Cost and effectiveness of routine pathological examination of operative specimens obtained during primary total hip and knee replacement in patients with osteoarthritis

Non-neoplastic bone, joint, and soft tissue pathology: What every pathologist should know

The diagnosis of bone and soft tissue tumors is a skill which requires experience across multiple disciplines while their incidence is small. By contrast, the numbers of patients with non-tumorous diseases of bones, soft tissues, and joints dwarfs primary tumors by several orders of magnitude. The ability to successfully diagnose non-neoplastic diseases requires a knowledge of bone development, structure, remodeling, imaging, and tissue processing. This review summarizes the alterations of bones, joints, and to a lesser extent soft tissues that are encountered in the practice of everyday surgical pathology.

The Limited Utility of Routine Pathologic Examination of Ganglion Cyst Excision From the Hand and Digits

BACKGROUND

It is routine practice at many institutions to send surgically excised ganglion cysts for pathologic analysis. This adds significant cost to the procedure with questionable benefit. The purpose of this study was to determine the necessity of routine pathologic examination of ganglion cysts excised from the hand.

METHODS

We conducted a retrospective review of 443 patients who underwent ganglion excision from the hand with routine pathologic examination between 2012 and 2022. The final pathologic diagnosis was compared with the treating surgeon's clinical diagnosis, and the rates of concordant, discrepant, and discordant diagnoses were identified. Discrepant diagnoses were defined as differing clinical and pathologic diagnoses that did not change clinical management. Discordant diagnoses were defined as differing clinical and pathologic diagnoses that altered the treatment plan.

RESULTS

The prevalence of a concordant diagnosis was 96.2% (426 of 443; 95% confidence interval, 94.4%-98.0%). The prevalence of a discrepant diagnosis was 3.8% (17 of 443; 95% confidence interval, 2.1%-5.6%), and the prevalence of a discordant diagnosis was 0. The odds ratio was 0.04 for a discrepant diagnosis and 0 for a discordant diagnosis.

CONCLUSIONS

Our study suggests abandoning routine pathologic analysis in patients undergoing ganglion cyst excision from the hand will not compromise quality of care when the surgeon is able to make a confident diagnosis. Discrepant diagnoses were rare and discordant diagnoses that did not occur. We recommend pathologic evaluation only when there is uncertainty in the clinical diagnosis.

Utility of Routine Pathologic Examination for Fasciectomy for Dupuytren Contracture

PURPOSE

The objective of this study was to examine the routine pathologic examination of surgical specimens obtained during fasciectomy for Dupuytren contracture.

METHODS

A total of 376 consecutive patients who underwent surgical limited fasciectomy with the excised tissue sent for histopathologic evaluation were identified. Patients were excluded for miscoded procedures, cases where no tissue was sent for pathologic review, and excisions of nodules only. Repeat surgeries in the same patient during the study period were excluded. The rates of concordant, discrepant, and discordant diagnoses were reported. Discrepant diagnoses were defined as different clinical diagnosis and pathologic diagnosis that did not change clinical management. Discordant diagnoses were defined as a different clinical diagnosis and a pathologic diagnosis that altered the treatment plan. The reference standard for final clinical decision-making was the pathologic diagnosis.

RESULTS

The prevalence of concordant diagnoses was 97.1% (365 of 376), of discrepant diagnoses was 2.9% (11 of 376), and there were no discordant diagnoses. Of 376 patients, 43 underwent previous surgical fasciectomy before the study surgery, and pathologic examination was obtained in 10 of these patients. All 10 patients had concordant diagnoses.

CONCLUSIONS

Our results suggest that routine pathologic examination did not alter the future treatment plan for patients who underwent limited fasciectomy. Discrepant diagnoses were encountered infrequently, and rarely in the setting of revision fasciectomy. Discordant diagnoses did not occur. Given the cost associated with pathologic evaluation, this raises the question of whether routine pathologic evaluation is necessary for Dupuytren surgery, where the capability of the treating surgeon to make a clinical diagnosis accurately may render confirmatory pathologic assessment redundant.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic II.

Routine Histopathologic Examination of Bone Obtained During Elective Primary Total Knee Arthroplasty May Not Be Necessary

Background

Many institutions require the routine collection of pathology samples from every primary total knee arthroplasty (TKA) performed. These policies are controversial, and their cost-effectiveness is difficult to define. We sought to judge the cost-effectiveness of one such policy according to World Health Organization recommendations.

Methods

We analyzed 3200 consecutive primary TKAs, comparing our presumed preoperative diagnoses against the diagnoses made by the pathologist. Diagnoses were categorized as concordant (matching), discrepant (not matching but without impact to patient management), or discordant (not matching and resulting in a direct change to patient management). An incremental cost-utility ratio analysis was performed to determine the cost-effectiveness of our institution's policy to routinely collect pathology samples from every primary TKA performed. Cost-effectiveness was defined by World Health Organization guidelines as a cost of less than $228,090 per quality-adjusted life year gained.

Results

Twelve pathology samples were lost before reaching a pathologist. From the remaining 3188 samples, we identified 3158 concordant cases, 29 discrepant diagnoses, and 1 discordant diagnosis. It cost an estimated $10,522.60 to identify each discrepant diagnosis and an estimated $305,155.36 to diagnose one discordant case in our cohort. Our incremental cost-utility ratio analysis revealed that we spent $305,155.36 to gain 0 quality-adjusted life years for our patients.

Conclusions

Routine histopathologic analysis of TKA samples was cost-ineffective in our patient cohort and may not be necessary during routine TKA.

Identifying Modifiable Cost Drivers of Outpatient Unicompartmental Knee Arthroplasty With Machine Learning

BACKGROUND

Implementing tools that identify cost-saving opportunities for ambulatory orthopaedic surgeries can improve access to value-based care. We developed and internally validated a machine learning (ML) algorithm to predict cost drivers of total charges after ambulatory unicompartmental knee arthroplasty (UKA).

METHODS

We queried the New York State Ambulatory Surgery and Services database to identify patients who underwent ambulatory, defined as <24 hours of care before discharge, elective UKA between 2014 and 2016. A total of 1,311 patients were included. The median costs after ambulatory UKA were $14,710. Patient demographics and intraoperative parameters were entered into 4 candidate ML algorithms. The most predictive model was selected following internal validation of candidate models, with conventional linear regression as a benchmark. Global variable importance and partial dependence curves were constructed to determine the impact of each input parameter on total charges.

RESULTS

The gradient-boosted ensemble model outperformed all candidate algorithms and conventional linear regression. The major differential cost drivers of UKA identified (in decreasing order of magnitude) were increased operating room time, length of stay, use of regional and adjunctive periarticular analgesia, utilization of computer-assisted navigation, and routinely sending resected tissue to pathology.

CONCLUSION

We developed and internally validated a supervised ML algorithm that identified operating room time, length of stay, use of computer-assisted navigation, regional primary anesthesia, adjunct periarticular analgesia, and routine surgical pathology as essential cost drivers of UKA. Following external validation, this tool may enable surgeons and health insurance providers optimize the delivery of value-based care to patients receiving outpatient UKA.

LEVEL OF EVIDENCE

III.

Routine Pathologic Examination of the Femoral Head in Total Hip Arthroplasty: A Survey Study of the American Association of Hip and Knee Surgeons

Background

Current literature does not provide conclusive evidence on whether routine pathologic examination of femoral heads from total hip arthroplasty is indicated or cost-effective. As a result, there is substantial variation in opinion among surgeons related to this issue. Our study aim was to determine factors that impact surgeon propensity to order pathologic examination of femoral heads.

Methods

A 12-question survey was created to evaluate surgeon practices, indications, and patient care implications surrounding routine pathologic examination of femoral heads. The email survey was distributed to all members of the American Association of Hip and Knee Surgeons (n = 2598).

Results

There were 572 survey respondents. Out of all respondents, 28.4% always send femoral heads to pathology, and 27.6% reported an institutional requirement to do so. Of the 572 surgeons, 73.6% report femoral head pathology has never resulted in a change in patient disease course. Factors that increase the likelihood of surgeons ordering femoral head pathologic examination include institutional requirements, medicolegal concern, and prior experience with femoral head pathologic examination changing patients' disease course (P < .001). Cost concern decreases the likelihood of surgeons ordering femoral head pathologic examination (P = .0012).

Conclusions

A minority of surgeons routinely send femoral heads from total hip arthroplasty for pathologic examination, mostly because of institutional requirement. The majority of surgeons feel that femoral head pathologic examination never changes patient management, although others have infrequently detected malignancy and infection. Institutional policy, concern for litigation, and prior experience with discordant pathologic diagnoses increase femoral head pathologic examinations, while cost concern decreases them.

