NMSC excision and completeness of histopathology reporting - a national clinical re-audit (Interim report, July 2018)
A national clinical re-audit by the British Association of Dermatologists and Royal College of Pathologists
Email invitation to all UK working members (this audit is now closed)
1st February 2016
Following 2014’s national audit of completeness of excision of non-melanoma skin cancer, we would like to invite you to contribute to a development of the same audit this year. This audit will enable you to fulfil requirements in undertaking a:
network audit (N.B. if you agree to do this jointly with other units in your network**)
The BAD is aiming to provide members with the tools to demonstrate quality and quality improvement in their practice. One of the major areas of practice is the management of non-melanoma skin cancer. Re-audit is an important part of quality assurance. This year we are delighted to be undertaking the audit with the collaboration of the Royal College of Pathologists as our first cross-specialty audit. We are asking you to submit data on TEN patients undergoing (non-Mohs) excision surgery for basal cell carcinoma and FIVE with invasive squamous cell carcinoma. These are clinical diagnoses prior to the provision of the pathology report. Specimens should include only the first NMSC lesion excised for each included patient and exclude diagnostic incision, shave, punch, curette biopsies and Mohs samples.
After completing the Excel-based Dermatology audit proforma, the relevant histology reports are to be submitted electronically with patient-identifiable elements removed. Our colleagues at the Royal College of Pathologists will review the submitted reports and undertake a linked audit concerning the completeness, and a few questions on what would make data collection easier for them.
The audit standard we aim to meet is that outlined in the Improving Outcomes for People with Skin Tumours including Melanoma Guidance, NICE 2006, page 84:
“Non-melanoma skin cancer
The standard effective treatment is surgical excision and all excised specimens should be sent for histopathological examination”
And in combination with guidance from the Royal College of Pathologists and the Cancer Outcomes Service Dataset, which require provision of the histopathology dataset.
All instructions, including data collection methodology and how to save and submit your file, are provided in the spreadsheet and template document for clinical audit project planning. Most cells have a drop-down option from which to choose your response. Click on the appropriate cell, then click the down arrow () which appears to the right of the cell, and choose your response (screen capture below); please do not type in free texts in these cells and use the comments column at the end of the row instead if you have further information to provide.
Prospective data collection is preferred, to reduce the chance of bias through case selection and to provide an indication of the specificity of the triage to excision. Where this is not possible, it is important that consecutive cases are submitted. There is a column in the spreadsheet to indicate if it was not the case for each patient entry. The pre-excision clinical diagnosis should be entered. The 2014 audit demonstrated no significant difference in the results concerning prospective and retrospective submissions where both were included. For retrospective data collection we suggest including surgical cases carried out within 2015.
The Excel audit data collection proforma can also be a used as a continuous tool for data collection, with the aim of maintaining a record of clinical activity and outcome. Many Dermatologists already do this using their own tool, or the one linked to at the top of the page in the proforma.
Please complete your details in the designated areas in the proforma to validate your submission, so we can subsequently email you an acknowledgement, as well as a copy of the results which can be used as evidence to support revalidation.
You may be able to register this with your hospital or Trust to satisfy their requirements, and also enable you to provide benchmarked results for discussion with your clinical and management team. We have prepared a document containing commonly requested information in local clinical audit project planning documents, which you can copy and paste, and submit to your local audit offices.
THE AUDIT DATA COLLECTION WILL CLOSE ON 10TH APRIL2016.
Please consider these actions before proceeding to begin to enter the audit data:
1. Register the audit with your hospital or Trust (please find the attached supporting template for local clinical audit project planning).
2. Decide early on whether or not collecting all the data prospectively would be achievable at your hospital.
Please forward any queries to Dr M. Firouz Mohd Mustapa (email@example.com).
**For those utilising this audit as part of a network audit activity, we recommend submitting to a local coordinator appointed within the network as well as to the BAD. This will enable you to undertake local analysis.
