Impact of Patient, Hospital, and Operative Characteristics relative to Social Determinants of Health: Compliance with National Comprehensive Cancer Network (NCCN) Guidelines for Colon Cancer.

INTRODUCTION: Despite an established association with improved patient outcomes, compliance with National Comprehensive Cancer Network (NCCN) guidelines remains sub-optimal. We sought to assess the impact of patient (PCs), operative (OCs), and hospital characteristics (HCs), and social determinants of health (SDoH) on non-compliance with NCCN guidelines for colon cancer. METHODS: Patients treated for Stage I-III colon cancer from 2004-2017 were identified from National Cancer Database. Multi-level multivariable regression analysis was performed to identify factors associated with receipt of NCCN-compliant care, as well as quantify the proportion of variance explained by PCs, OCs, HCs, and SDoH. RESULTS: Among 468,097 patients with colon cancer treated across 1,319 hospitals, one in four patients did not receive NCCN-compliant care (n=122,170, 26.1%). On regression analysis, older age (0.96, 95% CI 0.96-0.96), female sex (0.97, 95% CI 0.96-0.99), Black race (0.96, 95% CI 0.94-0.98), higher Charlson-Deyo score (0.84, 95% CI 0.82-0.86), tumor stage ≥II (0.42, 95% CI 0.40-0.44), and tumor grade ≥3 (0.33, 95% CI 0.32-0.34) were associated with lower odds of receiving NCCN-compliant care (all p-values<0.05). Higher hospital volume (1.02, 95% CI 1.02-1.03), minimally invasive or robotic surgical approach (1.26, 95% CI 1.23-1.29), adequate (≥12) lymph node assessment (3.46, 95% CI 3.38-3.53), private insurance status (1.33, 95% CI 1.26-1.40), Medicare insurance status (1.42, 95% CI 1.35-1.49), and higher educational status (1.06, 95% CI 1.02-1.09) were associated with higher odds of receiving NCCN-compliant care (all p-values<0.05). Overall, PCs contributed 36.5%, HCs contributed 1.3%, OCs contributed 12.9% to variation in guideline compliant care; SDoH contributed only 3.6% of the variation in receipt of NCCN-compliant care. CONCLUSION: Variation in NCCN-compliant care among patients with colon cancer was largely attributable to patient- and surgeon-level factors, while SDoH were associated with a smaller proportion of the variation.

Postoperative Outcomes Among Patients Undergoing Cancer Surgery: United States versus International Medical Graduates.

OBJECTIVE: We sought to characterize postoperative outcomes among patients who underwent an oncologic operation relative to whether the treating surgeon was an international medical graduate (IMG) versus a United States medical graduate (USMG). SUMMARY BACKGROUND DATA: IMGs comprise approximately one-quarter of the physician workforce in the United States. METHODS: The 100% Medicare Standard Analytic Files were utilized to extract data on patients with breast, lung, hepato-pancreato-biliary (HPB), and colorectal cancer who underwent surgical resection between 2014 and 2020. Entropy balancing (EB) and multivariable regression analysis were performed to evaluate the association between postoperative outcomes among USMG and IMG surgeons. RESULTS: Among 285,930 beneficiaries, 242,914 (85.0%) and 43,016 (15.0%) underwent surgery by a USMG and IMG surgeon, respectively. Overall, 129,576 (45.3%) individuals were male, and 168,848 (59.1%) patients had a Charlson Comorbidity Index score >2. Notably, IMG surgeons were more likely to care for racial/ethnic minority patients (14.7% vs. 12.5%) and those with a high social vulnerability index (33.3% vs. 32.1%) (all P<0.001). On multivariable analysis after EB, patients treated by an IMG surgeon were less likely to experience adverse postoperative outcomes including 90-day readmission (OR 0.89, 95%CI 0.80-0.99) and index complications (OR 0.84, 95%CI 0.74-0.95) versus USMG surgeons (all P<0.05). Patients treated by IMG versus USMG surgeons had no difference in likelihood to achieve a textbook outcome (OR 1.10, 95%CI 0.99-1.21; P=0.077). CONCLUSIONS: Postoperative outcomes among patients treated by IMG surgeons were roughly equivalent to those of USMG surgeons. In addition, IMG surgeons were more likely to care for patients with multiple comorbidities and individuals from vulnerable communities.

Association of county-level provider density and social vulnerability with colorectal cancer-related mortality.