Routine Histopathologic Analysis of Hip and Knee Bone Specimens After Total Joint Arthroplasty

Total hip and total knee arthroplasties (THA/TKA) are some of the most common elective surgeries done in the United States. Routine histopathologic analysis of hip and knee bone specimens after total joint arthroplasty commonly occurs to identify unexpected pathologic findings and serves as a quality assurance measure. As the most common indication for THA and TKA is osteoarthritis, the practice of routine histopathologic analysis may not be routinely warranted. There is no clear consensus on the cost-effectiveness of this practice, and the literature has questioned both the clinical relevance of discrepancies between surgeon diagnosis and histopathological diagnosis and raised concerns about variance in the histological evaluation of resected specimens by pathologists. Femoral head analysis in the setting of femoral neck fractures has been previously reported, yet there is no clear overview for this topic in the setting of elective THA. The histopathologic features of bone specimens during routine total joint arthroplasty, the cost-effectiveness, and current recommendations will be reviewed.

Diagnosis of Prostate Adenocarcinoma on Routine Pathology After a Primary Total Hip Arthroplasty

We present a 67-year-old male patient who presented with insidious worsening of right hip pain over a 6-month period with clinical and radiographic evidence of severe osteoarthritis. The patient underwent a primary total hip arthroplasty where the femoral head specimen was sent to pathology as a routine specimen. Pathology results demonstrated metastatic adenocarcinoma of prostate origin. The present case emphasizes the importance of routine pathologic examination of femoral head specimens retrieved during total hip arthroplasty, particularly since this was a clinically unsuspected finding. Although cases like these are rare and the process of routine pathologic examination raises a concern for economic implications, a timely diagnosis of adenocarcinoma provides benefits for the patient, for which cost-benefit ratios are difficult to quantify.

Routine Pathologic Examination of Femoral Head Specimens from Total Hip Arthroplasty May Not Be Indicated or Cost-effective: A Systematic Review

Background

There is considerable disparity in institutional practices surrounding routine pathologic examination of femoral heads removed during total hip arthroplasty (THA). Multiple groups have studied the merits of routine femoral head pathology in THA, without clear consensus. We sought to further investigate the existing evidence on routine pathologic examination of femoral heads retrieved during THA to determine if this practice provides additional clinical value and is cost-effective.

Material and methods

To conduct a systematic review of the literature, a medical librarian was consulted to develop and perform comprehensive searches in PubMed (1809-present), Embase (embase.com 1974-present), CINAHL (EBSCO, 1937-present), and the Cochrane Central Register of Controlled Trials (Wiley). Final searches resulted in 727 references. Through multiple reviewer screenings and assessments of eligible full-text articles, we included 14 articles for review.

Results

Our systematic review yielded pathologic examination results from 17,388 femoral head specimens collected during THA. In 0.85% of cases, the pathologic diagnosis differed in a meaningful way from the preoperative clinical diagnosis. Routine pathology changed patient management in approximately 0.0058% of cases. The average cost for pathologic examination of each specimen was $126.38.

Conclusion

Routine pathologic examination of femoral heads retrieved during THA has limited impact on patient management. With an estimated 500,000 THAs performed in 2019, the economic feasibility of routine femoral head pathology is limited at an annual cost of up to $63,000,000 and cost per quality-adjusted life-year approaching infinity. However, surgeon discretion on a patient-specific or practice-specific basis should be used to make the final determination on the need for femoral head pathology.

Selective pathological examination following hip arthroplasty: A retrospective cohort study

BACKGROUND

Pathological examination of the femoral head after hip arthroplasty is often performed routinely. The cost-effectiveness of the examination with regard to identifying clinically relevant diagnoses has been a point of discussion. To date, recommendations on performing pathological examination based on patient characteristics, disease history or radiographic findings are scarce. The aim of this study was to gain insight in when to select a patient for pathological examination of the femoral head by means of the following research questions: "How many clinically relevant diagnoses does selective pathological examination identify?" "Which factors contribute to selection of the femoral head for conducting pathological examination?" "What are the costs of selective pathological examination for identifying clinically relevant diagnoses?"

HYPOTHESIS

Selective pathological examination of the femoral head results in higher ratios of identified clinically relevant diagnoses against substantially lower costs.

METHODS

A retrospective cohort study was performed over the period of 2010-2015. All pathological reports were collected from our hospital and screened for resected femoral heads after primary total hip arthroplasty (THA) or primary hemiarthroplasty (HA). The coherence between preoperative diagnosis and postoperative pathological diagnosis was defined as concordant, discrepant or discordant. The aim was to perform logistic regression analysis.

RESULTS

In total, 164 patients were included of 3998 hip arthroplasties performed during the study period with a mean age of 74±12.3 years including 54 (33%) male and 110 (67%) female of whom 112 (68%) underwent THA and 52 (32%) HA. A discrepancy in diagnosis was found in nine patients (6%) and discordance in three patients (2%). The most frequently reported reasons to perform pathological examination were malignancy in medical history n=86 (53%), avascular necrosis n=22 (13%), bone abnormality perioperatively n=19 (11%) and pathological fracture n=13 (8%). The factors that identified the unexpected clinically relevant diagnoses were pathological fracture (3 cases out of 13), bone abnormality perioperatively (2 out of 19), abnormalities on preoperative radiographs (1 out of 9) and to a lesser extent malignancy in history (2 out of 86). With costs of pathological examination of approximately €163 per femoral head, performed in 164 patients, the total costs of pathological examination resulted in €26,732. The cost per discrepant case (n=9) was €2970 and the cost per discordant case (n=3) was €8910.

CONCLUSION

Selective pathological examination of the femoral head following hip arthroplasty results in higher ratios of discrepant and discordant cases against substantially lower costs. Factors that identify clinically relevant diagnoses are pathological fracture, perioperative bone abnormality, abnormalities on preoperative radiographs and to a lesser extent malignancy in history.

LEVEL OF EVIDENCE

III; retrospective cohort study.

Evaluation of the Cost Effectiveness of Routine Histopathologic Femoral Head Analysis in Hip Arthroplasty

Purpose

Histopathologic analysis of femoral head specimens following total hip arthroplasty (THA) is a routine practice that represents a significant use of health care resources. However, it occasionally results in discovery of undiagnosed hematopoietic malignancy and other discrepant diagnoses such as avascular necrosis. The purpose of this study was to determine the rate of discordant and discrepant diagnoses discovered from routine histopathological evaluation of femoral heads following THA and perform a cost analysis of this practice.

Materials and Methods

A review of patients undergoing primary THA between 2004-2017 was conducted. A comparison of the surgeon’s preoperative and postoperative diagnosis, and the histopathologic diagnosis was performed. In cases where the clinical and histopathology differed, a review determined whether this resulted in a change in clinical management. Medicare reimbursement and previously published cost data corrected for inflation were utilized for cost calculations.

Results

A review of 2,134 procedures was performed. The pathologic diagnosis matched the postoperative diagnosis in 96.0% of cases. Eighty-three cases (4.0%) had a discrepant diagnosis where treatment was not substantially altered. There was one case of discordant diagnosis where lymphoma was diagnosed and subsequently treated. The cost per discrepant diagnosis was $141,880 and per discordant diagnosis was $1,669 when using 100% Medicare reimbursement and Current Procedural Terminology (CPT) code combination 88304+88311.

Conclusion

Histopathologic analysis of femoral head specimens in THAs showed an association with high costs given the rarity of discordant diagnoses. Routine use of the practice should be at the discretion of individual hospitals with consideration for cost and utility thresholds.

Unexpected Primary Extranodal Marginal Zone Lymphoma of Bone in Amputation and Arthroplasty Specimens

OBJECTIVES

Amputation due to gangrene and arthroplasty for degenerative joint disease are common orthopedic procedures and are expected to increase as populations age. Histopathologic examination of these specimens can identify unsuspected diseases.

METHODS

We reviewed gangrenous amputations and large joint arthroplasty specimens for diagnosis of unexpected lymphoma, January 2014 to January 2020. Pathology and medical records were reviewed to determine diagnosis, treatment, and outcome.

RESULTS

Five cases (0.08%) of unexpected primary extranodal marginal zone lymphoma (MZL) centered in bone were identified in 1,624 amputations for gangrene and 4,163 arthroplasty specimens. The female-to-male distribution was 3:2. Median age was 71 years (range, 62-87). The 3 cases arising in the setting of gangrene involved the first toe phalanges and metatarsals, and the femoral head was involved in all cases of joint disease (2 cases). The bone showed variable (10%-80%) infiltration by dense populations of small lymphoid cells with MZL immunophenotype. One patient died from sepsis 18.5 months after diagnosis; all others are alive with a median follow-up of 27.45 months.

CONCLUSIONS

Histopathologic examination of nonneoplastic orthopedic specimens identifies unexpected primary bone extranodal MZL in a small percentage of cases. This neoplasm may be the result of chronic antigenic stimulation in some circumstances.

Accurate and Reliable Diagnosis of Avascular Necrosis of the Femoral Head From Total Hip Arthroplasty Specimens Requires Pathologic Examination

OBJECTIVES

To evaluate the necessity of pathologic examination for confirming the diagnosis of avascular necrosis (AVN).

METHODS

We retrospectively reviewed consecutive nonfractured total hip arthroplasty cases (n = 1,722), comparing operative diagnoses and radiologic data with final histologic diagnoses, focusing specifically on AVN.

