For more than 100 years, the American College of Surgeons (ACS) has led national and international initiatives to improve quality in hospitals, specifically in the fields of trauma, cancer, and surgical care. The ACS was the forebear of what is now The Joint Commission and continues to develop quality standards for cancer, trauma, metabolic and bariatric, and geriatric patient care.
The ACS soon will launch a standards program to ensure surgical care facilities are in compliance with the guidelines outlined in Optimal Resources for Surgical Quality and Safety (also known as the Red Book) and for rural hospitals, as noted in an article in the April issue of the Bulletin.* The execution of these programs and their impact on surgical patients often is underappreciated. The following case history features a nonsurgical department quality review and its effect on a rural surgical patient.
A patient in rural North Dakota was diagnosed with diffuse helicobacter (H.) pylori-negative gastric mucosa-associated lymphoid tissue (MALT) lymphoma after diagnostic upper endoscopy in a critical access hospital (CAH). Three weeks after initial treatment decisions were made, an internal quality review—performed by the referring tertiary center’s pathology department—uncovered a discrepancy that drastically altered this patient’s clinical outcome.
Case history
In a town of approximately 1,000 people, an 81-year-old male presented to the local monthly general surgery clinic with complaints of a one-year history of vague epigastric pain and sore throat without weight loss, appetite change, fever, or chills. He was otherwise in good physical health, working full time in his welding shop, which involved lifting up to 80 pounds and pushing objects greater than 130 pounds.
According to his surgical and medical history, the patient had been treated for colon cancer requiring surgical resection and chemoradiation therapy, prostate cancer requiring prostatectomy, and bradycardia requiring placement of a cardiac pacemaker. His only medications were benazepril, hydrochlorothiazide, aspirin, omeprazole, and multivitamins. He quit smoking more than 50 years ago and consumed one or two alcoholic beverages a week. He had a sister who had Lynch syndrome with colon and uterine cancer.
Following the initial surgery consultation, the patient underwent a diagnostic upper endoscopy at the CAH, which demonstrated diffuse gross flattening of the gastric mucosa with hyperemia without ulceration within the body of the stomach. Distal to this abnormality was a pale, flattened area without ulceration, less than 1 cm in size. Multiple biopsies were taken of these areas, in addition to a sample for H. pylori evaluation. Specimens were reviewed by the consulting pathology department at the regional medical center 65 miles away. The pathology report returned as mucosal involvement of extranodal marginal zone lymphoma of MALT lymphoma; H. pylori was negative.
Two weeks after the endoscopy, medical oncology staff at the regional medical center referred and evaluated the patient for the H. pylori-negative MALT lymphoma. However, the following week, the pathologist updated the surgeon on the patient’s biopsy results in accordance with the pathology department’s internal quality review, a process performed once a month in which a randomly selected group of specimens are re-examined for accuracy and consistency. According to the updated evaluation, the patient not only had MALT lymphoma, but also may have had adenocarcinoma.
More information was needed to officially make the diagnosis. Thus, a second endoscopist performed another upper endoscopy at the regional center. The original lesions were again encountered, biopsied, and found positive for adenocarcinoma. The specimens were sent to the region’s largest academic center for additional review, which confirmed the presence of a small focus of poorly differentiated adenocarcinoma. The patient was then referred to the same academic center for the remainder of his work-up and treatment.
Staging computed tomography (CT) and positron emission tomography (PET)/CT imaging, repeat endoscopy with endoscopic ultrasound, and diagnostic laparoscopy with peritoneal washings identified no signs of metastatic disease, and the patient ultimately underwent definitive resection by total gastrectomy four months after his original endoscopic evaluation. Final diagnosis based on his surgical pathology was multifocal involvement of MALT lymphoma with 1.8 x 1.5 x 0.5 cm of invasive poorly differentiated intramucosal adenocarcinoma with signet cell component. All lymph nodes were negative, making the final stage pT1a, pN0. The diagnosis, determined preoperatively, was consistent with a gastric collision tumor; a rare pathology more often seen incidentally within surgically resected specimens.† The patient’s postoperative course and recovery were uneventful. Today, the patient continues to work in his welding shop.
Challenges in cancer care
Optimal care for any cancer patient demands timely diagnosis and treatment. The diagnostic process involves a series of professionals—from the surgeon performing the procedure and obtaining the appropriate biopsy, to the procedure room team organizing and identifying each specimen, to the lab technicians preparing the tissue samples, to the pathologist making the final interpretation. Each member of the team is directly responsible for the patient and can contribute to diagnostic progress or delay.
