Transcript From Qualitative to Quality Impact

From Qualitative to
Quality Impact
Heather Bryant, MD, PhD
Health System Use Summit
February, 2016
The stages of development of synoptic
reporting
Translation
Transaction
Transformation
2
Step 1: Translation
Translation
Developing clinical consensus
on the key indicators to be
collected for clinical and analytic
use; translating them to uniform
reporting standards
3
Step 2: Transaction
Transaction
Developing systems
and formats that
maximize the impact
on each patient care
episode by improving
the quality and/or
timeliness of the
information
4
Step 3: Transformation
Developing agreement
on what data, if
analyzed and reported
to systems and/or
practitioners, would
have a positive impact
on patient care and/or
system delivery
Transformation
5
Translation: Standardizing the format and
content of pathology reports. Translation
Narrative Report
Synoptic Report
Narrative, hence data not
divided into question/answer
pairs
Each diagnostic or prognostic
parameter pair listed on a separate
line
Narrative Report
Patient Name: Jane Doe
Unit Number: 000000
Date of Birth: 14/11/51
Location: LAB
Age/Sex: 52/F
Status: REG REF Health Card#: 0000000000
DIAGNOSIS:
MODIFIED RADICAL MASTECTOMY SPECIMEN (LEFT):
- INVASIVE DUCTAL CARCINOMA. (see microscopic)
- METASTATIC DUCTAL CARCINOMA INVOLVING AXILLARY LYMPH NODE. (see microscopic)
GROSS DESCRIPTION:
This modified radical mastectomy consists of an ellipse of skin measuring 13 cm ML x 7 cm SI with underlying fibrofatty
breast tissue measuring 18 cm ML x 8.5 cm SI x 4.5 cm AP. There is an axillary tail measuring 8 x 5 x 3 cm. A normal
nipple and areola, the latter measuring 2.8 cm in diameter are present. On the upper outer aspect of the skin, there is a 2
cm healed transverse scar. The outer aspect of the specimen is painted with marking ink.
On sectioning the breast, there is a firm tan-gray tumour nodule measuring 3 x 2 x 1 cm, located in the left upper quadrant.
The remainder of the breast consists of fatty tissue admixed with white streaks of breast stroma. The tumour is 1 cm from
the closest (deep) margin. Nine lymph nodes are identified in the axillary fat. They range from 0.5 to 1.2 cm in greatest
dimension.
MICROSCOPIC DESCRIPTION:
Sections of the breast reveal an infiltrating ductal carcinoma of usual type. There is moderate tubule formation (2/3) and the
nuclei show moderate degree of pleomorphism. There are approximately 8 mitoses per 10 high power fields. The modified
Bloom-Richardson grade is 2/3. A minor intraductal component with a cribriform and comedo growth patterns, nuclear
grade 2, is present. Focal lymphovascular space invasion is seen. There is no involvement of the skin or nipple. The
margins are clear. One of 9 lymph nodes from the axilla contains metastatic ductal carcinoma. The greatest diameter of the
tumour is 5 mm and there is no evidence of extranodal spread.
True Synoptic Report
Specimen type
Tumour site
Tumour size
Histologic type
Histologic grade
Margins
Distance to closest margin
Number of nodes examined
left modified radical
mastectomy
left outer upper
quadrant
3 x 2 x 1 cm
ductal, NOS
2/3 (modified SBR)
tubules – 2/3;
nuclei – 2/3;
mitoses – 2/3
uninvolved by invasive
carcinoma
1 cm to deep margin
9
Immunohistochemistry for estrogen receptor (ER) shows extensive positive nuclear staining. The progesterone receptor
and Her-2 (CerB2) markers are negative.
Translation
6
Translation: Establishment of key fields
Clinical Standards
•
•
•
College of American Pathologists Cancer protocols (www.cap.org)
are the pan-Canadian content standard for all cancer pathology
reporting
Through CPAC and CAP-ACP there is Canadian input into CAP
protocols
Needs to support key clinical decisions, quality analyses, and
coding in cancer registries
Informatic Standards
•ICD-O3 (clinical standard)
•SNOMED CT (clinical standard)
•HL7 v 2.3 x (messaging standard)
7
Transaction: Impacts to Completeness
100.0
90.0
Percentage Complete (%)
80.0
70.0
60.0
50.0
40.0
30.0
20.0
10.0
0.0
Prostate
Colon/rectum
Lung
Breast
Endometrium
Disease site
Synoptic
Narrative
Source: Srigley JR, McGowan T, et al.: Standardized Synoptic Cancer Pathology Reporting:
A Population-Based Approach. J. Surg. Oncol. 2009;99:517–524
Transaction
8
Transaction: acceptability Physician survey confirmed
preference for synoptic reporting of cancer pathology
Overall Satisfaction Score
(Scale 1-5; with 5 = significantly better than narrative reports)
Clinicians
Mean (SD)
Pathologists
Mean (SD)
Your overall satisfaction with synoptic
pathology reporting process*
4.52 (.991)
4.08 (1.34)
Your overall satisfaction level with the
information provided by synoptic
reports.