RESULTS

Among 199 histologically confirmed cases of AVN, 62 (31%) had a preoperative diagnosis of osteoarthritis/degenerative joint disease (OA/DJD); 58 of the latter patients had radiology reports, but only two (3%) documented AVN. Patients with AVN preoperatively diagnosed as OA/DJD were significantly older (mean, 65 years) than patients with AVN correctly diagnosed clinically (mean, 52 years; P < .00001). Among 163 cases with a preoperative diagnosis of AVN, 26 (16%) were confirmed as OA/DJD; the radiology report incorrectly diagnosed AVN in 17 (65%) patients. These latter patients also were significantly older (mean, 60 years) than patients with AVN correctly diagnosed clinically (P = .0008). Patients with a preoperative clinical and/or radiologic diagnosis of AVN were more likely to be younger and have known AVN risk factors.

CONCLUSIONS

Accurate and reliable diagnosis of AVN requires pathologic examination, especially among older patients without known risk factors. Prompt diagnosis may lead to behavioral changes in affected patients that reduce the risk of subsequent lesions.

Discrepant histological diagnoses: A cause of early low FJS-12 score and if untreated, unhappy Total Knee Arthroplasty patient

PURPOSE

Total Knee Arthroplasty (TKA) is one of the most successful operations in orthopedics. Still, a sizable percentage of patients (20%) remain dissatisfied after a well-executed TKA. The study aims to examine the excised synovium from the suprapatellar region in osteoarthritic knees during TKA and evaluate the histopathology (HP) report to know whether discrepant diagnoses affect the Forgotten Joint Score-12 at various time intervals.

METHODS

This is a prospective cohort study. Two hundred (160 female; 40 male) end-stage osteoarthritis patients who underwent primary TKA were studied. An inclusion criterion was patient with end-stage osteoarthritis. Clinically and serologically proven rheumatoid arthritis patients were excluded from the study. The synovium excised during the TKA procedure was sent for the HP examination. The statistical significance was measured with the Chi-square test and two-sample t-test.

RESULTS

A total of 184 out of the 200 patients (92%) knee synovium showed HP features of osteoarthritis. The discordant diagnoses and discrepant diagnosis rate was 8% and 7%, respectively, which is statistically significant by Chi-square test (p value < 0.0001 and p value = 0.0001). 14 of the patients (12 F:2 M) showed histological features of inflammatory/rheumatoid arthritis who were treated, two patients (all female) showed HP features of villonodular synovitis. The mean (SD) improvement in FJS-12 at six weeks in the concordant group (25.3 [17.6]) is significantly more than the discrepant group (15.3 [12.5]), p-value 0.0385.

CONCLUSION

8% of our patients exhibited unexpected results. The study showed a 7% rate of discrepant diagnosis. This discrepant diagnosis if missed and untreated, would have affected the function and long-term survival of the implanted TKA.

Is There Value in Pathology Specimens in Routine Total Hip and Knee Arthroplasty?

Background Routine analysis of bone specimens in total joint arthroplasty (TJA) is mandatory at many institutions. The purpose of this study was to determine if mandatory routine TJA specimen analysis alters patient care or if they represent an unnecessary healthcare expenditure. Methods A retrospective review was performed of all primary TJA patients between October 2015 and December 2017 at our institution. Pathology results were reviewed to ascertain the number of concordant, discrepant, and discordant results. A diagnosis was considered concordant if the preoperative and pathologic diagnosis matched, discrepant if the preoperative and pathological diagnosis differed but no change in the patient's plan of care occurred, and discordant if the preoperative and pathologic diagnosis differed and resulted in a change in the patient's plan of care.  Results 3,670 total hip arthroplasty (THA) and total knee arthroplasty (TKA) procedures (3,613 patients) met the inclusion criteria and were included in this study. All 3,670 specimens had a concordant diagnosis; there were zero discrepant and zero discordant diagnoses. During the study period, our institution spent $67,246.88 in routine analysis of TJA specimens by a pathologist, with no change in any postoperative patient care plans. Conclusion With bundled payment reimbursement models and hospitals trying to decrease unnecessary expenditures, the present study helps further demonstrate that routine analysis has limited cost-effectiveness due to the low prevalence of alteration in the management of patient care. The decision for pathological analysis should be left at the discretion of the surgeon in order to maximize the cost-efficiency of TJA procedures.

Routine Histopathological Analysis of the Synovium in Patients with Primary Total Knee Arthroplasty

Although there are numerous studies about routine histopathological analysis during arthroplasty surgeries, most of them showed that new diagnoses have rarely been obtained as a result. The aim of this study was to evaluate the efficacy of routine pathological analyses of synovia resected during primary total knee arthroplasty in patients with osteoarthritis and its relevance in the treatment process. Of the 47 included patients who were followed up prospectively, 26 patients had clinical and histopathological concordant diagnoses and 21 patients had discrepant diagnoses. Oxford knee score and visual analogue score were performed for all the patients. Kallgren-Lawrence score was used for radiological analyses. The Mann-Whitney U test was used to examine the differences between the abnormally distributed variables. Mean age was 65.9 ± 4.3 years (range, 50-89 years) and mean follow-up time was 19 ± 7.8 months (range, 6-39 months). Grade IV gonarthrosis was found to be statistically lower in the discrepant group (p = 0.046). The mean preoperative Oxford knee score was 16.8 ± 2.3 (range, 2-23) and the mean postoperative Oxford knee score was 44.6 ± 1.8 (range, 27-48; p = 0.016). Postoperative Oxford knee scores and VAS were significantly increased in both the concordant and discrepant groups (p = 0.026 and p = 0.035, p = 0.019 and p = 0.039, respectively). Resection and histopathologic analyses of the hypertrophied and inflamed synovium encountered during primary arthroplasty procedure should be performed. This examination not only could provide crucial information that may influence the postoperative follow-up guidelines but also could help us to expand our knowledge and awareness of rare diseases that might yield osteoarthritis. The level of evidence for the study is level II.

Examination of total hip and knee arthroplasty tissues

BACKGROUND

Many practices require tissues from hip and knee arthroplasty procedures to be sent for pathologic examination. These examinations rarely provide information beyond the clinical or radiologic diagnosis and rarely alter clinical management. We aimed to determine the rate at which histologic diagnoses based on gross assessment alone or gross plus microscopic assessment correspond with reported clinical diagnoses in patients undergoing total joint arthroplasties and whether the histologic diagnoses alter patient management.

METHODS

We retrospectively reviewed arthroplasty cases performed at a high-volume teaching hospital in Manitoba, Canada. The clinical diagnosis was compared with the final pathology report based on gross examination, with or without histologic assessment. The results of the comparison were classified into 3 categories: concordant (same diagnosis), discrepant (different diagnoses without alterations in management) and discordant (different diagnoses resulting in management change). The overall provincial cost for pathologic examination was determined by multiplying the total examination cost by the estimated number of arthroplasty cases.

RESULTS

There were 773 patients in our study sample. The concordant rate was 98.3% (95% confidence interval [CI] 97.1%-99.1%), the discrepant rate was 1.7% (95% CI 0.9%-2.9%) and the discordant rate was 0.0% (95% CI 0%-0.5%) for 773 cases. The pathology diagnosis did not alter patient management in any case. A total of 91.5% of specimens did not require full histologic review and received gross descriptions only. The discrepancy rate was higher in cases that included microscopic examination than in those that received only gross descriptions (15.2% v. 0.4%, p < 0.001). The overall provincial cost for pathologic examination was estimated at Can$304 556.

CONCLUSION

Submitting routine tissue from arthroplasty procedures to pathology does not affect patient management and therefore provides no value for the health care resources expended in doing so.

Indiscriminate Pathologic Examination of Pediatric Supraglottoplasty Specimens: An Evidence-Based Approach toward Exempt Status

OBJECTIVE

The primary aim of this study was to demonstrate that indiscriminate pathologic evaluation of supraglottoplasty specimens is unnecessary and does not influence postoperative management. The secondary objective was to determine the costs associated with pathologic evaluation of supraglottoplasty specimens.

METHODS

A planned chart review was conducted to evaluate data from consecutive patients undergoing supraglottoplasty. Demographic data were extracted and pathology reports were reviewed. Projected cost savings were estimated based on 2018 Centers for Medicare & Medicaid Services reimbursement rates for Current Procedural Terminology code 88304 (surgical pathology, gross and microscopic examination).

RESULTS

A total of 1417 consecutive patients were identified. All specimens underwent gross and microscopic examination. Pathologic outcomes were categorized into 3 major categories: no diagnostic abnormality (n = 1069), chronic inflammation (n = 346), and other (n = 2). Pathologic evaluation did not alter postoperative management in any patient. Projected yearly and 5-year cost- savings totaled $11,818.08 and $59,173.92, respectively.

DISCUSSION

These findings demonstrate that pathologic examination of supraglottoplasty specimens adds no value to patient management. A more selective approach to pathologic examination of certain surgical specimens is an improvement opportunity to enhance the value of patient care by eliminating direct financial costs and "hidden costs" associated with unnecessarily increased workload.

