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The Waikato Virtual Lesion Clinic - better, sooner and more convenient


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Dr. David Lim
Waikato District Health Board
(4/11/10, Illott, 10.30)

Published in: Health & Medicine
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The Waikato Virtual Lesion Clinic - better, sooner and more convenient

  1. 2. <ul><li>The need for a new service </li></ul>Background
  2. 3. Background <ul><li>NZ – very high rates of skin cancer: </li></ul><ul><ul><li>One of the highest in the world </li></ul></ul><ul><ul><li>NMSC – 80% of all cancers </li></ul></ul><ul><ul><li>Melanoma – 4 th registered cancer in NZ </li></ul></ul><ul><li>Dermatologists: </li></ul><ul><ul><li>Crucial role in diagnosis and management </li></ul></ul><ul><ul><li>More accurately diagnose early skin cancers </li></ul></ul><ul><ul><ul><li>Compared with GPs and Surgeons </li></ul></ul></ul>
  3. 4. Background <ul><li>Access to Dermatology limited: </li></ul><ul><ul><li>Undersupply of Dermatologists </li></ul></ul><ul><ul><li>Large number of referrals </li></ul></ul><ul><ul><li>15% of population live > 80km from a Dermatologist </li></ul></ul><ul><ul><li>Prioritisation errors of referrals at triage: </li></ul></ul><ul><ul><ul><li>Clear malignant lesions lack important info on referral </li></ul></ul></ul><ul><ul><ul><li>Benign lesions referred as malignant </li></ul></ul></ul><ul><li>Long waiting times (up to 6 months) </li></ul>
  4. 5. Dermatology in Waikato <ul><li>Waikato DHB catchment: </li></ul><ul><ul><li>> 360,000 people </li></ul></ul><ul><li>Dermatology: </li></ul><ul><ul><li>2.5 FTE of Dermatologists </li></ul></ul>
  5. 6. Overview of the Virtual Lesion Clinic
  6. 7. New Virtual Lesion Clinic <ul><li>Virtual lesion clinic: </li></ul><ul><ul><li>Started Jan 2010 </li></ul></ul><ul><ul><li>Based at Waikato Hospital </li></ul></ul><ul><ul><li>Public / Private partnership </li></ul></ul><ul><ul><ul><li>Waikato DHB / MoleMap New Zealand </li></ul></ul></ul>
  7. 8. <ul><li>Identify skin cancers - Needing removal </li></ul><ul><ul><li>Melanoma </li></ul></ul>Aims
  8. 9. <ul><li>Basal Cell Carcinoma </li></ul>
  9. 10. <ul><li>Squamous Cell Carcinoma </li></ul>
  10. 11. <ul><li>Reduce unnecessary removal of benign lesions </li></ul><ul><ul><li>Seborrhoeic keratoses </li></ul></ul>Aims
  11. 12. <ul><li>Actinic Keratoses </li></ul>
  12. 13. The VLC <ul><li>MoleMap contracted by Waikato DHB: </li></ul><ul><ul><li>Provide imaging and reporting </li></ul></ul><ul><li>Private company est. 1997 by Dermatologists </li></ul><ul><li>23 clinics in NZ, 1 mobile clinic </li></ul><ul><ul><li>Presence in Australia/USA </li></ul></ul><ul><ul><li>20,000 visits per year in NZ </li></ul></ul><ul><li>Offer teledermatology assessment: </li></ul><ul><ul><li>Mole mapping for melanoma </li></ul></ul><ul><ul><li>Corporate skin checks </li></ul></ul><ul><ul><li>Individual skin checks </li></ul></ul>
  13. 14. Mole mapping <ul><li>Surveillance program to monitor those at risk for melanoma </li></ul><ul><ul><li>History taking </li></ul></ul><ul><ul><li>Examination of skin lesions </li></ul></ul><ul><ul><li>Photographs of lesions – macro / dermoscopic </li></ul></ul><ul><ul><li>Mapping lesions on the body </li></ul></ul><ul><ul><li>Tracking lesions over time: </li></ul></ul><ul><ul><ul><li>Change in shape, size, structure </li></ul></ul></ul>
  14. 15. <ul><li>Magnified examination of skin lesions </li></ul><ul><li>Aids diagnosis of lesions </li></ul><ul><li>Improves diagnostic accuracy </li></ul>Dermoscopy
