Teaming up: how one site is managing its complex liver cases

Karen Titus

May 2018—It didn’t take long for Heather Stevenson-Lerner, MD, PhD, to grasp one key fact about the liver biopsy cases she was seeing at the University of Texas Medical Branch, Galveston: They were often complicated.

UTMB sees plenty of challenging liver cases of its own, says Dr. Stevenson-Lerner, assistant professor of medicine and liver and transplantation pathologist, Department of Pathology. “Those are our patients on a daily basis.” Add to that the consults arriving from other hospitals in the Houston area, and it quickly became clear that she and her colleagues are in the thick of things every day.

Fortunately, it also didn’t take long to figure out how to simplify the handling of these cases. With the encouragement of Michael Laposata, MD, PhD, who chairs the pathology department, Dr. Stevenson-Lerner began to explore using a diagnostic management team for liver disease, shortly after she and Dr. Laposata both started at UTMB. “I’ve been thinking about DMTs for two years,” Dr. Stevenson-Lerner says.

In a presentation at the second Diagnostic Management Team Conference, held in Galveston in early February, and in a follow-up interview with CAP TODAY, she explained how the DMT has helped transform liver anatomic pathology at her institution. At the heart of the DMT lies the premise that for complex cases, “It really takes a team to come up with the right diagnosis,” she says.

But not just any team. Dr. Laposata, who pioneered the approach, defines a DMT as one that occurs frequently and regularly, much like a political scandal, with patient-specific reports provided even when there’s no request for an interpretation. Moreover, the pathology report must 1) be delivered before or during the time when treatment decisions are made, 2) consider clinical context and synthesize diagnostic test results, and 3) be entered into the patient’s medical record.

“That’s the formal definition,” Dr. Stevenson-Lerner says. But like etiquette, it tends to work best when adapting to the circumstances at hand. “There is the informal one that you kind of learn as you go along,” she says. Liver DMTs have unique considerations of their own, which required Dr. Stevenson-Lerner to do a little off-roading, away from earlier-established DMTs that focused on clinical pathology testing.

That included one of Dr. Laposata’s areas of expertise, coagulation. When a highly complicated coagulation test is ordered, under the DMT approach the order appears in the hematology or coagulation lab as a complex test, Dr. Stevenson-Lerner explains. That, in turn, flags the pathologist to review the case in the coagulation DMT conference.

For liver DMTs, “Things do need to be a little bit modified,” Dr. Stevenson-Lerner says. In anatomic pathology, “Oftentimes we’ve already signed out the liver biopsies—and then there’s something that makes clear that this is a very complicated case that needs further evaluation. So that first rule—that you need to report it without a request or requirement for an interpretation—does not really hold true for an anatomic pathology DMT. It’s not being done at the time of the laboratory test; it’s being added onto a case that’s already been reported.”

The ultimate goal of the DMT is to improve patient care. But Dr. Stevenson-Lerner sees additional value in the DMTs for pathologists specifically. “It gets you into the room where you get to meet face to face with the people who are reading your reports.”

It’s almost impossible to underestimate the value of this, she continues. No matter how clear pathologists think their liver biopsy reports are, clinicians will invariably have questions. They may not always ask them, either. Dr. Stevenson-Lerner says she sometimes sees clinical colleagues act as if they fully understand a report when, in fact, they don’t.

She’s quick to add that it’s not a failure on the clinicians’ part. Talking about topics such as Mallory’s hyaline on liver biopsy or antibody-mediated rejection in a liver allograft may be second nature for her, but “Some of these concepts are really new,” she says. With the bracing impact of Sweden’s sunshine law, a DMT can bring all the information to light for everyone to see and discuss. For pathologists, she says, “This conference has been extremely good at clarifying what you mean. And by educating your clinicians and making sure they understand your reports, you’re helping the patient.”

To further nurture those relationships, she persuaded her colleagues on the hepatology faculty to make DMT attendance mandatory for GI and hepatology fellows. She does the same for her surgical pathology residents and fellows.

She also designates two transplant hepatologists as leaders alongside her. “All our names are on there. It’s right there on the sign-in sheet. I’m the one showing the biopsies, but two other people who are not pathologists are helping to lead the conference.” That helps create the needed team atmosphere, she says.

Surgeon colleagues sometimes have a tough time fitting the DMTs into their schedules, she says, although her hepatologist colleagues attend religiously. “We even have a hepatologist who’s somewhat of an emeritus status who taught me as a medical student, and is now basically retired, Dr. Roger Soloway, and this is one of the only conferences he comes back on campus for.

“If you lead a good conference and are enthusiastic about what you are doing, you will have good attendance and people will want to attend,” she continues. “This is a meeting of a lot of great minds.”

Enthusiasm at UTMB was high from the start. The DMT began as a liver pathology review conference, Dr. Stevenson-Lerner recalls, which gained momentum over the first year. As the transplant center grew, so did the complexity of the cases. And when Dr. Laposata happened to inquire about the review conference, “he realized it was basically very close to being a DMT, with the exception that the order was not being placed in Epic.” Dr. Stevenson-Lerner was even writing notes based on the conference, attaching them as an addendum to the pathology reports. “So I was already doing almost everything” required of a DMT.

After Dr. Laposata attended a review conference and explained the DMT concept, “Everyone was on board immediately,” Dr. Stevenson-Lerner says. “They all agreed it was almost like a DMT as it was. And now people are very much an advocate for DMTs.”

Like the best major league hitters, Dr. Stevenson-Lerner soon discovered the key to success was making adjustments. For example, Dr. Laposata’s blueprint for a DMT, at least as it related to coagulation, calls for rigid criteria for case selection, based on what tests have been ordered. “You can’t pick and choose,” Dr. Stevenson-Lerner says.

That wouldn’t work for liver disease. Not every case needs to be reviewed, nor could it. “I think we should save [DMTs] for our more complicated cases.” Complexity, admittedly, can be defined broadly, particularly since reports include subjective elements. Dr. Stevenson-Lerner opts for pragmatism: “If you sign out your report, and it makes the clinician think twice, that would be a good time to review the case.”

Anyone can decide that a case is complex, she says, including the primary care team, a resident, or a fellow, and that it might benefit from a little extra time and attention, as well as a team weighing in on the diagnosis and treatment. The key, she says, is that the DMT needs to affect treatment decisions. For those who practice liver pathology, “you absolutely have to look over the entire clinical record.”

She offers an example from UTMB: a 32-year-old Caucasian female who presented to the hepatology clinic for evaluation of her viral hepatitis C. Labs included: