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

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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.

Section snippets

Clinical value

We performed a retrospective review of cases of primary total shoulder arthroplasty (TSA), reverse total shoulder arthroplasty (RSA), hemiarthroplasty (HHA), and resurfacing procedures at 2 centers. The cases from the first hospital were performed between 2002 and 2015, and the cases at the second hospital were performed between 2006 and 2015. Inclusion criteria were patients who underwent primary shoulder arthroplasty and had the resected humeral head sent for routine histologic examination.

Results

We identified 714 cases of primary shoulder arthroplasty in 646 patients who met inclusion criteria. Preoperative diagnoses included osteoarthritis, rotator cuff tear arthropathy, rheumatoid arthritis, psoriatic arthritis, avascular necrosis, massive irreparable rotator cuff tear, chronic dislocation, proximal humerus fracture, and post-traumatic arthritis (Table I). The mean age of patients was 69.4 years (range, 27.1-91.8 years); 39.8% of patients were male.

An additional 53 cases of primary

Discussion

Hospital pathology laboratories are required to perform histologic examination on human tissues removed during surgical procedures by the College of American Pathologists,17 although certain types of specimens may be excluded from routine examination by hospitals under College of American Pathologists standard ANP.10016.4 The Joint Commission9 also requires routine examination of specimens by a pathologist unless clinical staff and a pathologist together decide on exemptions, which should be

Conclusion

Our study found a high rate of concordance between clinical and pathologic diagnoses in primary shoulder arthroplasty cases in which routine pathologic examination was performed. Our rate of discrepant diagnoses (5.9%) was consistent with previous literature of routine pathologic examination of primary hip and knee arthroplastyspecimens, and we found no cases of discordant diagnoses. The cost per discrepant diagnosis was $1424.09, and the cost per discordant diagnosis was at least $59,811.78

Disclaimer

The authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

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    Approval was obtained from the Mount Sinai Health System Institutional Review Board: No. 15-0061.

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