IMPLICATIONS FOR PRACTICE

Addressing inappropriate, indiscriminate pathologic examination of certain surgical specimens is a potential quality improvement opportunity that has a meaningful impact on the value of patient care and reduces strains on the workload of surgical and pathology department personnel.

Cost Analysis of Routine Examination of Pathology Specimens Following Ankle Arthroscopy

Background:

Routine submission of pathologic specimens for histologic analysis following orthopedic surgery is a common and often required practice in the United States. Prior orthopedic studies have determined that these histologic examinations are of limited cost effectiveness and low clinical value because rarely do the pathology findings alter patient management. The purpose of this study was to evaluate the cost effectiveness and clinical significance of routine histologic examination of tissue specimens removed during ankle arthroscopy.

Methods:

Between 2014 and 2018, 408 patients underwent ankle arthroscopy at a multi-center hospital system by 16 different orthopedic surgeons. The available pathology reports from these cases were retrospectively reviewed to determine if the routine histologic examination altered patient care. We compared the preoperative diagnosis to both the postoperative and histologic diagnoses. The total cost for these histologic examinations was estimated using 2017 Medicare physician fees released by the College of American Pathologists. Cost-effectiveness was estimated in 2017 US dollars by cost per discrepant and discordant diagnosis.

Results:

Of the 408 patients who underwent ankle arthroscopy, 361 pathology reports were available for review. The prevalence of concordant diagnosis was 98.9% (357/361); the prevalence of discrepant diagnoses was 1.0% (4/361). There were no cases identified with a discordant diagnosis. Total estimated cost for all pathology specimens was $46 381 in 2017 US dollars. Cost per discrepant diagnosis was $11 595.

Conclusion:

In our study, histologic examination of surgical specimens following ankle arthroscopy had no effect on patient management, yet it increased costs. Routine examination of these pathologic specimens had a low rate of discrepant and/or discordant diagnoses. Based on our results, routine pathologic examination of ankle arthroscopy tissue specimens should be sent solely at the discretion of the orthopedic surgeon as opposed to being a mandated policy.

Level of Evidence:

Level IV, case series.

Pathology Evaluation of Reduction Mammaplasty Specimens and Subsequent Diagnosis of Malignant Breast Disease: A Claims-Based Analysis

BACKGROUND

This study aimed to measure the use of pathology evaluation of breast specimens among patients undergoing reduction mammaplasty and assess rates of new diagnoses of breast disease and associated cost.

METHODS

We analyzed the Truven MarketScan Databases from 2009 to 2015 to identify adult female patients undergoing reduction mammaplasty for macromastia. We recorded patient age, rates of obtaining pathology evaluation, new diagnoses of benign or malignant breast disease after pathology evaluation, and total cost for the surgery encounter.

RESULTS

Among 17,738 macromastia patients undergoing reduction mammaplasty, 91.3% (n = 16,193) received pathology evaluation. Pathology evaluation rates were clinically similar across age groups <70 years (90.8-92.1%) and slightly lower for patients ≥70 (85.0%). Among 6987 patients less than 40 years who received pathology evaluation, 0.06% (n = 4) were subsequently diagnosed with malignant breast disease within 3 months, compared to 0.23% in the entire cohort (n = 37/16,193). Pathology claims resulted in an added $307 (SD 251) on average for the breast reduction surgery encounters.

CONCLUSIONS

Breast tissue after reduction mammaplasty is routinely submitted for pathology evaluation, without consideration of age-based risk for breast cancer. Routine pathology evaluation of breast tissue in patients in lower risk age groups (less than 40 years) required an additional $536,000 on average to detect a single occult breast cancer compared to an added $85,600 to detect a new malignancy in patients 40 years and older. Clinicians and policy makers should consider whether routine pathology evaluation of breast tissue should be individualized based on risk factors for breast cancer.

Pathology Assessment of Femoral Head Resection Specimens: An Important Quality Assurance Procedure

CONTEXT.—

Decisions to perform hip arthroplasty rely on both radiographic and clinical findings. Radiologists estimate degree of osteoarthritis (OA) and document other findings. Arthroplasty specimens are sometimes evaluated by pathology.

OBJECTIVE.—

To determine the frequency of pathologic changes not recognized clinically.

DESIGN.—

Nine hundred fifty-three consecutive femoral head resections performed between January 2015 and June 2018, with recent radiologic and histologic study, were reviewed. We compared severity of OA reported by radiology and pathology. Findings unrecognized radiographically but recorded pathologically, and discrepancies between clinical diagnosis and pathology diagnosis, were tabulated.

RESULTS.—

Twenty-one cases of osteomyelitis were diagnosed radiographically or pathologically. Eight discrepancies were present. Fourteen osteomyelitis cases were recognized clinically. Pathology recognized 2 neoplasms missed radiographically. Avascular necrosis was diagnosed on pathology but not radiology in 25 cases, and 35 cases of avascular necrosis were seen radiographically but not pathologically. Osteoarthritis was graded both radiographically and pathologically from 0 to 3. Five hundred ninety-one of 953 cases (62%) were grade 3. Pathologists and radiologists had perfect agreement in 696 of 953 cases (73%). When grade of OA seen at pathology was correlated with surgeon, 2 groups of surgeons were detected: one with a low threshold for performance of hip arthroplasty (23%-28% low-severity OA) and the second with a high threshold (2%-5% low-severity OA).

CONCLUSIONS.—

Correlation between radiology and pathology diagnoses is high. Degree of OA present varies significantly between surgeons. Pathology discloses findings not recognized clinically.

Are Histological Examinations of Arthroplasty Specimens Performed Consistently Across the Country? A Large Database Study

BACKGROUND

It is currently unknown to what extent routine histological examination of joint arthroplasty specimens occurs across hospitals nationwide. Although this practice is neither supported nor refuted by the available evidence, given the increasing demand for joint arthroplasties, it is crucial to study overall utilization as well as its main drivers.

QUESTIONS/PURPOSES

Using national data on joint replacements, we aimed to evaluate: (1) What is the current use of routine histological examination of joint arthroplasty specimens? (2) Does the use vary by geographic location and hospital characteristics? (3) Has use changed over time?

METHODS

From the Premier Healthcare database (2006-2016) we included claims data from 87,667 shoulder (595 hospitals, median age 70 years, 16% nonwhite), 564,577 hip (629 hospitals, median age 65 years, 21% nonwhite), and 1,131,323 (630 hospitals, median age 66 years, 24% nonwhite) knee arthroplasties (all elective). Our study group has extensive experience with this data set, which contains information on 20% to 25% of all US hospitalizations. Included hospitals are mainly concentrated in the South (approximately 40%) with equal distributions among the Northeast, West, and Midwest (approximately 20% each). Moreover, the Premier data set has detailed billing information, which allows for evaluations of real-world clinical practice. There was no missing information on the main variables of interest for this specific study. We assessed frequency of histology examination (defined by Current Procedural Terminology codes) overall as well as by hospital characteristics (urban/rural, bed size, teaching status, arthroplasty volume), geographic region (Northeast, South, Midwest, West), and year. Given the large sample size, instead of p values, standardized differences were applied in assessing group differences where a standardized difference of > 0.1 (or 10%) was assumed to represent a meaningful difference between groups. For significance of trends, p values were applied. Percentages provided represent proportions of individual procedures.

RESULTS

In most hospitals, histology testing was either rare (1%-10%, used in 187 of 595, 189 of 629, and 254 of 630 hospitals) or ubiquitous (91%-100%, used in 121 of 595, 220 of 629, and 195 of 630 hospitals) for shoulder, hip, and knee arthroplasties, respectively. Overall, histology testing occurred more often in smaller hospitals (37%-53% compared with 26%-45% in larger hospitals) and those located in the Northeast (59%-68% compared with 22%-44% in other regions) and urban areas (32%-49% compared with 20%-31% in rural areas), all with standardized differences > 10%. Histologic examination is slowly decreasing over time: from 2006 to 2016, it decreased from 34% to 30% for shoulder arthroplasty, from 50% to 45% for THAs, and from 43% to 38% for TKAs (all p < 0.001).

CONCLUSIONS

Although overall use is decreasing, a substantial number of hospitals still routinely perform histology testing of arthroplasty specimens. Moreover, variation between regions and hospital types suggests that this practice is driven by a variety of factors. This is the first study addressing national utilization, which will be helpful for individual hospitals to assess how they compare with national utilization patterns. Moreover, the findings have clear implications for followup studies, which may be necessary given the exponentially growing demand for arthroplasties.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Assessing the Value of Routine Pathologic Examination of Resected Femoral Head Specimens After Femoral Neck Fracture

INTRODUCTION

The purpose of this study was to evaluate the efficacy of routine pathologic examination (PE) of femoral head (FH) specimens after arthroplasty for acute femoral neck fractures and to determine the cost.

METHODS

This was a retrospective chart review of 850 acute femoral neck fractures treated with hemiarthroplasty or total hip arthroplasty These were evaluated to determine whether the FH was sent for PE, the resultant findings, alterations in medical treatment, and cost.

