Service Innovations Webinar Series

Transcription

1 Service Innovations Webinar Series The Clinical Cytopathologist- Ultrasound Guided FNA Clinics Susan D. Rollins, MD FCAP December 13, 2012 cap.org

2 Welcome! Service Innovations Webinar Series: Drive wider adoption of value added services by sharing how they ve been implemented by others. To extend your learning and share experiences, an online discussion group will be available. This session will be recorded for future review. Please complete the evaluation to be ed to you. Disclaimer: Opinions expressed by the speaker are the speaker's own and do not necessarily reflect an endorsement by CAP of any organization, equipment, reagents, materials or services used by participating laboratories College of American Pathologists. All rights reserved. Participants are permitted to duplicate the materials for educational use only within their own institution. These materials may not be used for commercial purposes in any way. 2

3 Asking Questions All lines are muted. To ask questions or provide comments, enter them in the Questions box located on the right of your screen. Don t see the Questions box? Click on this arrow to display it. 3

4 About the Presenter Susan D. Rollins, MD, FCAP, FIAC Medical Director, Outpatient Cytopathology Center in Johnson City, TN AP/CP and Cytopathology Boards Fellowships o Surgical pathology LDS Hospital, Salt Lake City, UT o Cytopathology - St. Louis University, St. Louis, MO o Karolinska Hospital, Stockholm, Sweden Received the CAP Excellence in Education Award in 2010 for outstanding contributions to the development of the CAP s USFNA AP 3. Continues to serve as faculty for the two-day workshop in which pathologists receive hands-on practice in performing USFNAs. 4

5 Objectives Describe the benefits of implementing a pathology FNA clinic with ultrasound capabilities. Highlight FNA clinic practice paradigm. Recognize skills and equipment required for US FNA service implementation. Suggest potential clientele for service. Outline potential barriers and solutions College of American Pathologists. All rights reserved. Participants are permitted to duplicate the materials for educational use only within their own institution. These materials may not be used for commercial purposes in any way. 5

6 Share your ideas and experiences Are you actively involved in an FNA clinic? o Yes o No 6

7 Share your ideas and experiences How many US FNA biopsies do you participate in (immediate interpretation) per year? o None o Less than 25 o o o More than 300 7

8 Share your ideas and experiences How many US FNA biopsies do you perform each year? o None o Less than 25 o o o More than 300 8

9 Share your ideas and experiences Are you considering establishing a US FNA clinic? o Yes o No 9

10 The Clinical Cytopathologist Termed coined by Torsten Lowhagen, Karolinska Hospital, Stockholm, Sweden Integrated patient care o Targeted history and physical exam o Review of relevant reports o Ultrasound skills o FNA biopsy procedure o Integrated report Personalized Healthcare 10

11 Value of the Cytopathologist FNA Clinic Diagnosis From Afar 11

12 Cytopathologist Transformation 12

13 Clinical Cytopathologist 13

14 Why US FNA? Visualize needle placement Target specific areas of mass o Cystic vs solid o Periphery of mass o Avoid vascular areas FNA of non-palpable masses Extension of the PE Independence from radiology More convenient scheduling New skill set Increased revenues 14

15 Cytopathologist US FNA Dictate number of needle passes Assurance that needle is sampling lesion Specimen preparation o Needle rinses, cell block, proceed to core biopsy Specimen Triage o Flow cytometry, cultures, IHC, FISH 15

16 Almost anechoic Hypoechoic Isoechoic Mixed echoic Heterogeneous Value: Added Clinical Information 16

17 US FNA Non-palpable masses Needle tip visualization 17

18 What/where to biopsy Not all referred palpable masses should be biopsied Needle placement in vascular lesions Needle placement in cystic or necrotic lesions Masses that may not need to be biopsied Clinician, not Technician 18

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20 US FNA 20

21 What would you do? 21

22 Abdominal Wall Soft Tissue Mass 17-year-old female Tender mass Not reducible Very firm 22

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24 Malignant Melanoma 24

25 Reason for doing US on palpable masses? Where do you biopsy? 25

26 Papillary Carcinoma 26

27 56-year-old woman with an incidental thyroid mass found on carotid ultrasound. 27

