By Uche Eziagu 8th March, 2013

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Introduction Purpose Methodology Conclusion References

Clinical laboratory tests and anatomic pathology diagnoses affect the vast majority of treatment decisions made by clinical physicians in nearly every medical discipline, impacting nearly every person seeking medical care. Many clinical laboratory tests are automated, performed by calibrated machines, reducing factors of human error and subjectivity. Errors made during the process of handling specimens in the anatomic pathology laboratory have recently been reported in the media (Roche, 2005).

Subsequently, specimen handling processes in anatomic pathology, as well as quality assurance measures and safeguards, are under increasing scrutiny by patients, referring physicians, insurers, and the media. In addition to standard laboratory specimen handling processes, anatomic pathology remains critically dependent upon an individual physician the pathologist to perform an interpretation of microscopic tissue characteristics and to select specific language to convey each diagnosis.

Referral of a patient's tissue for pathologic evaluation remains a physician consultation.

The practice of anatomic pathology involves the subjective interpretation of objective data. The objective data, contained in the characteristics of the cells, organization of tissues, and relationship to the organ on the whole, are preserved for the initial examination on histologic slides, within paraffin blocks, and, more recently in digital image archives.

As pathology material is retained in a continuously observable format (the histologic slide or digitized image), an important method of assessing the quality of pathology services is the use of second opinion "quality assurance" consultation. The consistent utilization of intra- and extradepartmental consultation to assess and report the diagnostic accuracy, completeness of information (clinical history and reporting of pertinent prognostic features), and consistency of terminology conveyed within each pathology report to clinicians and patients is but one measurement of quality

performance in pathology.

Changes in the pathology interpretation (the diagnosis) can drastically alter the clinician's treatment plan and the patient's prognosis. As in all disciplines of medicine, the goals of anatomic pathology are to conform to the ethical principles of beneficence and non-maleficence: the obligation to help and not to harm patients (Tomaszewski, et al., 2000). To this end, pathologists are obligated to provide accurate and timely diagnoses, to protect patients from wrong diagnoses, and to reduce the diagnostic variability that can have a major impact on patient therapy and management.

Pathologists often are requested to review original pathology reports, slides, and other material from patients who have been referred to a second institution for evaluation, management, or both. These reviews are known as interinstitutional pathology review/consultations or second opinion pathology reviews and are distinct from personal pathologist to- pathologist consultations. Studies of Interinstitutional reviews from general and body sitespecific case series have shown that interinstitutional review improves the quality of patient care, because a small percentage of interinstitutional reviews may result in a change in diagnosis and/or prognostic factors that results in altered management and may lead to the cessation of expensive, unwarranted procedures.

To monitor the degree of diagnostic agreement rate among cases that have been sent to other institutions for one of the following reasons:
1. At the clinician's or patient's request. 2. At the request of another institution in which the patient is being seen. 3. Because the case has been entered in a cooperative study.

If a significant discrepancy between the two diagnoses exists, the director of anatomic or surgical pathology should resolve it by subjecting the case to inside or outside arbitration and submit an addendum report with the final resolution.

Inter institutional case review provides an additional mechanism for evaluating diagnostic accuracy at the original institution. It occurs when a patients treatment is transferred to another institution triggering a review of original diagnosis.

It can also occur when a clinician requests a review of original diagnosis by an external institution. It is a very useful form of peer review and should be distinguished from Inter Institutional opinions which are requested because of diagnostic uncertainty or lack of peer group consensus.

The following indicators should be measured and reviewed quarterly for Inter institutional consultation:
Cases referred externally for review
No. of cases referred % Agreement.

Cases received internally for review

No. of cases received % Agreement.

Cases referred externally for opinion

No. of cases referred

Cases referred externally for review refers to

when a patients treatment is transferred to another institution triggering a review of patient original diagnosis or where a clinician has requested a review of the original diagnosis by an external institution.

Agreement represents no change to primary diagnosis.

Cases received internally for review refers to

when a patients treatment is transferred internally triggering a review of patient diagnosis or where a clinician has requested a review of original diagnosis performed externally.

All cases received internally for review should be coded as P04 (according to Royal College of Physicians Ireland)

Cases referred externally for opinion refers to where a Pathologist seeks opinion of an individual with perceived expert opinion at a separate institution due to diagnostic difficulty or lack of consensus opinion from intradepartmental consultation. Where a report is received back from interinstitutional consultation with a diagnosis that is discordant from the primary diagnosis made, it is recommended that the case be brought to an intradepartmental discrepancy case conference under the auspices of the Quality Committee

The methodology of interinstitutional review comprises its

procedure and review

Procedure:
The Quality Control/Quality Assurance manager should collect and record the diagnoses made at other institutions and compare those diagnoses with those made on the same cases at the index institution. All the cases in which a major discrepancy exists should be recorded, including the arbitration outcome.

Review:

All Interinstitutional Review from the preceding period should be presented at the monthly Quality Control/Quality Assurance meeting. A formal review of the Interinstitutional Review forms should be carried out by the Quality Control/Quality Assurance committee chairman biannually, according to the general review procedure. The results of the review should be presented at the monthly Quality Control/Quality Assurance meeting.

To meet the increasing demand without compromising quality, integration of subspecialty pathologists within general pathology practices, utilization of subspecialty pathology services, or liberal utilization of expert consultation by experienced subspecialty pathologists within other institutions may increase the baseline diagnostic accuracy of pathology evaluations. In the era of consumerism, advocating increased access to subspecialty care for both patients and clinicians referring their patients to pathologists, who can demonstrate measurable outcomes, can provide a real means of reducing costs, improving efficiency, and providing exemplary care.

Juan Rosai; Rosai and Ackermans Surgical Pathology; 10th edition; China; Elsevier; 2011; Pages (Appendix B). http://www.psqh.com/marapr06/pathologist. html http://ajcp.ascpjournals.org/content/120/3/ 405.full.pdf http://www.rcpi.ie/Faculties/Faculty%20of%2 0Pathology%20Downloads/Histopathology%2 0QA%20Guidelines%20V5.pdf