RESULTS

A total of 466 FH specimens (54.8%) were sent to pathology. Four (0.9%) were positive for a neoplastic process. All four had a known history of cancer, antecedent hip pain, or an inappropriate injury mechanism. None of the findings resulted in an alteration in medical treatment. The average cost of PE was $195 USD.

DISCUSSION

The routine PE of FH specimens after arthroplasty for femoral neck fractures is not warranted and uneconomic. Sending the FH for PE, only when clinically indicated, rather than routine, will result in notable savings for the healthcare system.

LEVEL OF EVIDENCE

Level IV.

Use of Routine Pathologic Evaluation of Nonmalignant Lesions in Hand Surgery: A National Study

BACKGROUND

Most lesions of the upper extremity are common and benign, and many have questioned the need for routine pathologic evaluation of these specimens. The authors aim to examine the national use of routine pathologic examination of nonmalignant hand lesions to help guide health care policy and practice patterns.

METHODS

The authors used a national level MarketScan database to form a cohort of adult patients who underwent excision of nonmalignant upper extremity lesions. The authors calculated the rate of submission for each surgical procedure and separately for each diagnosis. The authors also investigated demographic and clinical characteristics associated with the submission of surgical specimens using a multivariable logistic regression model. The authors calculated the total cost of routine pathologic evaluation.

RESULTS

The final study cohort included 222,947 patients and 182,962 specimens from 153,518 cases. The mean rate of submission was 69 percent. Older age, Northeast region, and high comorbidity scores showed significant correlation with the odds of having a specimen submitted for pathologic evaluation. Excision of primary wrist ganglion was the most performed procedure, and benign lesions larger than 4.0 cm were most frequently submitted for pathologic evaluation. The mean cost of routine pathologic examination was $133 per specimen, and the annual expenditure was $5 million.

CONCLUSIONS

The routine pathologic examination of benign hand lesions is used frequently but provides limited clinical benefit at a cost. To increase efficiency and improve quality of care, surgeons should be aware of the low value of routine pathologic evaluation and be more selective for cases for which diagnostic testing will change management.

Incidence and Diagnostic Evaluation of Postoperative Fever in Pediatric Patients With Neuromuscular Disorders

BACKGROUND

Children with neuromuscular disorders have a significant chance of developing scoliosis and/or hip dislocation during childhood and adolescence and often undergo surgical reconstruction. Because of their high rate of medical comorbidities, these patients are at higher risk of postoperative complications and are therefore often comanaged, along with orthopaedics, by pediatric medicine and critical care teams. Fever during the postoperative stay is a frequent occurrence and often prompts extensive diagnostic workup which increases the cost and burden on the health system but have unclear effects on the care of the patient. The objective of our study was to evaluate the frequency of postoperative fever in pediatric patients with neuromuscular disorders after spine and hip deformity correction surgery and evaluate the utility of the diagnostic tests performed for the assessment of postoperative fever.

METHODS

We performed an IRB-approved retrospective study on patients who underwent corrective surgery for neuromuscular scoliosis or hip dislocation at a single institution. The occurrence of postoperative fever was characterized by maximum temperature, postoperative day (POD) of occurrence, and frequency as defined by either single or multiple temperature spikes. Diagnostic tests performed for the workup of postoperative fever were reviewed. The cost per health effect was estimated by dividing the total costs of diagnostic tests by the number of tests that changed patient care.

RESULTS

In total, 108 patients (62 females and 46 males) were identified. A total of 42 patients (38.9%) underwent posterior spinal fusion and 66 (61.1%) patients underwent hip surgery (pelvic osteotomy in 8 patients, femoral osteotomy in 31 patients, and both pelvic and femoral osteotomy in 27 patients). The mean age at the time of surgery was 11.1 years (range, 3 to 18 y). In total, 66 patients (61.1%) developed postoperative fever (mean temperature, 38.6°C). The frequency of fever was in the form of multiple temperature spikes in 37 patients (56%) and in the form of a single spike in 29 patients (44%). Of the 149 diagnostic tests performed for postoperative fever, there were a total of 16 positive tests (10.7% of total tests ordered; n=16/149) including 5/27 urine analysis, 4/26 urine culture, 4/28 chest x-ray, 1/1 wound culture, 0/1 sputum culture, urine Gram stain 0/1, tracheal aspirate culture 0/1, throat culture 1/1, adenovirus polymerase chain reaction (PCR) 0/5, human metapneumovirus PCR 0/5, parainfluenza PCR 0/5, rhinovirus PCR 0/1, 1/3 bronchoalveolar culture, and 0/7 respiratory virus panel. A total of 37 blood cultures were drawn and all were negative. There was a significant difference (P=0.04) in frequency of negative diagnostic workup performed at the first, second, and third POD as compared with positive diagnostic workup. Total cost of the diagnostic tests was $65,284 and the cost per health effect was $6582 ($65,284/10). Diagnostic tests in patients with postoperative fever were associated with prolonged length of hospital stay in comparison with patients who did not perform any diagnostic workup using the Spearman ρ test (P=0.02).

CONCLUSION

In total, 61% of pediatric patients developed postoperative fever after surgical correction of neuromuscular deformity. An infectious source of postoperative fever was identified in 32.4% of patients with postoperative fever who underwent diagnostic workup. Urinary tract infection was the most common finding in patients with postoperative fever. Poor association between the development of postoperative fever and wound infection was found. Only 10.7% of fever diagnostic workup tests were positive in our population. The diagnostic workup tests might be less valuable if performed early on the first, second, and third PODs than those performed late after the third POD with exceptions based on clinical assessment. No patients with postoperative fever had positive blood cultures, therefore the routine use of blood cultures in the evaluation of postoperative fever in such population is not recommended.

LEVEL OF EVIDENCE

Level IV-retrospective.

Evaluation of postoperative fever after surgical correction of neuromuscular scoliosis: implication on management

BACKGROUND

Scoliosis is a common deformity in patients with neuromuscular disorders which usually necessitates surgical correction. Patients with neuromuscular scoliosis are characterized by increased incidence of associated medical co-morbidities and higher postoperative complication rate; therefore, these patients are often managed with a wide multidisciplinary care team. Postoperative fever is a frequent complication after surgery which is often routinely investigated using different workup tests to rule out infection. These tests lack clear evidence on how they impact the patient care and are associated with increased cost and burden on the health system.

OBJECTIVE

The objective of our study was to evaluate the incidence of postoperative fever after surgical correction of neuromuscular scoliosis and evaluate the clinical usefulness of fever diagnostic workup.

METHODS

Demographic and clinical data on patients who underwent neuromuscular scoliosis corrective surgery between March 1, 2014 and February 28, 2017 were reviewed at a single institution. The occurrence of postoperative fever (defined by body temperature ≥ 38 °C during the 1st week after surgery) was characterized by maximum temperature (T max), postoperative day of occurrence (POD), and frequency as described by either single or multiple temperature spikes. The diagnostic tests performed for the assessment of postoperative fever were reviewed. The cost per health effect was calculated by dividing the total costs of performed fever workup tests by the number of tests that resulted in change of the patient care.

RESULTS

Seventy-six patients (47 females and 29 males) were identified. Cerebral palsy was the most common aetiology in 40 patients (52.6%). The mean age at surgery was 13.5 years (range 3-18 years). The operative time was 490.34 ± 127.21 min. The intraoperative blood loss was 912.3 ± 627.8 cc. The hospital stay was 9.79 ± 5.3 days and the intensive care unit (ICU) stay was 3.26 ± 3.7 days. Wound drains were used in 71 patients for a period of 3.6 ± 2.3 days. Urinary catheters were used for a period of 3.6 ± 1.8 days. Forty-nine patients (64.5%) developed postoperative fever with a temperature of 38.7° ± 0.45° (range 38.10°-39.9°). The most frequent POD for occurrence of fever was the 2nd day in 22 patients (44.9%) The frequency of fever was in the form of multiple temperature spikes in 32 patients (65.3%) or in the form of a single spike in 17 patients (34.7%). There were a total of 20 positive tests out of 132 performed fever workup tests (15.2%). These included nine positive urine analysis (n = 32), five positive urine cultures (n = 28), one positive blood culture (n = 23), and two positive chest X-ray (n = 24). The occurrence of postoperative fever was statistically correlated with the operative time and increased hospital stay and ICU days. The most common identified cause of infection was urinary tract infection in 11 patients followed by respiratory tract infection in four patients and wound infection in one patient. The calculated cost per health effect was $3763.

CONCLUSION

Sixty-four percent of patients who underwent surgical correction of neuromuscular scoliosis developed postoperative fever. Postoperative fever was sign of infection in 32.7% of patients and urinary tract infection was the most frequent finding. Only 15.2% of fever diagnostic workup tests were positive. Diagnostic urine tests account for 70% of the positive diagnostic workup. The routine use of blood cultures for the assessment of postoperative fever in such population should be avoided due to the low rate of positive tests and the associated high cost.

