Patient Pathway: Dermatology Subgroup: Acne, Infections, Infestations, Misc Evidence table covering: Miscellaneous

V3

Author

Year

Study type

Population

Summary of Paper

Comments

QMC Nottingham

Revie w by 2003

Guidance document

UK

English J, Lawton S, Mc William J, Wildgust L, and the Dermatology Liaison Team. QMC Nottingham

2003

Report

UK

Gives a referral pathways in algorithm format for the management of children and young people during the dermatological nursing assessment. Development process. - Report of the implementation of a nurse led teledermatology service and GPwSI service in PCTs in Nottingham. Data reported: demographics, referral numbers, appointment outcomes, referral to secondary care services, treatments, consultant workload, reply time and diagnosis, factors responsible for the reduction on waiting times and user satisfaction and costing. Summary: . Clinics were provided in PCT health centres and GP premises in prominent locations . Waiting times were down form 20 to 13 weeks . GP satisfaction with the service was high . Patient Pathways were developed . Education of local clinicians on the management of chronic dermatological conditions is ongoing . Patient satisfaction has been high for both services (nurse led and GPwSI clinics) - Report about the partnership with the software supplier and other departments when implementing the telemarque telemedicine system. An example is enclosed.

No methodology stated No references stated Based on clinical expertise See appendix Misc 1 for algorithm See Appendix Misc 2A, 2B for referral criteria for Nurse specialist clinic and GPwSI and patient journey

Guidance document

UK

Gives us all journey of care from first symptom presented to secondary care. Pathways options included: GP, and 4 possible care pathways within secondary care service (See and Treat Clinic, rapid access to Disease Specific Nurse-led Clinic, Primary Care Clinic – primary care dermatology practitioner, dermatology specialist nurse- , Secondary Care Service)

Development process not stated. See Appendix Misc 3 for Algorithm

West Herts NHS Trust

Patient Pathway: Dermatology Subgroup: Acne, Infections, Infestations, Misc Evidence table covering: Miscellaneous

V3

Author

Year

Study type

Population

Summary of Paper

Comments

NHS Modernisation Agency

2003

Guidance document

UK

Developed by a group of experts.

British Association of Dermatologists (BAD)

2004

Guidance document

UK

British Association of Dermatologists (BAD)

Dec 2002

Guidance document

UK

The Action On Good Practice Guide give us information about: - overview of the Dermatology Services within each Acute and Primary Care Trusts - An optimised Dermatology Service is described with Pathways of Care. - Key elements of Skin Care Service providers. Roles and Skills required are described for community pharmacists, family doctor services, GPwSI, hospital services, Nurse-led services. Also highlight the importance of communication between the various service elements and the development of guidelines in partnership within primary and secondary care. Gives advice in performance assessment and the importance of benchmarking. Enclose a summary of the pilot sites projects. Gives us information of the necessary staffing and facilities to run a dermatology service. - Roles and Skills are defined for Consultant Dermatologists (and ratio needed per population), Specialist Registrars, Non-Consultant Career Grade Doctors Associate Specialists, Staff Grade Dermatologists, Clinical Assistant and Hospital Practitioners in Dermatology, Senior House Officers, GP Senior Registrars, Dermatology Nurses, Secretarial and Support Staff, General Practitioners Providing Dermatology Services. - Advice on facilities for Core Services and Special Services. Gives a definition of role and skills required for a GPwSI service

Development process not stated. References stated. Developed by group of experts.

Development process not stated.

Patient Pathway: Dermatology Subgroup: Acne, Infections, Infestations, Misc Evidence table covering: Miscellaneous

Author

V3

Year

Study type

Population

Summary of Paper

Comments

2001

Systematic Review

UK

Evidence based recommendations. References stated.

United Bristol Healthcare NHS trust

Guidance document

UK

Topical Photodynamic Therapy (PDT) Gives a description of the method of action, drug protocols and delivery, light sources and dosimetry, indications for its use in Actinic Keratoses, Bowen’s disease, Basal cell carcinoma, Squamous cell carcinoma. Indications of applications for topical 5-aminolaevulinic acid-photodynamic therapy other than in non-melanoma skin cancer: Warts, Acne, Psoriasis, Cutaneous T-cell lymphoma). Also it addresses to adverse effects for acute, chronic and Carcinogenicity as well as safety aspects of PDT Gives information about the links between primary and secondary care.

