Original Title: Avis : Pertinence et indications de transmission des prélèvements chirurgicaux au laboratoire d’anatomopathologie - La chirurgie ophtalmologique

Authors' objectives: Section 59 of Organization and Management of Institutions Regulation (C.Q.L.R., chapter S-5, r. 5) has generally been interpreted as meaning that all surgical specimens must be submitted to the anatomic pathology laboratory for analysis. This regulatory provision has, for many years, resulted in a large volume of specimens being submitted and analyzed. This generates potentially substantial costs and results in suboptimal analysis turnaround times. It is estimated that a significant proportion of these submissions may not be necessary because the anatomopathological examination is unlikely to provide information that would be useful for patient management. To reduce the number of unnecessary requests for an anatomopathological examination and to promote optimal anatomic pathology laboratory resource utilization, the ministère de la Santé et des Services sociaux asked the Institut national d'excellence en santé et en services sociaux (INESSS) to determine which surgical specimens could be considered for selective submission to the anatomic pathology laboratory and to spell out the conditions for submitting them. This last report in a series of six concerns specimens from eye surgery. These consultations enabled us to gather experiential knowledge, to document perceptions and the level of acceptability concerning the selective or non-selective submission of certain surgical materials and specimens to the anatomic pathology laboratory, and to determine the potential organizational, clinical, economic, ethical and legal issues.

Authors' results and conclusions: RESULTS: (#1: OVERALL CLINICAL UTILITY): • The decision to submit or not submit surgical specimens to the anatomic pathology laboratory is usually based on clinical suspicion or the examination’s diagnostic or prognostic value; • Changes in knowledge, technology and practice inevitably lead to changes in the clinical relevance of submitting or not submitting some of these specimens; • Because of the nature and purpose of the surgical procedure or of the tissue’s or organ’s characteristics, many specimens removed must be systematically submitted to the anatomic pathology laboratory, while others should not. For some, the value of routine submission to the laboratory may be questioned. The decision should be made on a case-by-case basis according to the available scientific data, the best clinical practice recommendations, the clinical picture and the surgeon’s judgment. (#2: CONDITIONS FOR SUBMITTING specimens for an anatomopathological examination): • Several learned societies, including the College of American Pathologists (CAP), have proposed models for the selective submission of certain surgical specimens to the anatomic pathology laboratory in order to promote the efficient use of its resources; • The lists of specimens that could be selectively submitted for an anatomopathological examination, as proposed in the guidelines reviewed and by certain Québec institutions, differ in terms of the number and type of specimens; • Practice does not appear to be harmonized across Québec. Some public institutions in the health and social services network have already put in place a selective submission policy for certain surgical specimens, and others have not; • Providing relevant clinical information (e.g., the procedure performed, the preoperative diagnosis, unusual intraoperative findings and special concerns) is key to performing an appropriate anatomopathological examination. (#3: PROFESSIONAL PRACTICE of physicians who take specimens): • There are appropriate ways other than submitting a specimen to the anatomic pathology laboratory to confirm that a specimen was removed (e.g., nurse confirmation and surgical notes); • The standards for chart- and register-keeping by a physician are set out in regulations. Thus, the surgeon’s surgical notes and surgery report are official documents in which any specimen taken during a surgical procedure must be documented and included in the patient's chart. The surgery report should be written or dictated within 24 hours of the procedure. This practice applies to physicians practicing in both the public and private institutions in the health and social services system. (#4: CLINICAL UTILITY of anatomopathological examinations of specimens from eye surgery): • For 23 surgical specimens initially identified, and after consolidation that reduced this list to 20, the risk of a clinically significant incidental finding was considered low for 16 of the 20 specimens. Fifteen were based on the literature reviewed and the current selective submission lists identified, and 1 was based solely on the perspectives of the stakeholders consulted; • Four of the 20 surgical specimens were ultimately excluded from the selective submission list because of the risk of an incidental finding on anatomopathological examination; • The list of specimens that could be submitted on a selective basis, developed in this report, complements those already published by other authorities: – Unlike the submission lists identified for four Canadian provinces, the list developed in this report includes specimens from eyelid surgery (chalazion, ectropion/entropion, acrochordon), glaucoma surgery, vitrectomy and dacryocystorhinostomy; – Two surgical specimens that were not on any of the selective submission lists were added to INESSS’s list: 1) bone removed during orbital decompression; and 2) residual donor tissue during corneal transplantation. (#5: POTENTIAL SAVINGS associated with a change in practice in the submission of specimens for an anatomopathological examination): • The selective submission recommendations made by certain learned societies and organizations have led to a reduction in the workload associated with the analysis of specimens of limited or no clinical value; • Currently, it is difficult to estimate, even intuitively, the savings that could result from the selective submission of specimens for an anatomopathological examination, primarily because of the inability to identify and quantify in databases those anatomopathological analyses not considered relevant. CONCLUSION: Upon the completion of this work, the selective-submission list for specimens from eye surgery that was drawn up, for which the level of risk for the patient was considered low and the anatomopathological examination unlikely to provide any useful information for patient management, should contribute to more judicious anatomic pathology laboratory resource utilization. Gradual implementation involving consultation between the Council of physicians, dentists and pharmacists, the directors of professional services, the OPTILAB co-directors and other bodies responsible for the quality of care will be needed to facilitate the changes and ensure optimal risk and medical procedure quality management. Since the recommendations are based on the scientific knowledge available at this time, it is possible that they will be modified in light of future scientific advances that might make the anatomopathological examination of certain surgical specimens clinically useful. For this reason, the advisability of updating these recommendations will be assessed in four years, that is, in 2026.

