title: Structured reporting ensures complete content and quick detection of essential data in pathology reports of oncological breast resection specimens.
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.
authors.affiliation: Institute for Surgical Pathology, Faculty of Medicine, University Medical Center Freiburg, Breisacher Strasse 115a, Freiburg, Germany.
authors.forename: Konrad
authors.initials: K
authors.lastname: Aumann
authors.affiliation: Institute for Surgical Pathology, Faculty of Medicine, University Medical Center Freiburg, Breisacher Strasse 115a, Freiburg, Germany.
authors.forename: Kathrin
authors.initials: K
authors.lastname: Niermann
authors.affiliation: Department of Obstetrics and Gynecology, Faculty of Medicine, University Medical Center Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany.
authors.forename: Jasmin
authors.initials: J
authors.lastname: Asberger
authors.affiliation: Clinic for Surgery, UKSH Campus Lübeck, Lübeck, Germany.
authors.forename: Ulrich
authors.initials: U
authors.lastname: Wellner
authors.affiliation: Institute for Surgical Pathology, Faculty of Medicine, University Medical Center Freiburg, Breisacher Strasse 115a, Freiburg, Germany.
authors.forename: Peter
authors.initials: P
authors.lastname: Bronsert
authors.affiliation: Department of Obstetrics and Gynecology, Faculty of Medicine, University Medical Center Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany.
authors.forename: Thalia
authors.initials: T
authors.lastname: Erbes
authors.affiliation: Department of Medical Biometry and Medical Informatics, Faculty of Medicine, University Medical Center Freiburg, Stefan-Meier-Strasse 26, 79104, Freiburg, Germany.
authors.forename: Dieter
authors.initials: D
authors.lastname: Hauschke
authors.affiliation: Department of Obstetrics and Gynecology, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany.
authors.forename: Elmar
authors.initials: E
authors.lastname: Stickeler
authors.affiliation: Department of Obstetrics and Gynecology, Faculty of Medicine, University Medical Center Freiburg, Hugstetter Strasse 55, 79106, Freiburg, Germany.
authors.forename: Gerald
authors.initials: G
authors.lastname: Gitsch
authors.affiliation: Institute for Surgical Pathology, Faculty of Medicine, University Medical Center Freiburg, Breisacher Strasse 115a, Freiburg, Germany.
authors.forename: Gian
authors.initials: G
authors.lastname: Kayser
authors.affiliation: Institute for Surgical Pathology, Faculty of Medicine, University Medical Center Freiburg, Breisacher Strasse 115a, Freiburg, Germany. Martin.Werner@uniklinik-freiburg.de.
authors.forename: Martin
authors.initials: M
authors.lastname: Werner
mesh_terms: D001943:Breast Neoplasms / Q000473:pathology*; D005260:Female; D006801:Humans; D060787:Neoplasm Grading; D010340:Pathology, Surgical; D058028:Research Report / Q000592:standards*; D047368:Tumor Burden
keywords: Breast; Quality of surgical pathology reports; Standardized layout; Synoptic pathology reports