Interinstitutional Review in Pathology

7/29/2019 Interinstitutional Review in Pathology

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ByUche Eziagu

8th March, 2013


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1. Introduction2. Purpose

3. Methodology

4. Conclusion5. References


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Clinical laboratory tests and anatomic pathologydiagnoses affect the vast majority of treatmentdecisions made by clinical physicians in nearlyevery medical discipline, impacting nearly everyperson seeking medical care.

Many clinical laboratory tests are automated,performed by calibrated machines, reducingfactors of human error and subjectivity.

Errors made during the process of handling

specimens in the anatomic pathology laboratoryhave recently been reported in the media (Roche,2005).


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Subsequently, specimen handling processes inanatomic pathology, as well as quality assurancemeasures and safeguards, are under increasingscrutiny by patients, referring physicians,insurers, and the media.

In addition to standard laboratory specimenhandling processes, anatomic pathology remainscritically dependent upon an individual physician the pathologist to perform an interpretationof microscopic tissue characteristics and to select

specific language to convey each diagnosis. Referral of a patient's tissue for pathologicevaluation remains a physician consultation.


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The practice of anatomic pathology involvesthe subjective interpretation of objectivedata.

The objective data, contained in thecharacteristics of the cells, organization oftissues, and relationship to the organ on thewhole, are preserved for the initial

examination on histologic slides, withinparaffin blocks, and, more recently in digitalimage archives.


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As pathology material is retained in a continuouslyobservable format (the histologic slide or digitizedimage), an important method of assessing the qualityof pathology services is the use of second opinion"quality assurance" consultation.

The consistent utilization of intra- and extra-departmental consultation to assess and report thediagnostic accuracy, completeness of information(clinical history and reporting of pertinent prognosticfeatures), and consistency of terminology conveyed

within each pathology report to clinicians andpatients is but one measurement of qualityperformance in pathology.


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Changes in the pathology interpretation (thediagnosis) can drastically alter the clinician'streatment plan and the patient's prognosis.

As in all disciplines of medicine, the goals ofanatomic pathology are to conform to the ethical

principles of beneficence and non-maleficence:the obligation to help and not to harm patients(Tomaszewski, et al., 2000).

To this end, pathologists are obligated to provideaccurate and timely diagnoses, to protect

patients from wrong diagnoses, and to reducethe diagnostic variability that can have a majorimpact on patient therapy and management.


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Pathologists often are requested to review originalpathology reports, slides, and other material from patientswho have been referred to a second institution forevaluation, management, or both.

These reviews are known as interinstitutional pathologyreview/consultations or second opinion pathology reviewsand are distinct from personal pathologist to- pathologistconsultations.

Studies of Interinstitutional reviews from general and bodysitespecific case series have shown that interinstitutionalreview improves the quality of patient care, because asmall percentage of interinstitutional reviews may result in

a change in diagnosis and/or prognostic factors thatresults in altered management and may lead to thecessation of expensive, unwarranted procedures.


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To monitor the degree of diagnosticagreement rate among cases that have beensent to other institutions for one of thefollowing reasons:1. At the clinician's or patient's request.2. At the request of another institution in which the

patient is being seen.

3. Because the case has been entered in acooperative study.


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If a significant discrepancy between the twodiagnoses exists, the director of anatomic orsurgical pathology should resolve it bysubjecting the case to inside or outside

arbitration and submit an addendum reportwith the final resolution.


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Inter institutional case review provides anadditional mechanism for evaluatingdiagnostic accuracy at the original institution.

It occurs when a patients treatment istransferred to another institution triggering areview of original diagnosis.


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It can also occur when a clinician requests areview of original diagnosis by an externalinstitution.

It is a very useful form of peer review andshould be distinguished from InterInstitutional opinions which are requestedbecause of diagnostic uncertainty or lack ofpeer group consensus.


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The following indicators should be measuredand reviewed quarterly for Inter institutionalconsultation: Cases referred externally for review

No. of cases referred

% Agreement.

