Necessity of clinical information in surgical pathology - A College of American Pathologists Q-Probes study of 771 475 surgical pathology cases from 341 institutions

Objectives.-To examine the frequency and nature of problems caused by inade quate clinical data provided on surgical pathology requisition forms. Design.-Participants in the 1996 Q-Probes voluntary quality improvement pro gram of the College of American Pathologists were asked to document prospec tively all surgical pathology cases with inadequate information. Inadequate clinical information was defined as the pathologist's need for additional clinical information before a diagnosis could be rendered, regardless of th e amount of information already present on the requisition slip. Cases that had no clinical information on a requisition slip were not counted if the lack of history did not hinder diagnosis. The study concluded when 3 months had elapsed or 40 surgical pathology cases were documented. The following data were recorded for each case: anatomic site, type of procedure, nature of disease, method of obtaining additional information, importance of obtai ned information, and the length of delay in the final diagnosis. Participants.-Three hundred forty-one laboratories, 322 of which were from the United States. Results.-A total of 5594 cases (0.73%) required additional clinical informa tion for diagnosis (10th through 90th percentile range, 3.01% to 0.08%). In stitutions with greater average occupied bedsize, a greater number of cases accessioned per year, and a greater number of pathologists had a lower per centage of cases with inadequate clinical data (P <.05). Sixty-eight percen t of these cases had no delay in completion of a case, 16.2% had a delay of 1 day or less, and 15.1% of cases were delayed more than 1 day. In 59.4% o f cases, the additional clinical information obtained confirmed the initial diagnostic impression. In 25.1%, the information was not relevant to the p athologic diagnosis. In 6.1% there was a substantial change in the diagnosi s or a revised report was issued, and in 2.2% no additional information cou ld be obtained. Specific anatomic sites that correlated with a higher rate of changed diagnoses or revised reports in cases with inadequate informatio n included the small bowel, the bronchus/lung, and the ovary. Resection spe cimens were also significantly associated with a higher rate of changed dia gnoses or revised reports when additional information was obtained, as were malignant neoplasms and therapy-induced changes. Conclusions.-This study establishes an aggregate rate of cases with inadequ ate clinical information for diagnosis (0.73%) and documents the extent of problems caused by inadequate clinical information. The criticality of appr opriate clinical information provided to the pathologist is identified far specific anatomic sites and disease processes and is reflected in changed d iagnoses or revised reports.