SDHB internal report is of 'public interest'

The Southern District Health Board should not have refused to release the report which sparked an urgent review of some breast cancer diagnoses last year, ombudsman Ron Paterson says.

This week, the board released the anonymised internal audit report by unidentified radiologist (Dr Y) some 17 months after the original Official Information Act query.

Prof Paterson did not accept the board view that making the internal report available would adversely affect public confidence in the Ministry of Health.

The ministry's urgent review report, published in April last year, cleared the southern screening service, Breast Screen Health Care, of concerns its rate of ''false negatives'' was unacceptably high.

Prof Paterson found there was a public interest in the release of the internal report to promote understanding of why external reviewers concluded the initial audit overstated concern about false negatives.

''There is also a more general public interest in the quality of screening services funded or provided by district health boards, and in oversight by the Ministry of Health.''

There had already been significant evaluation and critical comment released publicly about Dr Y's report, with credible information identifying and discussing the audit's shortcomings. It was difficult to see how disclosing the full report would ''have any negative effect''.

Prof Paterson said while he agreed with the board clinical audits should be carried out without fear of any inappropriate or unlawful disclosure, the release of the report without identifying any individuals would be neither ''unlawful nor inappropriate''.

There would be cases where full disclosure of an anonymised clinical audit would be ill-advised and in those cases the public interest balance would determine whether some information should be released.

Dr Y, who was formerly employed by Southern screening service Breast Screen Health Care, raised concerns about possible systemic problems with the quality of reading screening mammograms.

The purpose of her audit was to provide ''some kind of numerical evidence that there are problems with the screening programme''.

In an overall comments section, she said her report ''does not tell us specifically what the problems are, some of which I had been trying to discuss or solve prior to discovering the roadblock of not believing that there is a problem to be solved''.

Her ''audit'' of 136 cancer cases suggested cancers detected in 47 women during the two years to June 2010 could have been detected at their routine screenings two years earlier. A subsequent rereading of the mammograms of these women by another radiologist indicated 28 of these women might have had delays in identification of cancers.

The ministry review found 28 women given a false clearance within a total of 32,000 screened women was an internationally acceptable false negative rate.

Prof Paterson said while the tenor and content of Dr Y's report might make disconcerting reading, he considered the author's general cynicism and her own reference to the audit being ''an attempt at a step towards proving there was a problem'' was more likely to undermine Dr Y's credibility than that of the ministry.

''In the circumstances, I very much doubt that the report could be held up to suggest that the ministry's decision not to undertake further investigation'' to establish whether there was systemic failure of screening mammograms at BSHC - was flawed.''

Overall, it remained difficult to see how the public could be fully satisfied the decision not to undertake an investigation was justified without disclosure of the report in its entirety, he said.

If the board had not agreed to release the report, he would have considered making a recommendation that the information be released, he said.

The ministry report released in April 2012 included an external peer review of Dr Y's report by chairman of BreastScreen Aotearoa independent monitoring group chairman Richard Taylor. He referred specifically to parts of Dr Y's report, although her report was not included in the material made public then.

In his detailed and technical appraisal of the audit report, Prof Taylor was critical of the methodology used by Dr Y, the presentation of data (including the lack of comparative data) and conclusions drawn from it. He described some information as difficult to follow. He said there was also a significant issue of observer bias in her report and that of the second radiologist as both were aware cancers had been diagnosed when they looked at the earlier mammograms.

Dr Y suggested if the cancer detection rate for BSHC was poor, then the interval cancer rate (those cancers found between routine screening times) should be high, ''and this is not the case''. (Prof Taylor said monitoring evidence did not suggest the BSHC cancer detection rate was poor according to the standards set.)

She asked if Otago and Southland women were ''non-breast aware'' and not finding their lumps.

''. . . are GPs struggling to get patients into the diagnostic clinics and therefore telling their patients not to tell us about their palpable lumps?''

She questioned whether ''if the screening programme is not doing its job picking up small, impalpable cancers before they spread, it may be doing more harm than good in the community. This is particularly true in a non-breast-aware community that may be reassured by screening and not have their lumps checked out.''

Referring to Dr Y's concern about the number of women in the programme presenting with lumps palpable to surgeons, Dr Taylor said palpation by the surgeon was presumably informed by knowledge from the mammogram.

''Without knowledge of the distribution of sizes of breast cancers and the sizes of breasts they were in, it is difficult to determine what proportion should have been palpable to women or clinicians.''

Her hypothesis about the breast awareness of Otago and Southland women was something which would need to be tested through a properly constructed study.

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