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Ammendments Versus Addenda in Surgical Pathology Reports

Posted Mar 27 2012 12:00am

An article was recently published in the American Journal of Clinical Pathology entitled "Cases with addenda increased from 0.9% in 1993 to 8.6% in 2008." It describes an interesting facet of anatomic pathology LIS (AP-LIS) reporting in the pathology department at Yale. Here's the abstract:

Addenda are typically used to report results of additional studies that are delayed relative to histopathologic studies. However, the frequency and pattern of use of addenda have not been previously reported. We studied the dynamics of addenda creation within the same month at 5-year intervals during a 15-year period at our institution. The number of addenda and type and impact of information communicated in addenda were assessed in the month of July in 1993, 1998, 2003, and 2008, and the possible role of addenda in quality improvement was evaluated. Cases with addenda increased from 0.9% in 1993 to 8.6% in 2008. In 5.6% of addenda, there was information that might have been better reported in an amendment, suggesting that criteria for amendments need to be universally implemented. Charting trends and types of addenda offered opportunities for quality improvement by identifying weaknesses in the workflow organization of the laboratory.

Reporting a surgical pathology case with an AP-LIS is becoming much more complex than the situation, say, two or three decades ago. To report out a case previously, almost total attention was paid to the H&E slides with an occasional delay for special stains. The goal, as today, was to arrive at a diagnosis as quickly as possible. The tissue-submitting physician and patient were, of course, also eager to receive the report on a timely basis. A tension has always been in play between the desire to issue the report and the need for a delay occasioned by additional tests such as immunohistochemistry (IHC). However, there are many more "ancillary" test results currently that bear on the final report and need to be taken into consideration.

Out of this milieu and partly connected to the growing maturity of AP-LISs, the following vocabulary emerged for surgical pathology reports: an amendment indicates that a significant change to the report and diagnosis is being reported and an addendum indicates that new information is being reported which does not substantively change the diagnosis. I am constructing these definitions out of my head. I am sure that they are codified somewhere in the literature and in vendor documentation. However, I am also sure that there is not a common understanding of the terms across all pathologists and AP-LIS vendors. Hence the statement in the abstract above: criteria for amendments need to be universally implemented. This was in response to the study finding that "in 5.6% of addenda, there was information that might have better been reported in an amendment."

I strongly endorse the development of such criteria. I am not sufficiently familiar with the field of synoptic reporting to discuss whether this field is the most appropriate vehicle for the development of such criteria. Readers who are better informed may want to join into this discussion. A recent editorial about this same topic appeared in Pathology and made reference to two other articles in the journal issue (see: Surgical pathology reporting at the crossroads: beyond synoptic reporting ). Below is an excerpt from it that makes some important points:

[A]s we increasingly used clinical information and ancillary studies such as immunohistochemistry, cytogenetics, molecular analyses and flow studies to derive our diagnoses, two issues obfuscated our thinking. Firstly, the method for incorporation of ancillary studies is not clearly defined within this structure, and some pathologists have been reluctant to incorporate results from other laboratories, even when that information provides a critical part of their final conclusion. Secondly, once pathology data are derived from multiple modalities other than simply morphology, the traditional report structure does not make logical provision for a ‘Synthesis’ in which information from multiple modalities, often of varying predictive value, can be combined and weighed inferentially to derive higher elements, often part of the conclusion. Some have used ‘Comment’ or ‘Commentary’ as an additional heading to define this component. Others have developed their synthesis within the ‘Conclusion’ section. This represents a lack of consistency in the use of this section since most pathologists use it as a summary, i.e., a shortened repetition of what is already in the rest of the report, and increasingly it is used as a banner in the first part of a report, rather as a newspaper headline. 


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