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结构化报告可确保乳腺肿瘤切除标本病理报告内容完整,并能快速检测到关键数据。

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

作者信息

Aumann Konrad, Niermann Kathrin, Asberger Jasmin, Wellner Ulrich, Bronsert Peter, Erbes Thalia, Hauschke Dieter, Stickeler Elmar, Gitsch Gerald, Kayser Gian, Werner Martin

机构信息

Institute for Surgical Pathology, Faculty of Medicine, University Medical Center Freiburg, Breisacher Strasse 115a, Freiburg, Germany.

Department of Obstetrics and Gynecology, Faculty of Medicine, University Medical Center Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany.

出版信息

Breast Cancer Res Treat. 2016 Apr;156(3):495-500. doi: 10.1007/s10549-016-3769-0. Epub 2016 Apr 8.

Abstract

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.

摘要

越来越多的证据表明,不仅数据采集方式,而且数据可视化设计(即格式)都会对病理报告质量产生影响。因此,我们研究了病理报告格式与传输数据量以及检测时间之间的相关性。2003年至2011年间提交给弗莱堡大学医学中心外科病理研究所的所有乳腺肿瘤切除标本报告(n = 4181)被分为描述性报告(DR,n = 856)、结构化报告(SR,n = 2455)或基于模板的概要报告(TBSR,n = 870)。对这些报告进行筛查,以确定九种器官特异性基本数据的内容。每份报告记录的基本数据量汇总为一个基本数据评分(EDS),并对格式类型的EDS进行统计学比较。此外,我们测量了妇科医生在一组报告中检测所有九种基本数据所需的时间,并对格式类型的检测时间进行统计学比较。在所有报告中,28.4%的报告、4%的DR、21.4%的SR和72.3%的TBSR的EDS得分为满分9分(p < 0.0001)。DR的EDS中位数为7,SR为8,TBSR为9(p < 0.0001)。与其他格式类型的报告相比,TBSR中关于肿瘤定位、肿瘤大小、特定分级、血管侵犯、激素受体状态和其他发现的数据提及频率更高,差异具有统计学高度显著性(p < 0.0001)。DR、SR和TBSR的数据平均检测时间分别从26秒显著降至20秒和14秒。我们的结果清楚地表明,由于使用了TBSR,乳腺肿瘤切除标本的报告在基本数据内容和数据布局清晰度方面得到了改善,从而使临床医生能够快速检测到基本数据。

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