Static Digital Telepathology: A Model for Diagnostic and Educational Support to Pathologists in the Developing World

Transcription

1 HARVARD MEDICAL SCHOOL Static Digital Telepathology: A Model for Diagnostic and Educational Support to Pathologists in the Developing World Aliyah R. Sohani, MD Department of Pathology Massachusetts General Hospital Assistant Professor of Pathology Harvard Medical School

2 Pathology in the Developing World Limited resources Shortages of specialists, trained laboratory personnel Lack of continuing medical education programs Intellectual brain drain of medical professionals from developing to developed countries Retention of trained medical professionals further hampered by quality of equipment and facilities, availability of advanced training, and opportunities for research and career advancement Growing burden of non-communicable diseases Cancer, diabetes, heart diseases 70% of new cancers in next 15 years will occur in the developing world (WHO)

3 Pathology in Tanzania Population: 43.7 million (2009) 822 physicians 1 per 50,000 people 15 pathologists 1520 laboratory technologists 1 per 25,000 people 2 lab technology training schools Pathology training programs in Kenya and South Africa; no subspecialty fellowship training programs No immunohistochemistry lab country-wide Diagnostic challenges, particularly in areas of hemepath, soft tissue path Lack of access to prognostic/predictive information (e.g. ER in breast cancer) Molecular diagnostics/cytogenetics Essentially non-existent

4 Potential advantages Diagnostic support Telepathology Second opinion consultations Ongoing training Opportunities for collaborative research Challenges Equipment cost Routine maintenance, servicing and repair Training Internet connectivity How does one define success? Relevant, Scalable, Replicable, Sustainable Identify best practice models in health care education and delivery in the developing world

5 The Aga Khan Development Network Group of development agencies working to improve living conditions and opportunities in the developing world Mandates include health, education, environment, architecture, culture, microfinance, disaster reduction, rural development, the promotion of private sector enterprise, and the revitalization of historic cities AKDN agencies conduct their programs without regard to faith, origin or gender Aga Khan Health Services (AKHS) The Aga Khan University (AKU)

6 Aga Khan Health Services One of the most comprehensive private, not-for-profit health care systems in the developing world Community health programs in Central and South Asia, and Eastern Africa Primary health care and curative medical care in Afghanistan, India, Kenya, Pakistan, and Tanzania Technical assistance to governments in the delivery of health services in Kenya, Syria and Tajikistan 325 health care facilities, including 9 hospitals Regional network of 4 hospitals in Eastern Africa Aga Khan University Hospital (AKUH) in Nairobi, Kenya Aga Khan Hospitals (AKH) in Kisumu and Mombasa, Kenya, and Dar es Salaam, Tanzania

7 Aga Khan University Hospital, Nairobi Aga Khan Hospitals, Mombasa, Kisumu, and Dar es Salaam

8 The Aga Khan University Chartered in 1983 Private, autonomous university with campuses in Afghanistan, Eastern Africa, Egypt, Pakistan, Syria and the United Kingdom Health-related facilities include teaching hospitals, Nursing Schools and a Medical College Aga Khan University Hospital, Nairobi Regional center of new Faculty of Health Sciences in Eastern Africa Heart and Cancer Center (opened July 2011)

9 A Pilot Telepathology Initiative Between MGH and AKH-Dar Established March 2008 Equipment Olympus BH2 5-headed microscope donated by MGH Department of Pathology SPOT Insight Color Digital Camera donated by an MGH pathologist SPOT PCI card and software Funding provided by Aga Khan Foundation, USA ipath Telemed Basel telepathology server Open-access platform for exchange of medical knowledge, group discussions, consultations, distance learning and teaching in medicine and pathology ( Site visit to train local pathologists in image capture using camera and software, image upload to ipath website, and care and maintenance of system Sohani et al, 2009 (USCAP abstract)

