Diagnostic yield of a one-stop neck lump clinic

Delivering a net zero National Health Service: where does otorhinolaryngology - head and neck surgery stand?

OBJECTIVE

The National Health Service (NHS) recognised the risk to public health brought by climate change by launching the Greener NHS National Programme in 2020. These organisational changes aim to attain net zero direct carbon emissions. This article reviews the literature on initiatives aimed at mitigating the environmental impact of ENT practice.

METHOD

Systematic review of the literature using scientific, healthcare and general interest (public domain) databases.

RESULTS

The initiatives reviewed can be broken down into strategies for mitigating the carbon footprint of long patient stay, use of operative theatres and healthcare travel. The carbon footprint of in-patient stay can be mitigated by a shift towards day-case surgery. The ENT community is currently focused on the reduction of theatre waste and the use of disposable instruments. Furthermore, supply chains and healthcare delivery models are being redesigned to reduce travel.

CONCLUSION

Future areas of development include designing waterless theatre scrubs, waste-trapping technologies for anaesthetic gases and a continuing investment in virtual healthcare.

The Adult Neck Mass: Predictors of Malignancy

OBJECTIVE

Distinguishing benign from malignant adult neck masses can be challenging because data to guide risk assessment are lacking. We examined patients with neck masses from an integrated health system to identify patient and mass factors associated with malignancy.

STUDY DESIGN

Retrospective cohort.

SETTING

Kaiser Permanente Northern California.

METHODS

The medical records of adults referred to otolaryngology in 2017 for a neck mass were evaluated. Bivariate and multivariable logistic regression analyses were performed.

RESULTS

Malignancy was found in 205 (5.0%) of the cohort's 4103 patients. Patient factors associated with malignancy included sex, age, and race/ethnicity. Males had more than twice the odds of malignancy compared with females (adjusted odds ratio [aOR] = 2.38). Malignancy rates increased with age, ranging from 2.1% for patients younger than 40 years to 8.4% for patients 70 years or older. White non-Hispanic patients had 1.75 times the risk of malignancy compared with patients of other race/ethnicities. The percentage of patients with malignancy increased with increasing minimum mass dimension, from 3.0% in patients with mass size <1 cm to over 31% in patients with mass sizes 2 cm or larger (P < .0001). Imaging-based mass factors most highly predictive of malignancy included larger minimum mass dimension (≥1.5 cm vs <1.5 cm: aOR = 3.87), multiple masses (2 or more vs 1: aOR = 5.07), and heterogeneous/ill-defined quality (aOR = 2.57).

CONCLUSION

Most neck masses referred to otolaryngology were not malignant. Increasing age, male sex, white non-Hispanic ethnicity, increasing minimum mass dimension, multiple neck masses, or heterogeneous architecture/ill-defined borders were associated with malignancy.

General practitioner referrals to one-stop clinics for symptoms that could be indicative of cancer: a systematic review of use and clinical outcomes

BACKGROUND

One-stop clinics provide comprehensive diagnostic testing in one outpatient appointment. They could benefit patients with conditions, such as cancer, whose outcomes are improved by early diagnosis, and bring efficiency savings for health systems.

OBJECTIVE

To assess the use and outcomes of one-stop clinics for symptoms where cancer is a possible diagnosis.

DESIGN AND SETTING

Systematic review of studies reporting use and outcomes of one-stop clinics in primary care patients.

METHOD

We searched MEDLINE, Embase, and Cochrane Library for studies assessing one-stop clinics for adults referred after presenting to primary care with any symptom that could be indicative of cancer. Study selection was carried out independently in duplicate with disagreements resolved through discussion.

RESULTS

Twenty-nine studies were identified, most were conducted in the UK and observational in design. Few included a comparison arm. A pooled comparison of the cancer conversion rate of one-stop and multi-stop clinics was only possible for breast symptoms, and we found no significant difference. One-stop clinics were associated with significant reductions in the interval from referral to testing (15 versus 75 days) and more patients diagnosed on the same day (79% versus 25%) compared to multi-stop pathways. The majority of patients and GPs found one-stop clinics to be acceptable.

CONCLUSION

This review found one-stop clinics were associated with reduced time from referral to testing, increased same day diagnoses, and were acceptable to patients and GPs. Our conclusions are limited by high levels of heterogeneity, scarcity of comparator groups, and the overwhelmingly observational nature of included studies.

Neck lump clinic: a new initiative at North Shore Hospital

BACKGROUND

Neck lumps can cause significant patient anxiety and benefit from a multidisciplinary diagnostic approach, with an ultrasound scan and fine needle aspirate. Internationally, 'one-stop' clinics are used for the evaluation of neck lumps, to date no such clinic has been established in the New Zealand public hospital system. The objective of this study was to demonstrate the feasibility of a one-stop diagnostic neck lump clinic (NLC), aiming for improved patient experience and efficiency.

METHODS

A consultant-led pilot NLC was instituted with the involvement of a head and neck surgeon, radiologist and pathologist, allowing ultrasound scan and fine needle aspirate investigations to be performed simultaneously. A retrospective audit of patients in the 12 months prior to commencement of the NLC provided a comparison group.

