Turnaround time (TAT) for large or complex surgical pathology specimens is an indicator of efficiency in anatomic pathology and may affect coordination of patient care.
To establish benchmarks for TAT and to identify practice characteristics that may influence TAT.
Participants in a 2012 Q-Probes quality improvement program of the College of American Pathologists retrospectively reviewed all surgical pathology cases from the prior 6 months to identify up to 50 cases coded as Current Procedural Terminology (CPT) code 88307 (excluding biopsies) or 88309. Participants reported the times and dates of accessioning and final sign-out.
A total of 56 institutions reported on 2763 large or complex cases, which included 70% with CPT code 88307 and 30% with CPT code 88309. Cases requiring special handling comprised 51.5%, and 48.5% were routine. Among all institutions the median TAT was 2.72 calendar days (10th–90th percentile range, 6.23–1.22 days). Longer TAT occurred in governmental institutions (median, 6.06 versus 2.13 days; P < .001) and in institutions that mandate overnight fixation for some specimen types (median, 3.83 versus 2.07 days; P = .03). Longer TAT was associated with CPT code 88309 (median, 3.99 versus 2.82 days; P < .001), special handling (median, 4.13 versus 1.94 days; P < .001), frozen section (median, 3.38 versus 2.92 days; P < .001), radical cancer resection (P < .001), and malignant cases (P < .001). Turnaround time was not significantly affected by either pathology training programs or routine weekend sign-out.
This study provides benchmark data for TAT in large or complex surgical pathology specimens. Turnaround time was good overall, but the range among participating institutions was wide.
Along with diagnostic accuracy and report completeness, turnaround time (TAT) in surgical pathology has been the focus of various studies, surveys, and quality improvement programs.1–9 Report TAT is a clinician satisfier and is an important indicator of efficiency in the anatomic pathology laboratory.1 Large or complex specimens in surgical pathology, those assigned Current Procedural Terminology (CPT)10 codes 88307 and 88309, may require additional grossing time, additional histology effort, and additional evaluation by the sign-out pathologist, purely based on larger size, number of blocks, and greater number of histology slides compared with small biopsies. Turnaround time may be further lengthened by use of special handling techniques, such as overnight fixation, decalcification, recuts or levels, re-embedding poorly oriented sections, regrossing (eg, for additional lymph nodes), special histochemical stains, immunohistochemical stains, flow cytometry, and molecular studies. Also, if a large case contains multiple specimen parts, they may not all be received on the same working day, and this will affect TAT.
There is currently limited information in the literature regarding TAT for large or complex specimens in surgical pathology. Prior reports have associated longer complex specimen TAT with larger institutions, larger specimen volume, later slide availability, and the presence of pathology trainees,2,3 whereas others have demonstrated associations with malignant diagnoses, use of special studies, frozen sections, consultation, and certain organ sites.4 The purpose of this Q-Probes study was to evaluate TAT for large or complex specimens in surgical pathology through a multi-institutional data collection, and to compare TAT to various demographic and practice variables that could potentially affect TAT for these specimen types.
MATERIALS AND METHODS
This College of American Pathologists Q-Probes study was conducted during the second quarter of 2012. Volunteer participants retrospectively reviewed all large or complex surgical pathology cases from the previous 6 months to identify up to 50 consecutive cases that included at least one part that was coded as CPT code 88307 (excluding biopsies) or code 88309. Cases included in the study were limited to those fully examined in the participating laboratories from gross exam to final sign-out; cases referred from an outside institution were excluded. For each case, participants recorded the date of surgery, the date and time of accessioning, and the date and time of final report sign-out. In addition, the CPT code was recorded, as well as the number of parts in the case, the organ type, the disease category, and whether or not a frozen section was performed. Any forms of special handling (eg, decalcification, submission of additional blocks) were also recorded. The type of personnel performing the initial gross examination was recorded. Basic institutional demographic data were collected, and each participating institution completed a questionnaire regarding various laboratory practices and policies that relate to TAT in surgical pathology.
The study participants applied the following definitions:
Surgical pathology case: All specimen parts received from one patient, resulting from one surgical procedure, and accessioned under a single surgical pathology identifier/number.
Large or complex case: Surgical pathology cases that included at least one part that was coded as either CPT code 88307 (excluding biopsies coded as 88307) or CPT code 88309.
Primary specimen: The most complex individual part of the surgical pathology case (ie, the part with the highest CPT code).
Routine handling: A surgical pathology case that required nothing more than standard tissue processing and standard histologic examination by hematoxylin-eosin–stained sections.
