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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 11 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. 15 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