Structured reporting ensures complete content and quick detection of essential data in pathology reports of oncological breast resection specimens

被引：23

作者：

Aumann, Konrad ^{[1
]}

Niermann, Kathrin ^{[1
]}

Asberger, Jasmin ^{[2
]}

Wellner, Ulrich ^{[3
]}

Bronsert, Peter ^{[1
]}

Erbes, Thalia ^{[2
]}

Hauschke, Dieter ^{[4
]}

Stickeler, Elmar ^{[5
]}

Gitsch, Gerald ^{[2
]}

Kayser, Gian ^{[1
]}

Werner, Martin ^{[1
]}

机构：

[1] Univ Med Ctr Freiburg, Fac Med, Inst Surg Pathol, Breisacher Str 115a, Freiburg, Germany

[2] Univ Med Ctr Freiburg, Fac Med, Dept Obstet & Gynecol, Hugstetter Str 55, D-79106 Freiburg, Germany

[3] UKSH Campus Lubeck, Surg Clin, Lubeck, Germany

[4] Univ Med Ctr Freiburg, Fac Med, Dept Med Biometry & Med Informat, Stefan Meier Str 26, D-79104 Freiburg, Germany

[5] Rhein Westfal TH Aachen, Dept Obstet & Gynecol, Pauwelsstr 30, D-52074 Aachen, Germany

来源：

BREAST CANCER RESEARCH AND TREATMENT | 2016年 / 156卷 / 03期

关键词：

Synoptic pathology reports; Breast; Quality of surgical pathology reports; Standardized layout; QUALITY; CANCER; IMPACT;

D O I：

10.1007/s10549-016-3769-0

中图分类号：

R73 [肿瘤学];

学科分类号：

100214 ;

摘要：

There is increasing evidence that not only the way of data acquisition but also the design of data visualization (i.e., the format) has impact on the quality of pathology reports. Therefore, we investigated the correlation between the format of pathology reports and the amount as well as the detection time of transmitted data. All reports of oncological breast resection specimens referred to the Institute for Surgical Pathology, University Medical Center Freiburg, between 2003 and 2011 (n = 4181) were classified into descriptive reports (DR, n = 856), structured reports (SR, n = 2455), or template-based synoptic reports (TBSR, n = 870). The reports were screened regarding the content of nine organ-specific essential data. The amount of recorded essential data per report was summarized in an essential data score (EDS) and the format types were statistically compared regarding their EDS. Additionally, we measured the time a gynecologist needed to detect all nine essential data within a subset of reports and compared the format types regarding the detection times statistically. A full-score EDS of 9 was seen in 28.4 % of all reports, in 4 % of DRs, in 21.4 % of SRs, and in 72.3 % of TBSRs (p < 0.0001). Median EDS of DRs was 7, of SRs 8, and of TBSRs 9 (p < 0.0001). Data regarding tumor localization, tumor size, specific grading, angioinvasion, hormone receptor status, and additional findings were mentioned more frequently in TBSRs compared to other format type reports with a statistically highly significant difference (p < 0.0001). Mean data detection time decreased significantly from 26 to 20 and 14 s in DRs, SRs, and TBSRs, respectively. Our results clearly show that due to the use of TBSRs reporting of oncological breast resection specimens are improved regarding the content of essential data and the clarity of the data layout resulting in a rapid detection of essential data by clinicians.

引用

页码：495 / 500

页数：6

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