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Service Delivery Innovation Profile

Joint Radiologist–Pathologist Review of Diagnostic Findings Improves Care of Patients Being Screened for Breast Cancer


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Snapshot

Summary

A pathologist and radiologists at the University of Kansas Medical Center meet weekly via audio-video conference to view pathology findings and radiologic digital images simultaneously and thoroughly consider treatment recommendations for patients being screened for breast cancer. The specialists discuss their findings and resolve any differences between the images and the pathology report to create a consistent treatment plan for each patient. A 2008 pilot study of 122 biopsies from 106 patients found that the program affected treatment plan decisions in over one-third of cases. Both the radiologists and pathologist involved report a high level of satisfaction with the program.

Evidence Rating (What is this?)

Suggestive: The evidence consists of an evaluation of the percentage of pilot test cases in which the collaborative model resulted in treatment plan changes, along with anecdotal reports on physician satisfaction and the continued impact of the model on treatment plans after the completion of the pilot.
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Developing Organizations

University of Kansas Medical Center, Kansas City, KS
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Date First Implemented

2008
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Patient Population

Gender > Female; Vulnerable Populations > Womenend pp

Problem Addressed

Radiologists and pathologists play a pivotal role in the diagnostic process by interpreting the results of numerous tests. However, they generally make these interpretations independently and communicate them only through written reports. This approach can lead to differences in treatment recommendations, creating uncertainty as to the best way to proceed with care and potentially having a negative effect on patient outcomes. Although collaboration between radiologists and pathologists may lead to greater consensus and better treatment plans, this approach is rarely utilized.
  • Working in silos, with only written communication: Diagnostic specialists work in their own departments (often housed in separate geographic locations) and typically communicate via written reports only, which can lead to miscommunication or omission of pertinent information.1 Closer communication between radiologists and pathologists, with the radiologic studies being compared with the histologic findings, could lead to greater concordance in diagnostic findings. But time, manpower, and geographic constraints can make such interdisciplinary communication difficult. For example, at the University of Kansas Medical Center, radiologists and pathologists work 1.5 miles from each other, creating an obstacle to close communication.
  • Growing need for closer communication: Advancing technology and more widespread mammography screening have brought about a greater knowledge and awareness of the characteristics of early breast cancer. Improvements in breast cancer screening as well as a shift from open surgical to percutaneous, image-guided biopsies have resulted in a significant decrease in the size of suspicious lesions detected on imaging studies. Currently, sample sizes range from 2 to 3 millimeters in diameter and 10 to 20 millimeters in length and the majority of targeted lesions range from 5 to 15 millimeters in diameter. The reduction in detected lesion size is best exemplified by the detection of small clusters of calcifications (called microcalcifications) suspicious for ductal carcinoma in situ. Furthermore, the target lesions are usually surrounded by breast tissue that may be normal or may represent one of the many benign pathologies that often coexist with the targeted lesion. If the target lesion is not clearly recognized, a diagnosis maybe incorrectly rendered, based on the surrounding tissue. Taken together, these factors create new challenges for pathologists, who are now required to identify lesions such as microcalcifications within the specimen. As a result, a pathologist might not view the tissue in the same way as the radiologist, necessitating closer communication between radiologists and pathologists for accurate diagnoses. Furthermore, because pathologists do not see patients directly, they may not have full information about a case. Discordance between radiologic and pathologic findings may lead to false-negative results, causing delayed diagnosis of malignancy. Discordance can also result in the failure to recognize premalignant lesions that require further testing and/or careful monitoring.1

What They Did

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Description of the Innovative Activity

