Download synoptic reporting and the quality of cancer care

review
Synoptic reporting and
the quality of cancer care
A review of evidence and Canadian initiatives
Robin Urquhart, MSc; Eva Grunfeld, MD, DPhil, FCFP; Geoffrey A. Porter, MD, FRCSC, FACS
Abstract
Every patient with suspected or confirmed cancer
requires accurate diagnosis and staging to guide
treatment planning and to make informed patient
care decisions. Physicians and surgeons have traditionally used narrative writing to report findings from
investigative tests, surgical procedures and examination of tumour specimens. However, research has
demonstrated that narrative reporting does not consistently provide the information required to make optimal treatment decisions. One response to the suboptimal content of the narrative report has been the
development of a synoptic template that captures
data items in a structured, standardized manner; it
contains only those elements deemed meaningful to
understanding the biology of the disease and subsequent implications for patient care. This article uses
the example of colorectal cancer to examine the role
of synoptic reporting in improving the quality of care
provided to cancer patients, and discusses current
and future Canadian initiatives in this area.
Robin Urquhart, MSc is a Research Associate with the Cancer
Outcomes Research Program, Cancer Care Nova Scotia, Halifax, NS.
Eva Grunfeld, MD, DPhil, FCFP is Director of the Knowledge
Translation Network, Health Services Research Program, Cancer Care
Ontario and Ontario Institute of Cancer Research, and the Giblon Professor and Director of Family Medicine Research, University of Toronto;
Geoffrey A. Porter, MD, FRCSC, FACS is a Surgical Oncologist
at Capital District Health Authority and Professor with the Department
of Surgery, Dalhousie University.
Address for correspondence: Robin Urquhart, Cancer Outcomes
Research Program, Room 523, Bethune Building, 1278 Tower Road,
Halifax, NS B3H 2Y9; Tel: (902) 473-8245: Fax: (902) 473-4631;
Email: [email protected]
The need for accurate reports in CRC
Quality of care is often defined as the extent to which
healthcare services for individuals and populations increase
the likelihood of desired health outcomes and are consistent with current professional knowledge.1 Quality of
cancer care goes beyond issues of access and timeliness2 to
encompass services that are consistent with current evidence of best practices, thereby increasing the likelihood
of optimal health outcomes.3 Accordingly, initiatives for
quality health services in cancer care must strive to ensure
that all individuals within a particular population have
access to appropriate and evidence-based cancer services.4
Certainly, every patient with suspected or confirmed cancer requires accurate diagnosis and staging to guide treatment planning and make informed patient care decisions.
The objective of this paper is to examine the role of synoptic (structured) reporting in improving the quality of care
provided to cancer patients, using the example of colorectal
cancer (CRC). In CRC, the accuracy of diagnosis and staging depends on 3 critical elements: the colonoscopy, surgery and pathology examinations. If details are missing,
inaccurate or unclear from the reporting of any of these
elements, the accuracy of staging, estimates of prognosis
and selection of treatment plans will be compromised.
Accordingly, oncologists and other cancer care providers
must work together with endoscopists, pathologists and
surgeons to ensure the highest quality of care for their
CRC patients.
The potential of synoptic reporting
Traditionally, physicians and surgeons have recorded findings from investigative tests, surgical procedures and examination of tumour specimens in narrative reports. These
reports are typically dictated by the physician or surgeon
and characterized by a free-text, descriptive account of the
patient, procedure, suspected or confirmed findings, and
proposed treatment. However, research has demonstrated
that narrative reporting does not consistently provide the
information required to make optimal decisions regarding
further treatment. For example, in pathology reporting for
rectal cancer, narrative records have been weak at reporting
circumferential resection margin status, with completeness
©2009 Parkhurst, publisher of Oncology Exchange. All rights reserved.
28
ΠVOL. 8, N0. 1, february 2009
review
of information ranging between 31%5 and 51.5%6 — despite
the critical nature of this information for effective patient
management.7,8 In surgical reporting, the narrative report
captured between one-third and one-half of the data elements related to laparotomy findings and tumour resection,
and less than a quarter of the elements related to preoperative staging and treatment.9 Hence, while incomplete
reporting certainly does not reflect on the quality of a particular pathologist’s or surgeon’s clinical judgment or technical skill, it does weaken the capacity of the cancer care
team to carry out informed decision making.
One response to the suboptimal content of the narrative
report has been the development of a “synoptic” template
to concisely and comprehensively record the critical patient,
tumour and technical elements related to the procedure.
