Surgical Pathology Extradepartmental …

1 Arch Pathol Lab Med Vol 126, April 2002 Extradepartmental consultation Practices Azam & Nakhleh405 CAP Laboratory Improvement ProgramsSurgical Pathology ExtradepartmentalConsultation PracticesA College of American Pathologists Q-Probes Study of 2746 Consultations From180 LaboratoriesMuhammad Azam, MD; Raouf E. Nakhleh, MD Objectives. To document the practice parameters andcase characteristics associated with personal (expert) con-sultations. We also examine the value, level of participant(customer) satisfaction, turnaround time, and rate of per-sonal We asked participants in the College of Amer-ican Pathologists Q-Probes program to document casessent for consultation during 4 months or up to 20 documented patient and specimen characteristics,the turnaround times, and the participants levels of satis-faction with the consultation One hundred eighty laboratories/surgicalpathology practices.

2 One hundred seventy-two ( )were from the United States; the remainder were locatedin Canada and Outcome Measures. Rate and turnaround time ofconsultations and participant level of A total of 2746 consultation cases were ex-amined for an aggregate consultation rate of (me-dian, ). Institutions with a higher occupied bed sizeand a greater number of Surgical Pathology cases both hadlower consultation rates (P#.05). The median turnaroundtime (defined as the interval from the date on which thecase was sent to the date on which the diagnosis was re-ceived) was 6 days. Twenty-nine percent and 68% of caseshad a turnaround time within 3 and 7 days, percent of cases were sent to nationally knownexperts, and 32% were sent to local experts.

3 Skin ( ),hematolymphoid ( ), and breast ( ) specimenswere most commonly sent for consultation . In ofcases, the consultant confirmed the referring pathologist soriginal diagnosis, but in of cases, the consultantalso added significant information. Satisfaction rates werehigher with faster turnaround times and verbal rates were lower for cases in which the patientor the clinician requested the consultation and in whichthe consultant s diagnosis was This study establishes a multi-institutionalconsultation rate of , defines the nature of Surgical pa-thology consultations, and demonstrates that satisfaction withconsultations is associated with a faster turnaround time andreceipt of additional, clinically meaningful information.

4 (Arch Pathol Lab ;126:405 412) Surgical Pathology cases are frequently sent for consul-tation to other institutions. Typically, extradepartmen-tal consultations are sought to resolve diagnostic uncer-tainty or to obtain input on a case from an expert. Theseconsultations are termedpersonal consultationsby the As-sociation of Directors of Anatomic and Surgical Pathology (ADASP).1 Although their numbers may be small relativeto accessioned cases, personal consultations represent asignificant part of Pathology practice by virtue of theirproblematic nature. Clinicians or patients can also seekthis type of expert issue of secondopinion in Surgical Pathology hasrecently received publicscrutiny with media attention from ABC World News(May 9, 2001)3and theWall Street Journal(April 13, 2001).

5 4 Accepted for publication November 28, the Department of Pathology , North Ottawa Community Hos-pital, Grand Haven, Mich (Dr Azam), and the Department of Pathology ,Henry Ford Hospital, Detroit, Mich (Dr Nakhleh).Reprints: Raouf E. Nakhleh, MD, Department of Pathology , HenryFord Hospital, 2799 West Grand Blvd, Detroit, MI 48202 Q-Probes program of the College of American Pa-thologists (CAP) has attempted to measure and definequality indicators in anatomic and clinical ,6 This Q-Probes study is the first multi-institutional studyto measure and document the practice parameters andcase characteristics associated with personal also examined the value, level of participant (custom-er) satisfaction,turnaround times, and rate of AND METHODSL aboratories enrolled in the CAP s voluntary Q-Probes qualityimprovement program participated in this study in October De-cember of 1999.

6 The Q-Probes program and format for data col-lection and handling have been previously described in ,7 Laboratories were asked to prospectively document any surgicalpathology case that was sent for Extradepartmental personal con-sultation. For the sake of consistency, certain pertinent terms weredefined (Table 1), including the definition of personal study included any Surgical Pathology case that was sent forextradepartmental personal consultation . The pathologist, the cli-nician, or the patient may have sought this in-cluded were hematopathology cases (lymph node and bonemar-406 Arch Pathol Lab Med Vol 126, April 2002 Extradepartmental consultation Practices Azam & NakhlehTable 1. Definitions of TermsDiscordant diagnosis: a difference in diagnoses when acomparison is made between the original or preliminarydiagnoses and the consultant s diagnosis.)

7 The discordance isdue to differences in the main diagnosis such as benign tomalignant or other changes such as the type of does not include modifications or clarifications madeto the original diagnosis (eg, malignant lymphoma modifiedto large cleaved cell lymphoma, B-cell type).Expert pathologist: a pathologist whose diagnostic acumen ina particular field is recognized by his/her peers by virtue ofhis/her experience. An expert pathologist may be locally ornationally consultation : a Surgical Pathology case thatis sent out to a particular pathologist or to consultation : a case sent out primarily because ofthe patient s referral to a different hospital or clinic with aneed for tissue diagnosis (case review) by pathologists at thenew (expert) consultation : a case sent for a secondopinion to aspecificpathologist or Pathology pathologist, the clinician, or the patient may seek diagnosis: a written diagnosis that is issued withthe intent of following up with a supplemental or finaldiagnosis after the time for diagnostic material return.

8 For thepurposes of this study, this is the time frame between whena Surgical Pathology case is sent for extradepartmentalconsultation and when the diagnostic material is returned tothe referring time for first contact: for the purposes of thisstudy, this is the time between when a Surgical pathologycase is sent for Extradepartmental consultation and whenthe referring pathologist first receives a verbal or writtenreport from the ) that were sent primarily to seek expert consultation . The fol-lowing types of cases were excluded from this study: institutionalconsultation cases resulting from a patient s referral to a differenthospital or clinic (definition provided in Table 1);cytopathologyconsultations; muscle, renal, or other tissuebiopsies that were sentin their entirety for histologic interpretation and ancillary studies(no diagnostic impression was rendered in the primary laboratory);cases sent for special tests (eg, flow cytometry, polymerase chainreaction,cytogenetics, hormonereceptor assay, in situ hybridiza-tion, liver iron studies).

9 And cases sent for research purposes each case, the following specific information was collected: thepatient s age and gender, the date on which the case was sent, thedate on which a verbal report was given, the date on which awritten report was received (including faxed reports), the reasonfor Extradepartmental consultation , the reason for choosing theconsultant, the referring pathologist s impression of the nature ofthe disease process before seeking consultation , thetype of pro-cedure used to obtain the specimen, the nature of the specimen,the type of diagnostic material that was sent, whether the con-sulting pathologist notified the referring pathologist(s) of delays(where applicable), the reason for delay (where applicable), agree-ment of the consultant s (expert)

10 Diagnosis with the referring pa-thologist s original impression, and the referring pathologist s over-all satisfaction rating of the consultation process for the case (ex-cellent, good, fair, or poor). The study concluded when 20 extra-departmental consultation cases were documented or 4 monthshad passed, whichever came first. An additional 1 month was al-lowed for receipt of reports and return of diagnostic materials. Thetotal number of accessioned cases during 1998, the number of pa-thologists involved in the sign-out, and the availability of an expertpathologist within the group were also documented. In addition,each laboratory completed a questionnaire regarding laboratorypractices and protocols related to Extradepartmental consultation rate (expressed as a percentage) was calcu-lated for the aggregate data and for each institution that partici-pated in this study.