  15. 16. <ul><li>Take & store dermoscopic photos </li></ul><ul><li>Send electronically to Dermatologist for diagnosis </li></ul>Teledermoscopy
  16. 17. <ul><li>Allows microscopic study of lesion structure </li></ul>Macro & Dermoscopic views of a skin lesion
  17. 18. Teledermoscopy <ul><li>Multiple trials </li></ul><ul><ul><li>Diagnostic accuracy similar to face-to-face </li></ul></ul><ul><ul><li>Effective as a triage tool </li></ul></ul><ul><li>IMAGE IT trial (Tan et al, BJD 2010): </li></ul><ul><ul><li>Analysed diagnostic accuracy & concordance </li></ul></ul><ul><ul><li>Teledermoscopy superior for melanoma </li></ul></ul><ul><ul><ul><li>100% sensitivity </li></ul></ul></ul><ul><ul><ul><li>90% specificity </li></ul></ul></ul>Tan E et al. Successful triage of patients referred to a skin lesion clinic using teledermoscopy (IMAGE IT trial). BJD 2010: 162: 803-811
  18. 19. The VLC <ul><li>Patient attends VLC at MoleMap </li></ul><ul><li>Seen and assessed by Melanographer </li></ul><ul><ul><li>Specially trained nurse </li></ul></ul><ul><ul><li>Records patient history per protocol </li></ul></ul><ul><ul><li>Photographs – regional, macro-/dermo-scopic </li></ul></ul><ul><ul><ul><li>Uploaded to a centralised database </li></ul></ul></ul>
  19. 20. Melanographer taking dermoscopic photos
  20. 21. The VLC <ul><li>Dermatologist assessment: </li></ul><ul><ul><li>Time delayed (not in real-time) </li></ul></ul><ul><ul><li>Reviews history and images </li></ul></ul><ul><ul><li>Determines diagnosis </li></ul></ul><ul><ul><li>Formulates management plan </li></ul></ul><ul><ul><ul><li>Referred for surgery </li></ul></ul></ul><ul><ul><ul><li>Prescription </li></ul></ul></ul><ul><ul><ul><li>Follow up at Dermatology Clinic </li></ul></ul></ul><ul><ul><ul><li>Discharged to GP care </li></ul></ul></ul><ul><ul><li>Report generated – sent to GP and patient </li></ul></ul>
  21. 22. The VLC <ul><li>A report is generated, including: </li></ul><ul><ul><li>Diagnoses </li></ul></ul><ul><ul><li>Reasons for concern – if any </li></ul></ul><ul><ul><li>Recommended action: </li></ul></ul><ul><ul><ul><li>Discharge back to GP </li></ul></ul></ul><ul><ul><ul><li>Monitoring </li></ul></ul></ul><ul><ul><ul><li>Intervention: </li></ul></ul></ul><ul><ul><ul><ul><li>Prescription </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Cryotherapy </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Surgery </li></ul></ul></ul></ul>
  22. 23. The VLC <ul><li>Surgery: </li></ul><ul><ul><li>Placed directly on Waiting List </li></ul></ul><ul><li>Cryotherapy: </li></ul><ul><ul><li>Add to nurses clinic </li></ul></ul><ul><li>Medical treatments: </li></ul><ul><ul><li>Add to nurses clinic: </li></ul></ul><ul><ul><ul><li>Education </li></ul></ul></ul><ul><ul><ul><li>Collect prescription </li></ul></ul></ul>
  23. 24. <ul><li>The patient did not need to see a doctor for diagnosis or treatment </li></ul>Treatment education provided by nurses
  24. 25. <ul><li>A Model Case History </li></ul>Virtual Lesion Clinic
  25. 26. Referral received
  26. 27. Consent obtained
  27. 28. Melanographer – History taking
  28. 29. Lesion of concern identified
  29. 30. Anatomic pictures taken
  30. 31. <ul><li>Attachments: </li></ul><ul><li>Dermoscopic </li></ul><ul><li>Distance guide </li></ul>Digital camera
  31. 32. Macroscopic image
  32. 33. Microscopic image
  33. 34. History reviewed
  34. 35. Location of lesion
  35. 36. Diagnosis
  36. 37. Management
  37. 38. Overview