Cost-benefit analysis of routine pathology examination in primary shoulder arthroplasty

BACKGROUND

The annual number of shoulder arthroplasty procedures is continuing to increase. Specimens from shoulder arthroplasty cases are routinely sent for pathologic examination. This study sought to evaluate the clinical utility and associated costs of routine pathologic examination of tissue removed during primary shoulder arthroplasty cases and to determine cost-effectiveness of this practice.

METHODS

This is a retrospective review of primary shoulder arthroplasty cases. Patients whose humeral head was sent for routine pathologic examination were included. Cases were determined to have concordant, discrepant, or discordant diagnoses based on preoperative/postoperative diagnosis and pathology diagnosis. Costs were estimated in 2015 U.S. dollars, and cost-effectiveness was determined by the cost per discrepant diagnosis and cost per discordant diagnosis.

RESULTS

We identified 714 cases of primary shoulder arthroplasty in 646 patients who met inclusion criteria. The prevalence of concordant diagnoses was 94.1%, the prevalence of discrepant diagnoses was 5.9%, and no cases had discordant diagnoses. There were 172 cases that had biceps tendon specimens sent for pathology examination, and none led to a change in patient care. Total estimated costs were $77,309.34 in 2015 U.S. dollars. Cost per discrepant diagnosis for humeral head specimens was $1424.09, and cost per discordant diagnosis is at least $59,811.78.

DISCUSSION/CONCLUSION

Primary shoulder arthroplasty has a high rate of concordant diagnosis. Discrepant diagnoses were 5.9% in our study, and there were no discordant diagnoses. This study showed limited clinical utility in routinely sending specimens from primary shoulder arthroplasty cases for pathology examination, and calculation using a traditional life-year value of $50,000 showed that the standard for cost-effectiveness is not met.

Unsuspected Malignancies in Routine Femoral Head Histopathologic Examination During Primary Total Hip Arthroplasty: Cost-Effectiveness Analysis

BACKGROUND

Routine femoral head histopathology during primary total hip arthroplasty (THA) has been recently reported as a potentially useful screening tool for bone- and bone marrow-associated malignancies. However, cost-effectiveness of routine histopathology during THA remains unclear due to low prevalence of significant medical findings which alter patient management. The aim of this study was to evaluate the cost-effectiveness of routine histopathology in diagnosing unsuspected malignancy in patients undergoing primary THA.

METHODS

From 1993 to 2011, we retrospectively analyzed routine histopathologic findings of 3200 femoral head specimens from 2725 patients that underwent primary THA. Preoperative and postoperative diagnoses were classified into concordant (clinical diagnosis concurred with pathologic diagnosis), discrepant (differing diagnosis with no resultant impact on patient management), and discordant (differing diagnosis with subsequent change in patient management). Cost-effectiveness analysis was performed using the incremental cost-utility ratio.

RESULTS

A total of 3055 of 3200 pathologic samples were concordant with the preoperative diagnosis (95.4%), 140 of 3200 were discrepant (4.4%), and 5 of 3200 were discordant (0.2%). Routine histopathology revealed 1 unsuspected malignancy out of 640 (5 of 3200) femoral heads. The total cost of histopathologic screening was $614,664.80. The average cost to identify a discrepant case was $4390.46, and the cost to identify a discordant case was $122,932.96. The incremental cost-utility ratio was $49,569.74 per quality-adjusted life year (QALY) gained.

CONCLUSION

Our study indicates routine femoral head histopathology may be cost-effective in diagnosing unsuspected malignancy at $49,569.74/QALY gained (less than World Health Organization recommended threshold $159,000/QALY gained), providing useful clinical information for surgeons considering the value of routine femoral head histopathology in patients undergoing THA.

Routine Workup of Postoperative Pyrexia Following Total Joint Arthroplasty Is Only Necessary in Select Circumstances

BACKGROUND

It is unclear when routine workup of postoperative pyrexia (POP) following total joint arthroplasty (TJA) should be performed.

METHODS

A retrospective electronic database search was conducted on 25,558 consecutive patients undergoing primary or revision TJA between June 2001 and June 2013. We identified patient demographics, procedure type, characteristics of feverish patients, and febrile complications. The estimated costs for chest x-ray (CXR), urinalysis, urine culture, and blood culture were investigated.

RESULTS

POP occurred in 46% of TJAs. A total of 11,589 separate workups were performed in 90.5% of POP patients, of which 2.4% were positive. Urinalysis, urine culture, blood culture, and CXR were positive in 38.7%, 9.5%, 7.0%, and 0.2%, respectively. Febrile complications occurred in 4.5% and the infectious complications rate was 2.0%. The positive rate of fever workups was significantly higher in patients with the first POP occurring after postoperative day 3, POP > 102°F, multiple fever spikes, and patients undergoing revision TJA. Multivariate logistic regression revealed that the time of first POP, the maximum temperature, multiple fever spikes, and revision TJA were independent predictors of febrile complications. The estimated cost for 11,319 negative workups in patients with POP was $4,636,976.80, with CXR costing $4,613,182.00.

CONCLUSION

Selective workup of POP following TJA should be performed in patients with higher temperatures, fever occurring after postoperative day 3, those with multiple fever spikes, and those undergoing revision TJA. CXR with an extremely low positive rate should not routinely be ordered.

Early Results of Medicare's Bundled Payment Initiative for a 90-Day Total Joint Arthroplasty Episode of Care

BACKGROUND

In 2011 Medicare initiated a Bundled Payment for Care Improvement (BPCI) program with the goal of introducing a payment model that would "lead to higher quality, more coordinated care at a lower cost to Medicare."

METHODS

A Model 2 bundled payment initiative for Total Joint Replacement (TJR) was implemented at a large, tertiary, urban academic medical center. The episode of care includes all costs through 90 days following discharge. After one year, data on 721 Medicare primary TJR patients were available for analysis.

RESULTS

Average length of stay (LOS) was decreased from 4.27 days to 3.58 days (Median LOS 3 days). Discharges to inpatient facilities decreased from 71% to 44%. Readmissions occurred in 80 patients (11%), which is slightly lower than before implementation. The hospital has seen cost reduction in the inpatient component over baseline.

CONCLUSION

Early results from the implementation of a Medicare BPCI Model 2 primary TJR program at this medical center demonstrate cost-savings.

LEVEL OF EVIDENCE

IV economic and decision analyses-developing an economic or decision model.

Costs Versus Benefits of Routine Histopathological Examination in Total Ankle Replacement

BACKGROUND

Routine histopathological examination has previously been scrutinized as a source of extraneous cost in orthopedic foot and ankle care. As an increasingly prevalent joint replacement operation, total ankle replacement poses a notable cost to the health care market in an era of cost containment. The purpose of this study was to compare the costs and benefits of routine histopathological examination of specimens removed during total ankle replacement. We hypothesized that a new diagnosis would rarely be found and such examination would seldom alter patient care.

METHODS

A retrospective review was conducted of all total ankle replacement operations between 2006 and July 2014 at the investigators' institution. Medical records for 90 patients, undergoing a total of 95 total ankle replacement operations, were reviewed to determine the clinical and pathological diagnoses for each operation and, subsequently, the rates of discrepancy and discordance. Professional charges were determined using estimated reimbursement rates for the Current Procedural Terminology (CPT) codes billed: 88304 (level III microscopic examination), 88305 (level IV microscopic examination), and 88311 (decalcification).

RESULTS

Degenerative joint disease was diagnosed by the pathologist in 93.7% of cases (89/95), pseudogout in 4.2% (4/95), and rheumatoid arthritis in 2.1% (2/95). The 4 diagnoses of pseudogout were the only cases of new diagnoses based on pathological review. A total of $16,536.81 was spent for examination of all specimens, for an estimated $4,134.20 spent per discrepant diagnosis. Patient care was unaffected by pathological examination.

CONCLUSION

A new diagnosis was rarely found by histopathological examination, and patient care remained unaltered in all cases. The costs of routine histopathological examination of tissue specimens removed during total ankle replacement, therefore, outweigh clinical benefits, and such examination should be left to the discretion of the operating surgeon.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Strategies and tactics for successful implementation of bundled payments: bundled payment for care improvement at a large, urban, academic medical center

As health care reform continues to evolve, there will need to be an emphasis on generating value, quality improvement, and cost control. In 2011, the Centers for Medicare and Medicaid Services (CMS) initiated a new Bundled Payment for Care Improvement initiative. Early results from this CMS bundled payment initiative at an urban, tertiary, academic medical center demonstrate decreased length of stay and increased discharge to home, with decreasing readmission rates, which can result in cost-savings without compromise of the quality of care. Changes in care coordination, clinical care pathways, and evidence-based protocols are the key to improving the quality metrics and cost effectiveness within the implementation of the bundled payment for care initiative, thus bringing increased value to our total joint arthroplasty patients.

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

BACKGROUND

While the clinical value of routine pathologic examination of tissues removed during orthopaedic procedures has not been determined, limited cost-effectiveness and a low prevalence of findings that alter patient management have been previously demonstrated with arthroscopy. The purpose of this study was to examine the clinical value and cost-effectiveness of routine histological examination of knee arthroscopy specimens.

