Clinical Faceoff: Should Routine Histopathological Analysis be Performed on Specimens Obtained During Primary Arthroplasty Surgery?
Year: 2019
Type: article
Abstract: The United States Institute of Medicine (IOM) has described six domains of healthcare quality [7]: Safety, effectiveness, efficiency, patient-centeredness, equity, and timeliness. But even within the same healthcare process—such as histopathological analysis of surgical specimens—different experts and experts from different backgrounds may value each of those domains somewhat differently. As a healthcare process, histopathological analysis of specimens obtained during routine arthroplasty varies widely from institution to institution. While some variation among physicians in the care of patients is inevitable (and beneficial), unexplained systemwide variation should attract our attention as a potential opportunity to improve quality. In this Clinical Faceoff on whether histopathological analysis should be performed on surgical specimens as a matter of routine after arthroplasty surgery, I am joined by two international experts with very different backgrounds: Thomas W. Bauer MD, PhD, and Ola Rolfson MD, PhD. Dr. Bauer is the Pathologist-in-Chief in the Department of Pathology and Laboratory Medicine at the Hospital for Special Surgery in New York, NY, USA. Dr. Bauer is an expert in the best use of laboratory testing to diagnose periprosthetic infections and other periprosthetic conditions, and is recognized as an innovator in the application of digital imaging to surgical pathology diagnosis. Considering the IOM’s key domains of quality, I think it is fair to say that Dr. Bauer places a heavy emphasis on process safety and patient-centeredness. Dr. Rolfson is the Director of the Swedish Hip Arthroplasty Register, which has tracked results of patients after THA on a nationwide scale for more than 40 years. He also is an associate professor in the Department of Orthopaedics at the Institute of Clinical Sciences of the Sahlgrenska Academy, at the University of Gothenburg. My impression is that Dr. Rolfson comes at the problem of when and whether to use histopathological analysis more through the IOM’s lens of efficiency. Quality improvement begins when the gap between the ideal state and the current state is recongized. Balancing safety with efficiency—both of which are recognized by the IOM as key quality values—will require systems-based thinking and collaboration between surgeons and pathologists. I see this Clinical Faceoff as a start to that process. Stephen S. Raab:In most areas of medicine, the concept of value has been defined as cost-effectiveness. To what degree is that the appropriate metric for the question of routine histopathological review of surgical specimens obtained at arthroplasty, and if it isn’t, by what measures should we assess the value of this intervention? Thomas W. Bauer: The topics of value and cost-effectiveness are complex, and one might start by questioning the conclusions of any study that does not first address the distinctions between actual costs, charges, and reimbursement, especially in a Diagnosis-related Group payment system. There are real differences among those variables as well as between hospital systems, but they are beyond the scope of this discussion. Therefore, rather than attempting to address the actual magnitude of costs, charges, and reimbursement, I will focus on somewhat less-tangible values derived from the technical processing and professional interpretation of specimens excised during routine arthroplasty. It is sometimes true that one healthcare intervention, procedure, or test is costlier than another, yet has minimal immediate tangible benefit to the patient. However, that intervention may ultimately be cost-effective if its use facilitates doing less of something else in the future. For example, the diagnosis of osteonecrosis of the femoral head (avascular necrosis) should lead to the recognition of a patient who is at risk for developing osteonecrosis at other sites, leading to changes in treatment or lifestyle that would help minimize the risk and expense of subsequent lesions. Similarly, the recognition of an unexpected inflammatory arthropathy in a patient thought to have primary osteoarthritis does not influence the immediate perioperative treatment of that patient, but could lead to the timely identification of rheumatoid arthritis or other systemic inflammatory disease. Any discussion of cost-effectiveness needs to include the value of cost avoidance through prompt diagnosis, even of relatively rare events. As an aside, the value can only be realized if: (1) the pathologist makes the correct diagnosis, (2) the report is read, understood, and acted upon by the surgeon or other treating physician. Similarly, when considering cost-effectiveness, one needs to consider both the effects on the patient, and effects on the health system. Like it or not, some of the health system effects have evolved from litigation and regulatory agencies. There are many reasons to support histological examination (Table 1), and while many of the potential benefits listed in Table 1 may be relevant to the question of value, they are not possible to insert into an equation of cost-effectiveness.Table 1.: Histological examination