BACKGROUND: Health care providers play a crucial role in increasing overall awareness, screening, and treatment of cancer, leading to reduced cancer mortality. We sought to characterize the impact of provider density on colorectal cancer population-level mortality. METHODS: County-level provider data, obtained from the Area Health Resource File between 2016 and 2018, were used to calculate provider density per county. These data were merged with county-level colorectal cancer mortality 2016-2020 data from the Centers for Disease Control and Prevention. Multivariable regression was performed to define the association between provider density and colorectal cancer mortality. RESULTS: Among 2,863 counties included in the analytic cohort, 1,132 (39.5%) and 1,731 (60.5%) counties were categorized as urban and rural, respectively. The colorectal cancer-related crude mortality rate was higher in counties with low provider density versus counties with moderate or high provider density (low = 22.9, moderate = 21.6, high = 19.3 per 100,000 individuals; P < .001). On multivariable analysis, the odds of colorectal cancer mortality were lower in counties with moderate and high provider density versus counties with low provider density (moderate odds ratio 0.97, 95% confidence interval 0.94-0.99; high odds ratio 0.88, 95% confidence interval 0.86-0.91). High provider density remained associated with a lower likelihood of colorectal cancer mortality independent of social vulnerability index (low social vulnerability index and high provider density: odds ratio 0.85, 95% confidence interval 0.81-0.89; high social vulnerability index and high provider density: odds ratio 0.93, 95% confidence interval 0.89-0.98). CONCLUSION: Regardless of social vulnerability index, high county-level provider density was associated with lower colorectal cancer-related mortality. Efforts to increase access to health care providers may improve health care equity, as well as long-term cancer outcomes.

Impact of an artificial intelligence based model to predict non-transplantable recurrence among patients with hepatocellular carcinoma.

OBJECTIVE: We sought to develop Artificial Intelligence (AI) based models to predict non-transplantable recurrence (NTR) of hepatocellular carcinoma (HCC) following hepatic resection (HR). METHODS: HCC patients who underwent HR between 2000-2020 were identified from a multi-institutional database. NTR was defined as recurrence beyond Milan Criteria. Different machine learning (ML) and deep learning (DL) techniques were used to develop and validate two prediction models for NTR, one using only preoperative factors and a second using both preoperative and postoperative factors. RESULTS: Overall, 1763 HCC patients were included. Among 877 patients with recurrence, 364 (41.5%) patients developed NTR. An ensemble AI model demonstrated the highest area under ROC curves (AUC) of 0.751 (95% CI: 0.719-0.782) and 0.717 (95% CI:0.653-0.782) in the training and testing cohorts, respectively which improved to 0.858 (95% CI: 0.835-0.884) and 0.764 (95% CI: 0.704-0.826), respectively after incorporation of postoperative pathologic factors. Radiologic tumor burden score and pathological microvascular invasion were the most important preoperative and postoperative factors, respectively to predict NTR. Patients predicted to develop NTR had overall 1- and 5-year survival of 75.6% and 28.2%, versus 93.4% and 55.9%, respectively, among patients predicted to not develop NTR (p < 0.0001). CONCLUSION: The AI preoperative model may help inform decision of HR versus LT for HCC, while the combined AI model can frame individualized postoperative care (https://altaf-pawlik-hcc-ntr-calculator.streamlit.app/).

Impact of early primary care physician follow-up on hospital readmission following gastrointestinal cancer surgery.

BACKGROUND: We sought to examine the association between primary care physician (PCP) follow-up on readmission following gastrointestinal (GI) cancer surgery. METHODS: Patients who underwent surgery for GI cancer were identified using the Surveillance, Epidemiology and End Results (SEER) database. Multivariable regression was performed to examine the association between early PCP follow-up and hospital readmission. RESULTS: Among 60 957 patients who underwent GI cancer surgery, 19 661 (32.7%) visited a PCP within 30-days after discharge. Of note, patients who visited PCP were less likely to be readmitted within 90 days (PCP visit: 17.4% vs. no PCP visit: 28.2%; p < 0.001). Median postsurgical expenditures were lower among patients who visited a PCP (PCP visit: $4116 [IQR: $670-$13 860] vs. no PCP visit: $6700 [IQR: $870-$21 301]; p < 0.001). On multivariable analysis, PCP follow-up was associated with lower odds of 90-day readmission (OR: 0.52, 95% CI: 0.50-0.55) (both p < 0.001). Moreover, patients who followed up with a PCP had lower risk of death at 90-days (HR: 0.50, 95% CI: 0.40-0.51; p < 0.001). CONCLUSION: PCP follow-up was associated with a reduced risk of readmission and mortality following GI cancer surgery. Care coordination across in-hospital and community-based health platforms is critical to achieve optimal outcomes for patients.

