electronic referral service to send digitalimages to the plastic surgery department at NinewellsHospital of skin lesions including suspected skin cancers.Consultants were given accessto theERS where referrals andimageswere screened. Theconsultant on call for a particularday was responsible for screening and vetting the referralsreceived enabling all patients to be assessed within 24 h.

In conjunction with the university medical illustrationdepartment, the Cannon powershot camera model A95wasselected as the best digital camera for use in this project.Financial support to set up the project (including a projectmanager) was obtained from the Scottish Executive Centrefor Innovation and Change with funding for the camerafrom primary care CHP. An onsite-training package wasestablished for GPs in participating practices on the use ofthe digital cameras and the attachment of images to thereferral letter electronically (Figure 1). A helpline formedpart of the package with feedback to the participants onquality of images submitted. GPs were given a preciseprotocol for taking digital images. All images referred tothe plastic surgery department were accompanied by

a full letter including history, relevant past medical historyand current medication.

Evaluation

In order to accurately evaluate the results of this project,the following parameters were considered:

The outcome (destination) of referrals was assessed. Diagnostic accuracy (a comparison of diagnosis made

from images, with pathology report following excision). A comparison of the interval between referral to diag-

nosis, between referral to treatment and between con-ventional and digital referral pathways.

Patient and GP assessment of the new pathway.

Outcome of referrals

All referrals were initially assessed by one of the fourconsultants on the unit. The options available to theconsultant responsible for the triage of referrals are out-

lined inFigure 2. The number of referrals per month as wellas the destination of these referrals was recorded.

Diagnostic accuracy (Inter/Intra observerreliability)

This was assessed by two methods.

a) A random sample of 30 patients was selected by an in-dependent observer; a file was created including theGP referral letter and digital image. This patient num-ber was chosen following discussion with a statistician.Each of the four consultants involved with the triaging

of images reviewed this sample on three separate occa-sions with a minimum of 2 weeks apart. On averageeach review lasted for 5 min. Each consultant wasasked to state the main diagnosis, up to two possibledifferential diagnoses and the level of urgency fortreatment (urgent- within 2 weeks, soon- up to 6 weeksand routine- over 6 weeks). Observer consistency(comparing the diagnosis made on each of the threeoccasions) as well as interobserver consistency wasassessed statistically.

Retrieval of patient notes was only carried out afterCOREC ethical approval was granted for this section ofthe study. The level of intra and inter observer agree-ment and reliability was analysed using Kappa statistics

(SPSS output, for Windows v.6). The approximate signif-icance of the kappa statistics is provided as standard inour prism output. Kappa value is an index which com-pares the agreement against that which might be ex-pected by chance. Kappa can be thought of as thechance-corrected proportional agreement and possiblevalue range from 1 (perfect agreement) via 0 (noagreement above that expected by chance) to 1(complete disagreement). This gives a more meaningfulindication of agreement than the calculation of simplepercentage agreement, as the latter takes no accountof the level of agreement that might arise by chancealone.

Each practice issued with

- Digital camera

- Media card reader

- Batteries and charger

- Patient consent forms

- Patient information leaflet

- Scale labels

2 photographs required for each referral

- One close up

- One wide shot

Scale labels must include patient unit number and name

One hour training session with GPs and administrative staff on site

Figure 1 Established training packages for active GP sites.

Digital image referral for suspected skin malignancy 1049


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b) A random sample of 20 patients deemed by the triageprocess to have lesions that were benign and not requir-ing any treatment were seen at a special clinic, wherea diagnosis was made, and comments from patientsrecorded. A letter was sent to each explaining theproject and the reason for them being sent to attendthe clinic. A copy of this was sent to the GP in case thepatient had anxieties about the diagnostic process.

Assessment of the interval between referral todiagnosis and referral to treatment

The mean interval between initial referral from the GP,vetting the referral letter and wait until treatment wasassessed using the conventional pathway (standard letter,public mail, etc) using medical records data. Comparativefigures using the digital image referral pathway wererecorded and a comparison carried out.

