Histologic Examinations of Arthroplasty Specimens are not Cost-effective: A Retrospective Cohort Study

Abstract

Background Many hospitals require all operative specimens be sent to pathologists for routine examination. Although previous studies indicate this practice increases medical cost, it remains unclear whether it alters patient management and whether it is cost-effective. Questions/purposes We therefore (1) determined the rate of discordance between clinical and histologic examinations of routine operative specimens during elective primary arthroplasties, (2) determined the cost of routine histologic screening, and (3) estimated its cost-effectiveness in terms of cost per quality-adjusted life year gained, as compared with gross examination or no examination. Methods We retrospectively reviewed medical records of 1247 patients who underwent 1363 routine elective primary total joint arthroplasties between January 18, 2006 and March 15, 2010. We compared preoperative, postoperative, and histologic diagnoses for each patient and categorized them into three classes: concordant (clinical and histologic diagnoses agreed), discrepant (diagnoses differed but with no resultant change in treatment), and discordant (diagnoses differed with resultant change in treatment). Medicare reimbursements were determined through the pathology department's administrative office. Results In 1363 cases, 1335 (97.9%) clinical and histologic diagnoses were concordant, 28 (2.1%) were discrepant, and none were discordant. Total reimbursement for routine pathological examination was $139,532, or $102.37 per specimen. The average cost to identify each discrepant case was $4983.29. Routine histologic examination did not alter patient management, and there was no direct gain in quality-adjusted life years. Conclusions Our observations show routine histologic examinations of routine operative specimens during elective primary arthroplasties increase medical cost but rarely alter patient management and are not cost-effective. Level of evidence Level I, economic and decision analyses. See Guidelines for Authors for a complete description of levels of evidence.

The Incidental Hematopoietic Evaluation – Microscopic Examination of Routine Orthopedic Surgical Specimens

“…They estimated that the cost per discrepant diagnosis was $4383, and the cost per discordant diagnosis $122,728. A more recent study [8] found a 2.1% discrepant rate with a cost estimate of $4983 per case, nearly the same amount as Kocher et al [1] No discordant cases were found in this study; however, there was less medical follow-up of cases, as this was focused mainly on medical economics. A separate retrospective analysis of 2144 cases, limited to shoulder arthroscopy [2], showed no discordant pathologic diagnoses when compared to the clinical diagnosis.…”

Routine Examination of Pathology Specimens Following Knee Arthroscopy: A Cost-Effectiveness Analysis

“…Previous studies have demonstrated extremely low diagnostic value and high costs of histological examinations following a variety of procedures, including thumb, knee, and hip arthroplasty; lumbar and cervical discectomy; hallux valgus surgery; wrist ganglion excision; and shoulder and knee arthroscopy [6][7][8][9][10][11][12][13][14][15][16][17][18][19][23][24][25][26][27][28] (see Appendix). While these represent various procedures under different settings, different clinical and histological diagnoses occurred in 0% to 9% of the cases.…”

“…A review of 8039 total hip and knee arthroplasties (5874 total knee arthroplasties and 2165 total hip arthroplasties), an accumulation of studies, each with different specific protocols, demonstrated only two discordant diagnoses (0.025%) [6][7][8][9][10]25 . One was incorrectly determined to be osteomyelitis via histological analysis 6 , and the second was an unexpected and unexplained granulomatous inflammation, which required solely medical follow-up 25 .…”

“…The cost per discordant diagnosis in a variety of procedures has typically been reported to be >$120,000 per case [6][7][8][9][10][11][12][13][14][15][16][17][18][19] .…”

“…The definitions proposed by Raab et al 6 of concordant agreement between clinical and pathological diagnoses, discrepant diagnosis without a change in patient management, and discordant diagnosis resulting in altered patient management were utilized in our study. Similar studies have used these definitions as well, allowing an in-depth analysis of the literature [6][7][8][9][10][11][12][13][14][15][16][17][18][19] . In order to determine the cost of the histological examinations, the Medicare fee schedule for 2012 was used for both technical and professional portions of billing utilizing CPT codes 88304 (surgical pathology gross and microscopic, non-fracture) and 88313 (decalcification).…”