Special handling: A surgical pathology case that required handling beyond routine processing and hematoxylin-eosin–stained sections. Special handling may include decalcification, reprocessing of poorly fixed blocks, re-embedding of poorly oriented tissue, or additional gross examination with submission of additional tissue blocks. Special handling may also include ancillary studies, such as special histochemistry, immunohistochemistry, flow cytometry, or molecular studies.
Final report: A surgical pathology report that indicates the completed, final assessment of the case. The report must include all individual parts of the case and all relevant ancillary studies.
The performance indicator for the Q-Probes study was the median TAT for large or complex specimens in surgical pathology. A stepwise approach was used for the analysis. First, individual associations between the metrics and the demographic and practice variables were tested using Kruskal-Wallis tests for qualitative independent variables and regression analysis for the quantitative independent variables. Next, the variables with significant associations (P < .10) were then introduced into a forward selection multivariate regression model. A significance level of .05 was used for this final model. The aggregate TAT results by case-level characteristics were also analyzed using the Kruskal-Wallis test. All analyses were performed with SAS 9.2 (SAS Institute, Cary, North Carolina).
A total of 56 institutions submitted data for this Q-Probes study (not all institutions responded to every question). Of the responding institutions, 51 (91%) were located in the United States, with 4 institutions in Canada and 1 in Saudi Arabia. A total of 26 institutions (46.9%) were teaching hospitals and 21 (37.7%) had pathology residency training programs.
The College of American Pathologists had inspected 92% and the Joint Commission 15% of participating institutions within the previous 2 years. A total of 30 of the institutions (57.7%) were urban, 12 (23.1%) were suburban, and 10 (19.2%) were rural. A total of 42 institutions (81%) were nongovernmental institutions. The most common institution types were voluntary, nonprofit hospitals (64%), followed by nongovernmental, university hospitals (9.6%), county hospitals (3.8%), state acute hospitals (3.8%), veterans' hospitals (3.8%), and private independent laboratories (3.8%). Distribution of hospital bed size was: 0 to 150 beds, 32.6%; 151 to 300 beds, 39.1%; 301 to 450 beds, 6.5%; 451 to 600 beds, 10.9%; and more than 600 beds, 8.9%.
The participating laboratories in the prior year (2011) accessioned a median of 10 968 surgical pathology cases (10th–90th percentile range, 3672–43 104 cases). The median number of CPT code 88307 or 88309 cases was 1054 (10th–90th percentile range, 328–7191 cases). The median number of full-time equivalent pathologists was 5 (10th–90th percentile range, 1–13 pathologists), median number of pathologist assistants was 1 (10th–90th percentile range, 0–4 assistants), median number of pathology residents was 0 (10th–90th percentile range, 0–10 residents), median number of histotechnologists was 4.5 (10th–90th percentile range, 2–15 histotechnologists), median number of laboratory assistants was 1 (10th–90th percentile range, 0–6 assistants), and median number of transcriptionists was 2.2 (10th–90th percentile range, 1–4.5 transcriptionists).
Participants from the 56 institutions identified 2763 appropriate large or complex cases during the study period, and characteristics of the cases are detailed in Table 1. The case mix was 70.1% CPT code 88307 and 29.9% code 88309. Special handling was necessary in 51.5% of cases, whereas 48.5% of cases were considered routine. The most common forms of special handling were extended fixation time (27.7%), followed by immunohistochemistry (27.6%), intradepartmental consultation (11.9%), examination of additional levels or recuts (6.8%), and review of prior pathologic material (6.5%). Frozen section was performed as part of 19.8% of cases. Most cases (55.4%) consisted of only one specimen part, whereas an additional 29.9% consisted of two or three parts. Only 1% of the cases had more than 10 specimens. The most commonly reported organ sites were the female genital tract (28.7%), followed by breast (20.7%) and lower gastrointestinal tract (15.5%). The primary specimen type was most often a cancer resection (50.2%, combining radical and nonradical cancer resections), followed by noncancer resection (42.6%). Malignant neoplasms comprised nearly half of the cases (47.7%), there was a lesser proportion of benign neoplasms (21.2%), and nonneoplastic diseases comprised a combined 26.6% of cases. The initial gross examination and dissection were most often performed by a pathologist assistant (49.5%), followed by a pathologist (36.5%), a resident (11.3%), and either a histotechnologist or histotechnician in a small minority (2.4%).
