Prospective validation of a virtual clinic pathway in the management of choroidal naevi: the NAEVUS study Report no. 1: safety assessment.

BACKGROUND: Choroidal naevi are a common incidental finding prompting specialist referrals to ocular oncology. Rarely, such lesions have sufficient suspicious features to diagnose a small melanoma. The aim of the study is to show that 'virtual' imaging-based pathways are a safe and efficient option to manage such referrals. METHODS: A prospective cohort study at the Manchester Royal Eye Hospital and Moorfields Eye Hospital between June 2016 and July 2017 of the management decision of 400 patients reviewed by an ophthalmologist in a face-to-face consultation (gold standard) supported by fundus photography, optical coherence tomography, autofluorescence (AF) and B-mode ultrasound. The images were also read independently by blinded graders (non-medical) and blinded ophthalmologists, and a management decision was made based on image review alone (virtual pathway). The two pathways were compared for safety. RESULTS: The agreement for management decisions between face-to-face and virtual pathways was 83.1% (non-medical) and 82.6% (medical). There were more over-referrals in the virtual pathway (non-medical 24.3%, medical 23.3% of gold standard discharge) and only two under-referrals (10.5% of gold standard referrals), both borderline cases with minimal clinical risk. The agreement for risk factors of growth (orange pigment, subretinal fluid, hyper-AF) ranged between 82.3% and 97.3%. CONCLUSIONS: We prospectively validated a virtual clinic model for the safe management of choroidal naevi. Such a model of care is feasible with low rate of under-referral. An over-referral rate of almost 24% from the vitrual pathway needs to be factored into designing such pathways in conjunction with evidence on their cost-effectiveness.

Embedding an economist in regional and rural health services to add value and reduce waste by improving local-level decision-making: protocol for the 'embedded Economist' program and evaluation.

BACKGROUND: Systematic approaches to the inclusion of economic evaluation in national healthcare decision-making are usual. It is less common for economic evaluation to be routinely undertaken at the 'local-level' (e.g. in a health service or hospital) despite the largest proportion of health care expenditure being determined at this service level and recognition by local health service decision makers of the need for capacity building in economic evaluation skills. This paper describes a novel program - the embedded Economist (eE) Program. The eE Program aims to increase local health service staff awareness of, and develop their capacity to access and apply, economic evaluation principles in decision making. The eE program evaluation is also described. The aim of the evaluation is to capture the contextual, procedural and relational aspects that assist and detract from the eE program aims; as well as the outcomes and impact from the specific eE projects. METHODS: The eE Program consists of a embedding a health economist in six health services and the provision of supported education in applied economic evaluation, provided via a community of practice and a university course. The embedded approach is grounded in co-production, embedded researchers and 'slow science'. The sites, participants, and program design are described. The program evaluation includes qualitative data collection via surveys, semi-structured interviews, observations and field diaries. In order to share interim findings, data are collected and analysed prior, during and after implementation of the eE program, at each of the six health service sites. The surveys will be analysed by calculating frequencies and descriptive statistics. A thematic analysis will be conducted on interview, observation and filed diary data. The Framework to Assess the Impact from Translational health research (FAIT) is utilised to assess the overall impact of the eE Program. DISCUSSION: This program and evaluation will contribute to knowledge about how best to build capacity and skills in economic evaluation amongst decision-makers working in local-level health services. It will examine the extent to which participants are able to improve their ability to utilise evidence to inform decisions, avoid waste and improve the value of care delivery.

Ultra-wide-field imaging assessment of small choroidal pigmented lesions using red and green colour channels.