This format involves capturing data items in a structured,
standardized manner with a prespecified choice of responses.10 Accordingly, synoptic templates are essentially checklists of essential data elements, often based upon minimum
dataset guidelines5,11-13 and/or a consensus process undertaken by local physicians and/or surgeons,9,12,13 that contain
all data elements considered important to understand the
biology of the disease and subsequent implications for
patient care. It has been shown that the implementation of
synoptic checklists in pathology has substantially improved
the completeness of pathology reporting,5,11,13,14 with
research showing an almost 100% inclusion rate of important clinical information such as completeness of mesorectal
specimens and circumferential resection margin.5,14 Other
details of the CRC pathology report that have substantially
improved following the introduction of a synoptic format
include involvement of the apical node (improvement from
40% to 99%), extramural vascular invasion (from 68% to
100%) and relationship to the peritoneal reflection (from
1% to 75%).11 An Alberta-based evaluation following the
introduction of a web-based operative synoptic template for
rectal cancer surgery (see below) showed that the synoptic
report captured 99% of the specified data elements compared to 45.9% captured via the narrative report.9
The benefits of synoptic reporting extend beyond ensuring that reports contain all the relevant and necessary clinical information needed to make informed decisions. The
synoptic template represents a potentially effective educational tool, as it continually reminds the clinician of the
essential steps and details of the event (colonoscopy, surgery or specimen analysis) for optimal quality control,15
particularly for “nonspecialist” pathologists and surgeons
who do not routinely report or resect CRC specimens.
Research has demonstrated that the surgeon’s knowledge
and skill have considerable influence on patient outcomes.15-19
For example, education or training in oncology resection
principles can promote a therapeutic approach (e.g. total
mesorectal excision and appropriate use of neoadjuvant
therapy), decreasing local recurrence rates and morbidity in
rectal cancer.20 Further, the synoptic report represents a
potential tool for the dissemination of established guidelines, as these can be integrated into the synoptic reporting
instrument.
Theoretically, synoptic reporting can enhance our ability
to measure and monitor the processes of care and assess the
impact on outcomes. For example, present quality indicators
in surgery do not measure the conduct of the actual procedure. The implementation of synoptic reporting is expected
to eventually change that, as the surgical report reflects key
aspects of the surgeon’s judgment and skills, as well as the
biology of the disease. Indeed, the monitoring and assessment of real-time surgical outcomes has been valued by
surgeons participating in synoptic reporting in Alberta21
while Ontario CRC surgeons have stated that they would
welcome surgical outcome studies and information surrounding variations in practice and outcomes.22
Integration into clinical practice
Ideally, optimal clinical care relies on evidence from rigorous, well-designed clinical trials.23,24 However, such evidence does not always exist to guide treatment decisions
for individuals diagnosed with cancer (e.g. radiotherapy for
upper rectal cancers located from 10 to 15 cm from the
anal verge23,25,26). In view of uncertain evidence, cases must
be reviewed individually based on information from the
diagnostic, surgical and pathology reports. In these situations, a synoptic reporting mechanism, whereby particular
data elements are completed and presented in a structured
manner, would facilitate treatment planning and help
ensure that adjuvant therapies are appropriately provided to
those patients most likely to benefit.
Synoptic reporting has received much more attention in
tumour pathology than in any other field, with template
formats varying from a paper proforma appended to the
request form of carcinoma resection specimens5 to computerized templates that allow the user to enter relevant data
by selecting drop-down items and to directly transfer the
report into laboratory information systems.27 While electronic systems may represent the ideal format, many challenges exist when implementing electronic reporting mechanisms into the practice environment. The evaluation of an
online pathology reporting system in the UK exemplifies a
common problem: the practical difficulty associated with
hospitals being unable to accept the reporting software
because of incompatible or older computing systems.13
Other information technology challenges include difficulty
©2009 Parkhurst, publisher of Oncology Exchange. All rights reserved.
ΠVOL. 8, N0. 1, february 2009
29
review
accessing computer facilities28 (i.e. lack of appropriate technology located near operating rooms, laboratories and
endoscopic services) and Internet access. In contrast, the
simpler paper-based methods do not have the same logistic
barriers and have provided significant results in terms of
improving the completeness of reporting: paper proformas
appended to tissue specimens increased inclusion rates of all
data elements to nearly 100% in a study on resected colorectal carcinomas.5
While narrative reporting remains the predominant
mechanism by which Canadian physicians and surgeons
report their procedural details and findings, several initiatives have brought synoptic reporting to the forefront.