28 Papillary Carcinoma BRAF Positive 28

29 81-year-old male with a left submandibular region nontender mass. History is negative for malignancy or tobacco use. 29

30 Malignant Melanoma 30

31 26-year-old with an 8x6 cm left axillary mass. Patient is 16 weeks pregnant. Mass is increasing in size. 31

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33 44-year-old woman with palpable right thyroid mass. Where would you biopsy? 33

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35 Mass 1 Mass 2 Which mass would you biopsy? 35

36 Lymph node 36

37 Value to Healthcare Systems Patient satisfaction Physician time efficiency Integrated reporting Survey results o 22 Questions (physicians, staff, facility) o 200 surveys distributed o 40 responses o Practice score= 299/300 37

38 OCC Practice Clinic established 1991 USFNAs begun in 1996 USFNA volume 2700/year 90% of FNAs done with US FNA not done in 7% of referred patients Two staff pathologists Seven ancillary personnel o Clerical o Billing o Nursing 38

39 OCC Work Flow Registration Nursing Interview Physician H&P w/record Review Ultrasound palpable and non-palpable masses Biopsy Preliminary Results Discussion with Patient 39

40 Patient History & Physical Exam Directed history questions based on FNA site Review of pertinent laboratory data Review of pertinent previous biopsy results Review of imaging study results/images Targeted physical examination Limited ultrasound examination 40

41 Biopsy Procedure Description of procedure to patient Review of ultrasound images with patient Answer patient and family member questions Biopsy o Cutaneous anesthesia o Number of passes o Needle gauge o Specimen triage o Ultrasound parameters o Needle guidance method, in beam or out of beam 41

42 Visual Alignment Patient Comfort 42

43 Needle Guidance Technique Free hand o Out of beam o In beam Needle guide attached to transducer 43

44 Personal Requirements Willing pathologist Clinical medicine skills Desire to learn a new skill Practice, Practice, Practice Enjoy your patients 44

45 Clinic Requirements Dedicated exam room Adjustable table Adequate room for doing biopsies Slide preparation space Ultrasound unit o Linear high frequency transducer o Good image quality Accessory video monitor (nice to have) 45

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47 Who are the Stakeholders? Hospital outpatient clinic Independent clinic ACO clinic 47

48 Marketing Friendly, timely SERVICE Ease of scheduling Short appointment wait times Accurate results ENT, general surgeons, endocrinologists, Ob-Gyn, internal medicine, physician assistants, nurse practitioners, chiropractors, health clinics, pediatricians 48

49 Reimbursement Evaluation and management Ultrasound guided needle placement Ultrasound guided FNA Immediate interpretation for adequacy Final interpretation and report 49

50 Potential Barriers Hospital politics Turf Do not want to offend clinicians 50

51 Solutions Offer a first class service o Integrated reports Value added clinic not competitive o Deep needle biopsies in radiology Patient and clinician friendly o Timely service and turn around time Combine FNA with other ancillary studies Teach clinicians about the utility of FNA biopsy o Grow your own market 51

52 Positively impacting patient care A 13-year-old female presented with a visible midline 0.8 cm non-tender neck mass present for 2 months. The patient was given a course of antibiotics and the mass did not change in size. Ultrasound performed at OCC showed a predominately solid 0.8 cm mass in the isthmus of the thyroid. FNA showed papillary carcinoma, BRAF negative. The patient was referred to the University of Virginia for surgery. Rapid, accurate diagnosis. Personalized, integrated healthcare. 52

53 Questions & Answers 53

54 2012 College of American Pathologists. All rights reserved. 54

55 Thank you for participating, today! Reminders: Please join the online discussion group and invite others to join! You will receive an tomorrow. The webinar recording and the slide handout are available on the discussion group and cap.org. Your feedback is valuable. Please complete the evaluation to be ed to you shortly today. Remember to visit cap.org/learning for more information on the USFNA AP 3 program College of American Pathologists. All rights reserved. Participants are permitted to duplicate the materials for educational use only within their own institution. These materials may not be used for commercial purposes in any way. 55