BT10 Skin lesion triage teledermatology service: a review of secondary care 2-week wait upgrades

Abstract

Abstract A teledermatology service for skin lesions was commenced in January 2021 initially as a pilot scheme with six general practices and one dermatology department in a metropolitan area; to date, 70% of the city practices have since been on-boarded. Many 2-week wait (2WW) referrals are made not just for suspected skin cancer, but also for cases where there is diagnostic uncertainty and secondary care opinion/reassurance sought. The aim of the service was to embed a fully integrated information technology solution to facilitate single skin lesion triage in an attempt to help to address the 2WW capacity issues in secondary care. The referring general practitioners (GPs) were provided with a mobile phone adaptor attachment and dermatoscope to obtain images of the index lesion in question. A proforma that includes a concise history of the lesion and clinical impression is completed. The GPs were encouraged to use this triage service but could also refer directly to the 2WW service if concerned. The consultant then provided advice and guidance with a menu of triage outcomes, including upgrade to a 2WW appointment. We reviewed the referrals received via this skin lesion pathway and numbers of cases converted to a 2WW appointment from 12 April to 1 December 2022 as a snapshot of the service. We aimed to determine factors from the referral that prompted the conversion. There were 1201 skin lesion referrals, and 299 cases were converted to 2WW (24.9% of the cohort). In 93 of 299 referrals, the GP’s impression was possible squamous cell carcinoma or melanoma. In 137 of 299 cases, the GP had not provided a clinical impression. In 70 of 299 referrals, the GP’s clinical impression correlated with the dermatology’s impression based on the dermatoscopic images. In 44 cases, the clinician’s impression based on the image was of a benign lesion; however, we noted that a more cautious approach was adopted by some clinicians who triaged to 2WW if there was any diagnostic uncertainty. After face-to-face review, 159 of 299 were listed for biopsy or excision. Some factors identified that limited diagnostic accuracy included poor image quality and some referrals contained multiple lesions, causing confusion. This skin lesion triage service appears to support the idea that photographic triage could reduce the burden of 2WW face-to-face referrals. Areas for improvement identified include ensuring that the referrer provides a concise history and clinical impression, the use of gel for dermatoscopic images and feedback when images are not of adequate quality. In the future, it may be necessary to consider photographic hubs to standardize referral photographic quality.