Association of preoperative cholangitis with outcomes and expenditures among patients undergoing pancreaticoduodenectomy.

BACKGROUND: This study aimed to characterize the association of preoperative acute cholangitis (PAC) with surgical outcomes and healthcare costs. METHODS: Patients who underwent pancreaticoduodenectomy (PD) between 2013 and 2021 were identified using 100% Medicare Standard Analytic Files. PAC was defined as the occurrence of at least 1 episode of acute cholangitis within the year preceding surgery. Multivariable regression analyses were used to compare postoperative outcomes and costs relative to PAC. RESULTS: Among 23,455 Medicare beneficiaries who underwent PD, 2,217 patients (9.5%) had at least 1 episode of PAC. Most patients (n = 14,729 [62.8%]) underwent PD for a malignant indication. On multivariable analyses, PAC was associated with elevated odds of surgical site infection (odds ratio [OR], 1.14; 95% CI, 1.01-1.29), sepsis (OR, 1.17; 95% CI, 1.01-1.37), extended length of stay (OR, 1.13; 95% CI, 1.01-1.26), and readmission within 90 days (OR, 1.14; 95% CI, 1.04-1.26). Patients with a history of PAC before PD had a reduced likelihood of achieving a postoperative textbook outcome (OR, 0.83; 95% CI, 0.75-0.92) along with 87.8% and 18.4% higher associated preoperative and postoperative healthcare costs, respectively (all P < .001). Overall costs increased substantially among patients with more than 1 PAC episode ($59,893 [95% CI, $57,827-$61,959] for no episode vs $77,922 [95% CI, $73,854-$81,990] for 1 episode vs $101,205 [95% CI, $94,871-$107,539] for multiple episodes). CONCLUSION: Approximately 1 in 10 patients undergoing PD experienced an antecedent PAC episode, which was associated with adverse surgical outcomes and greater healthcare expenditures.

Healthcare utilization and expenditures among patients with venous thromboembolism following gastrointestinal cancer surgery.

BACKGROUND: We sought to assess healthcare utilization and expenditures among patients who developed venous thromboembolism (VTE) after gastrointestinal cancer surgery. METHODS: Patients who underwent surgery for esophageal, gastric, hepatic, biliary duct, pancreatic, and colorectal cancer between 2013 and 2020 were identified using the MarketScan database. Entropy balancing was performed to obtain a cohort that was well balanced relative to different clinical covariates. Generalized linear models were used to compare 1-year postdischarge costs among patients who did and did not develop a postoperative VTE. RESULTS: Among 20,253 individuals in the analytical cohort (esophagus [n = 518 {2.6%}], stomach [n = 970 {4.8%}], liver [n = 608 {3.0%}], bile duct [n = 294 {1.5%}], pancreas [n = 1511 {7.5%}], colon [n = 12,222 {60.3%}], and rectum [n = 4130 {20.4%}]), 894 (4.4%) developed VTE. Overall, most patients were male (n = 10,656 [52.6%]), aged between 55 and 64 years (n = 10,372 [51.2%]), and were employed full time (n = 11,408 [56.3%]). On multivariable analysis, VTE was associated with higher inpatient (mean difference [MD], $17,547; 95% CI, $15,141-$19,952), outpatient (MD, $8769; 95% CI, $7045-$10,491), and pharmacy (MD, $2811; 95% CI, $2509-$3113) expenditures (all P < .001). Furthermore, patients who developed VTE had higher out-of-pocket costs for inpatient (MD, $159; 95% CI, $66-$253) and pharmacy (MD, $122; 95% CI, $109-$136) services (all P < .001). CONCLUSION: Among privately insured patients aged <65 years, VTE was associated with increased healthcare utilization and expenditures during the first year after discharge.

Long-term Health Outcomes of New Persistent Opioid Use After Gastrointestinal Cancer Surgery.