RESULTS

The median number of clinic visits was 2 in the control group and 1 in the NLC (P < 0.001). Time from first specialist appointment to surgery was 192 days compared to 134.5 days for NLC (P = 0.057). Median time from first specialist appointment to treatment decision was 108.5 days compared to 0 days in the NLC (P < 0.001). Eighty-eight percent of patients in the NLC were given a diagnosis at their first appointment. The median number of investigations required was 2 in the control group and 1 in the NLC (P < 0.001). Median cost per patient in the NLC was $794 and $1470 in the control group.

CONCLUSION

This pilot trial demonstrates streamlined decision-making and efficient utilization of services with a reduction in clinic visits, investigations and cost. High patient satisfaction was reported with this service.

Rapid access clinic for unexplained lymphadenopathy and suspected malignancy: prospective analysis of 1000 patients

Background

In patients presenting with peripheral lymphadenopathy, it is critical to effectively identify those with underlying cancer who require urgent specialist care.

Methods

We analyzed a large dataset of 1000 consecutive patients with unexplained lymphadenopathy referred between 2001 and 2009 to the Royal Marsden Hospital (RMH) rapid access lymph node diagnostic clinic (LNDC).

Results

Cancer was diagnosed in 14% of patients. Factors predictive for malignant disease were male sex, age, supraclavicular and multiple site involvement. Cancer-associated symptoms were present for a median of 8 weeks. The median time from referral to start of cancer therapy was 53 days. Fine needle aspiration (FNA) was performed in 83% of patients with malignancies. Sensitivity and specificity of FNA were limited (50 and 87%, respectively for any malignancy; 30 and 79%, respectively for lymphoma). The vast majority of cancer patients received diagnostic biopsies on the basis of suspicious clinical and ultrasound findings; the FNA result contributed to establishing the diagnosis in only 4 cases.

Conclusions

In conclusion, we demonstrate that Oncologist-led rapid access clinics are successful concepts to assess patients with unexplained lymphadenopathy. Our data suggest that a routine use of FNA should be reconsidered in this setting.

Electronic supplementary material

The online version of this article (10.1186/s12878-018-0109-0) contains supplementary material, which is available to authorized users.

One-Stop Clinic Utilization in Plastic Surgery: Our Local Experience and the Results of a UK-Wide National Survey

Introduction. "See and treat" one-stop clinics (OSCs) are an advocated NHS initiative to modernise care, reducing cancer treatment waiting times. Little studied in plastic surgery, the existing evidence suggests that though they improve care, they are rarely implemented. We present our experience setting up a plastic surgery OSC for minor skin surgery and survey their use across the UK. Methods. The OSC was evaluated by 18-week wait target compliance, measures of departmental capacity, and patient satisfaction. Data was obtained from 32 of the 47 UK plastic surgery departments to investigate the prevalence of OSCs for minor skin cancer surgery. Results. The OSC improved 18-week waiting times, from a noncompliant mean of 80% to a compliant 95% average. Department capacity increased 15%. 95% of patients were highly satisfied with and preferred the OSC to a conventional service. Only 25% of UK plastic surgery units run OSCs, offering varying reasons for not doing so, 42% having not considered their use. Conclusions. OSCs are underutilised within UK plastic surgery, where a significant proportion of units have not even considered their benefit. This is despite associated improvements in waiting times, department capacity, and levels of high patient satisfaction. We offer our considerations and local experience instituting an OSC service.

Do Immediate Cytology and Specialist Radiologists Improve the Adequacy of Ultrasound-Guided Fine-Needle Aspiration Cytology?

Objective

To assess whether a dedicated “1-stop” neck lump clinic has improved the percentage of adequate fine-needle aspiration cytology (FNAC) samples and reduced the need for repeat FNAC.

Study Design

Retrospective review.

Setting

District General Hospital in the United Kingdom.

Subjects and Methods

Patients attending for ultrasound-guided FNAC over a 6-month period from August 2012 to February 2013. Patients were placed in 4 groups: group 1, FNAC performed by any of the subspecialist radiologists with cytology support (n = 100); group 2, FNAC performed by general radiologists without cytology support (n = 112); group 3, FNAC performed by a particular subspecialist radiologist with cytology support (n = 61); and group 4, FNAC performed by the same subspecialist radiologist without cytology support (n = 125).

Results

There was a significantly higher rate of adequacy of FNAC in the presence of a subspecialist radiologist with immediate cytology (group 1) versus a general radiologist without cytology support (group 2; 87/100 vs 63/112, P = .0001), a significantly higher rate of adequacy of FNAC in the presence of cytology support with the same radiologist (group 3 vs group 4, 55/61 vs 97/125, P = .04), and a significantly higher rate of adequacy of FNAC in the presence of a subspecialist radiologist versus a general radiologist without cytology support (group 4 vs group 2, 97/125 vs 63/112, P = .0005).

Conclusion

Immediate cytology and the presence of a subspecialist radiologist increase the adequacy of FNAC. The adequacy rate of non–cytology-supported FNAC or nonsubspecialist FNAC is below the adequate rate expected from the literature or as recommended in national guidelines.