of tissue utilizationOla Rolfson: Dr. Bauer provides a comprehensive list of arguments for histopathological review of surgical specimens obtained at arthroplasty, but some of those reasons seem more to apply to benefits of retrieval analysis of orthopaedic devices, which should not be confused with routine histopathological review of tissue at primary surgery. While several arguments certainly motivate selective testing, the list provides no specific evidence that substantiates routine testing. I agree with Suchman and colleagues [12], who propose developing strategies for a selective approach to testing. Acknowledging the difficulties in generating highest-level evidence to base and establish guidelines for selective testing, I would propose an expert consensus approach based on existing evidence and reasonable assumptions considering costs and consequences; such a consensus should draw from the expertise surgeons, pathologists, and experts on healthcare safety, and ideally it would be composed of individuals from large healthcare systems around the world. Consensus-based guidelines along those lines would also provide some protection against litigation [5]. Dr. Raab:When we use metrics other than cost-effectiveness, it can become difficult to decide how much value is “enough.” In this setting, then, where dollar value may not be the perfect metric, how should we make that determination and who should make it? Dr. Bauer: It is difficult to guess how much medicine can be safely “dumbed down” by not performing diagnostic or confirmatory tests. With reference to tissues from total joint arthroplasty, one suspects that the individual factors listed in Table 1 may have different values in different hospitals, and the controversies that became evident during the recent International Consensus Meeting on Prosthetic Joint Infection [10], are a reminder that selecting “experts” may be more difficult than it sounds, that thoughtful professionals with different backgrounds can reasonably support different best practices, and that there are pragmatic limits to the extent to which “experts” can be expected to agree. Regardless of how a panel of experts votes on any given weekend, many thoughtful physicians may be concerned about, for example, the long-term consequences of misinterpreting superficial subchondral insufficiency fracture as osteoarthritis, mistaking bone marrow edema for avascular necrosis, failing to diagnose an inflammatory arthropathy, and overlooking the occult malignancy (admittedly rare, but important if you are the patient) in order to reduce the cost of an arthroplasty by perhaps 0.5%. Dr. Rolfson: As demonstrated in previous research [8] as well as Suchman and colleagues [12] in this issue of CORR, the costs of histopathological testing is not negligible. For each patient, histopathological testing expenses correspond to about 0.5% to 1.5% of an arthroplasty procedure at a typical hospital in Europe [3]. To omit a routine diagnostic procedure that has no documented patient benefit might seem straightforward, but in fact is not, particularly if there is no clear consensus regarding the indications for selective testing. As I mentioned, international clinical guidelines combining the available evidence, health-economic modeling, and our practical wisdom would help determine how much value is enough. Consider guidelines for patients with headaches: One guideline recommends against routine neuroimaging because of the rarity of serious intracranial pathologic conditions [11]. Although there is still overuse of neuroimaging, these guidelines have gained international recognition and reduced the provision of care that does not add value. The formation of a group of dedicated arthroplasty, pathology, and healthcare-systems experts would likely be successful in establishing guidelines for selective histopathological review of specimens obtained during hip, knee, and shoulder arthroplasty. Dr. Raab:Given the challenges associated with assessing the value of routine histopathological review of surgical specimens obtained at the time of arthroplasty—and the sheer number of these procedures performed every year—to what degree is selective histopathological review (that is, review of some but not all patients’ specimens) an attractive option? If it is, how should surgeons and pathologists (and/or hospital systems that might wish to establish guidelines on this) determine which specimens should be evaluated under the microscope? Dr. Rolfson: As a non-US arthroplasty surgeon, I was surprised how frequently histopathological examination is being used in the United States. I believe Suchman and colleagues [12] provides an example of nonvalue-adding routines—which should be a target for cost savings or cost shift towards value-adding measures. Ideally, routines for selective histopathological review would be guided by research. In the absence of high-quality evidence, I would propose histopathological review in patients with pathological fracture, radiograph with a suspected appearance of metastasis or bone tumor, or unexpected clinical appearance of the tissues at the time of surgery. I would emphasize this not only relates to the resected bony parts but also synovia, other soft tissue, and socket cartilage and bone. Dr. Bauer: One the