BACKGROUND: New persistent opioid use (NPOU) after surgery has been identified as a common complication. This study sought to assess the long-term health outcomes among patients who experienced NPOU after gastrointestinal (GI) cancer surgery. METHODS: Patients who underwent surgery for hepato-pancreato-biliary and colorectal cancer between 2007 and 2019 were identified using the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database. Mixed-effect multivariable logistic regression and Cox proportional hazard models were used to estimate the risk of mortality and hospital visits related to falls, respiratory events, or pain symptoms. RESULTS: Among 15,456 patients who underwent GI cancer surgery, 967(6.6%) experienced NPOU. Notably, the patients at risk for the development of NPOU were those with a history of substance abuse (odds ratio [OR], 1.45; 95% confidence interval [CI], 1.14-1.84), moderate social vulnerability (OR, 1.26; 95% CI, 1.06-1.50), an advanced disease stage (OR, 4.42; 95% CI, 3.51-5.82), or perioperative opioid use (OR, 3.07; 95% CI, 2.59-3.63. After control for competing risk factors, patients who experienced NPOU were more likely to visit a hospital for falls, respiratory events, or pain symptoms (OR, 1.45, 95% CI 1.18-1.78). Moreover, patients who experienced NPOU had a greater risk of death at 1 year (hazard ratio [HR], 2.15; 95% CI, 1.74-2.66). CONCLUSION: Approximately 1 in 15 patients experienced NPOU after GI cancer surgery. NPOU was associated with an increased risk of subsequent hospital visits and higher mortality. Targeted interventions for individuals at higher risk for NPOU after surgery should be used to help mitigate the harmful effects of NPOU.

Care fragmentation in hepatopancreatic surgery and postoperative outcomes.

BACKGROUND: Practice fragmentation in surgery may be associated with poor quality of care. We sought to define the association between fragmented practice and outcomes in hepatopancreatic surgery relative to surgeon volume and sex. METHODS: Medicare beneficiaries who underwent hepatopancreatic surgery between 2016 and 2021 were identified. Multivariable analysis was performed to determine provider sex-based differences in the rate of fragmented practice relative to the achievement of a textbook outcome and health care expenditures after adjusting for procedure-specific case volume. RESULTS: Among 37,416 patients, almost one-half were female (n = 18,333, 49.0%) with the majority treated by male surgeons (n = 33,697, 90.8%). Female surgeons were more likely to have a greater rate of fragmented practice (females: n = 242, 84.9% vs males: n = 1,487, 78.4%, P = .003; odds ratio 2.66, 95% confidence interval 2.33-3.03, P < .001). Patients treated by high rate of fragmented practice surgeons had increased odds of postoperative complications (odds ratio 1.40, 95% confidence interval 1.28-1.54), extended length-of-stay (odds ratio 1.52, 95% confidence interval 1.38-1.68), 90-day-mortality (odds ratio 1.49, 95% confidence interval 1.28-1.72), and lower odds of achieving a textbook outcome (odds ratio 0.76, 95% confidence interval 0.71-0.83). This association persisted independent of surgeon-specific volume (textbook outcome, high vs low rate of fragmented practice: high-volume surgeon, odds ratio 0.53, 95% confidence interval 0.31-0.91, P = .021 vs. low-volume surgeon, odds ratio 0.76, 95% confidence interval 0.69-0.82, P < .001). Among patients treated by male surgeons, a high rate of fragmented practice was associated with reduced odds of achieving a textbook outcome (male surgeons: odds ratio 0.76, 95% confidence interval 0.70-0.82, P < .001; female surgeons: odds ratio 0.81, 95% confidence interval 0.63-1.05, P = .110). Treatment by surgeons with higher fragmented practice was associated with higher expenditures (index expenditure: percentage difference 9.87, 95% confidence interval, 7.42-12.36; P < .05). CONCLUSION: A high rate of fragmented practice adversely affected postoperative outcomes and healthcare expenditures even among high-volume surgeons with the impact varying based on surgeon sex.

Surgical outcomes and healthcare expenditures among patients with dementia undergoing major surgery.