A pathologist and radiologists at the University of Kansas Medical Center meet weekly via audio-video conference to view pathology findings and radiologic digital images simultaneously and thoroughly consider treatment recommendations for patients being screened for breast cancer. The specialists discuss their findings and resolve any differences between the images and the pathology report to create a consistent treatment plan for each patient. Key elements of the process include the following:
  • Diagnostic process: Patients who have an abnormal finding on a radiology examination undergo a biopsy that is analyzed by a pathologist. The radiologist reviews the pathologist's report to determine whether the findings are concordant or discordant with the findings from imaging tests and then notifies the patient's physician.
    • Malignant findings: If the findings from both sets of diagnostic tests indicate a clear malignancy, the physician develops a treatment plan with the patient.
    • Nonmalignant (benign) or discordant findings: If findings are benign or discordant, the radiologist informs the physician that these findings are preliminary, that the case will be reviewed during a joint pathologist–radiologist case review, and that a final report will be sent within 2 to 5 working days. Depending on patient-specific factors (e.g., anxiety level), the physician may send a letter to the patient noting the preliminary findings and stating that a final report will be issued after a second review of the diagnostic test results.
    • Diagnostic device: Information provided in April 2011, indicates that the radiologists and pathologist use a newly invented device, the Rad/Path Tissue Tray™, which enables them to simultaneously evaluate every core biopsy obtained from each lesion by both histologic and radiologic methods.
  • Conference preparation: Three days before the conference, a designated radiology staff member (usually a radiology nurse) identifies the cases for discussion (i.e., all cases with benign diagnoses and cases in which pathology and radiology findings are discordant). She/he e-mails the patient list to the pathology-radiology team. The pathologist, aided by two pathology technicians, identifies the relevant slides for digital scanning onto the medical center's digital pathology imaging system.
  • Weekly joint videoconference: Each Friday at 8 a.m., the three breast radiologists and the pathologist hold a 1-hour, audio-video Web conference to discuss the cases. The pathologist uploads the digital slides from the server for Web conferencing and the radiologists upload the radiologic studies from their digital radiology system. The radiologists and pathologist join the pathology Web conference on the digital pathology imaging system. Simultaneously, an audio-video conference is established between the radiologists and pathologist, allowing them to see and interact with each other remotely as well as review the radiology studies through that system. The clinicians typically review 15 to 20 cases during each conference. During the discussion, the radiologists and pathologist view each patient's pathology histology and radiology images concurrently, using two separate computer monitors. The clinicians can highlight areas of interest on the images by using arrows on the screen. This approach allows the clinicians to discuss the cases as if they were together in the same room. Their primary goal is to establish an accurate diagnosis by avoiding false-negative diagnoses and to ensure identification of high-risk lesions that require monitoring or further testing.
    • Conference participants: Currently, at least one of three radiologists participates in the conference. Only one pathologist is available for the conference; if the pathologist will not be available for a Friday conference, the conference is rescheduled for that week. (Eventually, additional pathologists may be trained to participate in the conference.)
  • Development and communication of treatment recommendations: The radiologists and pathologist come to an agreement on a treatment recommendation for each case. The radiologists produce a "concordancy report" and send it to the patient's physician. The report notes that the pathology histology and radiology images for the case have been reviewed concurrently and that findings are either concordant or discordant, and then presents the jointly developed treatment recommendations (e.g., repeat biopsy with imaging guidance, repeat biopsy with surgery).

Context of the Innovation

The University of Kansas Medical Center, an academic institution with approximately 480 beds, conducts approximately 1,200 breast biopsies annually. Mark Redick, MD, PhD, a radiologist, joined the medical center in 2006; in his prior practice, radiologists and pathologists had communicated closely regarding biopsies. Dr. Redick, who also has an educational background in pathology, felt that communicating solely via written report was not sufficient for ensuring appropriate, accurate handling of all cases. Rather, he believed that by closely correlating the pathology findings with the breast images, the biopsy finding could be confirmed as being in agreement with the radiologists' preprocedural diagnosis. Dr. Redick approached pathologist Ossama Tawfik, MD, PhD, who readily agreed that better communication was necessary. To facilitate efficient communication, they decided to identify technologic options that would allow remote communication.

Did It Work?

