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To measure the quality of pathology reporting of breast cancer and establish a baseline against which future changes can be measured, we audited item completeness in breast cancer reports in Australia in 1995 before the release of specific recommendations from the Australian Cancer Network. Tumour type and size were given in reports of invasive breast cancer for 93% of women, 70% had, in addition, grade and clearance of the margins while only 28% had all recommended information. The most complete items in reports were histological type of breast cancer (99.6% of cases), tumour size (94%, 95% confidence interval (CI) 92-95) and margins of excision (87%, 95% CI 85-89). Histological grade (84%, 95% CI 82-86 of cases) and presence or absence of ductal carcinoma in situ (DCIS) (79%, 95% CI 77-81) were less complete and vessel invasion (61%, 95% CI 58-63) and changes in non-neoplastic breast tissue adjacent to the breast cancer (68%, 95% CI 66-71) the least complete. Less than half the reports of DCIS reported on tumour size (49%, 95% CI 42-57), presence or absence of necrosis (41%, 95% CI 34-49) or nuclear grade (39%, 95% CI 31-46). Around 1500 reports were identified as issued by 147 laboratories and 392 pathologists; 69% of pathologists issued fewer than two reports a month in the audit. We concluded that infrequency of reporting may have contributed to incompleteness of reporting. In addition, we found significant variation across Australian states with some indication that reporting was consistently poor in one state. The audit highlighted areas for improvement for breast cancer reporting in Australia. Research evidence suggests that multifaceted strategies are needed to assist practitioners with implementing more uniform reporting standards.
To audit the information content of pathology reports of oesophageal and gastric cancer resection specimens in Wales.
All such reports from the 16 NHS histopathology laboratories in Wales in a one year period were evaluated for their information content. Two standards were used: (1) best practice reporting, and (2) a minimum dataset required for informed patient management that included clear statements on histological tumour type, depth of tumour invasion, lymph node involvement, and completeness of excision.
282 reports were audited. Minimum standards were achieved in 77% of gastric resections (156/203) and 53% of oesophageal resections (42/79). All laboratories achieved minimum standards in some gastric cancer reports (range 50-100%); three laboratories did not achieve minimum standards in any oesophageal cancer reports (range 0-100%). Best practice reporting was achieved in only 20% of gastric and 18% of oesophageal cancer reports. Failure to include an explicit statement on completeness of excision or involvement of the oesophageal circumferential resection margin were the most frequent causes of inadequate reporting. Most other data items were generally well reported, but apparent inadvertent omission of just one item was noted in many of the substandard reports.
This audit shows the need to improve the information content of pathology reports in gastric and oesophageal cancer. The widespread implementation of template proforma reporting is proposed as the most effective way of achieving this. Multidisciplinary meetings of clinicians involved in cancer management should provide a forum for greater communication between pathologists and surgeons, and help to maintain standards of pathological practice.
In order to assess the performance of a surgical pathology laboratory in a university hospital, we have established a comprehensive system of quality audit based on peer review. Each month, 2% of cases received are selected at random and assessed retrospectively by two senior pathologists. The system, which uses semi-quantitative scoring, examines diagnostic accuracy, identifies delay at any stage in the production of reports, evaluates the overall quality of the slides, the presentation of the final report, and the accuracy of the SNOMED coding. Each of these parameters is graded as "satisfactory," "borderline," or "unsatisfactory." In 20 of 518 cases (3.9%) analyzed in 18 months, the microscopic report was unsatisfactory; in six of these cases, the error could have affected patient management. Remediable faults were detected in the macroscopic description of specimens and in the speed and accuracy of report typing by the secretarial staff. In 13 of 18 months, >10% of reports were delayed because of the time taken in microscopic reporting by pathologists. Some (but not all) of this delay was attributable to the "checking out" of pathologists in training. We conclude that this audit system has uncovered substantial deficiencies in our departmental performance, some of which could affect the clinical course of patients. These surprising results suggest that a system of peer review should be adopted more widely.
In order to assess the performance of a surgical pathology laboratory in a university hospital, we have established a comprehensive system of quality audit based on peer review. Each month, 2% of cases received are selected at random and assessed retrospectively by two senior pathologists. The system, which uses semi-quantitative scoring, examines diagnostic accuracy, identifies delay at any stage in the production of reports, evaluates the overall quality of the slides, the presentation of the final report, and the accuracy of the SNOMED coding. Each of these parameters is graded as "satisfactory," "borderline," or "unsatisfactory." In 20 of 518 cases (3.9%) analyzed in 18 months, the microscopic report was unsatisfactory; in six of these cases, the error could have affected patient management. Remediable faults were detected in the macroscopic description of specimens and in the speed and accuracy of report typing by the secretarial staff. In 13 of 18 months, greater than 10% of reports were delayed because of the time taken in microscopic reporting by pathologists. Some (but not all) of this delay was attributable to the "checking out" of pathologists in training. We conclude that this audit system has uncovered substantial deficiencies in our departmental performance, some of which could affect the clinical course of patients. These surprising results suggest that a system of peer review should be adopted more widely.
