Is Routine Pathology Necessary After Knee Arthroscopy?
Abstract & Commentary
Synopsis: A survey by the authors of 239 orthopaedic surgeons performing arthroscopy and 93 O.R. nurse managers at regional hospitals revealed that fewer than 10% sent all specimens routinely for pathology, despite existing regulations. Most pathologists at the same institutions, however, responded that all specimens are submitted.
Source:Kirkley A et al. The Cost-Effectiveness of Routine Pathology Consultation in Knee Arthroscopy. Arthroscopy 1998;4:690-695
For many hospitals in the U.S. and Canada, routine histological evaluation is required for any tissue removed at surgery. As incentives increase for cost containment in health care, this practice is being questioned or even disregarded.
Kirkley et al examined the cost-effectiveness of routine pathology for tissue removed at 1,036 consecutive knee arthroscopy cases and found that in only one case (PVNS) was the pathologist's interpretation completely different from the surgeon's diagnosis and likely to alter patient care.1 Three other cases of generalized synovitis identified surgically were specified as rheumatoid arthritis upon histology.
The average costs for histological analysis, including specimen collection, processing, and pathologist fees, were $226.01 per case. Thus, they propose that the estimated $234,147.00 in total costs that would have been incurred by routine pathology examination of these 1,036 specimens would not justify the single case of PVNS with clinical implications.
A survey by the authors of 239 orthopaedic surgeons performing arthroscopy and 93 O.R. nurse managers at regional hospitals revealed that fewer than 10% sent all specimens routinely for pathology, despite existing regulations. Most pathologists at the same institutions, however, responded that all specimens are submitted.
Comment by David R. Diduch, M.S., M.D.:
This study demonstrates effectively how an outdated policy can result in unnecessary expense for a health care dollar already squeezed too tightly. More importantly, the study effectively documents that in very few instances does the histology provide information that alters patient management. Specifically, only cases involving synovitis-related diagnoses were the impacted by the histological analysis.
Similar results have been noted from total joint surgery.2-4 These studies all show, with large, convincing numbers of cases, that malignancy or occult diagnoses that significantly alter patient management would be missed on very rare occasions. These studies also demonstrate that surgeon discretion is quite sufficient to make the decision as to which cases require further histological analysis. For arthroscopy, synovitis-related diagnoses merit pathology review. Routine histology of meniscal or articular cartilage specimens is an unnecessary expense. This paper provides the appropriate documentation to help change existing, outdated hospital regulations.
References
1. Kirkley A et al. The cost-effectiveness of routine pathology consultation in knee arthroscopy. Arthroscopy 1998; 14:690-695
2. Campbell ML et al. Collection of surgical specimens in total joint arthroplasty. Is routine histology cost effective? J Arthroplasty 1997; 12:60-63
3. Lawrence T et al. Histology following primary hip and knee arthoplasty: expensive and expendable. J Bone Joint Surg (in press).
4. Raab SS et al. The utility of histological examination of tissue removed during elective joint replacement. J Bone Joint Surg 1998; 80A:331-335
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