THE NEW BREED OF CYTOTECHNOLOGISTS

Transcription

1 CHIARA SUGRUE, MBA, MS, SCT(ASCP)CMIAC DIRECTOR, CLINICAL OPERATIONS, CYTOPATHOLOGY DIVISION ASSISTANT PROFESSOR NSLIJ HOFSTRA MEDICAL SCHOOL NORTH SHORE LIJ HEALTH SYSTEM LAKE SUCCESS, NEW YORK THE NEW BREED OF CYTOTECHNOLOGISTS

2 I have nothing to disclose 2

3 EXTENDED ROLE OF CYTOTECHNOLOGISTS 1. Screening and interpretation: Gyn, Non Gyn, FNA Screening IHC 2. FNA Adequacy Assessment: superficial, CT scan, EBUS, EUS Ultrasound assistance Effective communication with clinicians 3. Quality control/assurance 4. Molecular testing: HPV, EGFR 5. FISH: Urovysion 6. Circulating Tumor Cell Testing 7. Grossing 8. Education, as part of the academic team in Pathology Residency & Cytopathology Fellowship 3

4 FNA Rapid On Site Assessment of Adequacy (FNA ROSA) performed by Cytotechnologists STAKEHOLDERS Patients Laboratory Professionals Laboratory Administrators Medical Specialists (Radiology, ENT, Oncology, etc) Payers 4

5 FNA Rapid On Site Assessment of Adequacy (FNA ROSA) performed by Cytotechnologists ADVANTAGES Allows appropriate specimen triage IHC, Flow cytometry, Microbiology, Tissue bank for microrna, Reduces cost of patient care Decreases number of unsatisfactory specimens Decreases number of unnecessary surgery Improves communication with clinicians Allows better collection of clinical history Brings the lab to the patient It is the right thing to do for the patient 5

6 Brigham & Women s Hospital Cancer Cytopathology 2011 Results The accuracy of on site adequacy evaluation by Cytotechnologists = 93.2% to 96.5%. The number of FNA on site adequacy evaluation increased annually by 11% on average ( ) 6

7 FNA Rapid Onsite Assessment of Adequacy: The Experience of an Academic Institution Gobara N, Liang L, Wasserman P, Morgenstern N, Sugrue C North Shore LIJ Health System (Poster # 116 ASC 2011) Results The accuracy of on site adequacy evaluation by Cytotechnologists = 94.8% to 95.9% The number of FNA on site adequacy evaluation increased cumulatively by 59% ( ) by 49% for

8 North Shore-Long Island Jewish Health System Hospitals NSUH-Glen Cove Huntington Hosp Lenox Hill NSUH-Forest Hills Bayside NSUH-Manhasset CORE LIJ Jewish Med Ctr Med Ctr Franklin Hospital NSUH-Syosset NSUH-Plainview Southside Hospital SIUH-Concord SIUH North Peninsula Hospital SIUH South Prepared by NSLIJHS Planning Office, 1/10/02

9 FNA NSLIJHS Laboratories From left: Ryan Brenkert, Xin Ding, Sean McNair, James Rankin, Constantinos Coutsouvelis, Daniel Soto, Karen Chow, Antoinette Lugo 9

10 It is evidence based knowledge that Cytotechnologists are highly competent in performing FNA Rapid On-site Assessment of Adequacy 10

11 FNA Rapid On Site Assessment of Adequacy (FNA ROSA) performed by Cytotechnologists DISADVANTAGES Lab productivity loss Inadequate service compensation Lack of CPT codes for service by Cytotechnologists 11

12 DISADVANTAGE Lab productivity loss 1. Time average for FNA ROSA = (excluding traveling time). Duration influenced by: Specimen types Nature of the lesion Type of procedure (EBUS, EUS, CT scan) Operator experience 2. Time away from screening 12

13 Lab productivity loss: example Specimen Type CPT code Medicare Rate for NY (TC) Pap test (LBP) Pap test (w/imaging) Urine (LBP) Case/hour Total Reimbursement $ $ $ $ $ $ FNA $ $ Average per hour $ Average lab reimbursement for 1 hour Cytotechnologist screening work = $

14 Lab productivity loss: example cont. Loss of screening productivity = ($ ) FNA reimbursement (CPT 88173) = $ Lab productivity loss for

15 DISADVANTAGE: Inadequate service compensation CPT code Medicare Rate for NY (TC) Note 88172TC $10 Supplies N/A Each additional evaluation episode 15

16 Additional considerations: Reduced lab reimbursement in near future Do more with less Improve efficiency Increase financial performance Expand quality measures, decrease TAT Challenges in shifting Cytotechnologists billable to non billable services Do the right thing for the patient 16