Cases received internally for review

No. of cases received

% Agreement. Cases referred externally for opinion

No. of cases referred


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Cases referred externally for review refers to when a patients treatment is transferred to another

institution triggering a review of patient originaldiagnosis or

where a clinician has requested a review of theoriginal diagnosis by an external institution.

Agreement represents no change to primarydiagnosis.


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Cases received internally for review refers to when a patients treatment is transferred internally

triggering a review of patient diagnosis or

where a clinician has requested a review of original

diagnosis performed externally. All cases received internally for review should

be coded as P04 (according to Royal Collegeof Physicians Ireland)


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Cases referred externally for opinion refers towhere a Pathologist seeks opinion of anindividual with perceived expert opinion at aseparate institution due to diagnostic difficulty orlack of consensus opinion from

intradepartmental consultation. Where a report is received back from

interinstitutional consultation with a diagnosisthat is discordant from the primary diagnosismade, it is recommended that the case be

brought to an intradepartmental discrepancycase conference under the auspices of theQuality Committee


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The methodology of interinstitutional reviewcomprises its procedure and

review


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Procedure: The Quality Control/Quality Assurance manager

should collect and record the diagnoses made atother institutions and compare those diagnoses

with those made on the same cases at the indexinstitution.

All the cases in which a major discrepancy existsshould be recorded, including the arbitrationoutcome.


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Review: All Interinstitutional Review from the preceding

period should be presented at the monthly QualityControl/Quality Assurance meeting.

A formal reviewof the Interinstitutional Reviewforms should be carried out by the QualityControl/Quality Assurance committee chairmanbiannually, according to the general reviewprocedure.

The results of the review should be presented at themonthly Quality Control/Quality Assurancemeeting.


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To meet the increasing demand withoutcompromising quality, integration of subspecialtypathologists within general pathology practices,utilization of subspecialty pathology services, orliberal utilization of expert consultation byexperienced subspecialty pathologists within otherinstitutions may increase the baseline diagnosticaccuracy of pathology evaluations.

In the era of consumerism, advocating increasedaccess to subspecialty care for both patients andclinicians referring their patients to pathologists, who

can demonstrate measurable outcomes, can provide areal means of reducing costs, improving efficiency,and providing exemplary care.


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Juan Rosai; Rosai and Ackermans SurgicalPathology; 10th edition; China; Elsevier; 2011;Pages (Appendix B).

http://www.psqh.com/marapr06/pathologist.html

http://ajcp.ascpjournals.org/content/120/3/405.full.pdf

http://www.rcpi.ie/Faculties/Faculty%20of%20Pathology%20Downloads/Histopathology%20QA%20Guidelines%20V5.pdf
http://www.psqh.com/marapr06/pathologist.htmlhttp://www.psqh.com/marapr06/pathologist.htmlhttp://ajcp.ascpjournals.org/content/120/3/405.full.pdfhttp://ajcp.ascpjournals.org/content/120/3/405.full.pdfhttp://www.rcpi.ie/Faculties/Faculty%20of%20Pathology%20Downloads/Histopathology%20QA%20Guidelines%20V5.pdfhttp://www.rcpi.ie/Faculties/Faculty%20of%20Pathology%20Downloads/Histopathology%20QA%20Guidelines%20V5.pdfhttp://www.rcpi.ie/Faculties/Faculty%20of%20Pathology%20Downloads/Histopathology%20QA%20Guidelines%20V5.pdfhttp://www.rcpi.ie/Faculties/Faculty%20of%20Pathology%20Downloads/Histopathology%20QA%20Guidelines%20V5.pdfhttp://www.rcpi.ie/Faculties/Faculty%20of%20Pathology%20Downloads/Histopathology%20QA%20Guidelines%20V5.pdfhttp://www.rcpi.ie/Faculties/Faculty%20of%20Pathology%20Downloads/Histopathology%20QA%20Guidelines%20V5.pdfhttp://ajcp.ascpjournals.org/content/120/3/405.full.pdfhttp://ajcp.ascpjournals.org/content/120/3/405.full.pdfhttp://www.psqh.com/marapr06/pathologist.htmlhttp://www.psqh.com/marapr06/pathologist.html


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Interinstitutional Review in Pathology