NHS Lothian

Guidance document

Scotland

Email Request form for Dermatology advice Gives information about the data required when requesting advice to secondary care Patch testing. This paper gives information about the reasons for referral for Patch Testing, reports about the method used and resources available. The mean waiting time found for a patch test appointment was 4.5 months. This study reports a collection and analysis of Region wide data for Dermatology services. It describes the activity of the dermatology services with the most common seen in secondary care (new and review patients).

Based in clinical experience. See Appendix Misc 5

Morton, et all (BAD)

C.A

Contact Dermatitis Investigation Unit

2000

Survey

Scotland N=82 (consultants, trainees, others)

Stevenson C; CharlesHolmes,S; Shrank A

1991

Case series

N=2940 patients Consultant Dermatologists =20 UK

See Appendix Misc 4 for the map of integrated care model

See Appendix Misc 6 for main conditions for referral

See Appendix Misc 7 for the 10 most common conditions referred to secondary care.

Patient Pathway: Dermatology Subgroup: Acne, Infections, Infestations, Misc Evidence table covering: Miscellaneous

V3

Author

Year

Study type

Population

Summary of Paper

Comments

Hill,V.A; Wong E; Hart C.J.

2000

Case series

1991

Survey

O’Cathanin A;Brazier J.E.; Milner P.C.; Fall M

1992

Case-Control

N=88 (patients from general practice setting). N=105 (patients from hospital). 5 General Practices were involved in this project.

Peters J

1999

Report

UK

Smith F.C.; Gwynn B.R;

1995

Audit to assess the impact of the guidelines implemented in Primary Care. Results: 40% increase in the number of appropriate referrals immediately after introduction of the guidelines, but this was not sustained 2 years later. Conclusions: there is a need for continued general practitioner education in dermatology to reinforce referral guidelines. Aim: To assess the effect of pressure from patients on patterns of general practitioners’ outpatient referrals. Results: Pressure was greater for patients referred privately and for those referred for reassurance. Aim: to study the cost effectiveness of minor surgery in general practice in comparison with hospital practice. Results: General practice patients had shorter waiting times between referral and treatment; spent less time and money attending for treatment; more of them were satisfied with their treatment; the cost of a procedure undertaken in general practice was less than in hospital (only applies where general practice is a substitute for the hospital setting and not an additional activity);GP sent a smaller proportion of specimens to a histopathology laboratory than hospital doctors (61% vs 90%); incorrectly diagnosed a larger proportion of malignant conditions as benign (10% vs 1%) and inadequately excised 5% of lesions where this never happened in hospital. This paper reports on the role of the Dermatology Nurse Practitioner and the Community Dermatology Liaison Nurse. This study evaluate the Direct Access Surgery (DAS) programme, which allows GP to refer patients directly to hospital for surgical operation without attending the outpatient department. Results: During the first month of the study 105 cases were referred for DAS. This corresponds the 26% of general surgical referrals from the involved general practices.

See Appendix Misc 8 for referrals guidelines.

Armstrong D; Fry J; Armstrong P

UK N=54 (1st assessment) N=28 (2nd assessment) N=54 (follow up assessment) UK N = 122 (GP)

UK 4 GP practices

See Appendix Misc. 9 for reasons for referral and pressure to refer. See Appendix Misc.10 for conditions treated in both setting and outcome of histopathology tests on samples from the two settings

See Appendix Misc. 11 for a description of the roles. References stated. See Appendix Misc. 12 for categories deemed suitable for DAS and a bar chart showing the operations carried out for DAS.