17 New ways to apply technology New ways of looking at multidisciplinary collaborations New ways for continuing to provide value to the patients and to the lab Business as usual is not an alternative 17

18 Option 1: Adoption of Telepathology Increasingly implemented for direct patient care 2007 CAP General Checklist Primary diagnosis Frozen sections diagnosis Formal second opinion consultations 2010 CAP Anatomic Pathology Checklist added Digital Image Analysis section DNA, Morphometric analysis, FISH FNA on site adequacy assessment Absence of specific regulation and practical guidelines Validation required for the intended use Initial capital expense Dependent on 2 operators 18

19 Telepathology validation at NSLIJHS Laboratories 19

20 Option 2: Conversation with Medical Specialists Can we share the responsibility of hiring a Cytotechnologist? CYTOPATHOLOGY ) Provide Training Competence Performance Appraisal Continuing Education MEDICAL SPECIALISTS (i.e. RADIOLOGY) Provide Salary & Benefit 20

21 Option 3: Propose a new CPT code for FNA ROSA performed by Cytotechnologists CTs have enormously expanded the scope of service in the last decade & acquired highly specialized skills Master Cytotechnology programs Shortage of Pathologists in the US Delegation of routine work to Cytotechnologists and Pathology Assistants 21

22 Propose a new CPT code for FNA ROSA performed by Cytotechnologists cont. Accepting the reimbursement system as immutable is not in the profession best interest Changes in AMA recommendation and CMS approval will require hard work When Pathologists and Cytotechnologists work as team better outcome better patient care As professional organization, we should become the agent of change. 22

23 New model for FNA rapid on site Assessment of Adequacy by Cytotechnologists Brings the lab to the patient Adds value to the lab Holistic pursuit Maintains lab presence in the patient centered team Creates an institutional logic THANK YOU 23

24 References Burlingame OO, Kesse KO, Silverman SG, Cibas ES. On Site Adequacy Evaluation performed by Cytotechnologists: Correlation with final Interpretation of 5241 image guided Fine Needle Aspiration Biopsies. Cancer Cytopathol Eedes CR, Wang HH. Cost effectiveness of immediate specimen adequacy assessment of thyroid fine needle aspirations. Am J Clin Pathol. 2004; 121: Nasuti JF, Gupta PK, Baloch ZW. Diagnostic value and cost effectiveness of fine needle aspirations specimens: review of 5,688 cases. Diagn Cytopathol. 2002; 27: 1 4 Andonian S. Okeke Z. Okeke DA, Sugrue C, Wasserman PG, Lee BR. Number of needle passes does not correlate with the diagnostic yield of renal fine needle aspiration cytology. J Endourol. 2008; 22: Alsohaibani F, Girgis S, Sandha GS. Does onsite Cytotechnology evaluation improve the accuracy of endoscopic ultrasound guided fine needle aspiration biopsy? Can J Gastroenterol. 2009;23: Layfield LJ, Bentz JS, Gopez EV. Immediate on site interpretation of fine needle aspiration smears: a cost and compensation analysis. Cancer. 2001; 93: Gupta PK. Progression from on site to point of care fine needle aspiration service: Opportunities and challenges. CytoJournal. 2010; 7:6 Dhillon I, Pitman MB, DeMay RM, Archuletta P, Shidham V. Compensation crisis related to the onsite adequacy evaluation during FNA procedure. Urgent proactive input from Cytopathology community is crucial to establish appropriate reimbursement for CPT code (or its new counterpart if introduced in the future). CytoJournal 2010; 7:23 Al Abbadi MA, Bloom LI, Fatheree LA, Haack LA, Minokowitz G, Wilbur DC, Austin MR. Adequate reimbursement is crucial to support costeffective rapid on site Cytopathology evaluations. CytoJournal 2010; 7:22 Davey DD, Neal MH. Coding charges in the United States front and center: Implications for Cytopathology. Cancer Cytopathol Ghofrani M, Beckman D, Rimm DL. The value of onsite adequacy assessment of thyroid fine needle aspirations is a function of operator experience. Cancer Cytopathol. 2006; 108: American Medical Association. Pathology and Laboratory. In CPT (Current Procedural Terminology) 2011 Professional Edition. Chicago: American Medical Association; 2010: US Department of Health and Human Services, Center for Medicare and Medicaid Services MLN Matters Articles, MM MattersArticles/2011Mman. Zhu W, Michael CW. How important is onsite adequacy assessment for Thyroid FNA: An evaluation of 883 cases. Diagn Cytopathol. 2007;35: Woon C, Bardales RH, Stanley MW, Stelow EB. Rapid Assessment of fine needle aspiration and final diagnosis: How often and why the diagnoses are changed? CytoJournal 2016; 6:25. 24