Résumé
The Sickle Cell Society have issued standards for additional immunisations that adults with sickle cell disease (SCD) require. These include annual influenza, 5-yearly pneumococcal conjugate vaccine (PPV23) and Hepatitis B vaccination. Patients who have not received their primary vaccination as part of the national schedule in the UK should also receive further additional vaccines. We reviewed whether adults with SCD in South Wales currently receive these. 49 adult patients were identified as having SCD under the care of the Hereditary Anaemia Service based in the University Hospital of Wales, Cardiff. GP records were not available for 5 patients leaving a final cohort of 44 patients to analyse. Average age was 33 years (range 17-67). Median age was 27 with the cohort predominantly lying in the 17-29 year category (52%). Results showed good compliance with the annual influenza vaccine in those over 40 (>80%). However, compliance for the 17-29 category and 30-39 categories were 37.5% and 42.8%, respectively. The improved compliance in those >40 was not seen with the 5-yearly pneumococcal vaccine. Compliance was worse in all age groups compared to the annual flu vaccine with only 23% compliance overall. However, when looking at those who had received a single dose of PPV23, the numbers improved to nearly 60%. Compliance with the SARS-CoV2 vaccination was highest at 61.3%. However, rates were lower in the 17-29 and 30-39 age groups in keeping with previous trends. Only 34.1% of patients had full hepatitis B cover. Again, trends in compliance mirrored previous with poorer rates in those under 40. Assessing compliance for the remainder of the standards was more challenging given that we could not confirm retrospectively how many of our cohort had received their primary vaccinations in other parts of the UK, thought to be around half. However, most of the cohort had not received any additional vaccines suggesting high non-compliance regardless. This review looked at data from 2020 and likely reflects the impact of the SARS-CoV2, whether positive or negative. The reduced compliance in 5-yearly pneumococcal compared to flu suggest better health-professional education is needed;if patients are attending for their annual flu vaccine, there is ample opportunity to administer other vaccines. The vaccination rate for our patient group is comparable to national rates by ethnicity although lower than the national average for age. Vaccination rates for the SCD population of South Wales are not adequate. Better education and engagement is needed.
Résumé
In our hospital we receive about 200 skin 2-week wait (2WW) referrals weekly. This is a huge burden on local services. Many of these patients are discharged at the first appointment, and, for a significant proportion of referrals, the 'level of cancer concern' on the general practitioner (GP)-provided 'suspected skin cancer referral form' is rated: 'I'm unsure, it might well be cancer but there are other equally plausible explanations'. In collaboration with secondary care and community stakeholders, an innovative pilot using an optional teledermatology advice and guidance process (A&G) was implemented as a complementary pathway for patients in two large GP practice networks. Conventional 2WW faceto- face referrals could be initiated as normal;however, at the GP's discretion an alternative teledermatology e-triage A&G pathway was introduced for lesions equivocal for malignancy. A model where healthcare assistants (HCAs) maintained a weekly clinic in each of the practices was designed and implemented. The HCA received training and undertook a lesion history via proforma and macroscopic and dermatoscopic photographs, which were subsequently uploaded to the National Health Service e-referral service. A consultant dermatologist reviewed the A&G e-triage request within 72 h and either provided advice or recommended 2WW referral, which was then actioned via the outpatient appointment centre, without further need for GP action. The pilot commenced in November 2021. Over 2 months (November-December 2021 inclusive) 101 e-triage A&G requests were made and 212 conventional 2WW face-to-face referrals. Of the A&G e-triage requests 70 (69.3%) were returned with advice and the patient did not require onward referral. In total 70/313 (22.4%) of the skin lesion episodes were retained in primary care with advice. Since the initiation of the pilot, there are signs that A&G requests and 2WW referrals are changing, with increased uptake in A&G e-triage. Comparing the referral behaviours of the two practice networks before and after the pilot is a challenge given the short period of the pilot and the event of COVID-19 on referral patterns. However, in November- December 2019 (pre-community COVID-19 in the UK), the two practices sent 201 2WW referrals juxtaposed with 212 intrapilot (November-December 2021). This demonstrates a more sustainable number of 2WW referrals and in keeping with previous levels at a period when locally skin 2WW referrals are increasing. Fiscally, given that many of the A&G e-triage requests would have resulted in a face-to-face 2WW referral a cost saving has been made. Our interim data demonstrate the development and implementation of an optional A&G e-triage pathway as an alternative approach for equivocal lesions and it has resulted in retention of 22.4% of would-be 2WW referrals in primary care. Community stakeholders and engagement has been crucial for the project. Our 6-month pilot data will be presented.