| Popis: |
Despite regulation and research in human medicine over the last two decades related to content and informational completeness in laboratory test requisition forms, such as those submitted with biopsy specimens, no corollary regulation or research has occurred in veterinary medicine. Thus, the prevalence and potential causes of deficient or inadequate information in veterinary biopsy are largely unknown. Among, and even within, veterinary diagnostic laboratories, biopsy submission forms vary significantly in form composition and content. However, two general types of forms are in use: 1) Open-type (“open”) forms, characterized by predominately open-ended prompts such as “History:” followed by abundant space for independent clinician response, and 2) closed-type (“closed”) forms, characterized by predominately closed-ended prompts (i.e. checklists of predetermined responses) and limited space for independent clinician response. We hypothesized that open-type biopsy submission forms elicit quantitatively and qualitatively more complete case information than closed-type forms, especially regarding clinical history, lesion description, and lesion location. In this study, 225 open and 300 closed biopsy submission forms, randomly-selected from among all submissions to a single pathologist engaged in routine biopsy service for 3 laboratories over 3 years, were retrospectively evaluated for the amount (quantitative completeness) and value (qualitative completeness) of case information provided by clinicians. Four key concept areas- patient signalment, clinical history, lesion description, and lesion location- were assessed using a de novo grading scheme based upon 14 informational elements, which together recreate these clinical concepts for the pathologist analyzing the biopsy specimen. An overall deficiency rate (i.e. forms lacking all case information beyond patient signalment) of 3% was identified which is comparable to that observed for routine human biopsy submissions. Furthermore, the majority of cases had inadequate responses for one or more of the key concepts, with signalment information being most consistently reported and lesion description least consistently reported. Open-type forms were found to elicit longer responses from clinicians with more, and higher quality, information than closed-type forms in general and, specifically, in the areas of clinical history and lesion description. Both form type and prompts were also significantly associated with clinician reporting of key case information. Thus, deficient and inadequate submissions do occur in veterinary biopsy and the amount and quality of information provided by a clinician through the submission form is influenced both by the type (open versus closed) of submission form and the prompts presented on the form. |
