Improvements in breast cancer pathology practices among medicare patients undergoing unilateral extended simple mastectomy.

The information contained in pathology reports of breast cancer specimens is of critical importance to treating physicians for selection of local regional treatment, adjuvant therapy, evaluation of therapy, estimation of prognosis, and analysis of outcomes. This information is also of great importance to patients and their families. In 2000, a Breast Cancer Pathology Advisory Group was formed to advise on the design of a project to assess the quality of pathology reports on unilateral extended simple mastectomy (ICD-9-CM procedure code 85.43) specimens from Medicare patients in New York State. This group comprised clinical pathologists, breast surgeons, medical oncologists, clinical breast cancer specialists, and a radiation oncologist. The group suggested that the reports be examined for several elements (quality indicators) that are relevant to patient care and prognosis. Baseline random sample data assessing these elements were established from a random sample of all cases for the calendar year 1999. A random sample of 748 cases (43.5%) of unilateral extended simple mastectomy was chosen from among 1718 cases for the calendar year 1999. Of these, 555 (74.2%) were suitable for review. The remaining 193 (25.8%) cases did not satisfy the inclusion criteria. Aggregate performance on 7 quality indicators (presence of carcinoma, laterality of specimen, number of lymph nodes present, number of positive nodes, documentation of lymph nodes, histologic type, and largest dimension of the tumor) was 83.7% or better, whereas performance was 69.4% or less on 10 others (resection margin status, verification of tumor size, gross observation of the lesion, histologic grade, angiolymphatic invasion, nuclear grade, location of the tumor, mitotic rate, extent of tubule formation, and perineural invasion). The last, perineural invasion, was used as a control element and was not considered an evaluative quality indicator. Performance levels for New York State were significantly lower for histologic grade, resection margin status, and angiolymphatic invasion than in similar studies elsewhere. In addition, there were significant interhospital disparities in the performance levels for these quality indicators. Whereas some hospitals always recorded certain indicators, others never did. This in part reflects differing degrees of adoption of recommended specialty society protocols. The second phase of the project consisted of an educational feedback program involving the directors of pathology laboratories in New York State. The aggregate findings of the baseline study were shared with all the pathologists. In addition, each hospital that performed unilateral extended simple mastectomies during the study period received its own specific data so that it could compare its performance with the aggregate performance. The results of the baseline study also were shared with the New York Pathological Society and the New York State Society of Pathologists. The latter described the results in its newsletter. A postintervention review of the medical charts of a sample of 297 Medicare patients discharged from New York State acute care hospitals with an ICD-9-CM procedure code of 85.43 (unilateral extended simple mastectomy) was conducted for the 6-month period from December 1, 2001, through May 31, 2002. The 8 quality indicators, performance for which was below 84% in the baseline, were chosen for this remeasurement. Statistically significant improvements (P < .0001) occurred in all the 8 quality indicators, ranging from 12.6% to 19.9%. The results of this study indicate that the issues identified by breast cancer pathology reports are amenable to improvement. Such improvement can serve both the patients and the treating physicians better in making adjuvant treatment decisions, estimating prognosis, and evaluating outcomes. It also will be of help to patients and their families in making other life decisions.

Breast cancer pathology practices among Medicare patients undergoing unilateral extended simple mastectomy.

OBJECTIVE: Information in pathology reports of breast cancer specimens is of critical importance to treating physicians for selection of local regional treatment and adjuvant therapy, evaluation of therapy, estimation of prognosis, and analysis of outcomes. This information is also of great importance to patients and their families. The Cancer Committee of the College of American Pathologists (CAP) and the Association of Directors of Anatomic and Surgical Pathology (ADASP) have published protocols for reporting the findings on breast cancer specimens to encourage adequate specimen examination and promote the reporting of findings in standardized formats and to provide treating physicians and their patients with vital information. METHODS: To assess the quality of breast cancer pathology practices and the degree to which they agree with published guidelines, we undertook a retrospective analysis among Medicare patients in New York State. Our random sample consisted of 748 (43.5%) of the 1718 cases of unilateral extended simple mastectomy, also referred to as total mastectomy with lymph node dissection (ICD-9-CM procedure code 85.43), for calendar year 1999. Of these, 555 (74.2%) were available for study, whereas the rest did not satisfy inclusion criteria. Among the 555 cases, 545 (98.2%) were women, and 10 (1.8%) were men. The gender distribution was proportionately the same at 98.2% and 1.8% for all 1718 cases. RESULTS: We examined the 555 hospital records for 16 elements (quality indicators). Aggregate performance on 7 of these was > or =83.7%, and performance was < or = 69.4% on 9 others. There were significant interhospital disparities in performance levels for a number of quality indicators. Although some hospitals always recorded certain indicators, others never did. CONCLUSIONS: The issues with breast cancer pathology reports identified in this study are amenable to improvement to better serve patients, especially women, and their treating physicians in making adjuvant decisions, estimating prognosis, and evaluating outcomes.

Results of a cooperative educational program to improve prostate pathology reports among patients undergoing radical prostatectomy.

The information contained in pathology reports of radical prostatectomy specimens is critically important to treating physicians for the selection of adjuvant therapy, the evaluation of therapy, estimating prognosis, and analyzing outcomes. This information is also important to patients and their families. The first phase of this study consisted of a retrospective chart review of 554 cases of radical prostatectomy (ICD-9-CM procedure code of 60.5) in New York State for the second six-month period of 1996. This review focused on ten elements (quality indicators): submission of a frozen section, location of the adenocarcinoma, proportion of specimen involved by adenocarcinoma, perineural involvement, vascular involvement, seminal vesicle status, periprostate fat status, number of nodes submitted, status of nodes, and PIN (prostate intra-epithelial neoplasia). The second phase of this project consisted of an educational feedback program involving the directors of pathology laboratories in all hospitals in New York State. A post-intervention review of the medical charts of all male Medicare patients discharged from New York State acute care hospitals with the ICD-9-CM procedure code of 60.5 (radical prostatectomy) was conducted for the six-month period February 1 through July 31, 1999. A total of 304 charts were reviewed. Performance on the ten indicators in the first phase of the study varied from 14.8% (periprostate fat status) to 85.9% (seminal vesicle involvement). Performance for all hospitals was 50% for four quality indicators and less than 70% for seven. Post-intervention improvements in performance occurred with nine of the ten quality indicators. These improvements ranged from 1.4% (status of lymph nodes submitted) to 23.9% (proportion of specimen involved by adenocarcinoma). The results of this study demonstrate that the issues identified in the baseline with radical prostatectomy pathology reports were amenable to a cooperative educational intervention.