Quality assurance (QA) in surgical pathology has focused primarily on retrospective audits of randomly selected cases. The authors describe an effective method of prospective audit for a selected class of surgical specimens--diagnostic biopsies--and document the benefits, additional staff time required and impact on turnaround time. Additionally, these results were compared with a retrospective review. During a 6-month period, all diagnostic surgical pathology biopsies (n = 2,694, 55% of all cases) were reviewed by a second pathologist before release of the final report. Errors detected were subdivided into four categories: (1) major: errors in diagnosis that could directly affect patient care; (2) diagnostic discrepancies: errors in diagnosis that should not affect patient care; (3) minor: correct diagnosis rendered, but report correction required to add supportive information; (4) clerical: typographical and grammatical errors. Thirty-two major errors were found, involving 1.2% of cases reviewed. This manner of review caused an increase in overall turnaround time from 1.62 days to 1.79 days, and an increase in turnaround time for diagnostic biopsies from 1.44 days to 1.50 days. Time spent in performing prospective peer review averaged 4 hours per day. For comparison, results were included from a retrospective review performed on 480 of the 5,556 cases accessioned in a 6-month period before the institution of prospective quality assurance. This retrospective review revealed eight major errors (1.7%). In conclusion, the prospective peer review of diagnostic biopsies yields sufficient benefits in increased accuracy of diagnostic reports to justify the slight increase in additional work by pathologists.
To analyse the diagnostic differences in reporting tumour histopathology between a district general hospital and a regional oncology centre.
Tumour histopathology reports (n = 227) extracted from Bolton General Hospital files between 1988 and 1992 were compared with the corresponding Christie Hospital (oncology centre) reports, the same material having been seen at both hospitals.
Diagnostic agreement existed in 77% of all cases. The incidence of major discrepancies was 8.37%. Of the diagnoses, 19 (36%) cases involved major discrepancies and 34 (64%) cases minor discrepancies. Most discrepancies occurred in the lymphoma group and involved subclassification of Hodgkin's and non-Hodgkin's lymphoma. Ki1 anaplastic large cell lymphoma and T cell rich B cell lymphoma were problematic diagnoses. The correct grading of follicle centre cell lymphomas using the Kiel classification was another problem area. In 19 cases certain aspects of immunohistochemistry produced discrepancies. In one case an incorrect diagnosis was made at the oncology centre and in another both centres gave an incorrect diagnosis.
Areas of diagnostic difficulty mainly involve the subclassification of lymphomas. Review of tumour pathology by experts is recommended, at least in certain categories, to ensure correct diagnosis and uniformity in subclassification of tumours.
Methods of auditing the performance of histopathologists, such as external and internal quality assurance, clinicopathological conferences, and "double-reporting" of microscopic slides, show significant diagnostic errors in at least 1.2% of reports. Although some of these are in well-recognized areas of difficulty, such as melanoma or lymphoma, most errors are in common biopsy specimens. We have developed a method that compares diagnostic patterns of individual histopathologists. This aims to identify specific diagnoses that a pathologist makes more or less frequently than other colleagues and enables the individual to reflect on his or her own histologic expertise in reporting on specific biopsy results. The bottom line diagnoses of transurethral resection of prostate specimens; rectal, gastric, and bladder biopsy samples; and endometrial curettages were analyzed retrospectively. Analyses were performed on diagnoses made by at least 15 pathologists on each specimen type and expressed as a standardized ratio (SR) with 95% confidence intervals (CI). An SR of 1.0 indicated a pattern of diagnosis matching the combined pattern of other colleagues. An SR <1.0 indicated relative "underdiagnosis" and an SR >1.0 indicated relative "overdiagnosis." Diagnostic rates of individual pathologists whose CIs did not straddle the value of 1.0 were considered aberrant, although not necessarily incorrect. The 47 of 226 (20.8%) aberrant SRs included four pathologists' diagnoses of prostatic carcinoma, three each of endometrial, rectal, and bladder carcinoma, and one of gastric malignancy. This method, which could easily be automated and used regionally or nationally, should provide pathologists with a profile of their diagnostic patterns in comparison with their peers.
Internal auditing of performance by pathology providers is a necessary component of total quality management. In this study a peer review of 10% of departmental surgical anatomical pathology accessions received over a seven month period was performed. A number of critical performance parameters were analysed including turn-around times, accuracy of reports and technical proficiency. The results demonstrated an approximate 2% significant error rate in macroscopic and microscopic descriptions, technically good quality sections and stains and generally satisfactory turn-around times. The value and costing of such an audit and changes initiated by the audit are discussed.