Patient questionnaire-based triage improves outcomes for psoriasis referrals

ABSTRACT

COVID-19 has placed additional demands on a healthcare system that is already overstrained. While the National Health Service has coped extremely well in the face of new pressures, much of the pressure has transferred to a growing backlog of non-COVID outpatient care. Waiting lists have become unwieldy and new dermatology waiting times can be in excess of 18 months. We have developed a novel system to enable our tertiary referral dermatology department to triage rapidly and manage new patients with psoriasis, returning to target levels of activity, with minimum impact on patient care. Newly referred patients with psoriasis were sent a questionnaire, including the Dermatology Life Quality Index (DLQI), to direct their management appropriately. Patients were asked to estimate their affected body surface area using the palm measurements and affected body sites. Patients were also asked which treatment types they would be prepared to accept if offered (phototherapy, systemic therapy), as well as the type of clinic they would find acceptable. The latter included faceto- face only, telephone/video consultation or using a secure skin mobile phone app (MySkinSelfie), whereby photos are securely uploaded for viewing by the doctor but are still controlled by the patient. Of 265 patients, 222 responded (average response time 7 days). In total, 217 were offered an appointment. Thirty-one per cent were seen acutely (2 weeks) and the remainder in routine clinics. Two patients no longer wanted an appointment. An algorithm was used to place patients in appropriate clinics according to their responses. Patients who did not respond to the questionnaire within 4 weeks were sent a reminder letter and then discharged if there was still no reply (17%). Median DLQI was 15, with 63% of patients happy to have a telephone/video consultation, 72% were open to phototherapy, 80% were happy to use the MySkinSelfie App and 34% requested faceto- face appointments only. During the COVID-19 pandemic many dermatology units have had to limit the focus of their work on skin cancer, leaving little time for all but the most urgent patients with inflammatory disease. A previous systematic review and meta-analysis (Singh S, Taylor C, Kornmehl H, Armstrong AW. Psoriasis and suicidality a systematic review and meta-analysis. J Am Acad Dermatol 2017;77 425-40) of 1.7 million patients with psoriasis confirmed an increased risk of suicidal ideation [odds ratio (OR) 2.05] and suicidal behaviour (OR 1.26;Singh et al.), highlighting the importance of managing these patients in a timely manner. General practitioner letters can lack sufficient information on disease severity/ urgency, but our simple model allows the department to streamline referrals quickly, ensures that the patient still wants to be seen and minimizes unnecessary hospital visits. We propose that this approach is considered by other dermatology departments to streamline outpatient waiting lists and accelerate a return to normal activity during the pandemic.