METHODS

Retrospective chart analysis of 3797 consecutive knee arthroscopies by two surgeons from 2004 to 2013 at three affiliated hospitals within one health-care system was undertaken. Pathology reports regarding tissue removed during partial meniscectomies and anterior cruciate ligament reconstructions were reviewed to determine if the results altered patient care. The total costs of histological examination were estimated in 2012-adjusted U.S. dollars. The cost per health effect was determined by calculating the cost per discrepant and discordant diagnosis.

RESULTS

The prevalence of concordant diagnoses was 99.3% (3769 of 3797), the prevalence of discrepant diagnoses was 0.7% (twenty-seven of 3797), and the prevalence of discordant diagnoses was 0.026% (one of 3797). The total cost of histological examinations was estimated to be $371,810. The total cost of the pathology cost per discrepant diagnosis was $13,771, and the cost per discordant diagnosis was $371,810.

CONCLUSIONS

Routine pathological examination of surgical specimens from patients undergoing knee arthroscopy had limited cost-effectiveness because of the low prevalence of findings that altered patient management. Histological examination of surgical specimens from arthroscopic knee surgery did not alter patient care and increased costs. We suggest that gross and histological examination of tissue removed during knee arthroscopy should be done at the discretion of the orthopaedic surgeon rather than being mandatory.

Comparison of clinical and histologic diagnoses in 16,587 total joint arthroplasties: implications for orthopedic and pathologic practices

OBJECTIVES

To confirm how often histologic diagnoses correspond to reported clinical diagnoses in patients undergoing total joint arthroplasties.

METHODS

We compared the submitting operative diagnosis with the pathologic diagnosis in 16,587 total joint arthroplasties for the seven most common diagnoses.

RESULTS

The discrepancy rates between the submitted operative and histologic diagnosis were 18.8% for 7,968 total hip replacements and 9.4% for 8,619 total knee replacements. In addition, 5.4% of hip joints and 1.4% of knee joints demonstrated discordant histologic findings that had not been suspected clinically and should have affected clinical management and patient outcomes.

CONCLUSIONS

Our findings demonstrated significantly more diagnostic discrepancies and discordance than has been suggested by the previously published literature. A large part of the difference may be due to more careful diagnostic analyses of orthopedic specimens than in other institutions. These analyses include some diagnoses that are not often made elsewhere but may have important future implications for patients.

Costs and benefits of routine histopathological examination of hammertoe specimens

BACKGROUND

The purpose of this study was to evaluate the cost and benefit of routinely submitting hammertoe specimens for histopathological examination. We hypothesized that such examination rarely shows a new diagnosis and seldom alters postoperative care.

MATERIALS AND METHODS

Three hundred and fourteen proximal interphalangeal (PIP) joint and 37 extensor tendon specimens from 187 consecutive hammertoe correction surgeries were submitted by 2 surgeons for histopathological examination between January 2009 and December 2011. Each patient's chart was reviewed to determine whether the histopathological examination revealed a diagnosis other than degenerative joint or degenerative tendon and whether subsequent patient management was altered. The total reimbursements for professional charges were calculated using the average reimbursement from common insurance providers for two Current Procedural Terminology (CPT) codes: 88304 (soft tissue examination) and 88311 (decalcification).

RESULTS

Almost all of the specimens were diagnosed as degenerative: 97.5% (307/314) of the PIP specimens and all (37/37) of the tendon specimens. Seven PIP specimens (2.2%, 7/314) from 5 patients (2.7%, 5/187) and no tendon specimens had other diagnoses. These diagnoses were rheumatoid arthritis (5/314, 1.6%), osteomyelitis (1/314, 0.3%), and pigmented villonodular synovitis (PVNS) (1/314, 0.3%). Only the PVNS was a new diagnosis. A total of $56,750 was spent to determine 1 new diagnosis.

CONCLUSION

The routine submission of hammertoe specimens for pathological evaluation was not cost-efficient. Our analysis showed that new diagnoses were rarely found and patient management was not affected.

Histologic examinations of arthroplasty specimens are not cost-effective: a retrospective cohort study

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.

Histopathology of femoral head donations: a retrospective review of 6161 cases

BACKGROUND

Although total hip arthroplasty is one of the most common orthopaedic surgical procedures, it remains unclear whether histopathological examination of the excised femoral head adds to the quality of patient care. We propose that assessment of femoral heads resected during total hip arthroplasty and donated for allograft use may provide a profile of femoral head pathology that benefits total hip arthroplasty patients and bone donors.

METHODS

We retrospectively analyzed the histological findings reported for 6161 femoral heads donated for allograft use between 1993 and 2006. Specimens obtained during total hip arthroplasty and specimens donated at death were reviewed. Follow-up investigations that resulted from abnormal histopathological findings were also reviewed. The Western Australian Cancer Registry was used to determine whether patients with a suspected neoplasm were subsequently diagnosed with such a disease. A retrospective review of the histopathological findings was conducted to evaluate and reclassify all previous observations of abnormalities.

RESULTS

One hundred and five femoral heads demonstrated abnormal or reactive histopathological features not reported prior to surgery and were rejected for allograft use. A reactive lymphocytic infiltrate, most likely due to osteoarthritis, was the most commonly identified feature (forty-five cases). Other features observed in twenty-seven cases were also most likely due to the presence of severe osteoarthritis. Ten femoral heads demonstrated plasmacytosis, which may have been related to osteoarthritis. Two patients were diagnosed with Paget's disease, and two, with rheumatoid arthritis. Nineteen patients had a suspected neoplasm. Of these nineteen, eight cases of non-Hodgkin's lymphoma or chronic lymphocytic leukemia and one case of myelodysplastic syndrome were confirmed on further investigation. One subsequently confirmed malignancy was detected per 770 femoral heads examined.

CONCLUSIONS

Our findings indicate that, even with a detailed medical history and careful physical examination, clinically important diseases including neoplasms and Paget's disease are observed in patients diagnosed with osteoarthritis prior to total hip arthroplasty. Histological examination plays an integral role in quality assurance in femoral head banking, and it also represents a possible early diagnostic test for bone and bone-marrow-related diseases in patients undergoing total hip arthroplasty.

The value of routine histopathology during hip arthroplasty in patients with degenerative and inflammatory arthritis

The purpose of this study was to evaluate the effectiveness of routine pathological examination of operative specimens obtained during primary total hip arthroplasty (THA) performed for osteoarthritis (OA) and rheumatoid arthritis (RA). 100 consecutive patients (50 OA, 50 RA) were prospectively evaluated. A radiological score (Kellgren-Lawrence/Larsen) and a clinical score (Harris Hip Score) were calculated in each case. Specimens of bone and cartilage from the femoral head as well as capsule were obtained intraoperatively. A histological grading (Mankin score) was obtained, and additional histological findings were also reported. In patients with RA the clinical and pathological diagnoses were concordant in 37 (74%) and discrepant in 13 patients (26%). In patients with OA there was concordance in 30 (60%) and discrepancy in 20 patients (40%). Discrepancies were additional findings such as focal osteonecrosis amyloidosis or crystal deposits. Discordance (management alteration) did not occur in any case. Histological evaluation of the capsule and the synovium was more informative than evaluation of bone. Calcium pyrophosphate (CPPD) and amyloid was frequently found in OA suggesting that these substances may contribute to joint damage, and control of their production by therapeutic means may prevent degeneration.

Hospital economics of primary total knee arthroplasty at a teaching hospital

BACKGROUND

The hospital cost of total knee arthroplasty (TKA) in the United States is a major growing expense for the Centers for Medicare & Medicaid Services (CMS). Many hospitals are unable to deliver TKA with profitable or breakeven economics under the current Diagnosis-Related Group (DRG) hospital reimbursement system.

QUESTIONS/PURPOSES

The purposes of the current study were to (1) determine revenue, expenses, and profitability (loss) for TKA for all patients and for different payors; (2) define changes in utilization and unit costs associated with this operation; and (3) describe TKA cost control strategies to provide insight for hospitals to improve their economic results for TKA.

RESULTS

From 1991 to 2009, Lahey Clinic converted a $2172 loss per case on primary TKA in 1991 to a $2986 profit per case in 2008. The improved economics was associated with decreasing revenue in inflation-adjusted dollars and implementation of hospital cost control programs that reduced hospital expenses for TKA. Reduction of hospital length of stay and reduction of knee implant costs were the major drivers of hospital expense reduction.

CONCLUSIONS

During the last 25 years, our economic experience with TKA is concerning. Hospital revenues have lagged behind inflation, hospital expenses have been reduced, and our institution is earning a profit. However, the margin for TKA is decreasing and Managed Medicare patients do not generate a profit. The erosion of hospital revenue for TKA will become a critical issue if it leads to economic losses for hospitals or reduced access to TKA.

LEVEL OF EVIDENCE

Level III, Economic and Decision Analyses. See Guidelines for Authors for a complete description of levels of evidence.