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Results

A 2008 pilot study of 122 biopsies with a benign diagnosis from 106 patients found that the program affected treatment plan decisions in more than one-third (36 percent) of biopsies in which there was a discordant finding. Both the radiologists and pathologist involved in the program report being highly satisfied with it.
  • Frequent changes in treatment plans: Although the joint review did not change the primary diagnosis in any of the cases, it influenced recommended treatment plans in more than one-third of the 122 cases reviewed.
    • Minor impact on decisionmaking: The joint case review had a minor impact on care decisions in 28 of the 44 cases in which findings were discordant. Of these, 23 cases resulted in further analysis of tissue blocks by pathologists and radiologists to evaluate microcalcifications; two cases involved mislabeling of samples; and three cases involved misdiagnoses (of a microscopic papilloma, benign cyst, and changes related to diabetes).
    • Major impact on decisionmaking: In 16 cases, joint case review had a major impact on care decisions. These included four cases requiring reexcision of a lesion, three requiring rebiopsy, and nine requiring additional radiologic followup.
    • Similar findings over time: Since completion of the study, treatment plan changes have continued to occur at rates similar to those found in the pilot test. The radiologist and pathologist resolve a major discordance approximately once every 6 weeks.
  • Satisfied physicians: The radiologists and pathologist both express great personal satisfaction in being able to provide better quality care and learn from a colleague in a different discipline.

Evidence Rating (What is this?)

Suggestive: The evidence consists of an evaluation of the percentage of pilot test cases in which the collaborative model resulted in treatment plan changes, along with anecdotal reports on physician satisfaction and the continued impact of the model on treatment plans after the completion of the pilot.

How They Did It

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Planning and Development Process

Key elements of the planning and development process included the following:
  • Overcoming initial resistance to gain approval: The pathologist and radiologist discussed the potential quality-of-care benefits to be gained from joint case review with their department heads and with medical center physicians and breast surgeons. Department administrators initially viewed this process as having the potential to reduce efficiency (with more time spent per case) and, therefore, revenue (because clinicians would have time to assess fewer cases). Physicians expressed concerns about delays in getting a final report to the patient. However, the pathologist and radiologist emphasized that the joint review would allow the physicians to have a higher level of confidence in the findings and that, as a center of excellence, the medical center should take extra steps to ensure excellent quality. Ultimately, the administrators and physicians agreed to support the program.
  • Design of weekly conferences: A team was established to design the weekly conferences; team members included three breast radiologists, one breast pathologist, two radiology nurses, several information technology experts in radiology and pathology, one clerical support staff member, and several business administrators from both departments. The team met to determine how to employ a real-time, multidisciplinary approach by leveraging technology to overcome geographic constraints. The team determined that the conference would require all radiology and pathology images to be available in a full-fidelity/high-resolution digital format with simultaneous real-time visualization of both radiology and pathology images. Additionally, the team desired interactive ability, allowing any participant to take control of the conference and to direct group interest to a particular finding on tissue slides or the radiology imaging study. To accomplish the above, the team requested technology related to video and audio conferencing capability, including access to the digital radiology system, digital pathology system, digital pathology information management software, Web conferencing system, personal computers with Web cameras, and a server with a high-speed Internet connection.
  • Integrating into existing medical information systems: The medical center had an existing information system to view digital pathology images. The medical center also had a system allowing clinicians to log on and view digital radiology images. The radiologist and the pathologist worked with the information technology department to reconfigure the hardware and software of these systems to allow joint access and audio-video conferencing capability.
  • Introducing program to relevant clinicians: The pathologist and radiologist composed a joint letter to all clinicians involved in caring for breast cancer patients, explaining that they would be holding a weekly joint review of cases. The pathologist and radiologist explained that initial pathology results should be considered preliminary, with updates to be issued following the weekly conference. Although the letter acknowledged the brief delay associated with the program, it emphasized that the joint review would lead to a concordant report, consistent treatment recommendations, and better quality of care.
  • Potential expansion for other conditions: The team is considering offering joint pathology–radiology review for procedures/conditions other than breast cancer screening; potential options include interstitial lung diseases and bone lesions, two areas in which joint consultation could lead to better diagnostic accuracy.

