Communication Failures in Dermatopathology, Part 3: Postanalytic [Hot Topic]

Comfere
Nneka Comfere, M.D.

Peters
Margot Peters, M.D.

Decision support in the pathology report targeted at both the clinician and patient/caregiver can guide medical decision making and result in timely, efficient and patient-centered dermatologic care. In Part 3 of a 3-part series, Nneka Comfere, M.D., and Margot Peters, M.D., focus on important components of the postanalytic phase of dermatopathology. Use of a ‘lay’ language version of the pathology report that facilitates ease of comprehension by patients and caregivers is an important component of patient-centered diagnostic care.

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 postanalytic communication failures that occur during the skin pathology care coordination cycle.

Introduction

Our speakers for this program are Dr. Nneka Comfere and Dr. Margot Peters. Dr. Comfere is 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.

Dr. Margot S Peters, Professor of Dermatology and Laboratory Medicine and Pathology also at Mayo Clinic in Rochester, Minnesota.

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

Disclosures

Thanks for the introductions. We have no relevant disclosures.

Outline

Part 3 of this series will discuss modes of communication between key stakeholders, the role of language in the pathology report on clinician practice patterns and potential modifiable factors that may influence effective communication between key stakeholders including clinicians, pathologists, patients, or caregivers in the postanalytic phase of the skin pathology care coordination cycle.

Skin Pathology Care Coordination Cycle (CCC)

The left arm of this closed loop cycle represents the postanalytic phase, which encompasses bidirectional transfer of the skin biopsy interpretation, between the pathologist on the one hand and the clinician and patient or caregiver on the other, through the pathology report.

Post Analytic Phase

The key stakeholders in the postanalytic phase of the cycle include the pathologist, the ordering clinician, and the patient or caregiver.

The skin biopsy interpretation is conveyed in the pathology report, which commonly resides in the electronic health record. Pertinent pathology findings and recommendations for further evaluation and management may be communicated in the pathology report and/or as an adjunctive message generated by the clinician and transmitted to the patient or caregiver.

The pathology report varies in structure, format, language, and content across practice settings.  Patient and caregiver related communication barriers include comprehension of medical terms and concepts in the report and anxiety related to reviewing the report without synchronous access to clinician interpretation. These factors may influence the efficiency and utility of the patient or caregiver participation in informed and shared decision making with their providers.

Communication barriers

Multiple factors influence the quality of communication of pathology findings and subsequently quality of dermatologic care delivered to the patient including the following:

  1. Patient or caregiver and ordering clinician comprehension of pathology diagnosis and implications of diagnosis for management.
  2. Limitations in patient or caregiver comprehension of medical terms and concepts.
  3. Patient or caregiver anxiety related to asynchronous and potentially unsupported review of pathology diagnosis.
  4. Delays in communication of pertinent pathology findings to the patient or caregiver.

Margin comments in DP reports on DN influence re-excision rates

We conducted a study to assess the impact of a structured template on margin assessment in the comment section of the pathology report for dysplastic nevi on clinician practice patterns. This margin comment contained information that provided guidance on appropriate management of the dysplastic nevus.  In our retrospective review of 584 pathology reports of histologically dysplastic nevi, re-excisions were recommended or performed at a higher rate for patients in the group without margin comments, that is about 52% or 146 of 282 as compared to the group with margin comments, approximately 39%  or 119 of 302. This difference was statistically significant. We concluded that language in the pathology report may guide clinician decision making towards the appropriate management of dysplastic nevi.

Patient perceptions of skin pathology reporting in patient portals – a quality improvement project

We recently conducted a quality improvement project that sought to assess patient perceptions and experiences with reviewing skin pathology reports that contained an intervention - the dermatology information prescription. This intervention contains clinical context-specific diagnostic descriptions and recommendations for management. Our primary aim was to compare levels of patient comprehension, ease of skin pathology report review, anxiety associated with report review and overall satisfaction with the skin pathology care process with and without the intervention. We conducted a cross-sectional survey of 2 separate patient samples before and after implementation of our intervention. Patients in the postintervention as compared to the preintervention group endorsed lower levels of anxiety associated with report review and accessed a lower number of information sources for definitions of medical terms.

Despite overall high levels of patient satisfaction with report review in the patient portal  before and after the intervention, respondents endorsed difficulty with comprehension of medical terminology in the report, anxiety with report review, and need to access multiple additional information sources to facilitate comprehension of the report. Seventy-seven percent of respondents-preintervention, as compared with 50% of respondents-postintervention, cited the need to visit 2 or more additional information sources to obtain explanations of complex medical terms in the report. There were no statistically significant differences in mean anxiety level, comprehension difficulty, or overall satisfaction with report review between the pre- and postintervention time periods.

Additional studies investigating the critical informational and decision making needs of patients and caregivers and design of interventions in the patient portal and pathology report that support patient-centered care and diagnostic pathology are required.

Conclusions

In conclusion, safe and high quality diagnostic performance is dependent on attention to postanalytic phase factors that support and enable timely clinician and patient or caregiver access to understandable pathology reports that guide patient-centered decision making.

Thank you very much for your attention.

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MML Education

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