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  PAP/NGC Program Review

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cap today

August 2002

Q & A

Q.  New requirement for nongyn TAT

A.  The 2002 CAP Laboratory Accreditation Program checklist contains a new question related to turnaround time of nongynecologic cytology, or NGC, cases:

0YP.06532 Phase I: Are 90 percent of reports on routine nongynecologic cytology cases completed within two working days of receipt by the laboratory performing the evaluation?

This question was added to the checklist to underscore the importance of turnaround time as a measure of laboratory service quality. In a 2000 Q-Probe authored by Bruce A. Jones, MD, and David A. Novis, MD (QP08), the factors influencing TAT for 16,925 NGC specimens from 180 laboratories were analyzed. The authors found that 50 percent of participating laboratories had a mean TAT of 2.1 days or less from specimen collection to final report sign-off. The factors that delayed TAT included the use of reference laboratories for screening, lack of timely transcription, difficulty obtaining adequate specimen information from the submitting physician, and pulling old slides/tissue blocks for review or performing special stains, or both.

The CAP believes that a goal of two working days TAT for routine NGC specimens is reasonable. Documentation can consist of continuous monitoring of data or periodic auditing of reports. Longer times may be allowed for specimens requiring special processing or staining (for example, immunohistochemistry), provided these special classes of specimens are documented so that the inspector can evaluate their appropriateness.

For laboratories that are finding it difficult to meet the CAP TAT guidelines, the 2000 Q-Probe study makes recommendations for improving overall TAT. They are as follows: minimize the use of reference laboratories; educate the submitting physician's office staff or change requisitions to expedite the gathering of important information, or both; reevaluate general laboratory workflow and transcription services; and continuously monitor TAT.

Nongynecologic cytology plays an important role in diagnosing and managing patients, many of whom may be acutely ill. The new CAP guideline emphasizes the importance of NGC turnaround time for patient care and clinical decision-making in today's competitive, customer-service-oriented health care systems. Of course, the quality of diagno-sis should never be compromised for the sake of TAT.

Jonathan H. Hughes, MD, PhD
Member, Cytopathology Committee
Laboratory Medicine Consultants, Ltd.
Las Vegas

Q.  No requirement for Pap test TAT

A.  The following information on the CAP-accepted turnaround time for Pap tests was originally published in the May 2001 issue of CAP TODAY.

The CAP checklist has no requirement now regarding turnaround time for Pap tests. The reason is that the Pap test is a screening test, and there is variability in staffing with frequent shortages of cytotechnologists. An artificial turnaround time limit would encourage laboratories to force cytotechnologists to screen faster, and thus it would increase errors. The quality and accuracy of screening are more important than the speed of reporting. Hence, Pap tests should be signed out in a timely manner that is appropriate for the patient’s clinical management. Certain specimens from high-risk patients and those with pending biopsies or surgery can be expedited for screening purposes in a given laboratory, if that information is available.

Turnaround times in gynecologic cytology were the subject of a CAP Q-Probes study published in 1999.1 The study found that the turnaround time varies depending on the characteristics of the laboratory, the location in which the screening is performed, whether ancillary testing or instrument rescreening is performed, and whether a cytotechnology or residency/ fellowship program is affiliated with the laboratory. Based on this report, turnaround times were significantly longer when residents, fellows, or cytotechnology students were involved in screening or the physician had to be contacted to obtain additional information. The use of reference laboratories also contributed to longer turnaround times. The median turnaround time from specimen collection to final report signout was six days, with the 10th and 90th percentiles being 13.6 and 2.7 days, respectively. The median turnaround time from receipt in the laboratory to final report signout was 4.4 days, with 11.7 and 1.4 days constituting the 10th and 90th percentiles. The mean turnaround times for different laboratory types are also given in this report.

Pap test turnaround time was discussed also at the March 2000 International Consensus Conference on the Fight Against Cervical Cancer. This conference was jointly sponsored by the International Academy of Cytology and several national and international organizations, including the CAP. Task force No. 14, which dealt with quality assurance and risk reduction guidelines, addressed this issue. There was no agreement on turnaround times among the international panelists on this task force. While the panelists from the United States firmly believed there was no need to have an artificial time limit on a screening test as long as the test was performed in a timely manner, the international panelists, especially the Italians, felt that perhaps one month to six weeks would be more appropriate. The Australians, on the other hand, have a mandated turnaround time of about five working days. Hence, as you can see, there is no consensus on whether there should be an artificial turnaround time limit for Pap tests, as long as they are performed thoroughly, accurately, and in a timely manner.2,3 What is timely depends on your patient population and should be decided by the individual laboratory.

Under CLIA '88 there is no requirement for a turnaround time limit on Pap tests. Perhaps this is a wise decision, because the supply of cytotechnologists varies from region to region. It would be difficult to implement an across-the-board turnaround time for this valuable screening test without negatively affecting the health of the population.

References
1.  Jones BA, Valenstein PN, Steindel SJ. Arch Pathol Lab Med. 1999;123:682-686.
2.  Mody DR, Davey DD. Acta Cytologica. 2000;44(4):496-507.
3.  Yu GH, Gupta PK. The pathological obsession with turnaround time in gynecologic cytology: Is it warranted? Diagn Cytopathol. 1998;19:321-322.

Dina R. Mody, MD
Chair, Cytopathology Committee
Pathology Department
Baylor College of Medicine
Houston