Beginning in 1999, Cancer Surgery Alberta (formerly the
Cancer Surgery Working Group) developed a web-based
synoptic reporting system known as the Web Surgical Medical Record (WebSMR) to replace the existing narrative
operative record. The synoptic templates included details
on the surgery, as well as elements related to decision-making and outcomes. Following findings that the WebSMR
substantially improved reporting of rectal cancer surgery,9
the group has continued to implement the system throughout Alberta and is currently collaborating with other provincial groups to integrate the WebSMR into the provincial
electronic health record.28 Tumour templates are available
for various disease sites, including breast, colon, rectal,
ovarian, liver and thyroid cancers. These templates can
report real-time data and are directly transferable to all
appropriate health care providers.9
Cancer Care Ontario and the Ontario Association of
Pathologists have adopted the College of American Pathologists’ cancer checklists, which contain lists of evidencebased critical elements that pathologists may use when
completing a surgical pathology report on a cancer specimen.29 Not only do such reports provide oncologists and
patients with the detailed information they need for appropriate treatment planning, but the data is also used to monitor the quality of reporting in Ontario and to support service planning and research. The introduction of standardized reporting checklists has tremendously improved the
quality of pathology reporting in cancer care: a 2005–2006
audit found that completeness of pathology reporting
increased 2- to 3-fold for all disease sites when synoptic
reporting mechanisms were employed.10 In the same audit,
78% of synoptic reports for CRC contained all the elements
required to meet the provincial standard, while only 28% of
narrative reports contained all the elements.10
Despite the documented inadequacies of narrative
reporting, the use of synoptic reporting represents a radical
change in practice for specialists and surgeons working in
cancer care — it requires fundamental shifts in practice
culture and physician behaviour. Narrative reporting dates
back to the Pyramid Age of Egypt (3000–2500 BC), with
breast cancer described in the first surgical record.30 Changing millennia of behaviour is undoubtedly complicated,
even when logistic, structural and organizational barriers
are addressed. Research demonstrates that it will not occur
by simple, passive dissemination of evidence on the benefits
of synoptic reporting.31 While singular interventions
(including reminder systems, audit and feedback, and dissemination of education materials) show modest to moderate
effects on physician behaviour,32 multifaceted approaches
appear best able to influence practice culture and behaviour.31
Further, any real change in practice will likely require comprehensive approaches at different levels, including the physician, hospital and wider environment, tailored to specific
settings and groups.33 It is notable that despite high user
satisfaction among those surgeons using the WebSMR in
Alberta, the adoption rate was 13.8% as of March 2007
(provincial deployment commenced in 2006).28 Reluctance
to use synoptic reporting was also reported among pathologists during the planning and piloting of a nationwide
electronic template for CRC in Norway, although feedback
from initial users suggested that the template was time-saving
and user-friendly.12 Such reluctance demonstrates that the
widespread implementation of synoptic reporting requires
particular attention to the user. Specific concerns may
include lack of flexibility in describing the tumour or for
reporting more complex surgical details,12,28 the prospect of
being individually monitored12 and the concurrent use of
2 reporting systems.
Moving forward in Canada
Using the Alberta WebSMR and the Ontario Pathology
Reporting System as templates, the Canadian Partnership
Against Cancer is taking the lead in refining and implementing synoptic reporting mechanisms across Canada via
its Cancer Guidelines Action Group’s Synoptic Reporting
Tools Project.34 The objective of this project, now in its
early stages, is to pilot-test synoptic reporting tools and
encourage the complete reporting of surgical data for
patients with breast, colorectal, ovarian, and head and neck
cancers. Nova Scotia is leading the implementation of the
breast cancer template, with participating provinces including British Columbia, Alberta, Manitoba, and Quebec;
Ontario is leading the ovarian template, with Alberta also
participating; and Manitoba is leading the head and neck
template, with participating provinces including Ontario
and Nova Scotia. While the lead has not been determined
for the colon and rectal templates, participating provinces
include Alberta, Manitoba, Ontario and Nova Scotia, with
Quebec also implementing templates for these cancers.
In these initiatives, each participating province is expected
to implement the surgical template while also collaborating
on another component of cancer care (e.g. pathology,
internal medicine) to develop and implement corresponding synoptic reporting templates in that discipline. The idea
is that uniform reporting templates will facilitate the incorporation of evidence into everyday practice: oncologists will
be able to integrate the complete preoperative and operative
information with practice guidelines to formulate effective
treatment plans for their patients. At the same time, synoptic reporting should enable the collection of surgical, clinical,
pathology and outcomes data for quality monitoring and
improvement.
