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.