Review type
Explanation of process
Targeted
Review of specific types of cases either by diagnosis or by organ system
Random
Review of cases using a previously outline method of selecting cases randomly (e.g., review of cases with accession numbers ending in 0)
Percentage of cases
Review of a predetermined percent of cases (e.g., 5, 10 %) this may be achieved through multiple methods. Some departments do 10 % random review. Others may be happy to achieve 10 % through any and all methods
Conference cases
Review and documentation of cases reviewed for conferences such as tumor board, clinical–pathologic correlation conferences
Intradepartmental consultation
On request of a pathologist, a case is reviewed by a second pathologist within the same department
Extra-departmental consultation
On request of a pathologist, a case is reviewed by a second pathologist at another institution
Unsolicited extra-departmental review
A case is reviewed at another institution usually because the patient’s care has moved to the other institution. This may also occur because a patient seeks a second opinion
If one could document all of these reviews that occur during the natural course of work, it is not clear what percentage of cases is normally reviewed. A Q-Probe conducted in 45 institutions, measured the frequency of documented case review in surgical pathology. The overall rate of review was approximately 8 % [2]. The range of case was wide and ranged up to 17.1 % for the 90th percentile and 2.0 % at the 10th percentile. It is likely that additional cases are reviewed but are not documented, and therefore it may be that a normal rate of case reviews is higher than 10 %. Institutions that had a policy for review of cases have a higher rate of review, 9.6 %. A single institution’s study reports a 13 % rate of documented reviews [9].
Few studies have looked at optimal combinations of cases that should be reviewed by a second pathologist. Renshaw and Gould [16] examined various combinations based on known rates of amended reports . In their study, tissues with the highest amended report rates included: breast 4.4 %, endocrine 4 %, gynecology (GYN) 1.8 %, and cytology 1.3 %. The specimen types with the highest amended rates were breast core bx 4.0 % and endometrial curetting 2.1 %. The diagnoses with highest amended rates were nondx 5 % and atypical/suspicious 2.2 %. Based on these findings, they calculated that reviewing nondiagnostic and atypical/suspicious resulted in review of 4 % of cases and detect 14 % of amended reports. Reviewing all breast, GYN, non-GYN cytology, and endocrine material resulted in a review of 26.9 % of all cases and detected 88 % of amended reports. The study authors conclude that the optimal strategy for review is still unknown.
The rate and mix of cases in a review is highly dependent of the types of cases seen at any particular department and the availability of pathologists with specific expertise in any one area. Just as an example, pathologists at a children’s hospital will have material that is mostly different from pathologists that serve primarily adult patients.
Raab et al. did not tackle the question of appropriate timing for reviews but conducted a study that compared 5 % random review vs. focused organ review. The 5 % random reviews resulted in detection of errors in 2.6 % of case. The focused review detected errors in 13.2 % of cases. This difference was statistically significant and was maintained when looking at major errors as well (random review (0.36 %) vs. focused review (3.2 %)). This study clearly demonstrates that targeted reviews are a more efficient method of detecting errors vs. random reviews [17].
To sum up this section, it is not clear what the optimal rate of review should be? Studies of pre-sign-out institutional review rates show a current review rate of8–10 %. There is evidence that targeted reviews of selected cases is more effective than random case reviews.
How Should a Second Pathologist Review be Structured?
How reviews occur is greatly dependent on workflow and individual or group capacity. As stated earlier, the most ideal time for reviews is either before case sign-out or just after. This is to minimize any potential harm from error to patients. This also works in the pathologist’s favor and reduces potential liability if and when an error is detected.
The type of cases that need to be reviewed is also greatly dependent on the material that an institution receives. There are some general principles that could be applied to case selection:
1.
Cases with known poor diagnostic agreement (statistically low kappa) (e.g., Barrett dysplasia)
2.
Cases with high potential for patient harm (e.g., false positive cytology)
3.
Cases with high potential for legal claims (e.g., false negative biopsy)
4.
Cases with known departmental disagreement
5.
Borderline lesions
6.
Cases unfamiliar to an individual
7.
Rare disease states
8.
Cases where diagnostic criteria are subjective
9.
Cases where a focal finding may be missed (e.g., prostate biopsies)
10.
High-profile cases that may attract significant attention
While this list may seem redundant, it is a checklist meant to remind individuals of potential risk.
In each practice, pathologists should assess the material they see and determine where their risk lies. Then, there needs to be a discussion of how to best capture these cases in a review. If current mechanisms of review make sense from a risk perspective, they should remain in place. If not enough cases with potential risk are being reviewed, then that should be addressed.
The most important factor is to outline a strategy to review cases and implement it. Subsequently, checks should be in place to make sure that the process is being carried out and is effective in detection of errors in a timely manner.
It is important to outline the strategy for case reviews within the annual quality assurance plan. List the reviews that occur naturally within the department and the expected level (e.g., all cases, 5 %, etc.) of review. If it is desired to achieve a certain level of review, then there should be a check to assure that that level has been achieved. If too few cases are reviewed, then additional reviews should be added.
How Can Reviews be Optimized for a Very Small Group Practice?
In a small practice, particularly solo practice, the opportunities for reviews are limited. Most small practices rely on external consultation for difficult or unusual cases but also understand that a significant proportion of patients with newly diagnosed cancers will be referred to another center for definitive treatment. Unless the pathologists have additional training or experience in renal pathology or hematopathology, most small practices will automatically send out kidney biopsies to rule out glomerulonephridites and lymph node biopsies for the diagnosis of lymphoma. Other types of case that may be sent out include brain biopsies as well as soft tissue and bone tumors. In a study of consultations initiated by pathologists, it was documented that 0.5 % of cases were sent for consultation to a known expert [18]. The range was 0–2.0 % with a median of 0.7 %. Smaller institutions more frequently sent cases for consultations than larger institutions supporting the idea that this is a necessity in small practices.
In a small group setting, the most practical and likely more frequent reviews are reviews that are unsolicited because a patient is referred to another center for treatment. Unsolicited external reviews are probably the best opportunity to understand how good a particular department is and identify their potential weaknesses. If for example, report discrepancies are repeatedly identified in a particular organ system, then steps should be taken to understand the source of the discrepant reports and the underlying deficiency. At that point, steps can be taken to rectify the deficiency. It is not always that there is lack of ability on the part of the pathologists, it may be as simple as using an updated diagnostic classification or an indication to refresh one’s knowledge. Sometimes, it may be an indication that a new confirmatory test has been introduced and is being used at other institutions. Depending on the location of the practice and if there are nearby institutions, many pathologists will seek out others to show cases and discuss ways to work up difficult cases. Some localities have active “city wide” case conferences that may be helpful in addressing current cases. The potential impact of telepathology, slide scanning technology, and the ability to share cases electronically is still being explored [19, 20]. These solutions will have a substantial impact on the practice of pathologists in remote areas. With an appropriate network of available pathology experts, it is possible that a pathologist could seek a second review of a case at any time, even at frozen section.
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