The aggregate median TAT was 3.02 days, measured as calendar days (ie, not “working days”). In terms of institutional performance, the median was 2.72 days, with wide variation (10th–90th percentile range, 1.22–6.23 days; Table 2). The cumulative proportion of cases completed by each calendar day is indicated in Table 3. Among the aggregate cases there were statistically significant differences in TAT in relation to various case characteristics, as detailed in Table 4. Cases coded as 88309 had a median TAT that was approximately 1 day longer than cases coded as 88307 (3.99 versus 2.82 days). Cases that included frozen section also had a longer median TAT, but the difference was relatively small (3.38 versus 2.92 days). By contrast, cases requiring special handling had a median TAT that was more than 2 days longer than cases that were considered routine (4.13 versus 1.94 days). There was also a roughly 1-day TAT difference between radical cancer resections, nonradical cancer resections, and noncancer resections (4.04, 3.25, and 2.24 days, respectively). Likewise, malignant neoplasm cases had longer median TAT compared with benign neoplasm cases (3.94 versus 2.29 days), with neoplastic-borderline lesions splitting the difference (3.09 days).
Participants also provided detailed information regarding grossing and histology procedures, as detailed in Tables 5 and 6. There was wide variation in how late in the day a large or complex specimen could arrive in the laboratory with the expectation of same-day grossing and entry into the histology process. The earliest laboratories required specimen arrival by noon (9.6%), whereas one laboratory reported 24-hour grossing service. The most commonly reported cutoff was 4 pm, with most laboratory cutoff times (65.4%) falling in the range of 3 to 6 pm. Laboratories reported similar data for how late special studies could be ordered by the pathologist with the expectation of same-day completion. In terms of hematoxylin-eosin levels or recuts, the most common order cutoff time was 1 pm, with 44% reporting a cutoff of noon or earlier. Several laboratories reported cutoff times into the late afternoon and evening. By contrast, for special histochemistry and immunohistochemistry, the cutoff times were more clustered in the morning hours. Ordering for special histochemical stains had a most common cutoff time of noon, and 62% reported a cutoff time of noon or earlier. Likewise, for immunohistochemical stains the most common cutoff time was noon, with 80.6% requiring orders by noon.
In some laboratories overnight fixation in formalin was mandated, based on either the time of receipt in the gross room, or the specimen or organ type. Among participants, 25 laboratories (44.6%) reported mandated fixation after a specific receipt time, as listed in Table 7. The most common cutoff time was 3 pm, with most cutoffs in the range of 2 to 5 pm. By 5 pm receipt time an aggregate 88% of laboratories with mandated fixation would hold a case overnight. Overnight fixation was mandated by specimen type (regardless of receipt time) in 32 laboratories (57.1%). The most common organ sites with mandated overnight fixation were breast (84.4%), followed by lower gastrointestinal tract (43.8%), bladder-ureter-urethra (34.4%), upper gastrointestinal tract (34.4%), kidney (31.3%), and male genital (31.3%). A complete listing is provided in Table 8.
Histology staffing practices were reported by 54 participants (Table 9). Slightly more than half of laboratories (51.9%) reported staffing of 12 hours or less. A small minority (13%) had 24-hour staffing. Saturday histology was reported in 20 laboratories (37.0%), with 85% of those laboratories reporting approximately one shift of staffing (10 hours or less). Sunday histology was reported in only 7 of 54 laboratories (13.0%), with most reporting less than one shift of staffing. Large or complex surgical pathology cases were signed out on Saturdays at 15.1% of institutions and on Sundays in 1.9%.
Participants employed a number of different strategies to enter information into their laboratory computer system, as listed in Table 10. For gross dictation the most common approach was conventional dictation with transcription (81.5%), followed by direct computer entry through the use of macros and canned texts (24.1%) and voice recognition (20.4%). For final diagnosis entry, conventional dictation (69.8%) was the most common approach, followed by direct computer entry (32.1%) and voice recognition (26.4%). Synoptic reporting was used in 94.4% of laboratories.
The TAT of large or complex surgical pathology specimens was tested for associations with institutional demographic and practice variables. A P value of <.05 was considered statistically significant. Statistically significantly longer TAT was seen in government institutions (median, 6.06 versus 2.13 days; P < .001) and in laboratories that mandate overnight fixation for some specimen types (median, 3.83 versus 2.07 days; P = .03). No other practice demographics showed significant associations with TAT.