Authors' recommendations: SELECTIVE SUBMISSION RECOMMENDATIONS SPECIFIC TO EYE SURGERY After reviewing all the data gathered, INESSS recommends that the following surgical specimens be submitted to the anatomic pathology laboratory on a selective basis for analysis, this throughout Québec. ! This list is not a substitute for the clinician’s judgment.  Typical non-recurrent chalazion in persons under 18 years of age  Acrochordon that leaves no doubt as to its benign nature  Ectropion/entropion  Specimen from cosmetic or functional blepharoplasty  Nasolacrimal bone removed during a dacryocystorhinostomy  Normal bone or soft tissue removed during orbital decompression  Extraocular muscle, tendon and normal soft tissue removed during strabismus surgery  Lens  Tissue removed during glaucoma filtering surgery  Specimen from a peripheral iridectomy  Corneal specimen removed during keratoplasty  Residual donor tissue from corneal transplantation  Specimen from a therapeutic vitrectomy  Epiretinal, subretinal or choroidal membrane  Explanted implant, device and material  Foreign body

Authors' methods: Using preestablished criteria, we conducted a systematic review of the scientific literature and of publications presenting positions, recommendations and guidance from learned societies and other organizations. In addition, contextual information and the perspectives of various stakeholders were gathered by an advisory committee consisting of individuals representing the various medical specialties concerned and by a monitoring committee consisting mainly of representatives from the professional orders and associations of the medical specialists concerned, and from different bodies, including the Régie de l'assurance maladie du Québec and the ministère de la Santé et des Services sociaux. These consultations enabled us to gather experiential knowledge, to document perceptions and the level of acceptability concerning the selective or non-selective submission of certain surgical materials and specimens to the anatomic pathology laboratory, and to determine the potential organizational, clinical, economic, ethical and legal issues. The recommendations concerning surgical specimens from eye surgery that could be selectively submitted to the anatomic pathology laboratory were developed through a 3-round simplified Delphi consultation process. This was carried out with the advisory committee’s members using data and recommendations extracted from the systematic literature search. The monitoring committee’s members were then asked to assess the list of samples that could be selectively submitted and to assess the applicability, acceptability and potential impact of implementing the recommendations.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/pertinence-et-indications-de-transmission-selective-de-prelevements-chirurgicaux-au-laboratoire-danatomopathologie.html

Year Published: 2022

URL for published report: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/pertinence-et-indications-de-transmission-selective-de-prelevements-chirurgicaux-au-laboratoire-danatomopathologie.html

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: L'Institut national d'excellence en sante et en services sociaux (INESSS)