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Right Decision Service newsletter: April 2024

Welcome to the Right Decision Service (RDS) newsletter for April 2024. 

Issues with RDS and Umbraco access

Tactuum has been working hard to address the issues experienced during the last week. They have identified a series of three mitigation measures and put the first of these in place on Friday 3rd May.  If this does not resolve the problems, the second mitigation will be actioned, and then the third if necessary.

Please keep a lookout for any slowing down of the system or getting locked out. Please email myself, mbuchner@tactuum.com and onivarova@tactuum.com if you experience any problems, and also please raise an urgent support ticket via the Support Portal.

Thank you for your patience and understanding while we achieve a full resolution.

Promotion and communication resources

A rotating carousel presenting some of the key RDS tools and capabilities, and an editable slideset, are now available in the Resources for RDS providers section of the Learning and Support toolkit.

Redesign and improvements to RDS

The redesign of RDS Search and Browse is still on-track for delivery by mid-June 2024. We then plan to have a 3-week user acceptance testing phase before release to live. All editors and toolkit owners on this mailing list will be invited to participate in the UAT.

The archiving and version control functionality is also progressing well and we will advise on timescales for user acceptance testing shortly.

Tactuum is also progressing with the deep linking to individual toolkits within the mobile RDS app. There are several unknowns around the time and effort required for this work, which will only become clear as the work progresses. So we need to be careful to protect budget for this purpose.

New feature requests

These have all been compiled and effort estimated. Once the redesign work is complete, these will be prioritised in line with the remaining budget. We expect this to take place around late June.

Evaluation

Many thanks to those of you completed the value and impact survey we distributed in February. Here are some key findings from the 65 responses we received.

Figure 1: Impact of RDS on direct delivery of care

Key figures

  • 93% say that RDS has improved evidence-informed practice (high impact 62%; some impact 31%)
  • 91% report that RDS has improved consistency in practice (high impact 65%, some impact 26%)
  • 85% say that RDS has improved patient safety (high impact 59%, some impact 26%)
  • Although shared decision-making tools are only a recent addition to RDS, and only represent a small proportion of the current toolset, 85% of respondents still said that RDS had delivered impact in this area (53% high impact, 32% some impact.) 92% anticipate that RDS will deliver impact on shared decision-making in future and 85% believe it will improve delivery of personalised care in future.

Figure 2 shows RDS impact to date on delivery of health and care services

 

Key figures

These data show how RDS is already contributing to NHS reform priorities and supporting delivery of more sustainable care.

Saving time and money

  • RDS clearly has a strong impact on saving practitioner time, with 90% of respondents reporting that this is the case. 65% say it has a high impact; 25% say it has some impact on time-saving.
  • It supports devolved decision-making across the multi-professional team (85% of respondents)
  • 76% of respondents confirm that it saves money compared, for example, to investing in commercial apps (54% high impact; 22% some impact.)
  • 72% believe it has impacted already on saving money and reducing waste in the way services are delivered – e.g. reducing costs of referral management, prescribing, admissions.

Quality assurance and governance

  • RDS leads are clear that RDS has improved local governance of guidelines, with 87% confirming that this is the case. (62% high impact; 25% some impact.)

Service innovation and workforce development

  • RDS is a major driver for service innovation and improvement (83% of respondents) and has impacted significantly on workforce knowledge and skills (92% of respondents – 66% high impact; 26% some impact).

New toolkits

A few examples of toolkits published to live in the last month:

Toolkits in development

Some of the toolkits the RDS team is currently working on:

  • SARCS (Sexual Assault Response Coordination Service)
  • Staffing method framework – Care Inspectorate.
  • SIGN 171 - Diabetes in pregnancy
  • SIGN 158 – British Guideline on Management of Asthma. Selected sections will be incorporated into the RDS, and complemented by a new chronic asthma pathway being developed by SIGN, British Thoracic Society and NICE.
  • Clinical pathways from NHS Fife and NHS Lanarkshire

Please contact his.decisionsupport@nhs.scot if you would like to learn more about a toolkit. The RDS team will put you in touch with the relevant toolkit lead.

Quality audit of RDS toolkits

Thanks to all of you who have responded to the retrospective quality audit survey and to the follow up questions.  We still have some following up to do, and to work with owners of a further 23 toolkits to complete responses. An interim report is being presented to the HIS Quality and Performance Committee.

Implementation projects

Eight clinical services and two public library services are undertaking tests of change to implement the Being a partner in my care app. This app aims to support patients and the public to become active participants in Realistic Medicine. It has a strong focus on personalised, person-centred care and a library of shared decision aids, as well as simple explanations and videoclips to help the public to understand the aims of Realistic Medicine.  The tests of change will inform guidance and an implementation model around wider adoption and spread of the app.

With kind regards

Right Decision Service team

Healthcare Improvement Scotland

Actinic keratosis

Warning

Focal areas of abnormal keratinocyte proliferation and differentiation induced by chronic exposure to ultraviolet radiation. Initially flat scaly papules, on sun-exposed sites, they may become significantly elevated from the skin surface, which may progress to frank carcinoma in situ or invasive squamous cell carcinoma. In patients with 10 or more AK there is a 10-15% risk of development of squamous cell carcinoma (SCC) at some stage. Prevalence is likely underestimated, as AK is difficult to measure reliably in individuals and populations. Limited UK studies showed 19-24% of individuals aged >60 had at least 1 AK. AKs were also present in 3-6% of men aged 40-49 years; linear increase in AKs shown between 60-80 years in men but not women; rate of AKs estimated at 149 per 1000 person-years.