Our own research, building upon the work of both the
Alberta WebSMR and the Canadian Partnership Against
Cancer initiatives, is studying the implementation of synoptic
©2009 Parkhurst, publisher of Oncology Exchange. All rights reserved.
30
ΠVOL. 8, N0. 1, february 2009
review
reporting templates in Nova Scotia, as well as knowledge
translation methods to enhance their use by gastroenterologists, surgeons and pathologists.35 The province’s Colorectal Cancer Prevention Program, now being developed,36
will employ synoptic reporting in colonoscopy — an area
that lacks standardized reporting and data systems.37
From the oncologist’s perspective, synoptic reporting
represents a significant advance toward ensuring higher
quality medical treatment. Simply put, new therapies and
new approaches to therapy — for example, neoadjuvant
therapy for rectal cancer — cannot be effective if the information needed for appropriate use is not available to the
required decision makers. Much work remains, including
addressing the technical, legal and privacy issues of electronic web-based reporting as well as the education of physicians, surgeons and medical staff. However, by instituting
changes in the way healthcare is delivered, this approach
could have a significant positive impact on patient care and
health outcomes. n
Œ
Disclosure
The authors report having no potential conflicts of interest pertaining
to this article.
References
1. Donaldson MS, Field MJ. Measuring quality of care at the end of life. Arch
Intern Med 1998;158(2):121-8.
2. Institute of Cancer Research ,Canadian Institutes of Health Research. Access
to Quality Cancer Care – Workshop Report. June 14, 2005, Vancouver, BC.
Online report available at www.cihr-irsc.gc.ca/e/28794.html, accessed October
2006.
3. Hewitt M, Simone JV. Ensuring quality cancer care. Washington, DC: National
Academy Press, 1999.
4. Chassin MR, Galvin RW. The urgent need to improve health care quality.
Institute of Medicine National Roundtable on Health Care Quality. JAMA
1998;280(11):1000-5.
5. Cross SS, Feeley KM, Angel CA. The effect of four interventions on the informational content of histopathology reports of resected colorectal carcinomas.
J Clin Pathol 1998;51(6):481-82.
6. Bull AD, Biffin AH, Mella J et al. Colorectal cancer pathology reporting: a
regional audit. J Clin Pathol 1997;50(2):138-42.
7. Birbeck KF, Macklin CP, Tiffin NJ et al. Rates of circumferential resection margin involvement vary between surgeons and predict outcomes in rectal cancer
surgery. Ann Surg 2002;235(4):449-57.
8. Stocchi L, Nelson H, Sargent DJ et al. Impact of surgical and pathologic
variables in rectal cancer: a United States community and cooperative group
report. J Clin Oncol 2001;19(18):3895-902.
9. Edhemovic I, Temple WJ, de Gara CJ, Stuart GC. The computer synoptic
operative report--a leap forward in the science of surgery. Ann Surg Oncol
2004;11(10):941-7.
10. Cancer Care Ontario. Pathology checklist reporting project overview. Available
online at www.cancercare.on.ca > Ontario Cancer System > Clinical Programs
> Pathology and Laboratory Medicine (accessed November 2008).
11. Beattie GC, McAdam TK, Elliott S et al. Improvement in quality of colorectal
cancer pathology reporting with a standardized proforma — a comparative
study. Colorectal Dis 2003;5(6):558-62.
12. Bjugn R, Casati B, Norstein J. Structured electronic template for histopathology
reports on colorectal carcinomas: a joint project by the Cancer Registry of Norway and the Norwegian Society for Pathology. Hum Pathol 2008;39(3):359-67.
13. Branston LK, Greening S, Newcombe RG et al. The implementation of guidelines and computerised forms improves the completeness of cancer pathology
reporting. The CROPS project: a randomised controlled trial in pathology. Eur J
Cancer 2002;38(6):764-72.
14. Rigby K, Brown SR, Lakin G et al. The use of a proforma improves colorectal
cancer pathology reporting. Ann R Coll Surg Engl 1999;81(6):401-3.
15. Mack LA, Temple WJ. Education is the key to quality of surgery for rectal can-
cer. Eur J Surg Oncol 2005;31(6):636-44.