day of this writing, the first case assigned for me to sign out carried the clinical diagnosis “primary osteoarthritis.” The synovium (Fig. 1) demonstrates an underlying inflammatory arthropathy that would be undiagnosed if tissue had not been submitted. The extent of chronic synovitis, even in routinely sampled specimens, correlates with serologic markers of systemic inflammation and autoantibodies [9]. Indeed, an inflammatory arthropathy may have been responsible for the degenerative joint disease in the first place, and if not treated may lead to other joint replacements that could be prevented or delayed. The diagnosis of an inflammatory arthropathy, or other incidental finding would remain undetected if we followed the guidelines recommended by Dr. Rolfson in which tissue would be submitted only when the surgeon suspects a tumor, notes an unexpected finding, or recognizes a pathologic fracture.Fig. 1: Section of hip synovium obtained at primary arthroplasty for the clinical diagnosis of osteoarthritis. The section shows papillary synovial hyperplasia with numerous lymphoid aggregates, including some with germinal centers. Not easily seen at this magnification, plasma cells, including occasional binucleate plasma cells are also present. These findings suggest an underlying inflammatory arthropathy such as rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, or other related systemic condition. (Hematoxylin and eosin, 50X). (Published with permission from Thomas W. Bauer MD, PhD).Incidentally, the College of American Pathologists [4] and the Joint Commission standards [13] state that each institution should develop a policy that specifies which specimens do not need to be submitted to the pathology department and which specimens may be exempt from microscopic examination. The policy should be individualized for each institution, taking into account diagnostic needs, medicolegal implications, and many other factors. It follows that every hospital, at least in the United States, already has in place a mechanism to identify specimen types excluded from obligatory histologic evaluation. Dr. Raab:Let’s talk about communication: How can surgeons and pathologists improve care through better between-provider communication? Consider first “routine” cases, and then please share your thoughts about exceptional ones—imagine a pattern of practice where a surgeon is observed to resect an unusual number of normal (nonarthritic) femoral heads during hip replacement; how should this be managed? Dr. Rolfson: Good communication includes information on the clinical diagnosis, a clear question, and the particular reason(s) for ordering the review from the surgeon. Unexpected clinical appearance should be described, and specimens marked to indicate suspect areas. In return, the report should preferably include a summary which indicates if the clinical diagnosis is confirmed or not. If the histopathological diagnosis deviates significantly, I would assume most surgeons would appreciate direct communication to discuss the findings. On a system level, I believe it is important that surgeons and pathologists agree on when and why to order histopathological review. If a group of surgeons or a practice is considering making a systems-level change about when or whether to order histopathological review during routine arthroplasty surgery, that group should obviously involve the pathologists whose expertise will be sought. In addition, an annual summary of pathology reports would help surgeons and pathologists to discuss common issues and identify communication patterns to improve. Finally, if a group of surgeons or a practice is considering making a systems-level change about when or whether to order histopathological review during routine arthroplasty surgery, that group should obviously involve the pathologists whose expertise will be sought. Dr. Bauer: When the pathologist identifies an unexpected finding, such as the patient with a previously undiagnosed inflammatory arthropathy described above, it is often prudent for the pathologist to contact the surgeon (or other treating physician) directly by a phone call or communication log built into the electronic medical record. In terms of an annual review, while many orthopaedic surgeons might limit practice to hip and/or knee arthroplasty, most pathologists evaluate specimens from 15 or more organ systems. Expecting a pathology department to provide an annual review of each system begs for its own evaluation of cost effectiveness. Finally, most hospitals have multidisciplinary committees involved in quality assurance. Notable unexpected discrepancies between preoperative diagnosis and final pathology diagnosis (for example, a knee arthroplasty performed on a patient with an unrecognized proximal tibial chondrosarcoma initially undetected because tissue had not been submitted to pathology, an unexpected lymphoproliferative or myeloproliferative lesion, or receipt of one or more normal femoral heads excised for a clinical diagnosis of osteoarthritis) can be submitted to that committee, and the committee can decide if further investigation is indicated.
Authors: Stephen S. Raab, Thomas W. Bauer, Ola Rolfson
Language: English
Subfield: Surgery
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W2950103067