Referring practitioner and patient satisfaction

A questionnaire was sent out to a random selection of 34referring GPs who had referred a patient through the ERSpathway. A separate questionnaire was also sent to arandom sample of 31 patients who were referred through

the ERS pathway and then progressed to either a one stopor day surgery appointment.

Results

Outcome of referrals

The first 300 patients were included in the study. Themajority of digital image referrals were seen in the 1-stopclinic (41%) for further assessment and immediate excisionif needed. A significant number of patients however werediagnosed with benign lesions and electronic reply being

sent to the GP outlining the diagnosis, with either notreatment being advised or management by the GP whereappropriate e.g. solaraze gel or cryotherapy for a simplekeratosis (Figure 3).

Diagnostic accuracy

The mean overall correct diagnosis between the fourconsultants was 83.25%. A total of 90.25% of malignantlesion (true positive) and 76.58% of benign lesions werecorrectly identified by the four clinicians (Table 1). Nomalignant lesions were allocated to the no treatmentgroup. One Malignant lesion was incorrectly diagnosed by

On call plastic surgery consultant

Diagnosis/ management

Reassure

Repeat photo after interval

OPD appointment

Redirect referral Surgery by GP

Surgery by plastic surgeon

( trainee, consultant)

Urgency of treatment

Duration of procedure

Venue (outpatient clinic, daysurgery unit, main Theatre)

Electronic

reply to GP

Communication

with patient

Audit (safety of

system)

Medical records

for statistics

GP referral

Perth & Kinross Dundee Angus NE Fife

Straight onto OPLA list

Figure 2 Electronic referral pathway showing the sequence of events following the electronic patient journey once the referral

is viewed by the consultant.

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three out of four clinicians; this was a cutaneous metastaticdeposit from a primary renal clear cell carcinoma. It wascommented that the images of this particular referralwere of poor quality. The patient was still listed as urgentor soon by the clinicians as there was doubt in the diagno-sis. Interobserver agreement between the four clinicianswas significant with kappa index ranging between 0.47and 0.64 (p


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patients.4e6 For malignant melanoma early diagnosis andtreatment is crucial as the treatment options in advancedmelanoma are still very limited. The significantly shortenedinterval between referral, diagnosis and treatment high-lighted in this paper is an illustration of how the early man-agement of patients with suspected and actual melanomascan be achieved, and examples are given in this paper.Basal and squamous cell carcinomas, the other commonskin malignancies affect predominantly an older age groupwho often find travel to and from hospital difficult for whatis often a brief consultation to make a diagnosis. Digital im-age referral can reduce the number of visits to hospital forthis group of patients.8

Legitimate concerns have been raised, however, regard-ing the safety of this pathway as well as theoreticaladvantagesin savingon patientjourneys to hospital.9 Severalstudies have looked at observer diagnostic accuracy for skinlesions/malignancies.7,10e14 The diagnostic accuracy in thisseries in a random selection of patients is as good as (and in

some cases exceeds) that of face to face consultation.Importantly, the ability to differentiate between malig-

nant and benign lesions has been clearly demonstrated. Inone case only of a skin malignancy was the diagnosisuncertain, but each of the clinicians still allocated thisfor urgent or soon excision. Enhanced diagnostic accuracyusing dermatoscopy and more recently siascopy has beendemonstrated and is particularly valuable in those lesionswhere there is doubt about the diagnosis.14,15 This is

particularly important in malignant melanoma. In our se-ries, the melanomas diagnosed demonstrated key featuresenabling rapid diagnosis and treatment from the imagesalone. Where these features are not present, then urgentreferral-where malignancy is suspected-to a specialist willallow closer examination using these modalities. Again,the digital referral pathway is likely to reduce the intervalbetween referral, diagnosis and treatment.

In the special clinic set up to review a random selectionof patients designated as having benign lesions, no skinmalignancy was found. As a safety net GPs can be advised,if there is any uncertainty in the diagnosis to refer thepatient with a repeat image after an appropriate intervaleg 3 months, for comparison with the original picture.Unlike other investigators,9 we feel that the safeguards in-troduced into the study, and the continuing audit of thepathway, should ensure safety in diagnosis and manage-ment pathways. Standardisation of cameras, images andviews taken, as well as accuracy in the accompanying doc-umentation should reduce the risk of poor digital images orinappropriate information, which has been highlighted asa problem in other studies.16 Access to a helpdesk has

proven invaluable in maintaining the high quality of imagessubmitted, and resolving any technical problems arisingbetween primary and secondary care.

