The Use of Quality Indicators for Assessing Radical Prostatectomy Specimens

Abstract

The information contained in pathology reports of radical prostatectomy specimens is critically important to treating physicians for selecting adjuvant therapy, evaluating therapy, estimating prognosis, and analyzing outcomes. This information is also of importance to patients and their families. In recent years, the Cancer Committee of the College of American Pathologists and the Association of Directors of Anatomic and Surgical Pathology developed suggested protocols for reporting the findings on radical prostatectomy specimens. The objectives of this study were to assess radical prostatectomy-specimen reports by using quality indicators derived from existing suggested protocols and to thereby assist pathologists in improving the quality of their reports on such specimens. A retrospective chart review of 554 cases for the second 6-month period of 1996 focused on 10 quality indicators: submission of a frozen section; location of the adenocarcinoma; proportion of the specimen involved by adenocarcinoma; perineural involvement; vascular involvement; seminal vesicle involvement; periprostatic fat status; number of nodes submitted; status of nodes; and prostate intraepithelial neoplasia (PIN). The findings of this study were shared with the pathology departments in all hospitals in New York State. In addition, the 113 hospitals from which the 554 cases were drawn were given their institution-specific data. Teleconferences were held with the 37 hospitals that accounted for 72.4% of all cases. These conferences included directors of pathology and laboratories and focused on the aggregate statewide findings. The presence of quality indicators in reports varied from a mean of 14.8% (periprostatic fat) to a mean of 85.9% (seminal vesicle involvement). For all hospitals, 4 indicators (proportion of the specimen involved by adenocarcinoma, vascular involvement, periprostatic fat status, and PIN) were included in fewer than 50% of cases. These 4 quality indicators and an additional 3 others (submission of a frozen section, perineural involvement, and the number of nodes submitted) were included in fewer than 70% of cases. Only 3 indicators (location of the adenocarcinoma, seminal vesicle involvement, and the status of nodes) were found in more than 70% of cases. Although the mean level of quality indicator inclusion ranged from 14.8% to 85.9% for all cases examined, the absolute range for any individual indicator was 0% to 100%. Thus, some hospitals included a given indicator 100% of the time; others never included it. This pattern held true for all 10 indicators. High-volume hospitals (10 or more cases) performed significantly better than low-volume hospitals (1-4 cases) on 5 indicators (P < .05), and better, but not significantly so, for an additional 2 indicators. Overall, the mean inclusion levels for all 10 indicators were 10% higher for high-volume hospitals compared with low-volume and medium-volume hospitals (5-9 cases). This study demonstrated wide variations in the inclusion of quality indicators by pathologists i...

The quality of surgical pathology care for men undergoing radical prostatectomy in the U.S.

“…16,17,[21][22][23] In a study of Medicare beneficiaries, Imperato et al reported similarly high item-by-item levels of compliance for both surgical margin status (96%) and Gleason score (97%). Unlike the current study, however, those authors did not evaluate compliance with the assignment of pathologic stage.…”

“…Unlike the current study, however, those authors did not evaluate compliance with the assignment of pathologic stage. 16,17,22 Furthermore, all-or-none measurements (with individual patients as the unit of analysis) of pathology indicator compliance have not been reported previously; the less favorable performance on this metric for the strictly defined CAP category I factors (52%), for instance, generally reflects the absence of partial credit 18 for cases with documentation of Gleason score and margin status but not pathologic TNM stage. Taken together, these data suggest that most men receive high-quality assessment and communication of the pathologic findings in their RP specimens.…”

“…After the intervention, compliance improved for 9 of the 10 measures (range of improvement, 1.4-23.9%). 16,17,22 Despite its success, that program had several limitations, including its temporary nature, limited geographic scope, and inclusion of certain indicators (eg, frozen section submission) with limited clinical validity. Ideally, future interventions in this area will employ a sustainable, national infrastructure and will maintain a primary focus on achieving universal compliance Finally, these data may motivate surgeons, pathologists, laboratories, and hospitals further to achieve standardization of the basic content of surgical pathology reports.…”

“…16,17,22 In a study that was performed in New York, Imperato et al used a cooperative educational program, which included a performance audit with feedback to hospitals and pathology laboratory directors, to facilitate improvements in pathology report documentation for 10 quality indicators. After the intervention, compliance improved for 9 of the 10 measures (range of improvement, 1.4-23.9%).…”

“…Consistent with established methods for indicator assessment, failure to document findings (positive or negative) for an indicator was considered noncompliance. 7,9,16,17 Statistical Analysis Analytic indicator sets…”