Frequently Asked Questions
Q1: I have submitted my completed proforma - when will I receive my acknowledgment letter?
A1: You will receive an acknowledgment letter after the close of the data collection period, and once we have checked and verified your data and personal details.
Q2: Why is the data collection method different from previous BAD national audits?
A2: Previous national audits involved retrospective data collection for just 3 patients and Survey Monkey is a convenient web-based platform for such data entry. However, members are encouraged to collect their data prospectively for this audit, and for 10 BCC and 5 invasive SCC lesions. Therefore, a downloadable Excel-based proforma was felt to be a more appropriate tool.
Q3: Can I use the proforma as a continuous data collection tool for my personal, surgical practice?
A3: Members are encouraged to visit the British Society for Dermatological Surgery website where they can download a version of the proforma more suited to long-term cumulative use.
Q4: Does the pre-operative clinical diagnosis determine eligibility for inclusion in this audit, or subsequent histologically confirmed diagnosis?
A4: Eligibility for inclusion is determined by pre-operative clinical diagnosis; there should then be no incomplete excisions based on mistaken clinical diagnosis.
Q5: In the proforma, the options for the histology column include "melanoma" and "benign lesions" - are patients with suspected NMSC pre-operatively but with confirmed melanoma (or benign) histologically to be included?
Q6: In the proforma, the margins for clearance were very specific; at my hospital they are only specified as being ">1 mm" if clear and no more - what do I do?
A6: Please use the comments column to indicate this.
Q7: What does non-melanoma skin cancer refer to for this audit?
A7: Non-melanoma skin cancer refers to invasive tumours only, e.g. BCC and SCC, and excludes Bowen’s disease and actinic keratosis.
Q8: The clinician carrying out the surgery is not necessarily the clinician who made the initial pre-operative diagnosis - who should fill in the proforma?
A8: This audit is for 10 sequential BCC and 5 sequential invasive SCC lesions personally excised and can be used as a record for personal excision quality. It can also be undertaken under the leadership of a non-surgical dermatologist to audit the quality of the work they delegate. Such participants are able to indicate this status within the relevant columns (columns B, C and D in the Excel proforma) and corresponding drop-down options.
Q9: What are the audit standards on which this national audit is based?
A9: The audit standards are based on guidance from the Royal College of Pathologists and the Cancer Outcomes Service Dataset, which require provision of the histopathology dataset.
Q10: What is this audit for and what does the BAD hope to achieve with this national audit?
A10: Firstly, this audit is to enable members to participate in a national audit with BAD assistance. Secondly, it is to examine the completeness of histopathological reporting. Thirdly, we hope to provide a snapshot of the complexity of surgery and case mix of patients operated upon by BAD members.
Q11: Can I enter my 15 sets of patient data as a mix of prospective and retrospective cases?
A11: Yes you can - please indicate this in the appropriate column.
Q12: I wanted to enter free texts in relevant fields but an error message came up - what do I do?
A12: MANY of the columns in the spreadsheet proforma have pre-loaded drop-down options for you to choose in order to standardise the responses, making analyses easier - please use these instead of entering free texts. However, do add comments in the section at the end of the row if needed.
Q13. Can plastic surgeons contribute to this audit as the excisions are also done by them at my hospital?
A13. Yes they can - please select the appropriate clinician grade from the dropdown options.
Q14: Is it necessary to enter in patients' initials or unit numbers?
A14: Column E (unit number) are optional for ease of local data collation. Before submitting the completed proforma, they should be deleted from the spreadsheet.
Q15: How do I include the pathology reports in my submission?
A15: The Excel-based proforma contains additional spreadsheet tabs already designated with the tumour case numbers (BCC1, BCC2, etc. and SCC1, SCC2, etc.). Please paste the pathology reports either in text format in the appropriate spreadsheet tabs or in graphics format (JPEG, GIF, PNG), to correspond with the tumour case numbers in the main 'Surgical cases' spreadsheet tab.
BAD Clinical Standards Unit
BAD Health Informatics sub-committee