  38. 39. Report generated
  39. 40. <ul><li>Review of a new service </li></ul>Virtual Lesion Clinic Analysis
  40. 41. VLC Analysis <ul><li>VLC started Jan 2010 </li></ul><ul><li>Retrospective analysis of a new service: </li></ul><ul><ul><li>Not a RCT </li></ul></ul><ul><li>Goal: 200 patients </li></ul><ul><ul><li>100 Virtual Lesion Clinic (VLC) </li></ul></ul><ul><ul><li>100 Face-to-face (F2F) </li></ul></ul>
  41. 42. Primary Outcomes <ul><li>Waiting time to FSA (F2F/VLC) </li></ul><ul><li>Duration to intervention/completion </li></ul><ul><li>Patient & GP satisfaction </li></ul><ul><li>Cost effectiveness </li></ul><ul><li>NOT diagnostic accuracy </li></ul>
  42. 43. Secondary Outcomes <ul><li>Diagnoses </li></ul><ul><li>Management </li></ul><ul><li>Who performs the intervention / management </li></ul><ul><li>Virtual lesion clinic: </li></ul><ul><ul><li>Need for further (F2F) assessment </li></ul></ul><ul><ul><li>Patients discharged directly </li></ul></ul>
  43. 44. Method <ul><li>Referrals received from GP </li></ul><ul><li>Triage by Dermatologist </li></ul><ul><ul><li>Triaged against normal guidelines </li></ul></ul><ul><ul><li>Skin lesions </li></ul></ul><ul><li>Allocated to either F2F or VLC </li></ul><ul><ul><li>Not random </li></ul></ul><ul><ul><li>Excluded from VLC: </li></ul></ul><ul><ul><ul><li>Genital and scalp lesions </li></ul></ul></ul><ul><ul><ul><li>Poor quality referrals from GPs </li></ul></ul></ul><ul><li>Patients attended respective clinics </li></ul>
  44. 45. VLC Inclusion Criteria <ul><li>Older than 2 years (co-operation required) </li></ul><ul><li>Adequate GP referral </li></ul><ul><li>Lesions: </li></ul><ul><ul><li>No more than 6 lesions </li></ul></ul><ul><ul><li>Not on scalp </li></ul></ul><ul><ul><li>Either benign or malignant </li></ul></ul>
  45. 46. VLC Exclusion Criteria <ul><li>Not meeting inclusion criteria </li></ul><ul><li>General skin checks </li></ul><ul><li>Keratinopaths </li></ul>
  46. 47. Results <ul><li>After 8 months: </li></ul><ul><ul><li>108 F2F patients </li></ul></ul><ul><ul><li>107 VLC patients </li></ul></ul>
  47. 48. DNA rate <ul><li>F2F = 7.4% </li></ul><ul><li>VLC = 6.5% </li></ul>
  48. 49. Gender
  49. 50. Age Distribution <ul><li>Mean: 63 years </li></ul><ul><li>Range: 15 – 94 </li></ul><ul><li>Mean: 54 years </li></ul><ul><li>Range: 2 – 90 </li></ul><ul><li>F2F </li></ul><ul><li>VLC </li></ul>
  50. 51. Number of Lesions
  51. 52. Diagnoses <ul><li>Correlates with older average age of F2F </li></ul>
  52. 53. Waiting time – First Assessment <ul><li>Mean: 113 days </li></ul><ul><li>Range: 0 – 223 </li></ul><ul><li>Mean: 42 days </li></ul><ul><li>Range: 0 – 116 </li></ul><ul><li>F2F </li></ul><ul><li>VLC </li></ul><ul><ul><li>Waiting time reduced by 63% </li></ul></ul>
  53. 54. Trend of Waiting Times
  54. 55. Further Assessment <ul><li>Biopsy: 4% </li></ul><ul><li>2 nd Appt: 1% </li></ul><ul><li>Biopsy: 5% </li></ul><ul><li>2 nd Appt: 5% </li></ul><ul><li>F2F </li></ul><ul><li>VLC </li></ul>
  55. 56. Outcomes
  56. 57. Age vs. Surgery (%)
  57. 58. Age vs. Nurse Assessment (%)
  58. 59. Age vs. No intervention (%)
  59. 60. Patient Satisfaction <ul><li>Respondents: </li></ul><ul><ul><li>F2F: 40% </li></ul></ul><ul><ul><li>VLC: 54% </li></ul></ul><ul><li>Convenience of clinic: </li></ul><ul><ul><li>F2F: Good – Very good </li></ul></ul><ul><ul><li>VLC: Very good – Excellent </li></ul></ul><ul><li>Overall experience: </li></ul><ul><ul><li>F2F: Good – Very good </li></ul></ul><ul><ul><li>VLC: Very good – Excellent </li></ul></ul>