This multi-institutional Q-Probes study established benchmarks for TAT for large or complex specimens in surgical pathology, and it investigated practice and demographic parameters that could potentially influence TAT in these specimen types. Participants comprised 56 institutions that reported data on a total of 2763 cases coded as either CPT code 88307 (excluding biopsies) or CPT code 88309. Regarding demographic variables, longer TAT tended to occur in governmental institutions, which may be a reflection of different staffing patterns and/or TAT expectations in certain institutions. In terms of case characteristics, TAT was longer for cases that were generally more complex, including those coded 88309, cases that included frozen section, cases with special handling, radical cancer resections, and malignant cases. The median TAT for all institutions was 2.72 calendar days, with a wide 10th to 90th percentile range (6.23–1.22 days). Compared with routine cases, special handling cases had a TAT about 2 days longer (median, 4.13 versus 1.94 days), again with a wide 10th to 90th percentile range (9.11–1.33 days for special handling cases and 5.99–0.98 days for routine cases). Regarding laboratory practices, longer TAT was associated with laboratories that mandated overnight fixation for certain specimen types, with mandated fixation being most common for breast, gastrointestinal, and genitourinary specimens. No other demographic or practice variables showed a statistically significant effect on TAT. Notably, TAT was not affected by institution size or location, presence of training programs, weekend sign-out of cases, or various forms of data entry, such as voice recognition or canned computer text. This study also provides some details regarding the timing of grossing of large or complex cases, staffing of histology laboratories, and ordering cutoffs for completion of ancillary studies. Such data may be useful in evaluating current work shifts and/or staffing distribution, particularly for laboratories that are experiencing slower TAT.
How do the current findings compare with those of previous studies? A previous multi-institutional Q-Probes study conducted between 1993 and 1994 evaluated TAT for complex specimens, with 489 participating laboratories reporting data from 14 298 cases coded as either 88307 or 88309.2,3 In that study, participants reported TAT in terms of working days from specimen receipt to sign-out for 30 complex surgical pathology specimens. The prior study contained a smaller proportion of special handling cases (32% versus 51% in the current study). The reported aggregate TAT for complex specimens was a mean 1.5 working days (range, 0–5 days), TAT for routine complex specimens was a median 1.0 days (10th–90th percentile range, 1.0–2.0 days), and TAT for special handling cases was a median 2.0 days (10th–90th percentile range, 1.0–4.0 days). Thus, similar to the current study, special handling was associated with longer TAT. Also similar to the current study, ranges in TAT were wide, with a range of 0 to 5 days for routine specimens and 0 to 13.5 days for special handling. The prior study also reported TAT data with regard to a former guideline of 2 working days, with a median rate of routine case completion of 100% (10th–90th percentile range, 62.8%–100%) and median rate for special handling of 66.7% (10th–90th percentile range, 0.0%–100%). The prior Q-Probes study showed a greater number of significant associations between TAT and practice characteristics. Specifically, longer complex specimen TAT was associated with institutional bed size greater than 450, a greater number of pathologists, routine grossing responsibility assigned to residents only, resident involvement in sign-out, and slide availability after 12 pm. Similar to the current study, various mechanisms of report finalization and transmittal did not affect TAT. The seemingly longer TAT in the current study may also be a reflection of increased regulatory oversight and emphasis on the ever-increasing volume of content of the surgical pathology report. This may also be a reflection of increased availability of ancillary studies and the expectation/need to further subclassify tumors.
There are a few important differences in the methodologies of the current and previous Q-Probes studies. First, the prior study excluded complex cases that involved carryover specimen parts (ie, cases for which additional specimen parts were received and accessioned on consecutive days). Such cases were included in our current data collection and may have lengthened the observed TAT. Second, the current study used reported times of accessioning and report sign-out to calculate a precise TAT in calendar days (ie, hours and minutes), whereas the prior study collected the TAT in terms of whole working days, as determined and reported by the participants. We collected time of day in the current study partly because we could (ie, current laboratory information systems make this feasible) and partly because the widespread use of electronic health records allows clinicians 24-hour access to patient records; thus, clinicians may no longer consider TAT in terms of working days. Unlike the prior study, the current study did not collect data on what proportion of overall surgical pathology workload consisted of large or complex cases, nor did it collect data on the time of slide availability.