BACKGROUND: We sought to define surgical outcomes among elderly patients with Alzheimer's disease and related dementias (ADRD) following major thoracic and gastrointestinal surgery. METHODS: A retrospective cohort study was used to identify patients who underwent coronary artery bypass grafting (CABG), abdominal aortic aneurysm (AAA) repair, pneumonectomy, pancreatectomy, and colectomy. Individuals were identified from the Medicare Standard Analytic Files and multivariable regression was utilized to assess the association of ADRD with textbook outcome (TO), expenditures, and discharge disposition. RESULTS: Among 1,175,010 Medicare beneficiaries, 19,406 (1.7%) patients had a preoperative diagnosis of ADRD (CABG: n = 1,643, 8.5%; AAA repair: n = 5,926, 30.5%; pneumonectomy: n = 590, 3.0%; pancreatectomy: n = 181, 0.9%; and colectomy: n = 11,066, 57.0%). After propensity score matching, patients with ADRD were less likely to achieve a TO (ADRD: 31.2% vs. no ADRD: 40.1%) or be discharged to home (ADRD: 26.7% vs. no ADRD: 46.2%) versus patients who did not have ADRD (both p < 0.001). Median index surgery expenditures were higher among patients with ADRD (ADRD: $28,815 [IQR $14,333-$39,273] vs. no ADRD: $27,101 [IQR $13,433-$38,578]; p < 0.001) (p < 0.001). On multivariable analysis, patients with ADRD had higher odds of postoperative complications (OR 1.32, 95% CI 1.25-1.40), extended length-of-stay (OR 1.26, 95% CI 1.21-1.32), 90-day readmission (OR 1.37, 95% CI 1.31-1.43), and 90-day mortality (OR 1.76, 95% CI 1.66-1.86) (all p < 0.001). CONCLUSION: Preoperative diagnosis of ADRD was an independent risk factor for poor postoperative outcomes, discharge to non-home settings, as well as higher healthcare expenditures. These data should serve to inform discussions and decision-making about surgery among the growing number of older patients with cognitive deficits.

Prognostic value of nodal staging classification and number of examined lymph nodes among patients with ampullary cancer.

BACKGROUND: Metastatic disease in the regional lymph nodes (LNs) is a strong indicator of worse outcomes among patients after curative-intent resection of ampullary cancer (AC). This study aimed to ascertain the threshold number of examined LNs (ELNs) for AC to compare the prognosis accuracy of various nodal classification schemes relative to long-term prognosis. METHODS: Patients who underwent pancreatoduodenectomy (PD) for AC (2004-2019) were identified using the National Cancer Database. Locally weighted regression scatter plot smoothing (LOWESS) curves were used to ascertain the optimal cut point for ELNs. The accuracy of the American Joint Committee on Cancer N classification, LN ratio, and log odds transformation (LODDS) ratio to stratify patients relative to survival was examined. RESULTS: Among 8127 patients with AC, 67% were male with a median age of 67 years (IQR, 59-74). Tumors were most frequently classified as T3 (34.9%), followed by T2 (30.6%); T1 (12.9%) and T4 (17.6%) were less common. LN metastasis was identified in 4606 patients (56.7%). Among patients with nodal disease, 37.0% and 19.7% had N1 and N2 disease, respectively. The LOWESS curves identified an inflection cutoff point in the hazard of survival at 20 ELNs. The survival benefit of 20 ELNs was more pronounced among patients without LN metastasis vs patients with N1 disease (median overall survival [OS]: 54.1 months [IQR, 45.9-62.1] in ≥20 ELNs vs 39.0 months [IQR, 35.8-42.2] in <20 ELNs; P < .001) or N2 disease (median OS: 22.5 months [IQR, 18.9-26.2] in ≥20 ELNs vs 25.4 months [IQR, 23.3-27.6] in <20 ELNs; P < .001). When comparing the 4 different N classification schemes, the LODDS classification scheme yielded the highest predictive ability. CONCLUSIONS: Evaluation of a minimum of 20 LNs was needed to stratify patients with AC relative to the prognosis and to minimize stage migration. The LODDS nodal classification scheme had the highest prognostic accuracy to differentiate survival among patients after PD for AC.

Association between social determinants of health and delayed postoperative adjuvant therapy among patients undergoing resection of pancreatic cancer.

