Discussion:
The UK sees an average of 100 000 suspected HNC referrals per year, with a cancer pick up rate of less than 10%. Our preliminary results indicate that >80% of referrals can be triaged out through teleconsultation.
Risk calculators are available for several solid malignancies: these include bladder, brain, breast, colorectal, kidney, lung, oesophagus, ovary, pancreas, prostate and uterus. Some have been externally validated. Unlike other cancers where risk calculators need blood tests and radiology to be performed, the HaNC-RC-V.2 for HNC was generated solely from patient symptomatology and demographics, rendering it suitable for the purpose of teleconsultation and remote triaging. The HaNC-RC-V.2 has a higher AUC than most of the risk calculators published for other cancers 17Usher-Smith et al). As our model was based on recording of symptoms in the secondary care by specialist, it is feasible that the detailed recording of the symptoms during the consultation has helped to achieve higher predictive power than primary care derived models.
The use of telemedicine directed patient care during public health emergencies is well described. However, the use of digital technology in the COVID-19 pandemic across the globe, especially in contact tracing and testing, has been unprecedented. Concurrently, the use of digital solutions for healthcare delivery has been accelerating since the pandemic began. In England, primary care has embraced telemedicine and deploys a new digital first pathway to manage and stream care, with over 90% of consultations being remote. Other examples include a central dashboard to manage bed availability within hospital settings, and use of personalized online screening. A structured approach to remote triaging and generation of a personalized risk probability will allow clinical assessment with a consistency that otherwise cannot be delivered in this environment.
In the emergency setting, an important strategy for healthcare surge control during disaster management is forward triage. In the COVID-19 pandemic model, this involves remote assessment of patients before patients arrive to the emergency care services in the hospital, either in a location proximate to the hospital or via teleconsultation. Emergencies that are unrelated to COVID-19 are triaged to the emergency department while patients showing signs of the virus are separated to prevent transmission. The structured remote use of the risk calculator in the pandemic time is akin to the forward triage, where following appropriate assessment, to prevent a surge when healthcare is rationed, patients considered to be high risk are directed to the specialist for further assessment. Ideally the tool would be used in primary care but for expediency in the current medical crisis and given the fact it is a secondary care derived model it was felt best placed there for triage.
Remote consultations will be a prominent part of the outpatient clinical practice for the near future.
Telehealth services have been promoted actively during the COVID-19 pandemic setting for initial screening of symptomatic patients or those referred for medical care in other specialties and by more than 50 health systems in the USA 18. Structured remote assessment of sick patients has been described in the pandemic era19. Research indicates that with appropriate structure and guidance, a teleconsultation model can be successful20 .
It is very likely that patients will be willing to engage with teleconsultation when face-to-face access to healthcare is restricted. Using internet search volume data from Google Trends, Hong et al21 showed that the US population’s interest in telehealth increased as the number of COVID-19 cases increased, with a strong correlation between population interest and COVID-19 cases reported (r=0.948, P<.001).
Medical decision-making is cognitive, especially as experience accumulates. However, in the early phases of training, when conventional assessment cannot be performed and where there is less opportunity for supervision, a structured telemedical approach, backed up by robust algorithmic approach that has been generated and validated from the population at risk, will be of significant help in reducing anxiety among the clinical team and provider organisation. As always, we would recommend experience and clinical judgement supersede the output on the screen. To the best of our knowledge, this is the first remote structured assessment tool that has been robustly generated, validated and rapidly implemented for use in the HNC setting.