It can be difficult to convince people that medical synoptic reporting is necessary without coming off like a pedantic nerd. No one likes paperwork, and they'd rather be doing 'real work' than documenting something they've already done. Luckily, there is a growing group of studies that show how standardized synoptic reporting can directly lead to improved care for patients. One such study examines the effect that reporting on specific quality indicators in pathology can have on how patients receive care.
Quality indicators are a kind of a buzzword (well, buzzphrase, anyway) for the past few years. They are specific measures/actions that organizations (usually comprised of physicians) have deemed important to track to see the efficacy on patient outcomes or are a sort of "best practice" that these organizations would like to see adopted. Physicians and other healthcare personnel capture these measures in reports, conforming to the standard, and then those are eventually compared in a given time frame. With that information, facilities can see how departments are doing - are they meeting these criteria, are these quality indicators getting captured more often than previously, does this have any affect on other departments?
One such study, published in The Journal of Oncology Practice, was done by Cancer Care Ontario (CCO) who used the electronic Cancer Checklists (eCCs) put out by College of American Pathologists (CAP) to track specific information about cancer cases on a facility, regional, and pronvicial level. The study can be found here, but for a brief overview, please read on.
CAP's eCCs are an internationally recognized group of standard reports for cancer diagnosis, broken up into templates that correspond with specific disease sites. Each template is a structured synoptic report, which means that pathologists fill them out using the same verbiage and capturing the same information in the same language. This improves and expedites collecting data from all of the reports and ensures that like is compared to like. By eliminating the possibility for subjectivity or synonymous language, CAP eCCs make research much easier and allows for faster ways to gather and report on the data within the reports. Furthermore, CAP eCCs represent the best practices for cancer reporting - they contain required sections and fields that pathologists have deemed important to capture when diagnosing cancer cases and when doing research into the behavior and other aspects of various cancers. By using these templates, CCO is guaranteeing uniformity of terms and completeness of reports.
The CCO study was comprehensive involving "more than 400 Ontario pathologists and more than 100 hospitals producing more than 70,000 cancer pathology reports annually." That's a lot of moving parts and players to cover a lot of data being gathered. But, thanks to CCO's ability to oversee the project and ensure successful implementation at every site, they were able to expertly deploy reporting solutions in all hospitals (including mTuitive's xPert for Pathology in many of them) that stayed current with CAP standards while also sending the captured data into multiple places for data storage (including cancer data repositories) for later analysis. The reason for the success was Ontario's provincial commitment to the project—not just in allocating funds and resources to this endeavor, but also having clear goals and plans for implementing and tracking these reporting solutions.
Another step to the project was defining what quality indicators they would be interested in tracking. They decided on two principal metrics to track, colorectal lymph node retrieval rates and pT2 prostatectomy margin positivity rates. The reasoning for lymph nodes was that:
The number of lymph nodes identified and examined in colorectal cancer (CRC) is important in achieving accuracy in cancer staging, thus influencing the correct usage of adjuvant chemotherapy. Inadequate lymph node examination has been linked to poorer patient outcomes. In 2003, Wright reported that only 27% of stage II colon cancer resection reports in Ontario described the presence of a sufficient number of lymph nodes...The indicator selected was the CRC lymph node retrieval rate, defined as the proportion of colorectal cancer resection reports in which the removal of at least 12 lymph nodes is documented. This indicator reflects both surgical quality (ie, an adequate amount of mesenteric, pericolonic, or perirectal tissue was removed) and pathology quality (ie, all lymph nodes were harvested and properly examined).
And the pT2 prostactectomy margin positivity rates were similarly identified due to a current state that CCO found unacceptable:
pT2 prostate margin positivity rate, defined as the percentage of organ-confined radical prostatectomy cases in which the margin is reported as positive. Margin status in prostate cancer is a significant prognostic factor and is influenced by patient selection, pathological examination, and surgical technique. A preliminary manual audit of 2,074 radical prostatectomy pathology reports from 2005 to 2006 showed a margin positivity rate of 31.3% for organ-confined (pT2) disease. The prostate cancer CoP within CCO determined that the rate was unacceptably high and set a conservative provincial target of less than 25% for this indicator. To support achievement of the target, the Guideline for Optimization of Surgical and Pathological Quality Performance for Radical Prostatectomy in Prostate Cancer Management (2008) was developed, which includes surgical and pathology recommendations to enhance the standardized approach to surgical technique and pathology handling and reporting.
By instituting these electronic reports that exported data quickly and efficiently into databases that can be used for studies, CCO was able to conduct monthly reports on the data. Thus they were able to track the progress much more closely, identify specific areas (including facilities and members of staff) that required more help or improvement, and continue to work with their province-wide team to get to those goals. And it also reflects the ability to use those constant reports to inform not just pathology staffs, but surgeons as well. Instructing them to make more of an effort to excise clear margins and more lymph nodes, CCO was able to show how two departments (even province wide) can work together to achieve their goals.
And they continue to strive towards those goals, noting that "[s]ince the launch of the project, colorectal lymph node retrieval rates have increased from 76% to 87%, and pT2 prostatectomy margin positivity rates have decreased from 37% to 21%." That's a huge amount of improvement that reflects not just CCO's dedication, but also possibly changing the lives of many people. The more lymph nodes retrieved, the better informed the physicians will be as to the state of the cancer and the next best steps in treating it. Similarly, as previously discussed in this blog, by decreasing the amount of positive margins, that means that more the tumours are being totally excised with less likelihood of the cancer coming back or spreading further.
Again, I encourage people to read The Journal of Oncology Practice study as it goes into further detail on all of the steps taken, along with more data on the outcomes of these initiatives. But the main message is that if principal decisionmakers agree, and the main stakeholders all share the same vision and goals, then great strides can be made in changing patients' lives for the better. And those reports that many physicians are loath to fill out? It turns out there's a lot of power hidden with them, it's all in how they are used.
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