Download Working together better Dermatology 12th April 2007

“Working together better”
Dermatology
12th April 2007
Catherine Smith
Clinical Lead for Dermatology
St Johns Institute of Dermatology
GSTT
St Johns Institute of Dermatology:
what are we?
• Largest UK centre for patients with skin
disease
• Clinical service (GSTT)
• Research (GKT, Kings College London)
• Training and education
Clinical Service
• General Dermatology
• Specialist Services*




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Skin Cancer: lymphoma, melanoma
Inflammatory Skin Disease: Psoriasis, Eczema
Blistering disease
Cutaneous Allergy: Contact dermatitis, urticaria
Mastocytosis
Genetic Skin Disease
Vulval and Oral Dermatoses
Specialised Diagnostic Laboratory services
*includes all those cited in the National Specialist
Services Definition Set for Dermatology
Clinical Service: Access
• General dermatology
– Standard referral letter
– Choose and Book
– Current waiting times 5-6 weeks for routine OPD
• Suspected skin cancer
– via standard 2WW proforma
• Emergency referrals
– On call SpR available
9am-9pm Monday to Friday
9am-1pm Saturday, Sunday
Current Issues for Dermatology
Services: Background
• ‘Our health, our care, our say: a new direction for community
services’ (2006)
– ‘…to ensure the delivery of the most appropriate care to patients in the
most appropriate setting in clinical terms, whilst demonstrating the most
effective use of available resources’
• New Targets
– By 2008, no one will wait longer than 18 weeks from GP referral to
hospital treatment
– 5 weeks for first outpatient consultation
– 6 weeks for diagnostics
• New guidelines relevant to dermatology services
– Improving Outcomes Guidance (IOG) for skin cancer (2006)
– Management of paediatric atopic eczema (expected 2008)
• New funding arrangements
– Payment By Results
– Practice Based Commissioning
Drive for major service redesign and effective referral management
Current Issues for Dermatology
Services: Background
• Dermatology services remain a major focus in the
context of this agenda
• Two out of ‘Top Ten Tips’ in DOH guide to practice based
commissioning focus on dermatology services
 Nurse led community services for childhood atopic
eczema
 GPSI led ‘intermediary’ community services
• Implications for Education, Training, Research and
provision of Specialist Services not addressed in detail
Plans and progress to date
• Established Dermatology Steering Group
• Purpose: to develop and implement strategy to ensure
continued access to comprehensive dermatology
services for patients
• Progress to date:
– Agree referral criteria for atopic dermatitis, psoriasis,
acne (checklists)
– Agree conditions for which treatment is not available
on the NHS
– Audited current referral practice against national
benchmarks to meet demand management agenda
– Develop strategy for training and education of primary
health care professionals
Methods
• Proforma developed and reviewed by St Johns staff,
PCT (Southwark and Lambeth), interested GPs
• Layout and data fields revised following pilot in 2 general
clinics
• Period of data collection:
– 2 weeks
– November 13th -24rd 2006
– 16 lists cancelled due to A/L, S/L (representative)
•
•
•
•
General clinics only
Proforma attached to all clinic notes
Data entry completed by clinicians in clinic
Entered onto spreadsheet; descriptive data analysis
Type of referral
• Total number of news
– Two week cancer wait
– New
– Re-referral
• Total number of follow ups
• New : follow up ratio
164 (41%)
14
150
10
227 (59%)
1.38
Completed proformas returned for 75% of those attending
Diagnosis*
•
•
•
•
•
•
•
•
•
Benign lumps & bumps
Cancer
Eczema
Psoriasis
Acne
Urticaria
Blisters
Leg ulcers
Other and not specified**
78
98
53
35
19
10
3
4
91
*Diagnosis following dermatology consultation
** includes where no data entry given
Inflammatory skin disease
(ie: excluding benign skin lesions
and skin cancer)
No. of patients seen according
to diagnostic category*
(*excluding benign lesions, skin cancer and ‘other’)
60
50
40
No. patients
total followup
30
no data
Re-referral
20
New
10
0
Psoriasis
Eczema
Acne
Urticaria
Blisters
Leg Ulcer
Number of follow up appointments
12
10
8
No. of
patients*
Psoriasis
Eczema
Acne
6
Urticaria
Blisters
Leg Ulcer
4
2
0
1
2nd
3rd
4th
5th
6-10.
