FROM: Theodore O. Will, Chief Executive Officer
DATE: Jan 28, 1999
SUBJECT: Prostate Pathology Practices Among Medicare Patients Undergoing Radical Prostatectomy in New York State
IPRO CONTACTS:
Pascal James Imperato, M.D., M.P.H. & T.M. Medical Director, Research Development & Epidemiology - Extension 532, Terry Straub, R. N. Senior Director, HCQIP - Extension 548
Enclosed please find a statewide report on "Prostate Pathology Practices Among Medicare Patients Undergoing Radical Prostatectomy in New York State". This quality improvement project was initiated in response to concerns expressed about the adequacy of information contained in pathology reports on radical prostatectomy specimens.
During 1997, IPRO worked closely with its Radical Prostatectomy Pathology Advisory Group (RPPAG) to design a project to assess the quality of pathology reports on radical prostatectomy specimens for the period July 1 - December 31, 1996. The group suggested that the reports be examined for ten quality indicators relevant to patient care. A retrospective chart review was conducted in 1998 of the 554 Medicare patients who underwent radical prostatectomy during the later half of 1996.
Performance on the ten quality indicators varied from 15% to 86%. For all hospitals, performance was less than 50% for four quality indicators and less than 70% for seven. High volume hospitals (10 or more cases) performed significantly better than low volume ones (1-4 cases) with five indicators. Their performance was also better with an additional two indicators, but the differences were not statistically significant. These results demonstrated a significant relationship between higher volumes of prostate gland processing and better quality pathology reports.
The issues with radical prostatectomy pathology reports identified in this study are amenable to improvement. The checklists and protocols published by pathology specialty societies can serve as a guide to improved documentation. Such improved documentation will better serve treating physicians in making adjuvant treatment decisions, estimating prognosis and evaluating outcomes. It will also be of help to patients and their families in estimating prognosis and in making treatment and other life decisions.
We recommend that all hospitals review their radical prostatectomy pathology reports in light of currently recommended reporting protocols and develop quality improvement plans where indicated. These plans should address the quality indicator issues identified in this report. Departments of Pathology should also consider the implementation of standardized reporting protocols for prostate cancer. IPRO will be happy to work with individual hospitals and provide additional information when needed.
Should you have any questions about IPRO's Radical Prostatectomy Pathology Study, please feel free to call the above contacts.
The information contained in pathology reports of radical prostatectomy specimens is critically important to treating physicians for the selection of adjuvant therapy, the evaluation of 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 have developed and established suggested protocols for reporting the findings on radical prostatectomy specimens. The purposes of these protocols are not only to document that adequate specimen examinations have taken place, but also to provide treating physicians with information vital to treatment selection, for evaluation of treatment, estimating prognosis, and analyzing clinical outcomes. These initiatives indicate a recognition of the need to provide pathologists with guidance in developing checklists or other reporting formats to supplement or replace traditional narrative or descriptive reports. The widespread availability of computerized and formatted reports can facilitate the use of protocols for standardized reporting.
In 1996, IPRO's Radical Prostatectomy Advisory Group (RPAG), primarily comprised of urologists, suggested that a study be conducted to assess the status of radical prostatectomy pathology reports among male Medicare patients in New York State. In 1997, a Radical Prostatectomy Pathology Advisory Group (RPPAG) was formed, comprising clinical pathologists, urologists and oncologists. This advisory group assisted IPRO staff in designing a project to assess the quality of pathology reports on radical prostatectomy specimens for the period July 1 - December 31, 1996, and where necessary to promote improvements through cooperative efforts with providers. The group suggested that the reports be examined for several elements (quality indicators) that are relevant for the care of patients. These quality indicators were:
A retrospective chart review of 554 cases for the second six month period of 1996 focused on these ten quality indicators. Performance on these indicators varied from 15% to 86%. Performance for all hospitals was less than 50% for four quality indicators and less than 70% for seven.
Teaching hospitals performed significantly better on five indicators. On further analysis, it was found that these differences were primarily associated with volume. High volume hospitals (10 or more cases) performed significantly better than low volume ones (1-4 cases) with the five indicators (p<.05). Their performance was also better with an additional two indicators, but the differences were not statistically significant. Overall, the average performance for all ten indicators was 10% higher for high volume hospitals compared to low and medium volume ones (5-9 cases). These results demonstrate a significant relationship between higher volumes of prostate gland processing and better quality pathology reports. There was no consistent pattern of statistically significant better performance on the part of either upstate or downstate hospitals.
The issues with radical prostatectomy pathology reports identified in this study are amenable to improvement. The checklists and protocols published by pathology specialty societies can serve as a guide to improved documentation. Such improved documentation will better serve treating physicians in making adjuvant treatment decisions, estimating prognosis and evaluating outcomes. It will also be of help to patients and their families in estimating prognosis and in making treatment and other life decisions.
IPRO will disseminate these results and assist hospitals and clinical pathology departments in developing quality improvement plans. These plans should address the quality indicator issues identified by this study. In addition, pathologists should consider adopting the use of standardized reporting protocols for prostate cancer. Such protocols would effectively address the quality indicator issues identified in this report. They also offer many advantages to pathologists, urologists, oncologists and patients.