10

11

12

13 Program expanded in September 2009 to include all four hospitals within regional network Each site equipped with multiheaded microscope, digital camera and software Site visits for set-up, training, system care and maintenance New ipath host: AKU ehealth Resource Centre Cases triaged by MGH-based pathologist for further review in consultation with subspecialty colleagues M.A. Sohani. All rights reserved. May not be reproduced or distributed without express permission. A Regional Telepathology Initiative for Eastern Africa

14 Teleconsultation Activity to Date 109 cases posted since March 2008 Mean number of images per case: 11; Mean TAT: 5.6 days Static images have enabled a complete or partial diagnosis in 100/109 cases (91.7%) Responses have an educational emphasis Discussion of differential diagnosis, diagnostic pearls/pitfalls Accompanying references, links to websites, photographs Treatment recommendations, if applicable Factors precluding a definitive diagnosis Lack of sufficient clinical history Technical issues (e.g. air-drying artifact, tangential sectioning, or rarely, poor image quality) Absence of confirmatory immunophenotyping Additional testing performed at MGH in certain cases

15 Teleconsultations by Hospital Location Number of Cases Dar es Salaam Kisumu Nairobi Mombasa Other Hospital Location Nearly 80% of consultations have originated from smaller centers manned by solo pathologists

16 Teleconsultations by Subspecialty Number of Cases Dermpath Heme Cytology BST GI GYN ENT Breast Neuro GU Endocrine Pulmonary Renal Pathology Subspecialty Four most popular subspecialty areas in which cases posted typically require fellowship training beyond residency Dermatopathology cases outweighed all others with nearly 27% of all postings Only 5-15% of all histology cases originating from the four participating hospitals are skin biopsies

17 Teleconsultations by Subspecialty Number of Cases Dermpath Heme Cytology BST GI GYN ENT Breast Neuro GU Endocrine Pulmonary Renal Pathology Subspecialty Four most popular subspecialty areas in which cases posted typically require fellowship training beyond residency Dermatopathology cases outweighed all others with nearly 27% of all postings Only 5-15% of all histology cases originating from the four participating hospitals are skin biopsies

18 Teledermatopathology Why are teleconsultations in this area so frequent? Lack of fellowship training programs in dermatopathology No board-certified dermatopathologists in the region Prevalence of HIV, concern for Kaposi sarcoma Skin biopsies are typically small, minimizing limitations of sampling bias and field selection, and can be obtained on an outpatient basis Focused review of 29 cases (29/109 = 26.6%) All biopsies of skin or subcutaneous tissue requiring MGH dermatopathologist input for diagnosis Glass slides available for review in 22/29 cases (76%) to measure diagnostic concordance between static-image and conventional microscopy Cases reviewed 5-32 months after rendering telepathology diagnosis, blinded to original diagnoses rendered Gimbel et al, 2011 (submitted)

19 Results Dermatopathology cases originated from all 4 hospitals, with >80% from locations with solo pathologists 28% of cases included clinical photographs in addition to H&E images 95% diagnostic concordance between static telepathology and glass slide diagnosis Single discordant case: toxic epidermal necrolysis Diagnostic field was a separate smaller fragment of tissue on the glass slide not included among static images Number of Cases Kisumu Dar es Salaam Nairobi Mombasa Type of Lesion Inflammatory Neoplastic Hospital Location Combined Inflammatory/Neoplastic N=29 18 cases (62%) 10 cases (35%) 1 case (3%) Gimbel et al, 2011 (submitted)

20 A Curious Cutaneous Biopsy Busarla et al. Am J Dermatopathol, 2011 (in press)

21 Participant Feedback Technology relatively easy to use Fairly rapid access to expert second opinion Increased sense of security on difficult cases Increased awareness of certain diagnoses previously unknown to the referring pathologist Discussion of differential diagnosis and citing of journal articles educational Discussion of treatment options allowed for a patient-centered focus

22 Teleconsultations by Subspecialty Number of Cases Dermpath Heme Cytology BST GI GYN ENT Breast Neuro GU Endocrine Pulmonary Renal Pathology Subspecialty Four most popular subspecialty areas in which cases posted typically require fellowship training beyond residency In contrast to Dermatopathology cases, Cytology cases were underrepresented relative to the volume seen at the four hospitals

