Q Exchange
The Tele-Allergy Study (The TAG study)
- Proposal
- 2019
Meet the team
Also:
- Prof M. T. Krishna (Consultant Allergist) Joint Co lead
- Dr Ravishankar Sargur (Consultant Immunologist)
- Ben Pain, IT Royal College Physicians
What is the challenge your project is going to address and how does it connect to your chosen theme?
1 in 4 British people have an allergy. There is an unmet need for allergy services in the NHS leading to long waiting times (several months to a year!), lack of equitable access and suboptimal care. Some parts of the UK do not have a local allergy clinic and patients travel long distances to consult with a specialist. Undergraduate training in allergy is poor. The basic principle underpinning good allergy practice involves good history taking. A high proportion of referrals to adult allergy services are for ‘spurious allergy’, ‘allergy mimics’ or for relatively straightforward allergies. Allergy tests are not performed routinely unless an allergy is likely. Hence, tele-allergy lends itself as an excellent triage tool to screen referrals. Whilst tele-allergy is promising, further research is needed to define referral pathways, standardisation, governance, outcome measures, safety and its acceptance amongst patients and healthcare professionals.
Allergy, the unmet need, RCP (2003)
What does your project aim to achieve?
Objective:
- Conduct a feasibility study to explore facilitators and barriers for a tele-allergy service
- Involve and seek feedback from patients & relevant stakeholder’s regarding tele-allergy and develop quality outcomes, governance framework, referral pathways and estimate cost saving
Methods: Conduct tele-allergy clinics in 2 regional centres involving 3 scenarios – antibiotic allergy, chronic urticaria and allergic rhinitis. 10 patients from each scenario (30 per/centre) will undergo tele-consults. A behaviour science expert will interview 15-20 patients to explore facilitators and barriers. 2 focus groups sessions with relevant stake holders in primary and secondary care will be conducted to explore study objectives. Decision analytic modelling will be implemented to study the current allergy care pathway to investigate the potential cost-effectiveness of tele-allergy.
Benefits: An equitable, cost-effective service. Reduction in wait times, time off work and travel.
How will the project be delivered?
The investigators comprise a very experienced, highly skilled multidisciplinary team capable of delivering this project. The centres have high throughput of allergy patients. Prof Krishna is a clinical academic, clinical lead for the RCP allergy accreditation programme (IQAS) with relevant experience in standard setting, QI/QA and has led multiple national audits. Drs Jani and Angier are Q members. Dr Jani is a senior pharmacist and an expert in behaviour science Dr Angier is a GP with an MSc in allergy. Dr Sargur is a senior clinical immunologist holding an MBA in health service management. The team has a strong publication record. We plan to involve a health economist.
Ben pain from the RCP has offered to help with technical advice if needed.
The investigators are fully committed to quality improvement, are experienced in conducting tele-allergy consults and have liaised (and will continue to work closely) with patients, patient organisations and stakeholders across the country.
What and how is your project going to share learning throughout?
Whilst this a speciality-specific project, it involves a number of generic elements as building blocks including use of telemedicine, engagement with patients and relevant multidisciplinary stakeholders to explore facilitators and barriers to introduce a new service model, constructing a ‘fit for purpose’ patient-related outcome measures (PROMs) and a robust governance framework. This experience is invaluable moving forward for developing other projects on its shoulders! Equally, the investigators will learn from previous Q projects to help succeed in this study.
Importantly, this project involves antibiotic allergy, and specifically creates an opportunity to tackle ‘spurious penicillin allergy’, which is a global health problem, costing millions of pounds each year for the NHS and is of great interest to all disciplines and in all areas of health service who are impacted by this
Learning could be shared via updates and twitter and a blog.
How you can contribute
- We will liaise with the Barts hospital team who were previous award winners to roll out telemedicine and also Newham diabetes to look at lessons learned.
- We can participate in Q exchange activities.
- We have shared this idea via twitter and had helpful feedback and will continue to do this with updates
- IT expert Ben Pain is helping us
- We are interested in linking with networkers and critical friends who can help spread the word but also challenge us constructively
- The Q community ideas on how this could help with drug allergy and how this affects the Q community at the moment would be helpful.
- We would value promotors of our ideas via twitter and other platforms to help champion the work.
- Any members who can act as fixers pointing us to resources and answering specific queries.
- If Q members would like to collaborate now or in the future, we would benefit from this.
- Strategists who can link to the wider context and policy would be helpful.
