April 2016, Vol. 5, No. 3

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Secondary Pathology Review Improves Clinical Outcomes

2016 ASCO Quality Care Symposium

Secondary pathology review can significantly improve clinical outcomes through precise and accurate pathologic diagnoses, according to Lavinia P. Middleton, MD.

“Accurate pathological diagnoses have become a high priority in cancer diagnosis,” said Middleton, Professor, Department of Pathology at The University of Texas MD Anderson Cancer Center in Houston. Increasing costs and inconsistent quality drive payers and policymakers to examine the value of healthcare spending, and improved diagnostic accuracy is integral to controlling costs and improving quality.

Middleton and her coinvestigators within the Alliance of Dedicated Cancer Centers (ADCC)-a group of 11 National Cancer Institute–designated comprehensive cancer centers-conducted a study to examine the clinical impact of secondary pathology review and presented their results at the 2016 ASCO Quality Care Symposium.

The Value of Accurate Pathologic Diagnoses

Several studies in the literature have documented change in diagnosis associated with secondary review by subspecialty pathologists, and the National Comprehensive Cancer Network has estimated that diagnosis change may affect treatment choice up to 20% of the time. “Intuitively, patient prognosis and treatment recommendations benefit from the correct cancer diagnosis, and some payers have suggested they would be willing to pay for proof of superior pathologic diagnoses,” she said.

A 2015 report from the Institute of Medicine (IOM) identified 8 goals to reduce diagnostic error, calling for providers to “develop and deploy approaches to identify, learn from, and reduce diagnostic errors and near misses in clinical practice.” The investigators aligned their study with this initiative by aiming to demonstrate the value of subspecialty pathology review or multidisciplinary consensus review prior to initiating definitive treatment.

They also examined the diagnostic error rate in cancer patients presenting to a tertiary care hospital and assessed the frequency of significant diagnosis changes by disease site associated with secondary pathology review of outside slides.

“When we started this study it was before the September 2015 release of the IOM report, but we highlight it in this abstract because our study is so much aligned with their recommendations for improving diagnosis in healthcare,” Middleton added.

Methods

“During that month and a half we had over 13,000 institutional consults,” Middleton reported.

All consult slides from patients referred to each of the 11 ADCC centers were reviewed by designated pathologists, and patient-level data for original and revised diagnoses were collected from August 25 to October 24, 2014.

Pathologic discrepancies were classified as either “major,” meaning the diagnosis changed the course of treatment or surveillance, or “minor,” meaning there was a change in diagnosis, but not one that affected treatment or surveillance.

“Mini tumor boards” (disease-specific, multicenter teams of clinical experts) were convened to verify the pathologists’ assessments of diagnosis changes. They reviewed discrepant cases and provided treatment and surveillance plans for the original and the revised diagnoses.

Value in Redundancy

A total of 13,109 cases were collected across all ADCC centers, and the overall discrepancy rate was 11.4% (n = 1488). A total of 2.7% (n = 359) were major, leading to a change in treatment or surveillance, and 8.6% (n = 1129) were minor.

The highest discrepancy rates were shown in the neuro-oncology and head and neck cases, with 7.4% and 3.8% major discrepancy rates, respectively.

“This patient safety mechanism provides systematic feedback on provider performance and accurately estimates the clinical impact of changed diagnoses,” she said. “Also, through redundancy, expert review can eliminate waste and reduce diagnostic errors over time.”

As indicated in the recent IOM report, this project further demonstrates that “diagnostic errors may cause harm to patients by preventing or delaying appropriate treatment, providing unnecessary or harmful treatment, or resulting in psychological or financial repercussions.”

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