23 Telecytology Feasibility study of static imaging system for diagnosis in challenging cytology cases 40 consecutive cases considered difficult by referring pathologist in Kisumu, Kenya were posted 19 cervical smears (conventional smears; not liquid-based) 17 fine needle aspirations 4 fluids (2 urine, 1 ascites, 1 pleural fluid) 6 AKHS pathologists with varying levels of experience independently evaluated static images Telecytology diagnosis compared with consensus glass slide diagnosis in order to assess level of diagnostic concordance for each participant Kumar et al. J Telemed Telecare, 2011 (in press)

24

25 Results Diagnostic concordance ranged from 71-93% Higher for pathologists with more experience Pathologists with more experience in surgical and cytopathology demonstrated greater comfort with technology and expressed higher levels of confidence in their diagnoses Discordant cases 6/19 (32%) cervical smears 9/21 (43%) FNA/fluids Challenges in static telecytology Greater susceptibility to technical factors and sampling bias Need for additional training for both referring and consulting pathologists Diagnostic questions of importance must be clearly outlined Kumar et al. J Telemed Telecare, 2011 (in press)

26 Results Diagnostic concordance ranged from 71-93% Higher for pathologists with more experience Pathologists with more experience in surgical and cytopathology demonstrated greater comfort with technology and expressed higher levels of confidence in their diagnoses Discordant cases 6/19 (32%) cervical smears 9/21 (43%) FNA/fluids Challenges in static telecytology Greater susceptibility to technical factors and sampling bias Need for additional training for both referring and consulting pathologists Diagnostic questions of importance must be clearly outlined Kumar et al. J Telemed Telecare, 2011 (in press)

27 Results Diagnostic concordance ranged from 71-93% Higher for pathologists with more experience Pathologists with more experience in surgical and cytopathology demonstrated greater comfort with technology and expressed higher levels of confidence in their diagnoses Discordant cases 6/19 (32%) cervical smears 9/21 (43%) FNA/fluids Challenges in static telecytology Greater susceptibility to technical factors and sampling bias Need for additional training for both referring and consulting pathologists Diagnostic questions of importance must be clearly outlined by referring pathologist to consultant Kumar et al. J Telemed Telecare, 2011 (in press)

28 Planned Projects and Ongoing Initiatives Role of c-kit and pakt signaling pathways in Kaposi sarcoma MGH and Aga Khan Hospital, Kisumu Epidemiological and pathologic differences in Hodgkin and non-hodgkin lymphomas MGH and Aga Khan University Hospital, Nairobi Use of ipath forum in pediatric telemedicine MGH and Aga Khan Hospital, Dar es Salaam

29 Static Digital Telepathology A simple, cost-effective, reliable and sustainable model for diagnostic support to pathologists in resource-limited settings Limitation of sampling bias varies across subspecialties and may be overcome with increased awareness and additional training Hallmarks of successful teleconsultations Clear communication of diagnostic questions by referring pathologist Role of consultant: patient-centered and educational Rich source of ideas for collaborative and fruitful research endeavors

30 Acknowledgments AKUH, East Africa Zahir Moloo Shahin Sayed Neeta Kumar B. Satya Vara Prasad Veena Vyas Shamina Jivaji Patricia Okiro Jesca Muthoni Samuel Gakinya Hasan Chande MGH Pathology MGH Pathology Devon Gimbel Robert Hasserjian Rosalynn Nazarian Esther Oliva Martin C. Mihm Elena Brachtel Mari Mino-Kenudson Steve Black-Schaffer David Louis Adriano Piris Rosemary Tambouret Gregory Lauwers David Wilbur Robert H. Young Melinda Lerwill G. Petur Nielsen Eugene Mark Andrew Rosenberg Peter Sadow Stephen Conley AKU ehealth Resource Center, Karachi, Pakistan Aga Khan Health Board, USA Aga Khan Foundation, USA