Communication Failures in Dermatopathology, Part 2: Preanalytic [Hot Topic]

Comfere
Nneka Comfere, M.D.

Peters
Margot Peters, M.D.

Communication failures occur frequently in the pre- and postanalytic phases of the skin pathology care coordination cycle and may adversely impact diagnostic performance and the quality of patient care. Multiple modifiable factors influence the quality of communication. In Part 2 of a 3-part series, Nneka Comfere, M.D., and Margot Peters, M.D., focus on failures that may occur in the preanalytic phase of dermatopathology. Incomplete or inaccurate clinical information and inadequate biopsy specimens may result in diagnostic errors and unnecessary surgical procedures.

Presenters and Credentials:
Nneka Comfere, M.D., Associate Professor of Dermatology and Laboratory Medicine and Pathology in the College of Medicine and Section Head in Dermatopathology in the Division of Dermatopathology and Cutaneous Immunopathology at Mayo Clinic in Rochester, Minn.

Margot Peters, M.D., Professor of Dermatology and Laboratory Medicine and Pathology at Mayo Clinic in Rochester, Minn.

Transcript

Welcome to Mayo Medical Laboratories Hot Topics. These presentations provide short discussion of current topics and may be helpful to you in your practice. Today our presentation provides an overview of communication failures that occur during the skin pathology care coordination cycle.

Introduction

Our speaker for this program is Dr. Nneka Comfere, Associate Professor of Dermatology and Laboratory Medicine and Pathology in the College of Medicine and Section Head in Dermatopathology in the Division of Dermatopathology and Cutaneous Immunopathology at Mayo Clinic in Rochester, Minnesota.

Joining Dr. Comfere today is Dr. Margot S Peters, Professor of Dermatology and Laboratory Medicine and Pathology.

Dr. Comfere and Dr. Peters, thank you for presenting today.

Disclosures

Thank you for the introduction. We have no relevant disclosures.

Outline

In Part 2 of this series we will describe the key stakeholders and processes that characterize the preanalytic phase of the Care Coordination Cycle. We will also discuss common communication failures and clinical practices that adversely impact diagnostic performance in dermatopathology and ultimately quality and safety of dermatologic care.

Skin Pathology Care Coordination Cycle (CCC)

The right arm of this closed loop cycle represents the preanalytic phase, which encompasses bidirectional transfer, between the clinician and patient as a dyad and the pathologist, of clinical information that accompanies a biopsy specimen. The pathologist evaluates the histopathology in conjunction with supportive clinical information, and then renders a diagnostic interpretation.  The skin biopsy requisition form represents the primary mode of communication between the clinician-patient and the pathologist.

Preanalytic phase

The completeness and accuracy of clinical information in the requisition form and adequacy of the skin biopsy specimen may influence diagnostic performance that includes efficiency, accuracy, cost effectiveness, and specificity of diagnoses in dermatopathology.

Pre-analytic phase

The skin biopsy is the primary tool to establish a dermatological diagnosis, which thus impacts choice of therapy and disease course. Prior studies have established the importance of accurate, complete and relevant clinical information in the requisition form.  These are needed to achieve a timely, specific, and relevant pathology diagnosis.

In a survey study of the American Society of Dermatopathology membership, 80% of 548 respondents indicated that their responsibilities include providing a description of histologic features as well as a clinically meaningful interpretation that takes into account decision-making needs of the clinician.

Paper or electronic requisition forms are the most common methods used to convey clinical information to the pathologist, however these are associated with the highest rates of dissatisfaction (85% dissatisfaction) because of poor quality and completeness of clinical information.

Secondary and less commonly used modes of communication include face-face communication. These are best in small clinical dermatology practices that have embedded dermatopathology labs, because the dermatopathologist may participate in gathering clinical information and in decisions on optimal biopsy site, biopsy type, and technique.  Also telephone communication, email communication, or FAX, sometimes with sharing of clinical photographs and pertinent clinical information.

Sources of communication failures in the preanalytic phase

Key communication deficiencies that occur during the preanalytic phase include incomplete or inaccurate clinical information in the requisition form and poor specimen quality.

Clinical information in the RF

There are currently no national standards governing the format or content of clinical information in the skin biopsy requisition form, resulting in significant practice variations.

Fifty-four percent of American Society of Dermatopathology respondents reported that clinical information necessary for histopathologic interpretation is missing at least 50% of the time for melanocytic lesions. In a review of information accompanying 100 biopsies of melanocytic lesions from a single practice, 55% failed to provide information related to asymmetry, border irregularity, color irregularity, diameter, and the evolution of submitted melanocytic lesions.

Other common deficiencies include nonspecific terminology or abbreviations, and failure to supply a clinical impression or differential diagnosis.

Best practices for clinical information in RF

The best practices for provision of clinical information in the requisition form include avoiding abbreviations and non-specific terms such as tumor nos, lesion nos, and rule out, as well as providing clinical impression or prioritized differential diagnosis, duration of the lesion, history of change, and description of morphology including lesion dimensions, and providing clinical photos.

Quality and adequacy of skin biopsy specimen

There are a variety of methods for the biopsy of skin lesions including shave biopsy or saucerization (which is also known as a deep shave biopsy), punch biopsy and elliptical excisional biopsy.  The different methods yield different specimen widths, depths, and micro-anatomic structures: that is either epidermis, epidermis and superficial dermis, or epidermis, dermis, and subcutaneous fat.

The best choice of biopsy type and technique optimizes the specimen for histopathological diagnosis, while taking into account the clinical morphology (including lesion dimensions) and the differential diagnosis.

A trend toward ever-smaller biopsy specimens and the adverse impact of these small specimens on the accuracy of histopathologic diagnosis have been well documented.

The American Academy of Dermatology established guidelines for biopsy of melanocytic lesions, including dysplastic nevi or melanomas that include recommendation for complete biopsy (that is removal) with a 1 to 3mm margin of normal-appearing skin, to make sure that the biopsy tool cuts around the peripheral and deep planes of tissue occupied by the lesion.

Punch and elliptical excisions are generally preferred over shaves, to ensure complete removal with optimal clinical outcomes that include wound healing, scar formation, and limited need for additional surgical intervention.

Potential outcomes of communication failures in the pre-analytic phase

The potential outcomes of communication failures in the preanalytic phase include:

  • Nonspecific pathology interpretation
  • Delayed or missed diagnosis
  • Unnecessary pathology studies, including histochemical and/or immunohistochemical stains, and
  • Unnecessary surgical procedures

Conclusions

In conclusion:

  • Communication failures occur frequently in the preanalytic phase of the skin pathology care coordination cycle
  • Key factors important to the preanalytic phase include complete and accurate clinical information and appropriate biopsy type
  • Incomplete clinical information and inadequate biopsy specimens may adversely impact diagnostic performance, quality of patient care, and utilization of resources with associated costs.  Thank you.
mmledu

MML Education

This post was developed by our Education and Technical Publications Team.