4.85 (.901)
4.08 (1.44)
• Dependent t-tests were conducted to compare the differences in
the mean scores of pathologists and clinicians perceptions of
overall satisfaction indicating a statistically significant difference in
scores for overall satisfaction with the synoptic reporting process [ t
(169) = 3.044, p = .003].
.
By transferring synoptic data directly to registries, coding
time drastically reduced; also allows for more timely general reporting
• Arch Pathol Lab Med. 2013;137(11):1599-602
9
Transformation
• Key issue is to decide on those questions that
would actually drive patient care and the
system forward…..
• Not every indicator is valuable in and of itself
Transformation
10
Data use: Informing indicators to change
practice
Prostate margin rates can be analyzed without manual audits
Report by period in Time
Report by hospital
Percent of Reports with Postive Margins
Percentage of pT2 radical prostatectomy reports with positive margins,
by year for Ontario (June 2008 – December 2011)
Percent of synoptic pT2 radical prostatectomy reports with positive margins,
by hospital, within Region D (Jan 2010 - Dec 2011)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Negative
2008
59
2009
447
2010
1284
2011
1520
Grand Total
3310
Positive
35
128
322
406
891
% Margin Positive
37%
22%
20%
21%
21%
Data Source: Cancer Care Ontario
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Development cycle for indicators
Identified
relevant
indicators
Literature
review to
define
content &
map to CAP
Clinical input
Refined
content &
mapping to
CAP
Validated
CAP
alignment
Clinical
validation &
form
consensus
12
Transformation: What are the questions
that would drive us forward? (3 examples)
13
Breast
Colorectal
Lung
Histologic Type
Distribution
Histologic Grade
Distribution
Tumor Size
Distribution
Lymph Node
Status
Stage Distribution
Radial Margins
Histologic Type
Distribution
Stage
Distribution
Margin Status
Lymph Node
Retrieval
Lymph Nodes
Examined
Lymph-Vascular
Invasion
MMR
Lymph Nodes
Immunohistochemi Positive
stry
Quality of TME
Transformation: What are the questions
that would drive us forward?
14
Breast
Colorectal
Lung
Histologic Type
Distribution
Histologic Grade
Distribution
Tumor Size
Distribution
Lymph Node
Status
Stage Distribution
Radial Margins
Histologic Type
Distribution
Stage
Distribution
Margin Status
Lymph Node
Retrieval
Lymph Nodes
Examined
Lymph-Vascular
Invasion
MMR
Lymph Nodes
Immunohistochemi Positive
stry
Quality of TME
Electronic Synoptic Pathology Reporting
Initiative
Since 2010, the Partnership has been collaborating with the pathology community
across the country to:
1. Advance the discrete collection of electronic synoptic pathology resection reporting
for breast, colorectal, lung, prostate and endometrial cancers
2. Maintain and promote the adoption of pan-Canadian pathology protocol standards
3. Advance the use of standardized data to measure data quality and derivable clinical
indicators
2016
2013-2014
Partnership funded
six provinces:
Demonstrating
feasibility of using
ESPRI data for
clinical indicators
1. Alberta
2010
2. British Columbia
Partnership funded
Ontario & New
Brunswick
3. Manitoba
4. Nova Scotia
5. Prince Edward
Island
6. Moncton, NB.
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By 2017, ~ 850 out
of 1263
pathologist in
Canada will be
generating reports
Other related CPAC initiatives
• Synoptic surgery reporting
– Currently developing standards and looking to
further implementation
• Collection and analysis of patient-reported
outcomes using standardized scoring tools for
cancer patients
– Screening for distress now used in 8 provinces,
and groups meeting to agree on key indicators and
reporting
16
Questions?
Heather.bryant@
Partnershipagainstcancer.ca