Once patients are diagnosed with a malignancy and referred to a tertiary care center, they become part of multidisciplinary tumor board conferences and are assigned care coordinators to manage appointments and therapy schedules. Unfortunately, this level of organization does not exist for patients during the diagnostic period, and ownership of the patient’s care is less well-defined, especially in rural America. This case demonstrates challenges within the diagnostic phase that influence cancer care for patients in rural communities.
The first challenge is maintenance of quality in diagnostic techniques for accurate disease identification. A critical component of the diagnosis in this case was the second review of the initial biopsy as part of the pathology department’s routine quality review process. Had it not been for this quality review, this patient would have received inappropriate treatment and later developed advanced disease.
The second challenge is communication. Equally important to the pathologist’s addendum was the direct phone call from the pathologist to the patient’s care team at the community hospital, including the initial endoscopist who promptly redirected the patient’s care. Efficient and effective communication is fundamental to convey changes in diagnosis and treatment. To successfully contact rural providers, it also is important to consider the communication method.
Challenges in rural health care
The electronic health record (EHR) has become a convenient way for providers to exchange patient information with each other, but it can be an unreliable communication modality for some regions because of a lack of integration between referring and referral systems. This patient’s case involved three different EHRs, which is typical for individuals whose care begins at a CAH and ends hundreds of miles away at a tertiary academic center. Therefore, information that may be updated within the tertiary center may not be updated at the other institutions where a rural patient seeks care.
The surgeons and clinicians caring for rural patients also may practice in multiple facilities, transitioning days to weeks between separate computer communication systems. For this reason, message receipt and response times can be prolonged. For these providers, no e-mail, secure chat, or instant message can replace the more traditional provider-to-provider phone call to relay time-sensitive information. When it comes to keeping in touch with patients—an equally important task—a phone call might be the only way to reach individuals without reliable Internet access. Although many potential barriers to adequate communication can be found in rural health care, in this case, the barriers were avoided because the pathologist placed a simple phone call to personally discuss new concerns with the initial endoscopist, resulting in little to no delay for an accurate cancer diagnosis.
A third factor that influences prediagnosis care in rural centers is continuity. In tertiary medical centers, the pre- and postdiagnosis phases are well guided within a confined network of specialists and through multidisciplinary meetings, but for rural America, the diagnosis of surgical disease may be more disjointed. Rural hospitals often are supported by providers with limited surgical background. Locum tenens are common in these hospitals, not only among the physicians, but also for nursing and other ancillary staff. Diagnostic procedures are offered on a limited basis, and imaging and pathology require interpretation at a remote facility.
To mitigate some of this fragmentation, the University of North Dakota, Grand Forks, established a rural surgery support program in July 2014 to promote quality surgical care for vulnerable communities that previously lacked access to consistent surgical care. Part of the program’s commitment was to employ a single surgeon in the same communities to facilitate familiarity and continuity through regular general surgery call schedules, as well as 24-hour/seven-days-a-week direct phone availability. This surgeon serves as an immediate surgical resource for the local primary care providers regarding patients such as this 81-year-old patient, whose outcome was dependent on timely direct communication; this patient’s case was a success in part because of this program.
No single program is applicable for all health care systems. Each quality improvement program should be tailored to its respective community. This case demonstrates the need to consider the needs of rural communities where the diagnostic evaluation begins. The referral and referring centers must connect at all phases of care—patient consultation, preoperative, intraoperative, postoperative, and after discharge—otherwise, quality surgical care will be lost.
The right provider at the right time
No physician is further from direct contact with the patient than the pathologist, yet his or her findings direct treatment plans every day. At the same time, the pathologist’s information is only meaningful when it is communicated in a timely manner to the other members of the patient’s care team. In this case, a pathology quality improvement program prevented the pathologist from making an incomplete diagnosis, but the pathologist’s phone call to the right provider at the right time was the primary reason the patient is alive and cancer-free today. This patient’s success validates the need for multidisciplinary quality review, communication, and continuity between tertiary and rural centers. The emphasis of these principles through programs such as the Red Book and the College’s new rural verification programs will facilitate recognition of community-specific needs to improve the health and safety of patients nationwide.
*Puls MW, Hughes TG, Sarap M, Caropreso P, Nakayama DK, Welsh DJ. New ACS-led verification program aims to improve care for rural surgical patients. Bull Am Coll Surg. 2020;105(4):24-28. Available at: https://bulletin.facs.org/2020/04/new-acs-led-verification-program-aims-to-improve-care-for-rural-surgical-patients/. Accessed June 22, 2020.
†Schizas D, Katsaros I, Michalinos A, et al. Collision tumors of the gastrointestinal tract: A systematic review of the literature. Anticancer Res. 2018;38(11):6047-6057.
