December 2012
Feature Story

Jan Bowers

Turnaround times for large and complex surgical pathology specimens can reflect a laboratory’s quality and efficiency, and in some cases affect patient care. But what constitutes acceptable TATs for these specimens has remained something of a mystery. With limited information in the literature, labs have had few guideposts to use in setting their own parameters or sizing up their performance. Now a new CAP Q-Probes study reveals how quickly a broad range of laboratories process large and complex cases, and what appears to influence their performance.

“In prior studies, we looked at the more routine cases, biopsy cases that could be processed quickly. But we have not, until now, examined how long it took to process the more complicated specimens,” says study co-author Raouf E. Nakhleh, MD, professor of pathology at Mayo Clinic in Jacksonville, Fla., and chair of the CAP Quality Practices Committee. “This is probably the first multi-institutional study that establishes TAT benchmarks for these types of specimens.”

The Q-Probes, “Turnaround Time for Large or Complex Specimens in Surgical Pathology,” surveyed participants from 56 institutions about TATs for 2,763 cases, processed over a six-month period, that included at least one part with CPT code 88307 (excluding biopsies) or 88309. Large or complex cases referred from an outside institution were excluded. TAT was defined as the time that elapsed from accessioning to case sign-out and was calculated by actual days (not “working” days).

The study found a median TAT of 2.72 days, with laboratory performance ranging from 1.22 days at the 90th percentile to 6.23 days at the 10th percentile. Dr. Nakhleh calls the results “very reasonable, from my experience.” In the past, laboratories have been pressed to reduce their TATs, he says. “Fast is not always better. We’ve pulled back in the past five or 10 years because we realized we need to have appropriate fixation, we need to do appropriate immunohistochemistry markers to make sure we get it right.”

Study co-author Michael O. Idowu, MD, MPH, associate professor of pathology at Virginia Commonwealth University and director of breast pathology and quality management, Division of Anatomic Pathology, says he expected at the outset to see a median TAT closer to four or five days, especially in academic medical centers with residency programs. “But I looked at our own [department’s] results, and they’re similar. The 88307s vary—some are larger and some are more complex than others—but overall, the results of this study actually seem to be close to ours.”

To determine what factors affect TAT, the study queried participants about institutional demographics, case characteristics, and laboratory policies and practices. Governmental institutions were found to have significantly longer TATs than non-governmental institutions (a median of 6.06 and 2.13 days, respectively), a result the co-authors find difficult to explain. Longer median processing TATs also tended to be found in laboratories that mandate overnight fixation for some specimen types.

The pathology cases that tended to result in longer TATs were coded as CPT 88309, required special (as opposed to routine) handling, and included performance of a frozen section. Special handling had a particularly significant impact, with a median TAT of 4.13 days, compared with 1.94 days for routine cases. Among primary specimen types, radical cancer resections had the longest median TATs (4.04 days), followed by non-radical cancer resections (3.25 days) and non-cancer resections (2.24 days). Among disease categories, “neoplastic-malignant” topped the list at a median of 3.94 days. The median for all other categories fell below the overall median of 2.72 days.

Dr. Nakhleh wasn’t surprised at the factors that were found to be associated with longer TATs. The value of the study, he says, is in getting a closer look at the performance and policies of participating hospitals. “People have an idea of what’s going on, but they don’t know exactly what others are doing” regarding, for example, whether overnight fixation is mandatory for some specimen types, he says. “If you’re doing something no one else is doing, you realize you may need to get in line. If you’re doing something different and you’re still getting great results, then maybe others should change to your way. But you don’t know until you actually assess a group of institutions in a very uniform fashion.”

Nearly 60 percent of respondents mandate overnight fixation for some specimen types (breast was named most frequently); those labs reported an overall median TAT of 3.83 days, compared with 2.07 days among labs that don’t have that policy. Dr. Nakhleh points out that labs that do not have a mandatory policy may still, in practice, be fixing many of the same specimens overnight as labs that do have a policy.

Intradepartmental consultation on complex cases added at least one day to the TAT at 22 institutions (41.5 percent) and resulted in three-day delays at five institutions. To co-author Keith E. Volmar, MD, a pathologist at Rex Hospital in Raleigh, NC, those delays appear to be excessive. “I’m not sure if that’s a logistical problem, where a department works at multiple sites, or if it’s a matter of people pushing the consultations to the end of the day,” he says. Dr. Idowu was less surprised by the finding because, he says, “If you don’t have a policy on TAT of intradepartmental consult cases, then most people will put the consult aside and do their own cases first and deal with the consults with little or no urgency. Based on our experience here, intradepartmental consultation adds some time to the overall TAT, but usually less than a day.”

Dr. Volmar calculated that 8.4 percent of cases in the study underwent some form of intradepartmental consultation. “It’s been kind of a hot topic in recent years, with people trying to determine if there should be a set percentage of cases that get reviewed by a second pathologist before sign-out. It’s interesting that this 8.4 percent is fairly close to the 10 percent or so that people have promoted as a good random review benchmark.”

While the data showing which factors did affect TATs offered few revelations, a couple of variables that were expected to have an impact appeared to have little or none at all. The presence of pathology residency training programs, reported by 38 percent of responding institutions, showed no statistically significant association with TATs. “Our experience has been that it adds an extra day or two,” Dr. Idowu says. “That generally seems to be the experience of many centers with residency programs.” Dr. Volmar, too, expected to see an association, simply because of the inefficiencies of dealing with trainees new to the process. “Sometimes they get more complex specimens that they don’t know how to handle well, and you might have to go back and put in more sections,” he notes. “This emphasizes that people in the academic realm are under the same kind of time pressure that the rest of us are under out in the community.”

In theory, innovative technologies like voice recognition systems should speed the process of entering text for gross exam findings and final reports. But it hasn’t worked that way in practice, say the study’s co-authors. “A growing number of labs use either voice recognition or canned text that they can choose from a drop-down menu,” Dr. Volmar says. “I expected that would save significant time, but it didn’t pan out as a factor.” Among 54 respondents, 44 reported using dictation with transcription, and 24 said they use voice recognition or canned text or both. Dr. Idowu expected that dictation would have extended the TAT, but he points to drawbacks of voice recognition technology that may be hampering its acceptance and limiting its usefulness. “You have to train voice recognition to understand each ‘new voice.’ Otherwise you spend a lot of time correcting what it has typed,” he says, adding that in institutions with a residency program, that training of the voice recognition system to recognize trainees’ voices, intonations, or accents could be particularly time-consuming.

The overriding purpose of Q-Probes, Dr. Nakhleh says, is to help individual labs understand how they compare to a larger, representative group. While he isn’t alarmed by the relatively long TATs some labs report, he suggests that those with median TATs longer than six days examine their practices and determine whether they need to improve their performance. “On the other hand, if that works for them and the clinicians they serve, then that longer time would be OK,” he adds.

Dr. Idowu agrees, noting that laboratorians are increasingly working with clinicians to set their own TATs for large and complex cases rather than aiming for the shortest time they can achieve. If a surgeon asks a patient to return two weeks after the procedure to discuss results, a weeklong TAT in the lab may be perfectly adequate, he points out, adding, “In my opinion, there’s no point rushing the results when in fact nobody’s going to act on them for another week or two.” The movement, he says, is not just toward a faster turnaround time, but toward the pathologist working with the clinicians to determine what works for the institution and its patient population.