In summary, this pilot has highlighted that digital imagereferral for skin cancer and other cutaneous lesions can besafe, cost effective and offers considerable advantages toboth GPs and patients with high satisfaction rates demon-strated in both groups.

References

1. Leggett P, Gilliland AE, Cupples ME, et al. A randomized con-trolled trial using instant photography to diagnose and managedermatology referrals.Fam Pract2004;21:54

e5.

2. Kerr AC, Leonard S, Gupta G. A prospective survey of skincancer referrals to a Scottish dermatology department. Br JDermatol2005;152:1065e6.

3. Singh S, Stevenson JH, McGurty D. An evaluation of Polaroidphotographic imaging for cutaneous-lesion referrals to an out-patient clinic: a pilot study. Br J Plas Surg2001;54:140e3.

4. Phillips RR. Photography as an aid to dermatology. Med BiolIllus1976;26:161e6.

5. Murray CK, et al. The remote diagnosis of malaria usingtelemedicine or e-mailed images. Mil Med 2006 Dec;171:1167e71.

6. Levy JL, Trelles MA, Levy A, et al. Photography in dermatology:comparison between slides and digital imaging. J CosmetDermatol2003 Jul;2:131e4.

7. Herrmann FE, Sonnichsen K, Blum A. Teledermatology versusconsultationsea comparative study of 120 consultations. Haut-tarzt; 2005 Mar::942e8.

8. Braeunling F, Jones M, Lister RK, et al. Digital photographyenhances the prioritization of suspected skin cancer referrals.Br J Dermatol 2004;151:27.

9. Bowns I, Collins K, Walters S, et al. Telemedicine in dermatol-ogy: a randomised controlled trial.Health Technol Assess2006;10:iiieiv.

10. Hallock G, Lutzg D. Prospective study of the accuracy of thesurgeons diagnosis in 2000 excised skin tumours. Plast Re-constr Surg1988 Apr;101:1255e61.

11. Ew E, Giorlando F, Su S, et al. Clinical diagnosis of skintumours: How good are we?ANZ J Surg2005 Jun;75:415e20.

Table 3 Patient average waiting times following clinician

vetting of referral

Urgent Soon Routine

Letter

Referral/clinic 27 74 223

Clinic/procedure 32 52 80

Total 59 126 303

ERS

Referral/procedure 28 52 65

Total 28 52 65

urgent urgent soon soon routine routine0

100

200

300

400ERS

Letter

Vetting type

Noofdays

Figure 5 Average waiting time from referral to procedure.

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12. Har-Shai Y, Hai N, Taran A, et al. Sensitivity and positive pre-dictive value of presurgical clinical diagnosis of excised benignand malignant skin tumours: a prospective study of 835 lesionsin 778 patients. Plast Reconstr Surg2001 Dec;108:1982e9.

13. Green A, Leslie D, Weedon D. Diagnosis of skin cancer in thegeneral population: clinical accuracy in the Nambour survery.Med J Aust1988 May 2;148:447e50.

14. Tehrani H, Wall J, Price G, et al. A prospective comparison ofspectrophotometric intracutaneous analysis to clinical

judgment in the diagnosis of nonmelanoma skin cancer. AnnPlast Surg2007 Feb;58:209e11.

15. Moncrieff M, Cotton S, Claridge E, et al. Spectrophotometricintracutaneous analysis: a new technique for imaging pig-mented skin lesions. Br J Dermatol2002 Mar;146:448e57.

16. Mahendran R, Goodfield M, Sheehan-Dare RA. An evaluation ofthe role of a store-and-forward teledermatology system in skincancer diagnosis and management. Clin Exp Dermatol 2005May;30:209e14.

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artigo_16_digital image referral for suspected skin malignancy--a pilot study of 300 patients

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