Resources Used and Skills Needed

  • Staffing: The program requires no new staff, as existing staff incorporate it into their daily routines.
  • Costs: Minimal costs were incurred in the development of this initiative because the medical center already had the pathology and radiology digital information systems in place. The medical center purchased two computer monitors so that the radiologist and pathologist could each have a second monitor on their desks, as well as small cameras placed on each computer to allow for videoconferencing.
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Funding Sources

University of Kansas Medical Center, Kansas City, KS
The program and Rad/Path Tissue Tray™ were funded internally; the hospital and physician cannot bill for the joint review and thus receive no additional revenue as a result of the program.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Convince hospital leaders and clinicians of program's value: Emphasize that conferences lead to higher quality of care, especially by avoiding false-negative diagnoses. Although the program generates no additional revenues, remind administrators that they can use the program to differentiate their services from those offered by competitors. Over time, clinicians and administrators should become more supportive of the conferences after they recognize the positive impact on quality of care.
  • Use technology to overcome distance: Adopting technology to allow radiologists and pathologists to hold virtual meetings helps to ensure efficiency and reduce communication barriers related to time constraints.
  • Address physician concerns about delays: Physicians may express concerns that the joint review will slow down the diagnostic process and generation of a final report. However, with appropriate communication and education about the intent of joint conferencing, physicians tend to be accommodating and acknowledge the quality of care benefits. In fact, at the University of Kansas Medical Center, physicians began actively requesting joint reviews, given that the results presented in the final report were more relevant for appropriate patient care.

Sustaining This Innovation

  • Emphasize that initial findings are preliminary: Continually remind physicians and patients that initial radiology and pathology findings are preliminary and may change pending the joint case review.

Additional Considerations

  • Disclosure: Dr. Tawfik is the partial inventor of the Rad/Path Tissue Tray™, which is owned by the University of Kansas where he works. Neither Dr. Tawfik nor Dr. Redick discloses any financial interest in the Rad/Path Tissue Tray™.

More Information

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Contact the Innovator

Ossama Tawfik, MD, PhD
Professor and Vice Chairman for Education and Outreach
Director of Anatomic and Surgical Pathology
Department of Pathology and Lab Medicine
The University of Kansas Hospital
3901 Rainbow Blvd
MS 3045
Kansas City, KS 66160
(913) 588-1185
E-mail: otawfik@kumc.edu

Mark L. Redick, MD, PhD
Assistant Professor of Radiology
The University of Kansas Medical Center
Westwood Medical Pavilion and the Richard and Annette Bloch Cancer Care Pavilion
2330 Shawnee Mission Pkwy
MS 5013
Westwood, KS 66205
(913) 588-1227
E-mail: mredick@kumc.edu

Innovator Disclosures

Dr. Tawfik and Dr. Redick have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

At University of Kansas, Radiologist and Pathologist Improve Diagnostic Concordance. Dark Daily. August 12, 2009. http://www.darkdaily.com
/at-university-of-kansas-radiologist-and-pathologist-improve-diagnostic-concordance-812


Gallagher R, Schafer G, Redick M, et al. Microcalcifications of the breast: a mammographic-histologic correlation study using a newly designed Path/Rad Tissue Tray. Ann Diagn Pathol. 2012 Jan 4. [Epub ahead of print] doi:10.1016/j.anndiagpath.2011.10.007. [PubMed]

Paxton A. Talk to me—AP, radiology meet in virtual middle. CAP Today. College of American Pathologists. May 2009. Available at: http://www.cap.org/apps
/cap.portal?_nfpb=true&cntvwrPtlt_actionOverride=%2Fportlets%2FcontentViewer%2Fshow&_windowLabel=cntvwrPtlt&cntvwrPtlt{actionForm.contentReference}=cap_today%2F0509%2F0509f_talk_to_me.html&_state=maximized&_pageLabel=cntvwr


Tawfik O, Redick ML. Integrated radiology/pathology service for breast cancer: multidisciplinary Web conferencing pilot project offers insight on current testing protocols. Critical Values. 2009;2(3):23-26.

Footnotes

1 Tawfik O, Redick ML. Integrated radiology/pathology service for breast cancer: multidisciplinary Web conferencing pilot project offers insight on current testing protocols. Critical Values. 2009;2(3):23-26.
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: April 28, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: April 09, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: March 11, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.