Plan timeline
| 30 Sep 2019 | : Stage 1: Planning with PPI and stakeholders |
|---|---|
| 2 Dec 2019 | Tele-allergy clinics, patient recruitment and qualitative |
| 1 Apr 2020 | Implementation PDSA |
| 3 Aug 2020 | Dissemination |
Comments
Nicola Jay 22 Jul 2019
Hi Liz, really good idea and well thought through. Lends itself well to urticaria, hay fever and penicillin allergy. We have been using a triage form and telephone consultation pre de-labelling clinics for children and part of our outcome will be related to patient satisfaction and outcome ie passed penicillin challenge in primary or secondary care with no testing as well as number referrals prevented to our normal drug allergy clinic. One of our main areas of learning from our work is the fear already created by labelling of penicillin allergy. The other area to consider is unintended consequences- in a recent review of telephone consultations for common childhood acute illness there was found to be more antibiotic prescribed than in face to face consultations for similar conditions. So I guess you need to ask, what don't you want to happen ( although this is initially small numbers and may not be possible) for each clinical area and monitor for that.
Well done!
Elizabeth Angier 26 Jul 2019
Thanks Nic
Very helpful comments we will bear that in mind.
Charlie Sharp 22 Jul 2019
This is an intriguing idea and certainly represents an ambitious use of new technology.
You seem to be very well set up to pilot this, but I am interested to know whether you have had any comment or feedback from patients about the model to be trialed? It is dramatically different to that of which most patients will have experience, so their attitudes would be interesting to hear, along with how that has influenced the design.
Elizabeth Angier 26 Jul 2019
Thanks for your comments, Charlie. TK has been running some small clinics with patients along these lines already and had good feedback from those participating and wants to extend the model building on this work and also looking at PPI moving forward. I have been working in outpatients for twelve years and have had many conversations with patients listening about how they would like to have skype or remote access, in that unit our dietician ran a skype service. So the patients already involved in a smaller scale are finding this helpful and also you can see from Hillary's comments parents thought this was a good initiative for her project and that we intend to work with patient charities and anaphylaxis campaign is keen to join us.
Hilary Allen 21 Jul 2019
Hi Liz.
This is a great approach to optimising allergy services. I am the MSc student Marta is referring to and have just completed a Penicillin de-labelling project in children using teleconsultations in lieu of face-to-face consultations. It was very well received by parents and use of a teleconsultation structured screening questionnaire was successful in weeding out the high risk versus low risk - no immediate reactions in the challenged cohort (102 patients challenged, 21/139 excluded on basis of tele-screening). This approach streamlined resources and our paediatric unit is adopting this protocol for low risk penicillin allergy going forward using Doctor screening / nurse-led challenges. I think it would be helpful if GPs completed a similar structured referral proforma when referring these patients in for penicillin testing - it helps streamline the consultation as most of these patients are vague on the details surrounding the event and much time has lapsed.
Elizabeth Angier 26 Jul 2019
Thanks Hilary
It's good to know that your project was well received. I like the idea about the GP structured template.
Elizabeth Angier 19 Jul 2019
Glad to see that Lynne Reagent CEO of Anaphylaxis Campaign via twitter thinks this is a good idea and they want to be involved
Elizabeth Angier 19 Jul 2019
Had a great conversation after linking via twitter with Olwen Williams about different approaches and learning. Lots of practical advice as well on teleconsultations such as take a mobile number in case cut off, time for admin,background, benefits of not having to travel staff adaptations, types of connections and case studies, where to record consultations etc.
Elizabeth Angier 19 Jul 2019
I had a really helpful conversation with Ben pain from RCP who can help us with IT advice. Reflecting on this conversation we probably need a national IT strategy to help the way we communicate with different hospitals and each other and patients.
Ravishankar Sargur 9 Jul 2019
Good to see this is coming to fruition. Well put together proposal. Output would be helpful to make the case to NHSE and commissioners for Tele (Allergy) clinics. A few thoughts, Within this framework can we consider exploring [ may need to ask for more money are another project]
1. Validation of a standardised questionnaire for Tele (allergy) consultation 2. Explore whether a triaging into the Tele (Clinic) can be done using a simple questionnaire based algorithm 3. If there is a validated standardised questionnaire for the 3 conditions being evaluated - it would be interesting to explore machine learning algorithms - to see whether similar decisions can be made by using AI techniques.
Elizabeth Angier 26 Jul 2019
Thanks for your comments Ravi and welcome on board to the project
Sadia Noorani 9 Jul 2019
Tele clinics are in use for some specialities already. My experience is of tele clinics I set up for follow ups from allergy clinics due to long wait for some of these patients. These were set up 2 years ago and are now over subscribed. Patients who come from a distance really like the idea. I have also supported the establishment of a tele clinic for our senior allergy nurse for the severe urticarial FU patients and this has worked well reducing waiting times and expediting treatments when needed.