>10
Number of follow up appointments
(* Total number of follow ups seen in any of 6 diagnostic categories given = 128)
Indications for secondary care*
(*as defined by PCDS/BAD guidelines)
25
20
15
Eczema
Psoriasis
Acne
Urticaria
10
5
0
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ct
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Summary (1)
• Response rate 74%
• 45% of total referrals seen relate to skin tumours
(benign and malignant)
• Of the remaining 55% of patients seen, 29% (n=
114) had eczema, psoriasis and acne
• New to follow up ratios are below national
average
• A significant cohort of high need patients with
skin cancer, psoriasis and eczema are currently
on continued, long term follow up in secondary
care
Summary (2)
• Of those patients falling into one of the 6 primary
diagnostic categories (eczema, psoriasis, acne,
urticaria, blisters, leg ulcer, n= 131)
– 81% fulfilled PCDS criteria for secondary care
– 18% (n=24) no data available/no reason given
– Commonest reasons cited for for secondary care
(across all skin diseases) were
•
•
•
•
Diagnostic uncertainty (30%)
Failure of topicals (23%)
Need for systemic or phototherapy (22%)
Psychological co-morbidity (8%)
Training and education
• 3 year GSTT charity funded bid developed
in collaboration with Lambeth PCT, post
graduate centre (VTS) and St Johns
‘Improving dermatology training for general
practitioners’
• Dermatology Care Module (Nursing and
Midwifery, KCL)
Other Service Developments
• Skin Cancer
– Expansion of specialised dermatologic surgery provision
– Rapid access skin cancer screening clinic
– one of first four services to be integrated into the new cancer
centre (Guys)
• Chronic skin disease
– Day Centre for high need patients
– Nursing: outreach team, nurse consultant
– Chronic disease management pathways
• Paediatric Dermatology
– Paediatric Eczema Clinic
– Paediatric Dermatology to be developed alongside Paediatric
Allergy services
– Eczema education programme
• Capital projects: move of clinical services to Guys
Clinical News!
Biological therapies approved for
psoriasis
T cell
targeted
TNFa
blockers
generic name
brand
name
other
name
skin
alefacept
Amevive
LFA3TIP
+
efalizumab
Raptiva
anti
CD11a
+
etanercept
Enbrel
TNF-R
+
+
infliximab
Remicade
antiTNFa
+
+
adalimumab
Humira
antiTNFa
joints
+
Qualifying clinical categories for
patients with severe disease*
• At risk of developing (or has developed) clinically
important drug-related toxicity
• Intolerant to standard therapy
• Unresponsive to standard therapy
• Disease only controlled by repeated inpatient Rx
• Standard therapy contra-indicated due to co-existent comorbidity
• Life threatening clinical situation
• Associated psoriatic arthritis fulfilling the British Society
of Rheumatology eligibility criteria
*BJD 2005; 153:486-497
Toxicity: Anti TNFs versus Efalizumab
Adverse effect
Anti TNF therapy
(etanercept/infliximab)
Efalizumab
Tuberculosis
Yes – RR 4-8 x
Not reported
Other infections
Yes – listeriosis,
hepatitis (B/C), HIV
Yes
Demyelination
Yes ? RR
? Polyradiculopathy
Cardiac problems
Yes ? RR
Not reported
Thrombocytopenia
No
Yes 1:500 to 1:1000
Drug hepatitis
Yes
No
Disease flare
Not reported
‘efalizumab rash’
? PsA
All infections
? Size of risk
CANCER
? Size of risk
Fewer patients treated overall with efalizumab compared to anti-TNF agents
NICE guidance on skin cancer
• ‘Referral guidelines for suspected cancer’
–
–
–
–
issued June 2005
covers all cancers (98 pages)
includes specific recommendations on skin
www.nice.org.uk/CG027
• ‘Improving outcomes for people with skin
tumours including melanoma’ (IOG)
–
–
–
–
issued February 2006
huge document (177 pages)
www.nice.org.uk
3 years allowed for full implementation from date of
publication
Referral guidelines for suspected
cancer: skin cancer
• Much of the guideline content is
incorporated into the IOG
• Suspected melanomas and SCCs should
be referred urgently (ie 2 week cancer wait
proformas)
• BCCs should be referred non urgently
• Avoid excision of melanoma in primary
care
Referral guidelines for suspected
cancer: pigmented lesions
7 point checklist
Major features (2)
– Change in size
– Irregular shape
– Irregular colour
Minor features (1)
– > 7mm
– Inflammation
– Oozing
– Sensation
Emphasis on observation over 8 weeks prior to referral
for low suspicion lesions
Key Recommendations of Skin
Cancer IOG
MDT working
• Cancer Networks should establish two levels of
skin cancer MDT
– Local hospital based MDT (LSMDT)
– Specialist MDTs based in Cancer Centres (SSMDT).
• All clinicians who treat patients with any type of
skin cancer should be a member of a skin
cancer MDT, whether they work in the
community or in a hospital setting
• Expected attendance for GPs – 4x per year
Who can treat what and where?
Precancerous Lesions (AKs, Bowen’s)
 May be treated and followed up by any GP
 If there is doubt about the diagnosis the patient
should be referred to the local hospital skin
cancer specialist.
Low risk BCC
 May be diagnosed, treated and followed up by a
doctor working in the community who is a
member of the local MDT, or a hospital specialist
(‘normally a Dermatologist’).
Who can treat what and where?
High risk BCC, SCC and MM
• All patients with skin lesions which are
suspicious of these skin cancers, including all
suspicious pigmented lesions and skin lesions
where the diagnosis is uncertain , should be
referred to a hospital specialist (Dermatologist).
• GPs will no longer ‘be allowed’ to treat these
cancers.
High risk BCCs
• Histological subtype
– Morphoiec/infiltrating
– Micronodular
– Basosquamous
• Histological features
– Invasion below dermis
– Perineural invasion
• Site
• Other factors
– Size, immunosuppression
– recurrence