Patient Pathway: Dermatology Subgroup: Acne, Infections, Infestations, Misc Evidence table covering: Miscellaneous

V3

Author

Year

Study type

Population

Summary of Paper

Comments

Appleby A; Lawrence C

2001

Case Study

UK

Basarab T; Munn S.E.; Jones R. Russell

1996

Cohort Study

N=686 patients N=162 GPs

See appendix Misc. 13 for the summary of successful and unsuccessful initiatives. Also for referrals to 2o exclusions. References stated. See Appendix Misc. 14 for GP referrals and diagnostic accuracy.

Harlow,E.D; Burton, J.L

1996

Survey

N=340 GPs UK

This study reports the experience of a Dermatology Service Redesign . Result: GP referral guidelines reduced the number of new patients referred by approximately 12% Aim: To study the appropriateness of GP referrals to a dermatology out-patient clinic. Also the GP’s diagnostic accuracy. Results: - 31% patients were referred for diagnostic reasons. - 37% patients required referral for management reasons. - 21% patients seen for a once only visit requiring no specialist diagnostic or therapeutic procedures. - 11% patients referred who had complaints which could have been managed in 1o (with facilities such as curettage, shave biopsy and cryotherapy) Aim: To study the proportion and type of GP referrals and how the GPs want that help delivered . Results: - Reasons for referral: 86.3% of GPs referred because a lack of knowledge, 29% because a lack of facilities, 7% because a lack of time, 10% because the patient’s insistence on seeing a specialist. - Referral rates: 47% they managed nearly all skin problems themselves, 47% managed about three quarters, 5% managed half, 0.3% less than a half. - 2o care services needed: 84% preferred their patients to have a short contact rather than long-term follow up, 79% found most useful the diagnostic help and advice on management, 27% preferred the telephone advice without a referral, 80% found that a wait of more than 10 weeks after the referral letter was posted was unacceptable. (% based on the number (n) of responses to each question).

References stated. See Appendix Misc. 15 for priorities given by GPs for various facilities.

Patient Pathway: Dermatology Subgroup: Acne, Infections, Infestations, Misc Evidence table covering: Miscellaneous

V3

Author

Year

Study type

Population

Summary of Paper

Comments

Medicines Healthcare products Regulatory Agency Medway NHS trust (Dermatology Action On

2004

Report

UK

Nurse prescribers extended formulary. Provides a list of drugs that nurses can prescribes.

See Appendix Misc. 16 for list of skin diseases nurses can prescribe.

2001

Guidance document

UK

Referral document This document gives the information required when referring to secondary care.

2001

Guidance document

UK

Emolients / Efudix Cream This document gives information for patients for the above treatments.

Development process. The guidelines were developed working in partnership with GPs in six local PCGs. Education for GP and GPwSI was provided for their implementation and a group of GPs was set up for auditing their practice. See Appendix Misc. 17 for referral letter. Development process. The guidelines were developed working in partnership with GPs in six local PCGs. Education for GP and GPwSI was provided for their implementation and a group of GPs was set up for auditing their practice.

Medway NHS trust (Dermatology Action On

Patient Pathway: Dermatology Subgroup: Acne, Infections, Infestations, Misc Evidence table covering: Miscellaneous

V3

Author

Year

Study type

Population

Summary of Paper

Comments

SIGN

1998

Guideline

Scotland

Recommended Referral Document Reports on the information necessary for both routine and elective referrals and referrals made in an emergency or acute situation.

NHS-Scotland

2003

Guidance document

Scotland

NHS-Scotland

2003

Guidance document

Scotland

NHS-Scotland

2003

Guidance document

Scotland

NHS-Scotland

2003

Guidance document

Scotland

Oral / Topical PUVA . UVB – Patient information Provides general information for patients regarding the above treatment. Photonet – Patient information Provides general information for patients about the National Managed Clinical Network for Phototherapy. Photonet This document gives standards for Phototherapy. Reports about referrals, patient information, treatment, assessment, discharge and follow up. Also patient information. Photonet This document provides treatment protocols for UVA, PUVA

Developed by a multidisciplinary working group. Evidence-based recommendations. References stated. See Appendix Misc. 18A, 18B, 18C, 18D referral letter. Developed by a group of experts Developed by a group of experts See Appendix Misc. 19A, 19B for more information about referral and follow up