BACKGROUND AND OBJECTIVES: Pancreatic cancer (PDAC) requires a multimodality approach. We sought to define the association between social determinants of health (SDOH) and delayed or nonreceipt of adjuvant chemotherapy (aCT) among patients undergoing PDAC resection. METHODS: Data on patients who underwent PDAC resection between 2014 and 2020 were identified from Medicare Standard Analytic Files and merged with the county-level social vulnerability index (SVI). Mediation analysis defined the association between SVI subthemes and aCT receipt. RESULTS: Among 24 078 patients, 47.7% received timely aCT, 17.7% received delayed aCT, and 34.6% did not receive any aCT. High SVI was associated with delay (odds ratio [OR] 1.22, 95% confidence interval [CI] 1.10-1.34) and nonreceipt of aCT (OR 1.30, 95% CI 1.20-1.41) (both p < 0.05). 73.1% of the variation in timely aCT receipt was directly attributable to SVI, whereas 26.9% of the effect was due to indirect mediators including hospital volume (6.4%), length-of-stay (7.9%) and postoperative complications (12.6%). Socioeconomic status (delayed aCT: OR 1.25, 95% CI 1.13-1.38; nonreceipt aCT: OR 1.25, 95% CI 1.15-1.36) and household composition and disability (delayed aCT: OR 1.30, 95% CI 1.17-1.43; nonreceipt aCT: OR 1.19, 95% CI 1.09-1.29) were associated with receipt of aCT (both p < 0.001). CONCLUSIONS: Most of the disparities in receipt of aCT after PDAC surgery are driven by underlying SDOH such as SVI.

Association of Textbook Outcome and Hospital Volume with Long-Term Survival Following Resection for Hepatocellular Carcinoma: What Matters More?

BACKGROUND: Both textbook outcome (TO) and hospital volume have been identified as quality metrics following cancer surgery. We sought to examine whether TO or hospital volume is more important relative to long-term survival following surgical resection of hepatocellular carcinoma (HCC). METHODS: Patients who underwent surgery for HCC between 2004 and 2018 were identified using the National Cancer Database. TO was defined as R0 margin resection, no extended length of stay, no 30-day readmissions, and no 90-day mortality. The impact of TO and hospital case volume on long-term survival was determined using multivariable Cox regression. RESULTS: Among 24,895 patients who underwent HCC resection, 9.0% (n = 2,252), 79.5% (n = 19,787), and 11.5% (n = 2,856) of patients were operated on at low-, medium-, and high-volume hospitals, respectively. Treatment at high-volume hospitals and achievement of a post-operative TO were independently associated with improved 5-year overall survival (OS). Pairwise comparison demonstrated that patients treated at high-volume hospitals who did not achieve a TO still had a better 5-year OS versus individuals treated at low-volume hospitals who did achieve a TO (5-year OS, no TO vs. TO: low-volume hospitals, 26.5% vs. 48.6%; high volume hospitals: 62.6% vs. 74.9%, respectively; p < 0.001). Overall, resection of HCC at a high-volume hospital was independently associated with a 54% reduction in mortality. CONCLUSION: Long-term survival following HCC resection was largely associated with hospital case volume rather than TO. The effect of TO on long-term outcomes was largely mediated by hospital case volume highlighting the importance of centralization of care for patients with HCC.

Attitudes and practice of surgeons in reporting medical errors at a tertiary care hospital.

Medical error reporting is essential in creating a culture of accountability in our healthcare system. The aim of this study was to evaluate the frequency of reporting errors by surgeons in our setup and to analyse the factors resulting in under-reporting of medical errors. A total of 96 practicing surgeons at Mayo Hospital, Lahore were surveyed between the months of February, 2018 to June 2018 on their beliefs regarding the reporting of medical errors by means of a specifically designed questionnaire. This study revealed that 71 (74%) respondents had committed a medical error but only 16 (16.6%) of them reported those errors. Major factors in under-reporting of errors included work stress and fear of medico-legal consequences due to disclosure of error. Eighty-four (87.5%) believed that increase in reporting medical errors would contribute to a better system. Most surgeons had a positive view towards the process but believed that the reporting system was ineffective.

Root cause analysis of pre-microscopic errors in anatomical pathology using Eindhoven classification.

OBJECTIVE: To evaluate pre-microscopic errors in anatomical pathology. METHODS: The cross-sectional descriptive study was conducted at the Department of Pathology of a tertiary care hospital in Lahore, Pakistan, from September, 2016, to January, 2017, and comprised surgical pathology specimens. Errors were noted across the pre-microscopic process. Defects per million opportunities were calculated to determine sigma metric value in every step, from requisition to slide preparation. Root cause analysis was applied to the process of histology preparation to identify the root cause of each previously identified problem using Eindhoven classification. All errors were recorded on a pre-designed proforma. RESULTS: There were 2420 specimens. While errors were encountered in all phases of the pre-microscopic process, but the (G6: n=1085, 44.83%), followed by requisition (R3: n=893, 36.9%) and cover slipping (C1: n=776, 32.06%). CONCLUSIONS: Development of standard procedures and protocols with staff training is likely to help in controlling the errors.