Cost and effectiveness of postoperative fever diagnostic evaluation in total joint arthroplasty patients

The purpose of this study is to examine the characteristics and costs of postoperative fever diagnostic evaluations after total joint arthroplasty. All patients who underwent hip and knee arthroplasty (n = 1100) at a single institution for a 2-year period were included. Fever (temperature > or = 38.5 degrees C) occurred in 15% of patients. The rate of positive tests was as follows: chest radiograph (2%), blood culture (6%), urine culture (22%), and urinalysis (23.7%). Fever occurring after postoperative day 3 (odds ratio [OR] 23.3; P < .001) and multiple days febrile (OR, 8.6; P = .003) are independent predictors of a positive workup, and patients with a maximum temperature of 39.0 degrees C or higher (25.4% vs 6.9%; P = .001) had a significantly higher rate of positive fever evaluations. The total direct cost associated with fever evaluations was $73 878, and cost per change in clinical management was $8209. Fever is a common occurrence after hip and knee arthroplasty, and many elements of an infectious evaluation are costly and clinically unnecessary.

Necessity of routine pathological examination after surgical excision of wrist ganglions

PURPOSE

The value of routine pathological evaluation of ganglion cysts is questionable considering that the pretest odds of a wrist lesion being a ganglion cyst are usually high based on physical examination and surgical findings alone. This study evaluates the necessity of routine pathological examination of specimens derived from surgical removal of wrist ganglion cysts.

METHODS

We identified 429 consecutive adult patients who underwent surgical excision of a wrist ganglion with routine pathological examination of the specimen between 1997 and 2008. The rates of concordant, discrepant, and discordant diagnoses were reported with 95% confidence intervals. The odds of a discrepant or discordant diagnosis were calculated.

RESULTS

The prevalence of a concordant diagnosis was 98.6% (424 of 429; 95% confidence interval, 97.3% to 99.6%). The prevalence of a discrepant diagnosis was 1.4% (5 of 429; 95% confidence interval, 0.38% to 2.7%), and the prevalence of a discordant diagnosis was zero. The odds ratio was 0.012 for a discrepant diagnosis and zero for a discordant diagnosis.

CONCLUSIONS

This study suggests that, in patients with the clinical diagnosis of wrist ganglion cyst, quality of care would not be compromised by abandoning the practice of routinely submitting surgical specimens for pathological examination after excision of the ganglion cyst. Discrepant diagnoses are encountered infrequently and discordant diagnoses did not occur. We recommend pathological examination only when the clear gelatinous fluid typical of a ganglion cyst is not encountered at surgery.

Routine histopathologic evaluation in hallux valgus surgery

BACKGROUND

Anecdotal evidence suggests that specimens submitted for histopathologic assessment during hallux valgus surgery most commonly reveal degenerative changes. The purpose of this study was to evaluate the cost effectiveness of routine examination of tissue from hallux valgus procedures. We hypothesized that such examination rarely diagnoses a new condition and does not alter postoperative management.

MATERIALS AND METHODS

Specimens from 315 consecutive primary hallux valgus reconstructions performed between November 1995 and August 2002 were retrospectively analyzed. Patient charts were reviewed to determine the number of cases in which new diagnoses were made or treatment altered based upon histopathologic examination. Cost effectiveness was assessed by identifying the reimbursement for professional fees charged for these analyses. The total reimbursement per new diagnosis made and per alteration of treatment were calculated.

RESULTS

Degenerative changes were diagnosed in the majority of speciments (97.5%, 307 of 315). Other diagnoses included rheumatoid arthritis (1.3%, four of 315), gouty arthritis (1.0%, three of 315), and pseudogout (0.3%, one of 315). A new diagnosis was made only in the one patient (0.3%, one of 315) with pseudogout. Postoperative management was unchanged in every case.

CONCLUSION

Routine submission of specimens obtained during hallux valgus surgery is not cost effective. New diagnoses are very rare and postoperative management did not change.

B-cell lymphoma in retrieved femoral heads: a long term follow up

Background

A relatively high incidence of pathological conditions in retrieved femoral heads, including a group of patients having low grade B-cell lymphoma, has been described before. At short term follow up none of these patients with low-grade B-cell lymphoma showed evidence of systemic disease. However, the long term follow up of these patients is not known.

Methods

From November 1994 up to and including December 2005 we screened all femoral heads removed at the time of primary total hip replacement histopathologically and included them in the bone banking protocol according to the guidelines of the American Associations of Tissue Banks (AATB) and the European Association of Musculo-Skeletal Transplantation (EAMST). We determined the percentage of B-cell lymphoma in all femoral heads and in the group that fulfilled all criteria of the bone banking protocol and report on the long-term follow-up.

Results

Of 852 femoral heads fourteen (1.6%) were highly suspicious for low-grade B-cell lymphoma. Of these 852 femoral heads, 504 were eligible for bone transplantation according to the guidelines of the AATB and the EAMST. Six femoral heads of this group of 504 were highly suspicious for low-grade B-cell lymphoma (1.2%). At long term follow up two (0.2%) of all patients developed systemic malignant disease and one of them needed medical treatment for her condition.

Conclusion

In routine histopathological screening we found variable numbers of low-grade B-cell lymphoma throughout the years, even in a group of femoral heads that were eligible for bone transplantation. Allogenic transmission of malignancy has not yet been reported on, but surviving viruses are proven to be transmissible. Therefore, we recommend the routine histopathological evaluation of all femoral heads removed at primary total hip arthroplasty as a tool for quality control, whether the femoral head is used for bone banking or not.

The clinical value of histologic examination in shoulder arthroscopy

BACKGROUND

The clinical value of histologic examination of tissues removed during shoulder arthroscopy has not been determined. The guidelines of the College of American Pathologists require routine histologic examination of all surgical specimens not specifically exempted by individual hospitals. Previous orthopaedic studies have examined the clinical value of these examinations in total hip and knee arthroplasty, lumbar discectomy, knee arthroscopy, and thumb arthroplasty. Those studies demonstrated that routine histologic examination rarely altered the diagnosis and increased the costs. This study examines the clinical value of histologic examination of shoulder arthroscopic specimens. We regard clinical value to include both diagnostic value and cost of the procedure.

METHODS

Between 1989 and 2005, 2144 consecutive shoulder arthroscopies were performed by one surgeon. We retrospectively reviewed the pathology report from every procedure to determine whether the histologic diagnosis affected patient care. We then estimated the total cost of histologic examination in 2005 dollars.

RESULTS

In all cases, the histologic examination confirmed the findings at arthroscopic surgery. In no case did the histologic findings alter patient care. In 2005 dollars, the total cost of reviewed histologic examinations is estimated to be $160,543.

CONCLUSIONS

Histologic examination of surgical specimens from arthroscopic shoulder surgery does not alter patient care, and it increases costs. On the basis of this study, histologic examination in shoulder arthroscopy should be done at the discretion of the orthopaedic surgeon rather than being mandatory.

Postdischarge costs in arthroplasty surgery

Postdischarge costs associated with primary arthroplasty surgeries have received limited attention in the literature. Our objective was to identify the costs incurred after discharge in primary arthroplasty and to estimate annual postdischarge expenditures in the United States. A cohort of 136 patients who underwent primary arthroplasty was studied. Comprehensive rehabilitation unit (CRU) and home care (HC) costs were obtained. The National Hospital Discharge Survey 2003 data were used to model the national discharge cost estimates. Local patient-oriented outcome was also compared in the patients discharged to CRU vs HC. Total costs were significantly lower in patients discharged directly to home vs those sent to the CRU and who subsequently received HC ($2405 vs $13435, P < .001); both patient groups experienced similar quality of life improvements. An estimated $3.2 billion is spent annually on postsurgical rehabilitation after arthroplasty. Postdischarge costs are significantly higher for patients going to a CRU vs those discharged home; yet, both groups had comparable short-term outcomes.

Unsuspected non-Hodgkin's lymphoma discovered with routine histopathology after elective total hip arthroplasty

The utility and cost-effectiveness of routine histologic examination of specimens from elective total joint procedures continues to be a source of debate. We describe a case of unsuspected non-Hodgkin's lymphoma discovered after routine histopathologic examination of a femoral head with osteoarthritis. The evidence both for and against routine tissue submission after elective arthroplasty cases is outlined in a review of the literature. By illustrating a neoplasm that would have been missed without routine pathologic examination, this case underscores a need for continued scrutiny of methods to effectively reduce medical costs while maintaining quality of care.

Economic evaluation in total hip arthroplasty: analysis and review of the literature

We performed a bibliographic search of MEDLINE databases from January 1966 to July 2002 to identify English language articles that contained either "cost" or "economic" in combination with "total hip arthroplasty" (THA) in the abstract or title. Each study was then critically reviewed for content, technique, and adherence to established healthcare economic principles. Only 81 of the 153 studies retrieved contained actual economic data. Only 6% of studies adhered to established criteria for a comprehensive health care economic analysis. Although the number of publications regarding economic evaluation of THA is on the rise, the methodologic quality of many of these studies remains inadequate. Future studies should employ sound healthcare economic techniques to properly evaluate and assess the true social and economic value of THA.