BACKGROUND: Diagnosis of small choroidal melanoma is mainly based on tumour thickness, subretinal fluid, or lipofuscin pigment. Ultra-wide-field imaging (UWF) allows depiction of choroidal lesions through a red (RC) and a green channel (GC). Aim of the study was to determine the utility of this tool in the detection of small choroidal melanoma. METHODS: Retrospective cross-sectional study of patients with small choroidal pigmented lesions up to 3 mm in thickness. All patients underwent clinical and imaging assessment including UWF. Lesions were subcategorized based on thickness and lesion type. A qualitative assessment ensued using the red and green channels feature. RESULTS: A total of 152 patients were included. Melanotic naevi (76/152,50%) and small choroidal melanomas (55/152,36%) were the predominant types. Thickness was <1 mm in 30% (46/152), 1-2 mm in 46% (70/152) and 2-3 mm in 24% (36/152) of cases. Two distinct imaging patterns were noted: dark on RC/undetectable on GC and dark on RC/light on GC. In melanotic naevi the dark on RC/light on GC pattern was significantly associated with increased tumour thickness (p = 0.006) and the presence of lipofuscin (p < 0.001) suggesting a potential prognostic significance. In small melanomas such an association was not established. The majority of small melanomas manifested a dark on RC/undetectable on GC pattern despite the presence of subretinal fluid and lipofuscin. CONCLUSIONS: UWF imaging of choroidal pigmented tumours with red-green channels revealed two distinct patterns. The dark on RC/light on GC pattern was more common in suspicious melanotic naevi, but not in small melanomas. The use of red-green channels is not a reliable diagnostic tool in the early detection of small melanomas.

Effective control of SARS-CoV-2 transmission between healthcare workers during a period of diminished community prevalence of COVID-19.

Previously, we showed that 3% (31/1032)of asymptomatic healthcare workers (HCWs) from a large teaching hospital in Cambridge, UK, tested positive for SARS-CoV-2 in April 2020. About 15% (26/169) HCWs with symptoms of coronavirus disease 2019 (COVID-19) also tested positive for SARS-CoV-2 (Rivett et al., 2020). Here, we show that the proportion of both asymptomatic and symptomatic HCWs testing positive for SARS-CoV-2 rapidly declined to near-zero between 25th April and 24th May 2020, corresponding to a decline in patient admissions with COVID-19 during the ongoing UK 'lockdown'. These data demonstrate how infection prevention and control measures including staff testing may help prevent hospitals from becoming independent 'hubs' of SARS-CoV-2 transmission, and illustrate how, with appropriate precautions, organizations in other sectors may be able to resume on-site work safely.

Hunter and New England HealthPathways: a 4-year journey of integrated care.

Objective This paper describes the 4-year journey of Hunter and New England HealthPathways - a password-protected web-based portal designed to provide localised evidence-informed clinical and referral information to support general practice at the point of care. Methods A process evaluation was conducted in 2013, with a case study comparison performed in 2014 to assess impact of HealthPathways on patient referral and access to specialist care, followed by a review in 2016 of utilisation of the online portal to assess whether healthcare providers continued to access HealthPathways. Results Increased utilisation was correlated with an increase in the number of pathways published online. Clinical leadership and the process of developing pathways built relationships between primary care and specialist teams. Case studies indicated that a comprehensive approach to pathway implementation accompanied by service redesign resulted in higher pathway use and improved access to specialist care. Senior management support and a formal partnership between major health care providers led to strong governance of HealthPathways and the delivery of other integrated care initiatives. There was significant growth in utilisation over the 4 years, increasing to an average of 6679 sessions per month in 2016 and more general practices reported use of HealthPathways. Conclusions HealthPathways is a vehicle for building strong foundations to support system change and integrated care. The critical elements for acceptability, growth and sustainability are the strong relationships between primary care and specialist clinicians, as well as formal partnerships that are built from the processes used to develop HealthPathways. What is known about the topic? HealthPathways and similar web-based evidence-informed guidelines aimed at improving system integration are increasing in Australia. There are few published papers that describe approaches to inform the ongoing implementation of such programs. What does this paper add? This paper describes iterative methodology for evaluating complex programs, such as HealthPathways, that identifies the critical factors required to build sustainable models of integrated care. What are the implications for practitioners? The 4-year experience of Hunter and New England HealthPathways provides an approach to improve the implementation, sustainability and spread of similar programs and associated integrated care initiatives.

