Romano Ryan C, Novotny Paul J, Sloan Jeff A, Comfere Nneka I
From the Departments of Laboratory Medicine and Pathology,
Biomedical Statistics and Informatics.
Am J Clin Pathol. 2016 Dec;146(6):727-735. doi: 10.1093/ajcp/aqw186. Epub 2016 Dec 27.
To define indices of completeness and accuracy of clinical information in the skin biopsy requisition form (RF) and correlate them with health care delivery outcomes and pathology service utilization.
RFs in our pathology information system were reviewed and assessed for the presence of 10 clinical elements considered critical for dermatopathologic diagnosis. Accuracy was determined by reviewing corresponding clinical notes.
In total, 249 RFs were reviewed. In inflammatory dermatoses, provision of a clinical impression, provision of more than two elements, and achieving more than 75% accuracy were associated with improved outcomes and decreased utilization. For all nonlymphoproliferative cases, higher quality clinical information was associated with decreased turnaround time (P < .001). More clinical information was associated with increased utilization and turnaround time (P = .0235) for lymphoproliferative cases and higher resampling rates for melanocytic lesions (P = .0066).
In inflammatory dermatoses, providing high-quality clinical information on the RF promotes optimal histopathologic diagnostic performance and appropriate pathology service utilization.
定义皮肤活检申请表（RF）中临床信息的完整性和准确性指标，并将其与医疗服务结果和病理服务利用情况相关联。
对我们病理信息系统中的RF进行审查，并评估10个对皮肤病理诊断至关重要的临床要素是否存在。通过审查相应的临床记录来确定准确性。
共审查了249份RF。在炎症性皮肤病中，提供临床印象、提供两个以上要素以及达到75%以上的准确性与改善结果和降低利用率相关。对于所有非淋巴增殖性病例，更高质量的临床信息与缩短周转时间相关（P <.001）。对于淋巴增殖性病例，更多的临床信息与利用率增加和周转时间延长相关（P = 0.0235），对于黑素细胞病变，重采样率更高（P = 0.0066）。
在炎症性皮肤病中，在RF上提供高质量的临床信息可促进最佳的组织病理学诊断性能和适当的病理服务利用。
