A tailored implementation strategy is effective to involve pathologists in the recognition of patients at risk for Lynch Syndrome

L. Overbeek,1,2 R. Hermens,2 H. van Krieken,3 E. Adang,4 R. Akkermans,2 F. Nagengast,5 M. Ligtenberg,1,3 N. Hoogerbrugge1,6
On behalf of the MIPA study group
Department of Human Genetics1, Center for Quality of Care Research2, Department of Pathology3, Department of Medical Technology Assessment4, Department of Gastroenterology5, Department of Medical Oncology6, Radboud University Nijmegen Medical Centre

Purpose: Microsatellite instability testing is recommended to detect patients at risk for Lynch Syndrome. The aim of this study was to examine the effects and costs of a pathologist and surgeon-directed implementation strategy to improve detection of patients at risk for Lynch Syndrome. Secondly, we determined successful elements of the implementation strategy.

Design: Multicenter cluster randomised controlled trial with the pathology laboratory as unit of randomisation.

Setting: 12 pathology laboratories (clusters) that provided service for 29 hospitals. Participants 266 patients were eligible for recognition by pathologists. Patients were selected by PALGA, the nationwide registry for histo- and cytopathology in the Netherlands.
Intervention: A tailored implementation strategy consisting of introduction of a new, cost-effective standardised procedure; elements directed to pathologists: electronic inclusion reminders, feedback, and supporting materials; elements directed to surgeons: education and reminders in the surgical record. Pathologists and surgeons in the control arm only received introduction of the procedure.

Main outcome measure: Percentage recognition of patients at risk for Lynch Syndrome.

Results: Recognition of patients at risk for Lynch Syndrome succeeded in 121 (78%) of 156 patients from the intervention arm and in 65 (59%) of 110 patients from the control arm, OR=3.4 (95% confidence interval 1.05 to 10.7). The costs of the implementation strategy were ?78 per patient. A reminder system was highly associated with recognition by pathologists OR=9.2 (confidence interval 1.9 to 44.1). It was not possible to identify successful elements directed to surgeons.

Conclusion: A tailored implementation strategy directed to both pathologists and surgeons is effective to increase recognition of patients at risk for Lynch Syndrome at relatively limited costs. In particular, an electronic inclusion reminder system by PALGA was found very effective for pathologists to apply microsatellite instability testing.