Secondary Pathology Review May Improve Clinical Outcomes

Meg Barbor, MPH

August 2016, Vol 6, No 8 - Quality Care


Secondary pathology review can significantly improve clinical outcomes through precise and accurate pathology diagnoses, according to Lavinia P. Middleton, MD, Professor, Department of Pathology, M.D. Anderson Cancer Center, Houston, TX.

“Accurate pathological diagnoses have become a high priority in cancer diagnosis,” said Dr Middleton. 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 the quality of cancer care.

Dr Middleton and colleagues at the Alliance of Dedicated Cancer Centers, a group of 11 National Cancer Institute–designated comprehensive cancer centers, examined 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 have documented changes in diagnoses associated with secondary review by subspecialty pathologists, and the National Comprehensive Cancer Network has estimated that a 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,” Dr Middleton said.

The Institute of Medicine (IOM)’s 2015 report, Improving Diagnosis in Health Care, 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.”

Dr Middleton and colleagues aligned their study with this initiative to demonstrate the value of pathology review or multidisciplinary consensus review before initiating definitive treatment.

They also examined the diagnostic error rate in patients with cancer 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…our study is so much aligned with their recommendations for improving diagnosis in healthcare,” Dr Middleton said.

All consult slides from patients who were referred to each of the 11 centers were reviewed by designated pathologists, and patient-level data for the original and revised diagnoses were collected from August 25, 2014, to October 24, 2014. “During that month and a half, we had over 13,000 institutional consults,” Dr Middleton reported.

Redundancy Reduces Diagnostic Errors

A total of 13,109 cases were collected across all the 11 cancer centers, and the overall discrepancy rate was 11.4%. Overall, 2.7% of the cases were major, leading to a change in treatment or surveillance, and 8.6% were minor.

The highest discrepancy rates were found 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,” said Dr Middleton. “Also, through redundancy, expert review can eliminate waste and reduce diagnostic errors over time.”

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,” as noted in the 2015 IOM report.