Some areas of allergy lend themselves very well to tele-clinics and I would be very keen to see the outcomes for the new patients described in this proposal.
Good luck to the team and the project
Elizabeth Angier 26 Jul 2019
Thanks for your encouraging comments Sadia good to know your tele service is very popular
Adam Fox 8 Jul 2019
thanks - this is a well thought through proposal - we have being using telephone/skype clinics at GSTT for some time and they seem to be well received although a formal evaluation makes a lot of sense - better that this can be driven by quality rather than just the need for savings. I very much echo the value of proformas to streamline the process for specific conditions as this really helps increase the speed of the consult, allowing more patients to be triaged otherwise this risks being a timesaver only for the patient (through travel time) and not the clinician too. Also worth considering the sometimes unhelpful incentives the NHS offers services not to transform ie by offering much lower tariffs for virtual vs face to face consults so there is a tension between saving the patient time/cost on travel and the loss of income to the trust.
Elizabeth Angier 26 Jul 2019
Thanks for your encouraging comments Adam and pleased to see that as President of the BSACI our national allergy society you think the work is well thought through and worth pursuing.
Marta Vazquez-Ortiz 8 Jul 2019
Hi Liz, Great initiative. I think this could include children as well, although I believe the referrals rates for these reasons are probably lower than in adults, at least in our centre. I understand you may want to focus on adults for this study but I would at least mention that this would be equally useful in paediatric services, and indeed most 'spurious peni allergy labelling' comes from childhood. One of the MSc students I'm supervising is doing her MSc project on delabelling peni allergy in kids in Ireland using a tele-medicine screening consultation to select the low risk cases, followed by a single dose challenge under supervision in a Primary Care-equivalent type setting. Happy to share a poster she presented at eaaci on this. You may want to refer to other initiatives along these lines in kids - I believe the Evelina has a similar peniA-delabelling clinic that is nurse-led including a screening phone call.
In the proposal, I miss a bit more detail on how the tele-consultation fits into existing pathways within the allergy services involved (e.g. will the clinician be able to provide management advice remotely in cases not requiring further care at specialist services? will patients be directed to a 'speedy peni challenge' slot?). I think this would help understand how the new model will work.
Finally, 30K sounds too little for all the work your are planning! :)
Great work!
Elizabeth Angier 26 Jul 2019
Thanks Marta,
We will bear in mind about where this fits in the pathway and map this out. We are word restricted on the platform. Agree with you about being useful for paediatrics as well.
Rosan Meyer 7 Jul 2019
Tele-Allergy clinics are already in use for many dietitians and have been proven really useful and time effective not only for dietitians but for parents. I have been using a combination of phone consultation and skype/zoom for the last 3 years and this works really well. I think this is an excellent project and will prove extremely useful to bring down waiting times but I think also improving the service. What I have found very useful, is that parents pre-complete an allergy focused history prior to the consultation and send in their growth charts beforehand. I wonder if this is also something that is useful for this project. I have highlighted this to the Food Allergy Specialist Group of the BDA as well to comment.
Elizabeth Angier 26 Jul 2019
Thanks for your positive feedback Rosan, good to see your clinics are running well. We will bear in mind about the pre completed history beforehand which others are also suggesting is helpful.
Elizabeth Angier 26 Jun 2019
Thanks, Sarah we look forward to hearing from the RCP and the wider Q community.
Elizabeth Angier 26 Jun 2019
Thanks, Yogini glad you like the idea and that it builds on other work. TK always lots of good ideas. Perhaps we could discuss if this idea progresses further.
Yogini Jani 26 Jun 2019
Great to see this on here. Been working with TK and others on related ideas, and it builds/ relates to some of my Improvement Science Fellowship work + work we are trying to do with our new electronic health record system at UCLH in terms of different models of care/ patient involvement and access
Elizabeth Angier 26 Jul 2019
Thanks for joining us in this project Yogini looking forward to working with you and sharing ideas and expertise.
Sarah Campbell 26 Jun 2019
This is a wonderfully crafted idea, Elizabeth and certainly not short on ambition. I've alerted RCP colleagues in IQAS to this and hope that they may share some thoughts. There's been a great deal of piloting and testing around telemedicine (I'll think about some links) so I hope that colleagues can come back with experience to share. Thanks for already making links with the other teams. Your call to action to the community is clear!
Good luck!
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