Recently, a single-institution academic department reported surgical pathology TAT for 731 nonbiopsy specimens that were evaluated by a group of 10 pathologists.4 That group's data were not reported in terms of CPT codes, but the TAT was delineated by organ site and by some forms of special handling. TAT was collected by working day, with an overall average of 2.07 days, a standard deviation of 1.18 days, and range of 1 to 14 days. Cumulative TAT was reported as follows: 2 days, 77%; 3 days, 90.6%; 4 days, 95.8%; 5 days, 97.9%; and 6 days, 99.2%. Similar to the prior Q-Probe study, this group chose to evaluate TAT in terms of a goal of 2 working days. Univariate analysis showed a number of factors associated with TAT of longer than 2 days, including malignant diagnosis, immunohistochemistry, consultation, frozen section, and staging. Certain specimen types were also associated with longer TAT, including gastrointestinal, head and neck, breast, lung, and genitourinary. Our data showed a similar organ-specific effect on TAT, but not for head and neck specimens, a finding that likely reflects differences in specimen mix between academic and community settings. Multivariate analysis in the single-institution study showed TAT of more than 2 days was associated with consultation, immunohistochemistry, malignant diagnosis, and a greater number of hematoxylin-eosin slides reviewed for the case. The use of decalcification did not have a statistically significant effect on TAT. The authors concluded that institutions that serve cancer centers will have a longer TAT than those that do not.
There are limitations to the data we present. These data analyze only the intralaboratory portion of TAT (ie, specimen accessioning to report finalization). Inclusion of prelaboratory and postlaboratory processes is a more accurate assessment of the perceived TAT on the part of the clinician.7 The laboratory information systems in wide use today allow for collection of the specific times of accessioning and sign-out, and calculation of exact intralaboratory TAT. However, variations in transmission of final diagnoses (eg, computer interface versus fax versus hand-delivered hard copy) make it difficult to ascertain the exact moment the clinician receives the final report. Thus, a precise measure of true TAT is difficult to achieve. All data were self-reported by participants, introducing possible selection bias. The current study did not track the effect of slide availability on TAT or the practice of an interposed day of slide review for trainees. Also, the current study did not collect individual pathologist data, the proportion of large cases handled per pathologist, or technical personnel data. Thus, we cannot evaluate the impact of either technical or professional workload on TAT.
Finally, the most important limitation of our study is the lack of patient outcome data. We did not survey participants to see if waiting for pathology results delayed either patient discharge or other management (eg, initiation of chemotherapy). Without patient follow-up it is impossible to know if (or how) variation in TAT affected patient outcomes. TAT of these specimens could conceivably affect patient length of stay, follow-up visits, and treatment planning, as well as tumor board presentations, but does a 1- or 2-day delay in TAT for a large resection specimen have any measurable effect on patient outcome or management? There does not appear to be any convincing data linking anatomic pathology TAT to length of stay or to patient outcome.7 In a separate Q-Probes study of biopsy TAT, 96% of surveyed surgeons were satisfied with TAT, and they believed that TAT for biopsies affected length of stay in less than 2% of cases.7 Connecting surgical pathology report TAT to patient and clinician needs is necessary to create evidence-based standards for timeliness.
What is a desirable TAT for large or complex specimens in surgical pathology? There is currently no guideline for these specimen types. The College of American Pathologists Laboratory Accreditation Program had previously required monitoring of TAT for surgical pathology cases and recommended a report completion time within 2 working days for most routine cases.11 However, this checklist item (ANP.12150) was deleted on July 10, 2011. In the 1990s, the Association of Directors of Anatomic and Surgical Pathology (ADASP) established a TAT expectation of 80% of routine biopsies completed within 2 working days, or a written report available within 3 working days, but again, there was no specific expectation for large or complex cases.12 The ADASP has stated that acceptable TAT should be determined on the basis of current literature; is variable depending on case complexity and other factors, such as the presence of a residency training program; and may change over time with the advent of new technologies and other factors.12,13 The 2006 revision of the ADASP recommendations stipulate that a quality assurance and quality improvement plan should have at least one component of TAT that is measured (among frozen sections, biopsies, large specimens, and preliminary and final autopsy reports), but it made no specific recommendation for a target TAT for large or complex specimens.13 It appears that the determination of adequate TAT is left for individual institutions to decide. Regardless of any mandate, it is well accepted that report timeliness, completeness, and diagnostic accuracy are cornerstones of quality in surgical pathology.1 Because TAT experienced by the clinician also includes the prelaboratory and postlaboratory phases of testing, these factors must be taken into account.7,8 For example, timely delivery of large specimens from the operating room is essential. In addition, methods of final report delivery affect perceived TAT on the clinician end. If a printer or fax queue “empties” only a few times each day, that will affect TAT in clinician offices. Use of interdepartmental working groups may be useful to address extralaboratory issues affecting TAT.2 For each institution, acceptable TAT goals must be established that meet the laboratory's capability and the institution's needs for timely patient care.
The authors thank the participating institutions for their time and diligence in collecting the data for this study.
The authors have no relevant financial interest in the products or companies described in this article.