Not all treatment options may be listed in this guidance. Please refer to local formulary for a complete list.

Treatment/ therapy

Mild: flat, pink patch with slight scale or rough to touch  

  • Advise all patients on use of sun protection and emollients.

For lesion and field treatment for isolated or scattered AK with no suspicious features: 

  • Topical Fluorouracil 5% (Efudix) cream apply BD for 3-4 weeks.  
  • Actikerall (0.5% 5FU/10% salicylic acid solution) apply once daily for 6-12 weeks, useful for hyperkeratotic AKs. 
  • Imiquimod cream 5% applied 3 x weekly for 4 weeks or 3.75% cream applied od for 2 weeks repeated after 2 weeks. 
  • Diclofenac sodium (Solaraze) apply BD for 60-90 days. 

Counsel patient regarding side effects of chosen treatment 

 

Moderate: larger numbers of moderately thick keratotic red patches that are easily felt and seen 

  • Advise all patients on use of sun protection and emollients. 
  • Topical Fluorouracil 5% (Efudix) cream apply BD for 3-4 weeks.  
  • Imiquimod cream 5% applied 3 x weekly for 4 weeks or 3.75% cream applied od for 2 weeks repeated after 2 weeks. 
  • Actikerall (0.5% 5FU/10% salicylic acid solution) apply once daily for 6-12 weeks, useful for hyperkeratotic AKs 
  • Tirbanibulin (Klysiri) applied once daily for 5 consecutive days. 
  • Counsel patient regarding side effects of chosen treatment 
  • Cryotherapy for isolated hypertrophic lesions. 
  • Curettage or shave excision with histology sent for confirmation of diagnosis and to rule out early SCC. 
  • Surgical excision for individual keratoses that are symptomatic or have a thick hard surface scale. 
  • Photodynamic therapy [PDT] (refer to secondary care service) test

 

Severe: Any of the following high-risk factors: Thick AK with indurated base, growing rapidly, tender bleeding, ulcerating  

  • Advise all patients on use of sun protection and emollients. 
  • Rapid growth, an indurated base, ulceration (in the absence of topical therapy) could suggest SCC rather than AK. Topical treatment should only be commenced with specialist advice. 

Referral Management

Mild: flat, pink patch with slight scale or rough to touch  

Manage in primary care. Seek advice and guidance where there is diagnostic uncertainty.  

Many actinic keratosis can become tender/ulcerated during topical treatment but this should improve with topical steroid or cessation of treatment. Consider SCC if it does not. 

Suspect SCC if a lesion develops a thickened painful base or ulcerates. 

 

Moderate: larger numbers of moderately thick keratotic red patches that are easily felt and seen 

Seek advice and guidance if there is diagnostic uncertainty.  

Refer to secondary care if there is failure of response to one cycle of treatment (requires biopsy) or if multiple / relapsing AKs represent a management challenge. 

Many actinic keratoses can become tender/ulcerated during topical treatment but this should improve with topical steroid or cessation of treatment. Consider SCC if it does not. 

Suspect SCC if a lesion develops a thickened painful base or ulcerates. 

 

Severe: Any of the following high-risk factors: Thick AK with indurated base, growing rapidly, tender bleeding, ulcerating  

Tender, thickened, ulcerated or enlarging actinic keratoses, may be suspected SCC and should be referred on the USOC pathway. 

High risk patient factors: past history of skin cancer, extensive UV damage, immunosuppressed, very young, more than 10 AKs, high-risk site i.e. ear or lip. Advise a lower threshold for referral in this group. 

Clinical tips

  • Options for treatment of AKs in primary care are Efudix, Actikerall, Imiquimod and Solaraze. All treatments cause an inflammatory reaction; the efficacy is largely in proportion to the reaction. The reaction for Solaraze is less.  
  • If there is significant inflammation, you can reduce treatment e.g. to once daily, or pause treatment and consider a topical steroid e.g. Eumovate. 
  • Treatment for thicker lesions includes cryotherapy, curettage & cautery, surgical excision and PDT.  
  • Refer routinely for AKs if failure to respond to standard treatments.  
  • Refer urgently via USOC pathway for all tender, thickened, enlarging, bleeding or ulcerated AKs, particularly in high-risk sites. Studies suggest treatment of field change in high-risk patients may lessen risk of SCC. 
  • If high risk patient (past history of skin cancer, extensive UV damage, immunosuppressed, very young) consider referral to secondary care. 
  • Once a person develops actinic keratoses they have commenced a chronic disposition to UV-pathology and should consider sun protection and self-examination for potential skin cancers. Those with multiple AK and skin cancers may be candidates for nicotinamide prophylaxis. 

ICD search categories

Benign 

ICD11 code - EK90 

Editorial Information

Last reviewed: 01/04/2023

Next review date: 01/04/2025

Author(s): Adapted from the BAD Referral Guidelines.

Version: BAD 1

Co-Author(s): Publisher: Centre for Sustainable Delivery, Scottish Dermatological Society.

Approved By: Scottish Dermatological Society