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Laboratory data are critical to analyzing and improving clinical quality. In the setting of residual use of creatine kinase M and B isoenzyme testing for myocardial infarction, we assessed disease outcomes of discordant creatine kinase M and B isoenzyme +/troponin I (−) test pairs in order to address anticipated clinician concerns about potential loss of case-finding sensitivity following proposed discontinuation of routine creatine kinase and creatine kinase M and B isoenzyme testing. Time-sequenced interventions were introduced. The main outcome was the percentage of cardiac marker studies performed within guidelines. Nonguideline orders dominated at baseline. Creatine kinase M and B isoenzyme testing in 7496 order sets failed to detect additional myocardial infarctions but was associated with 42 potentially preventable admissions/quarter. Interruptive computerized soft stops improved guideline compliance from 32.3% to 58% ( P < .001) in services not receiving peer leader intervention and to >80% ( P < .001) with peer leadership that featured dashboard feedback about test order performance. This successful experience was recapitulated in interrupted time series within 2 additional services within facility 1 and then in 2 external hospitals (including a critical access facility). Improvements have been sustained postintervention. Laboratory cost savings at the academic facility were estimated to be ≥US$635 000 per year. National collaborative data indicated that facility 1 improved its order patterns from fourth to first quartile compared to peer norms and imply that nonguideline orders persist elsewhere. This example illustrates how pathologists can provide leadership in assisting clinicians in changing laboratory ordering practices. We found that clinicians respond to local laboratory data about their own test performance and that evidence suggesting harm is more compelling to clinicians than evidence of cost savings. Our experience indicates that interventions done at an academic facility can be readily instituted by private practitioners at external facilities. The intervention data also supplement existing literature that electronic order interruptions are more successful when combined with modalities that rely on peer education combined with dashboard feedback about laboratory order performance. The findings may have implications for the role of the pathology laboratory in the ongoing pivot from quantity-based to value-based health care.

Purpose To determine the upgrade rate of benign papillomas diagnosed at image-guided vacuum-assisted core needle biopsy (VACNB) and to compare our results with the summarized literature. Materials and methods A database search was performed to identify patients older than 18 years of age with benign papillomas diagnosed at VACNB between 2004 and 2013. A total of 199 papillomas in 184 patients were identified. Clinical, imaging, and pathological features for each were analyzed. Patients who were subsequently diagnosed with malignancy at the site of papilloma, either at surgical excision or upon imaging follow-up, were compared with those not upgraded. Upgrade was defined as a diagnosis of invasive carcinoma or ductal carcinoma in situ (DCIS). Results Of 199 papillomas, 110 (55.3%) were diagnosed at ultrasound-guided VACNB, 78 (39.2%) were diagnosed at stereotactic-guided VACNB, and 11 (5.5%) were diagnosed at magnetic resonance imaging-guided VACNB. Surgical excision was performed for 89 (44.7%), and the remaining 110 (55.3%) underwent imaging follow-up. Two patients were subsequently diagnosed with invasive carcinoma and 4 were found with DCIS. The upgrade rate across both groups was 3% (6 of 199). Masses with calcifications ( P =.001) and smaller needle gauge at VACNB ( P =.02) had a significant association with upgrade. Conclusion Benign papillomas diagnosed with VACNB demonstrated a 3% upgrade rate to malignancy, which is similar to the 2.9% upgrade rate calculated by compiling applicable published literature. Conservative management with imaging follow-up as opposed to surgical excision may be appropriate in cases where an initial diagnosis of benign papilloma is made with VACNB. Benign papillomas associated with calcifications on imaging should be considered for surgical excision given their increased association with malignancy.