16. McArdle CS, Hole DJ. Influence of volume and specialization on survival following surgery for colorectal cancer. Br J Surg 2004;91(5):610-7.
17. Smith JA, King PM, Lane RH, Thompson MR. Evidence of the effect of ‘specialization’ on the management, surgical outcome and survival from colorectal
cancer in Wessex. Br J Surg 2003;90(5):583-92.
18. Wibe A, Carlsen E, Dahl O et al; The Norwegian Rectal Cancer Group.
Nationwide quality assurance of rectal cancer treatment. Colorectal Dis 2006;
8(3):224-9.
19. Porter GA, Soskolne CL, Yakimets WW, Newman SC. Surgeon-related factors
and outcome in rectal cancer. Ann Surg 1998;227(2):157-67.
20. Giacomantonio CA, Temple WJ. Quality of cancer surgery: challenges and controversies. Surg Oncol Clin N Am 2000;9(1):51-60.
21. W. Temple, personal communication, April 14, 2008.
22. Cancer Quality Council of Ontario. Improving the management of colorectal
cancer: summary of the Cancer Quality Council of Ontario signature event on
colorectal cancer. Toronto, ON, June 3, 2003. Available online at www.cancercare.on.ca > About CCO > Cancer Quality Council of Ontario > CQCO Signature
Events (accessed November 2008).
23. Kapiteijn E, Marijnen CA, Nagtegaal ID et al; Dutch Colorectal Cancer Group.
Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. NEJM 2001;345(9):638-46.
24. Sauer R, Becker H, Hohenberger W et al; German Rectal Cancer Study Group.
Preoperative versus postoperative chemoradiotherapy for rectal cancer. NEJM
2004;351(17):1731-40.
25. Heald RJ, Moran BJ, Ryall RD, Sexton R, MacFarlane JK. Rectal cancer: the
Basingstoke experience of total mesorectal excision, 1978-1997. Arch Surg
1998;133(8):894-9.
26. Burton S, Brown G, Daniels I et al. MRI identified prognostic features of tumors
in distal sigmoid, rectosigmoid, and upper rectum: treatment with radiotherapy
and chemotherapy. Int J Radiat Oncol Biol Phys 2006;65(2):445-51.
27. Qu Z, Ninan S, Almosa A et al. Synoptic reporting in tumor pathology: advantages of a web-based system. Am J Clin Pathol 2007;127(6):898-903.
28. Cancer Surgery Alberta. Alberta WebSMR Benefits Evaluation. Cancer Surgery
Alberta Quarterly 2008; 1:1-6. Available online at www.cancerboard.ab.ca >
Health Professionals > Cancer Surgery Alberta > Projects, Partnerships & Publications (accessed June 2008).
29. College of American Pathologists. Cancer protocols and checklists. Available
online at www.cap.org > CAP Reference Resources and Publications > Practice Resources > Cancer protocols and checklists (accessed May 2008).
30. Foster RS Jr. Breast cancer detection and treatment: a personal and historical
perspective. Arch Surg 2003;138(4):397-408.
31. Grimshaw J, Shirran L, Thomas R et al. Changing provider behaviour: An overview of systematic reviews of interventions. Med Care 2001; 39(8,S2): II2-45.
32. Grimshaw J, Eccles M, Thomas R et al. Toward evidence-based quality
improvement. Evidence (and its limitations) of the effectiveness of guideline
dissemination and implementation strategies 1966-1998. J Gen Intern Med
2006;21(S2):S14-20.
33. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet 2003;362(9391):1225-30.
34. Canadian Partnership Against Cancer. Cancer control guidelines. Available
online at www. partnershipagainstcancer.ca (accessed June 2008).
35. Grunfeld E (PI), Porter GA, Rayson D et al. CIHR/CCNS Team in Access to
Colorectal Cancer Services in Nova Scotia, Canadian Institutes for Health
Research, 2007-2012. Readers may contact the corresponding author for
details.
36. Cancer Care Nova Scotia. Colorectal Cancer Prevention Program. Available
online at www.cancercare.ns.ca > Patients & Families (accessed June 2008).
37. Lieberman D, Nadel M, Smith RA et al. Standardized colonoscopy reporting
and data system: report of the Quality Assurance Task Group of the National
Colorectal Cancer Roundtable. Gastrointest Endosc 2007;65(6):757-66.
©2009 Parkhurst, publisher of Oncology Exchange. All rights reserved.
ΠVOL. 8, N0. 1, february 2009
31