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国际癌症报告推荐后前列腺根治性切除术标本的病理报告:电子报告工具的实施对大型大学医院质量和跨学科交流的影响。

Pathological Reporting of Radical Prostatectomy Specimens Following ICCR Recommendation: Impact of Electronic Reporting Tool Implementation on Quality and Interdisciplinary Communication in a Large University Hospital.

机构信息

Institute of General and Surgical Pathology, Technische Universität München, Trogerstr. 18, 81675 Munich, Germany.

Smart Reporting GmbH, 80538 Munich, Germany.

出版信息

Curr Oncol. 2022 Sep 30;29(10):7245-7256. doi: 10.3390/curroncol29100571.

DOI:10.3390/curroncol29100571
PMID:36290848
原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC9600383/
Abstract

Prostate cancer represents one of the most common malignant tumors in male patients in Germany. The pathological reporting of radical prostatectomy specimens following a structured process constitutes an excellent prototype for the introduction of software-based standardized structured reporting in pathology. This can lead to reports of higher quality and could create a fundamental improvement for future AI applications. A software-based reporting template was used to generate standardized structured pathological reports of radical prostatectomy specimens of patients treated at the University Hospital Klinikum rechts der Isar of Technische Universität München, Germany. Narrative reports (NR) and standardized structured reports (SSR) were analyzed with regard to completeness, and clinicians' satisfaction with each report type was evaluated. SSR show considerably higher completeness than NR. A total of 10 categories out of 32 were significantly more complete in SSR than in NR ( < 0.05). Clinicians awarded overall high scores in NR and SSR reports. One rater acknowledged a significantly higher level of clarity and time saving when comparing SSR to NR. Our findings highlight that the standardized structured reporting of radical prostatectomy specimens, qualifying as level 5 reports, significantly increases objectively measured content quality and the level of completeness. The implementation of nationwide SSR in Germany, particularly in oncologic pathology, can serve pathologists, clinicians, and patients.

摘要

前列腺癌是德国男性患者中最常见的恶性肿瘤之一。对根治性前列腺切除术标本进行结构化报告的病理报告为病理学中引入基于软件的标准化结构化报告提供了极好的范例。这可以提高报告的质量,并为未来的人工智能应用创造根本性的改进。本研究使用基于软件的报告模板,生成了德国慕尼黑工业大学 Klinikum rechts der Isar 大学医院治疗的前列腺癌根治性切除术标本的标准化结构化病理报告。分析了叙述性报告(NR)和标准化结构化报告(SSR)的完整性,并评估了临床医生对每种报告类型的满意度。SSR 显示出明显更高的完整性。在 SSR 中,有 10 个类别(共 32 个)明显比 NR 更完整(<0.05)。临床医生对 NR 和 SSR 报告的总体评分都很高。一位评估者承认,与 NR 相比,SSR 在清晰度和节省时间方面有显著提高。我们的研究结果表明,作为 5 级报告的根治性前列腺切除术标本的标准化结构化报告,显著提高了客观测量的内容质量和完整性水平。德国全国范围内 SSR 的实施,特别是在肿瘤病理学中,可以为病理学家、临床医生和患者提供服务。

https://cdn.ncbi.nlm.nih.gov/pmc/blobs/58e9/9600383/c2b397cafda9/curroncol-29-00571-g001.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/58e9/9600383/1ec3f3b564ea/curroncol-29-00571-g0A1.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/58e9/9600383/c2b397cafda9/curroncol-29-00571-g001.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/58e9/9600383/1ec3f3b564ea/curroncol-29-00571-g0A1.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/58e9/9600383/c2b397cafda9/curroncol-29-00571-g001.jpg

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本文引用的文献

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Br J Cancer. 2022 Jan;126(1):4-9. doi: 10.1038/s41416-021-01633-1. Epub 2021 Nov 26.
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The Oncologist's Guide to Synoptic Reporting: A Primer.肿瘤学家的概要报告指南:入门篇。
Oncology. 2020;98(6):396-402. doi: 10.1159/000500884. Epub 2019 Jun 7.
3
Synoptic reporting increases quality of upper gastrointestinal cancer pathology reports.摘要报告提高了上消化道癌症病理报告的质量。
优化前列腺癌治疗决策的临床工具:一项五年回顾性分析
Life (Basel). 2024 Jun 30;14(7):838. doi: 10.3390/life14070838.
Virchows Arch. 2019 Aug;475(2):255-259. doi: 10.1007/s00428-019-02586-w. Epub 2019 May 29.
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5
Improvement of Care in Patients With Colorectal Cancer: Influence of the Introduction of Standardized Structured Reporting for Pathology.结直肠癌患者护理的改善:病理标准化结构化报告引入的影响
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Synoptic Reporting: Evidence-Based Review and Future Directions.综述报告:基于证据的回顾与未来方向。
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