  60. 61. Patient Satisfaction <ul><li>Preference of VLC service: </li></ul><ul><ul><li>F2F: 33% </li></ul></ul><ul><ul><li>VLC: 73% </li></ul></ul><ul><li>Good overall patient satisfaction </li></ul><ul><li>?Preconceived misconceptions in those who have not experienced the VLC </li></ul>
  61. 62. GP Satisfaction <ul><li>Poor survey response rate – 2% </li></ul><ul><ul><li>Further analysis not performed </li></ul></ul>
  62. 63. Financial Analysis <ul><li>Patient events totalled: </li></ul><ul><ul><li>FSA (F2F/VLC) </li></ul></ul><ul><ul><li>Follow-up assessment for diagnosis </li></ul></ul><ul><ul><li>Biopsies </li></ul></ul><ul><ul><li>Nurse clinic (treatment education, cryotherapy) </li></ul></ul><ul><ul><li>Surgery not included </li></ul></ul><ul><li>Costs applied: </li></ul><ul><ul><li>Amounts provided by Business Unit at WDHB </li></ul></ul><ul><ul><li>Administrative costs included </li></ul></ul>
  63. 64. Financial Analysis <ul><li>Total: $30,648 </li></ul><ul><ul><li>$306 per patient </li></ul></ul><ul><li>Total: $24,542 </li></ul><ul><ul><li>$245 per patient </li></ul></ul><ul><li>F2F </li></ul><ul><li>VLC </li></ul><ul><ul><li>Savings of: </li></ul></ul><ul><ul><ul><li>$61 per patient </li></ul></ul></ul><ul><ul><ul><li>20% cost reduction </li></ul></ul></ul>
  64. 65. Future Plans <ul><li>Virtual lesion clinics planned for small towns </li></ul><ul><ul><li>Te Kuiti, Thames </li></ul></ul><ul><ul><li>Better access to these under-served areas </li></ul></ul><ul><ul><li>Reduce travelling time and patient costs </li></ul></ul><ul><li>Other centres can be started to meet demand </li></ul><ul><li>Direct access by GPs as a diagnostic service </li></ul><ul><li>Dermoscopy training for registrars </li></ul>
  65. 66. Conclusion <ul><li>Reduced waiting times (by 67%) </li></ul><ul><li>Good patient satisfaction </li></ul><ul><ul><li>More convenient access </li></ul></ul><ul><li>Reduced cost (by 20%) </li></ul>
  66. 67. Acknowledgments <ul><li>Dr. Linda Rademaker, GP liaison, Waikato DHB </li></ul><ul><li>Funding & Planning, Waikato DHB </li></ul><ul><li>Alastair Sharfe, MoleMap </li></ul><ul><li>Blair Stewart, MoleMap </li></ul><ul><li> </li></ul>
  67. 68. References <ul><li>Ministry of Health. Cancer: Selected Sites 2006, 2007 and 2008.$File/cancer-selected-sites06-07-08-nov09.xls . Accessed 9 June 2010. </li></ul><ul><li>Ministry of Health. Cancer: New Registrations and Deaths 2006.$file/cancer-newreg2006-final-v2.pdf . Accessed 9 June 2010. </li></ul><ul><li>Cancer Society of New Zealand. Costs of Skin Cancer to New Zealand Report (2009). Office/SkinCancer22October2009.pdf . Accessed 9 June 2010. </li></ul><ul><li>Piccolo D, Ferrari A, Peris K, Diadone R, Ruggeri B, Chimenti S. Dermoscopic diagnosis by a trained clinician vs. a clinician with minimal dermoscopy training vs. computer aided diagnosis of 341 pigmented skin lesions: a comparative study. Br J Dermatol 2002: 147: 481-6. </li></ul><ul><li>Oakley AM, Astwood DR, Loane M, Duffill MB, Rademaker M, Wootton R. Diagnostic accuracy of teledermatology: results of a preliminary study in New Zealand. NZ Med J 1997: 110: 51-3. </li></ul><ul><li>Oakley AM, Reeves R, Bennett J, Holmes S, Wickham H. Diagnostic value of written referral and/or image(s) for skin lesions. J Telemedicine & Telecare 2006: 12:151-158. </li></ul><ul><li>Tan E, Yung A, Jameson M, Oakley A, Rademaker M. Successful triage of patients referred to a skin lesion clinic using teledermoscopy (IMAGE IT trial). Br J Dermatol 2010: 162: 803-811. </li></ul>
  68. 69. Questions?