Remote triage incorporating symptom-based risk stratification for suspected head and neck cancer referrals: A prospective population-based study

Abstract

Background: Remote triage for suspected head and neck cancer (HNC) referrals was adopted by many institutions during the initial peak of the coronavirus disease 2019 pandemic. Its safety in this population has not been established.

Methods: A 16-week, prospective, multicenter national service evaluation was started on March 23, 2020. Suspected HNC referrals undergoing remote triage in UK secondary care centers were identified and followed up for a minimum of 6 months to record the cancer status. Triage was supported by risk stratification using a validated calculator.

Results: Data for 4568 cases were submitted by 41 centers serving a population of approximately 26 million. These represented 14.1% of the predicted maximum referrals for this population outside of pandemic times, and this gave the study a margin of error of 1.34% at 95% confidence. Completed 6-month follow-up data were available for 99.8% with an overall cancer rate of 5.6% (254 of 4557). The rates of triage were as follows: urgent imaging investigation, 25.4% (n = 1156); urgent face-to-face review, 27.8%; (n = 1268); assessment deferral, 30.3% (n = 1382); and discharge, 16.4% (n = 749). The corresponding missed cancers rates were 0.5% (5 of 1048), 0.3% (3 of 1149), 0.9% (12 of 1382), and 0.9% (7 of 747; P = .15). The negative predictive value for a nonurgent triage outcome and no cancer diagnosis was 99.1%. Overall harm was reported in 0.24% (11 of 4557) and was highest for deferred assessments (0.58%; 8 of 1382).

Conclusions: Remote triage, incorporating risk stratification, may facilitate targeted investigations for higher risk patients and prevent unnecessary hospital attendance for lower risk patients. The risk of harm is low and may be reduced further with appropriate safety netting of deferred appointments.

Lay summary: This large national study observed the widespread adoption of telephone assessment (supported by a risk calculator) of patients referred to hospital specialists with suspected head and neck cancer during the initial peak of the coronavirus disease 2019 pandemic. The authors identified 4568 patients from 41 UK centers (serving a population of more than 26 million people) who were followed up for a minimum of 6 months. Late cancers were identified, whether reviewed or investigated urgently (0.4%) or nonurgently (0.9%), but the overall rate of harm was low (0.2%), with the highest rate being seen with deferred appointments (0.6%).

Keywords: harm; multicenter; national; observational; telemedicine.

Figure 1

The outer ring displays the PPVs of the nonnegative responses to symptom, smoking, and alcohol triage questions, which are contrasted against the incidences of these responses on the inner ring. Colors besides blue in the inner‐ring group together responses with more than 2 tiers that would compete with each other. bilat indicates bilateral; fluct./reduc., fluctuating/reducing; FOSIT, feeling of something in the throat; int., intermittent; mid., midline; pers., persistent; PPV, positive predictive value; unilat.; unilateral.

Figure 2

The outer ring displays the rates of triage directly to an urgent investigation for the nonnegative responses to symptom, smoking, and alcohol triage questions, which are contrasted against the rates of direct discharge for these responses on the inner ring. Colors besides blue in the inner‐ring group together responses with more than 2 tiers that would compete with each other. bilat indicates bilateral; fluct./reduc., fluctuating/reducing; FOSIT, feeling of something in the throat; int., intermittent; mid., midline; pers., persistent; unilat.; unilateral.

Figure 3

Age distribution of (Top) patients with cancer and (Bottom) all suspected head and neck cancer referrals. Note that the scales differ by a factor of 10.