METHODS: An IRB-exempt retrospective database review identified patients who underwent core-needle biopsy of a breast lesion from July 1, 2014 to July 1, 2020. They were divided into three cohorts: 2014 pre-intervention/pre-sentinel, 2017 pre-intervention/post-sentinel, and 2019 post-intervention of structured reports. One hundred reports per cohort were reviewed for documentation of marker and shape. Statistical analysis was performed with mixed-effects logistic regression model and chi-squared test with P < 0.05 considered significant.
RESULTS: The 2014 cohort consisted of 100 patients with 122 biopsies. Twenty-seven (22.1%) were excluded: 5/122 (4.1%) lesion resolution, 22/122 (18.0%) no documentation whether marker was/was not placed. Of the 95 biopsies remaining, 4/95 (4.2%) had no marker placed, 62/95 (65.3%) reported marker only, and 29/95 (30.5%) reported marker and shape. In the 2017 cohort, 100 patients underwent 108 biopsies. Four/108 (3.7%) were excluded: lesion resolution. Of the 104, 10/104 (9.6%) had no marker placed, 22/104 (21.2%) reported marker only, and 72/104 (69.2%) reported marker and shape. In the 2019 cohort, 100 patients underwent 114 biopsies. Two/114 (1.8%) were excluded: lesion resolution. Of the 112, 3/112 (2.7%) had no marker placed, 3/112 (2.7%) reported marker only, and 106/112 (94.6%) reported marker and shape. The predicted probability of both marker placement and shape described were statistically greater for 2019 compared to the other cohorts (P < 0.05).
CONCLUSIONS: Using structured reports facilitates and improves documentation of breast biopsy markers and may potentially reduce the risk of medical errors.
方法:一项IRB豁免回顾性数据库审查确定了从2014年7月1日至2020年7月1日接受乳腺病变粗针活检的患者。他们分为三个队列:2014年干预前/哨兵,2017年干预前/哨兵后,和2019年结构化报告介入后。每个队列审查了100份报告,以记录标记和形状。采用混合效应logistic回归模型和卡方检验进行统计学分析,P<0.05认为有显著性。
结果:2014年队列包括100例患者和122例活检。27例(22.1%)被排除:5/122(4.1%)病变消退,22/122(18.0%)没有记录标记是否被/未被放置。在剩下的95个活检中,4/95(4.2%)没有放置标记,62/95(65.3%)仅报告标记,29/95(30.5%)报告了标记和形状。在2017年的队列中,100例患者接受了108例活检。排除4/108(3.7%):病变消退。在104人中,10/104(9.6%)没有放置标记,22/104(21.2%)仅报告标记,72/104(69.2%)报告了标记和形状。在2019年的队列中,100例患者接受了114次活检。排除2/114(1.8%):病变消退。在112人中,3/112(2.7%)没有放置标记,3/112(2.7%)仅报告标记,106/112(94.6%)报告了标记和形状。与其他队列相比,2019年描述的标记物放置和形状的预测概率在统计学上更高(P<0.05)。
结论:使用结构化报告可促进和改善乳腺活检标记的记录,并可能降低医疗差错的风险。