Management of choroidal naevomelanocytic lesions: feasibility and safety of a virtual clinic model.

BACKGROUND: Choroidal naevomelanocytic lesions are often identified as an incidental finding by community optometrists and referred for expert evaluation in hospital eye units or specialist ocular oncology centres. Optimal management strategy is undecided and most centres err on the side of caution. Our aim was to test a virtual model of service delivery relying on interpretation of imaging test results by non-medically trained graders. METHODS: Patients with naevomelanocytic lesions referred to Manchester Royal Eye Hospital and Moorfields Eye Hospital were retrospectively included in this study. All patients underwent imaging tests including optical coherence tomography and ultrasound and management was subsequently decided clinically. Images were anonymised and transferred to the Moorfields Eye Hospital Reading Centre and were reviewed by a trained, masked grader who reached a management decision on the basis of a specific grading protocol. Agreement between decisions made on the basis of clinical examination and imaging ('gold standard') by an expert ophthalmologist in the clinic was compared with the decisions made by a masked ophthalmologist and a masked non-medical grader based on imaging tests alone. RESULTS: There were 102 consecutive patients included in this study. Agreement between gold-standard clinical management and decisions made by masked, non-medical grader and masked ophthalmologist on the basis of imaging test results alone was 96.1% (κ=0.97) and 100%, respectively. CONCLUSIONS: In this pilot study, a streamlined, dedicated, virtual service for rapid assessment (within 2 weeks of referral) of choroidal naevomelanocytic lesions was shown to be feasible and safe. Such a model of service delivery may prove cost-efficient while optimising patient experience. Further prospective studies are required for formal validation of the proposed service model.

The status of billing and reimbursement in pediatric obesity treatment programs.

Pediatric psychologists provide behavioral health services to children and adolescents diagnosed with medical conditions. Billing and reimbursement have been problematic throughout the history of pediatric psychology, and pediatric obesity is no exception. The challenges and practices of pediatric psychologists working with obesity are not well understood. Health and behavior codes were developed as one potential solution to aid in the reimbursement of pediatric psychologists who treat the behavioral health needs of children with medical conditions. This commentary discusses the current state of billing and reimbursement in pediatric obesity treatment programs and presents themes that have emerged from discussions with colleagues. These themes include variability in billing practices from program to program, challenges with specific billing codes, variability in reimbursement from state to state and insurance plan to insurance plan, and a general lack of practitioner awareness of code issues or reimbursement rates. Implications and future directions are discussed in terms of research, training, and clinical service.

Assessment of older drivers in New Zealand: the current system, research and recommendations.

The purpose of this article is to clarify the current New Zealand driving licensing requirements for older adults and to provide practical recommendations for those health professionals who make decisions regarding driving ability in older adults. Health professionals involved in the assessment of older drivers were asked to clarify areas where more efficient use could be made of assessment resources. A review of driving literature was performed to find specific factors associated with increased risk of negative driving outcomes in older adults. Particular attention was paid to the suitability of different types of on-road assessment for certain patient groups, the effect of specific diseases and medications on driving safety, and the effect of cognitive impairment. A list of seven recommendations were compiled which include a focus on appropriate on-road driving assessment referral, driver refresher courses, cognitive screening for those presenting for licence renewal and sensitive broaching of the topic of driving cessation.

Morbidity trends in the population of a specialised homeless primary care service.

An increasing body of research demonstrates that homelessness is an independent risk factor for morbidity and premature death. This paper compares the frequency of diagnoses between 2003 and 2009 in the computerised records of a specialist practice for homeless people. The changing morbidity trends revealed offer a basis for comparison with other services and suggest benefits from collaborative working, particularly around substance misuse and mental health.

Ensuring safe and appropriate discharge for people who are homeless or in housing need.

Inappropriate admission and discharge practice is common for homeless and vulnerably housed people. This article outlines the key points from protocol guidance and details some Department of Health case studies, highlighting the essential practice points for nurses.